Every finding on record at Liberty Health Care Center

Based on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 11 residents (Resident #1) reviewed quality of care. LVN C did not immediately assess Resident #1 after she was informed Resident #1 had left leg swelling on 03/07/26 at approximately 5:15 a.m. LVN B assessed Resident #1 at approximately 6:40 a.m. (after being asked by LVN C) on 03/07/26 and discovered discoloration to arms and legs and pain when touched. The noncompliance was identified as PNC (past noncompliance). The IJ began on 03/07/26 and ended on 03/10/26. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions.Findings included: Record review of Resident #1's face sheet dated 03/17/26 indicated she was an [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (form of dementia), cerebral infarction (stroke), dementia (decline in cognitive function), and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she had clear speech and sometimes was able to make herself understood and sometimes understood others. She had severe cognitive impairment (BIMS-4). She utilized a wheelchair for mobility. She was dependent for all ADLS and transfers. Record review of Resident #1's care plan dated 12/26/23 (revised 11/28/25) indicated she had limited physical mobility or was at risk for decline related to Alzheimer's', and limited ROM to right arm and hand. Interventions included: Total assist for all ADLS (revised 07/15/25) and Resident #1 was non weight bearing and was a Hoyer lift X2 by staff at all times with transfers (revised 11/20/25). Record review of Resident #1's Kardex (electronic care record utilized by care staff) dated 03/17/26 indicated Resident #1 was non weight bearing and was a Hoyer lift X2 by staff at all times with transfers. Record review Resident #1's daily note dated 03/06/26 at 1:56 p.m., completed by LVN B indicated no edema present. There were no injuries noted. Record review of Resident #1's daily note dated 03/06/26 at 11:24 p.m., signed on 03/07/26, by LVN C indicated edema present. Location and grade were not noted. There was no signs or symptoms of pain or discomfort this PM. There were no injuries noted. Record review of Resident #1's progress note dated 03/07/26 at 8:33 a.m., completed by LVN B indicated she was asked by LVN C to look at Resident #1. Upon entering the room, LVN B pulled back the covers and discovered discoloration to arms and legs and resident having pain when being touched. LVN B immediately called the administrator and completed a full head to toe assessment and pain assessment. Resident #1 was not able to tell LVN B what happened. LVN B obtained a verbal order from MD to transfer Resident #1 to hospital for further evaluation. RP was notified. Record review of Resident #1's progress note dated 03/07/26 at 9:07 a.m., completed by LVN B, LVN B identified Resident #1 had skin tears and bruising. Resident #1 was lying in bed with the sheets pulled up. A full head to toe assessment was completed. Resident #1 had bilateral bruising to both arms right side and right thigh. Left lower extremity swelling and discoloration. There were 4 skins tears. The right forearm had swelling with a knot. There was a scratch on her forehead. Resident #1 was not able to articulate what happened. The MD was notified with new order to send to hospital for continuation of care. The RP, DON and Administrator were notified. There was no progress notes completed by LVN B on 03/06/26 or 03/07/27. Record review of hospital records dated 03/07/26 indicated Resident #1 was sent to the hospital out of concern for bruising on her extremities. There was a small 2 cm linear abrasion over the right superior forehead, obvious deformities of the left lower extremity, severe hematoma (trauma or injury to blood vessels to the right upper extremity along the distal brachium (lower arm), elbow and forearm, bilateral upper extremity contusion (bruise) with avulsion injuries around both wrists. CAT scan indicated displaced comminuted fractures (bone is broken into three or more pieces and the pieces have moved apart creating a gap) of the distal shafts of the left tibula and fibula and soft tissue swelling. Concern for elder abuse was noted. Resident was placed in cast. Orthopedic surgeon consulted for possible surgery following stabilization. These are life threatening diagnosis. Patient was treated with morphine. At the time of the investigation the surgical records were not available for review. Record review of the facility investigation dated 03/12/26 indicated: On 03/07/2026 at approximately 06:40 AM, the Facility Abuse Coordinator was notified Resident #1 was observed with bruises, and skin tears to her upper extremities. Swelling and discoloration was also noted to her left leg. The abnormalities were identified by day shift nurse LVN B. Review of facility documentation revealed no reported or documented falls or incidents on the prior shift that would explain the injuries. Facility nursing staff were unable to determine or identify how the injuries occurred. LVN B stated she was notified by the night nurse LVN C that Resident #1 had Edema. LVN B immediately went to assess the resident. LVN B was also the day shift nurse for 03/06/2026 from 6:00 am to 6:00 pm. LVN B stated that Resident #1 did not have any skin tears or abnormalities when she left her prior day shift at 6:00 pm. Prior to transferring to the hospital, the resident was interviewed by facility nursing staff. The resident, who is cognitively impaired but able to answer simple questions, was asked whether she had fallen or if anyone had harmed her. The resident responded no. Resident #1 was immediately assessed by nursing staff. A full head-to-toe assessment was completed, which confirmed the presence of bruising, swel1ing, and skin tears. Due to the unknown origin of the injuries and the need for further evaluation, the resident was transferred to (named hospital) for continuation of care. The physician (MD), responsible party (RP), police department, and Ombudsman were notified immediately. Documentation review showed that the resident received a shower on 03/06/2026 (time not indicated). The shower aide reported that at the time of care the resident did not have visible bruising, swelling, or skin tears. Additionally, the resident had been seen in person by the facility physicians on both 03/05/2026 and 03/06/2026, with no new or abnormal findings documented during those visits. CNA A stated that after placing the resident in bed, she requested assistance from the 600 Hall CNA E to help reposition the resident in bed. She stated she noticed bruising on the resident's arms and inquired about it. She reported she was told by CNA A that the bruising and skin tears were old and that the nurse had already been notified. The 100 Hall nurse LVN C acknowledged to the facility Director of Nursing and Administrator that she had been notified around approximately 5:00 AM that the resident's leg appeared bruised. The nurse stated she was providing care to another resident at the time and did not go to assess the resident following notification. Due to concerns identified during the investigation, CNA A and LVN C assigned to the resident's hall were immediately suspended pending investigation. Following further review, the nurse was terminated for failure to assess and document a resident after being notified of a change in condition. CNA A resigned effective immediately during questioning regarding the circumstances surrounding the resident's injuries. Additional investigative actions included:Facility-wide skin assessments completed with no new or abnormal findings.Environmental and safety rounds conducted with no hazards or abnormal findings identified.Resident safe surveys conducted, with residents reporting they feel safe in the facility environment.Staff education provided on abuse, neglect, and exploitation policies.Mechanical lift competencies completed with nursing staff.Targeted staff interviews conducted with employees who had direct contact with the resident within the previous 72 hours, specifically addressing whether abnormalities were observed and whether they were reported appropriately. Re-education provided to staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations. Record review of LVN C's personnel records indicated her date of hire was 11/03/09. She signed she was trained and completed competencies on 11/20/25 that included performing physical assessments/evaluations, documenting change of condition and monitoring pain. During an interview on 03/17/26 at 12:00 p.m., the Administrator said she was the Facility Abuse Coordinator. She said on 03/07/26 at approximately 6:40 a.m. she was notified that Resident #1 was observed with bruises, skin tears to her upper extremities, and swelling and discoloration of her left leg. The injuries were identified by LVN B. She said they were not able to determine how the injuries occurred. She said LVN B was notified by the night nurse, LVN C, that Resident #1 had edema and LVN B immediately went to assess Resident #1. LVN B was also the day shift nurse for 03/06/26 from 6:00 a.m. to 6:00 p.m. She said LVN B stated Resident #1 did not have any skin tears or abnormalities when she left her prior day shift at 6:00 p.m. Resident #1 was asked whether she had fallen or if anyone had hurt her. Resident #1 responded no. Resident #1 was assessed with bruising, swelling and skin tears. Due to the unknown origin of the injuries and the need for further evaluation, the resident was transferred to the hospital for continuation of care. The MD, RP, police department, and Ombudsman were notified immediately. Staff interviews did not reveal any reports of falls, injuries, or incidents involving Resident #1. No staff member was able to identify the cause of the observed injuries. She said Resident #1 received a shower on 03/06/26, before the lunch meal. The shower aide (CNA G) reported Resident #1 did not have visible bruising, swelling, or skin tears. Resident #1 was seen by the facility physicians on both 03/05/26 and 03/06/26, with no new or abnormal findings documented during those visits. She said CNA A worked the night shift of 03/06/26 to 03/07/26. She said CNA A reported at approximately 10:30 p.m. on 03/06/26 she was notified Resident #1 remained in her chair and needed to be placed in bed. Resident #1 was dependent for transfers, and her care plan and Kardex identified her as a two-person transfer using a mechanical Hoyer lift. CNA A stated that she transferred Resident #1 to bed using the Hoyer lift alone, without a second staff assist. She said CNA A acknowledged she had been trained Hoyer lifts required two staff for safe operation but did not provide a reason for performing the transfer alone. CNA A denied dropping the resident, denied finding the resident on the floor, and denied knowledge of any incident occurring prior to or during her shift. She said CNA A requested assistance from CNA F to help reposition Resident #1 in bed. She said CNA F noticed bruising on Resident #1's arms and inquired about it. CNA F said CNA A reported the bruising and skin tears were old and that the nurse had already been notified. The Administrator said LVN C acknowledged she had been notified around approximately 5:00 a.m. on 03/07/26 that Resident #1's leg appeared bruised. LVN C stated she was providing care to another resident at the time and did not go to assess the resident following notification. CNA A and LVN B were immediately suspended pending investigation. She said LVN B was terminated for failure to assess and document a resident after being notified of a change in condition. CNA A resigned during questioning of Resident #1's injuries. She spoke with Resident #1's family member, who reported Resident #1 had sustained a break in her leg in multiple places. She said the facility was unable to determine the exact cause of the injuries. She said Resident#1's roommate was not interviewable and did not provide any information regarding the incident. She said all staff were trained with Hoyer transfer during orientation, annually, and as needed, were aware two staff were required, and were aware the information was located in the Kardex. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. During an interview on 03/17/26 at 2:09 p.m., CNA A said she arrived at the facility on 03/06/26 at 6:30 p.m. She said she started on Hall 500 and used a Hoyer lift to transfer Resident #5. She said she did not ask anyone to help. She said CNA H directed her to work on hall 100 and put Resident #1 to bed. She said she took the Hoyer she previously used on Resident #5 and went to Resident #1's room and transferred Resident #1 to her bed from her wheelchair. She said when she changed Resident #1 and took off her sweater she found the skin tears on her arms by her wrists. She said she went to the nurse and asked if this resident was the resident who was always black and blue and the nurse said no. She said she put a gown on Resident #1 and told the nurse Resident #1 appeared in pain. She said the nurse said Resident #1 would be screaming if she was in pain. She said she did not ask for help. She said she did not notice any skin tears or bruises before she completed the Hoyer lift transfer without assist from a second staff. She said when she provided incontinent care for Resident #1 she noticed there was bruising on the left leg. She said she told her supervisor (CNA H) and the supervisor said it was always like that. She said the supervisor did not check Resident #1's leg. She said she asked LVN C to check Resident #1's leg. She said LVN C said it was edema and to elevate her leg. She said her leg was already on a pillow so she got a sheet and added it to the pillow for more elevation. She said she did not drop Resident #1 when she did the Hoyer transfer or when she provided incontinent care. She said she was aware Resident #1 was two person Hoyer lift. She said she was not trained in the facility with the Hoyer lift. She said she did not check the Kardex because she did not have access to the electronic system. During an interview on 03/18/26 at 10:23 a.m., LVN C said she saw Resident #1 in her wheelchair at approximately 10:30 p.m. She said Resident #1 was in her room. She said she looked over Resident #1 while she was in her wheelchair because Resident #1's Medicare charting was due. She said she did not see anything wrong with Resident #1. She said there were no bruises or skin tears. She said she asked CNA H to have CNA A put Resident #1 in bed. She said she saw CNA A go to Resident #1's room with the Hoyer lift. She said she saw CNA A walk past the nurse station and then she came back with CNA E and assumed it was to assist with the Hoyer lift to transfer Resident #1 from her wheelchair to her bed. She said she checked Resident #1 at 1:00 a.m. and Resident #1 was sleeping. She said she did not pull covers back because Resident #1 was sleeping and she did not want to wake her. She said she saw Resident #1 again at 3:00 a.m. and she was still sleeping. She said she was doing rounds at 5:00 a.m. and CNA A was changing Resident #1. She said the door to Resident #1's room was closed and she did not observe Resident #1 at 5:00 a.m. She said CNA A asked her to look at Resident #1's foot at approximately 5:10 a.m. or 5:15 a.m. She said CNA A rolled back the blanket on Resident #1's left foot and she saw the edema. She said she told CNA A to elevate Resident #1's leg and she continued to provide care to other residents. She said she checked Resident #1's chart to see if there was any prior documentation of the edema because CNA A said the edema was already known. She said she did not find any documentation of the edema. She said she asked LVN B to witness while she completed an assessment of Resident #1. She said she always had a witness for skin assessments. She said she and LVN B went to Resident #1's room and LVN B pulled back the covers and observed Resident #1's left leg was bruised and there were skin tears on both arms. She said the top layer of skin was missing from the skin tears and there were no skin flaps. She said Resident #1 was turned towards her (LVN C) and LVN B observed a cantaloupe sized bruise on her back. Resident #1 also had a scratch on her face. She said when Resident #1 was touched or moved she grimaced and moaned in pain. She said LVN B immediately called the Administrator to report the injuries. She said the Administrator called the police, the police arrived very quickly and asked for statements. She said CNA A had already left. She said the MD was notified and EMS arrived to transfer Resident #1 to the hospital for evaluation. She said she did not provide care or use the Hoyer lift to transfer for Resident #1. She said she did not properly assess Resident #1 when she was informed of the edema. She said she was not informed of any bruises or skin tears. She said not properly assessing a resident could lead to further decline of health and resident would not receive timely care. She said all Hoyer lift transfers are supposed to be with 2 person assist. She said risks of not having 2 person could include injuries and death. During an interview on 03/18/26 at 3:05 p.m., LVN B said she observed Resident #1 on 03/06/26 and Resident #1 had no injuries when she left the faciity on [DATE] at 6:00 p.m. She said Resident #1 wore a dress and had no edema or bruises on her legs. She said she arrived at the facility on 03/07/26 at 6:00 a.m. and received report. She said there was no report of any issues or concerns related to Resident #1. She said LVN C asked her to assess Resident #1 at approximately 6:40 a.m. She said she pulled back Resident #1's covers and was shocked and immediately called the Administrator. She said Resident #1 was in the same condition the day before. She said Resident #1 had fresh skin tears on both her arms that had no skin flaps with purple and red bruises. She said there was a scratch on her right forehead. She said Resident #1's left leg was bruised and purple. She said there was fresh blood on her gown and blankets. She said Resident #1 showed pain with grimace and frown when she was moved and touched. She said the police arrived and told her to tell the administrator Resident #1 needed to go to the hospital. She said she told the administrator she had to send Resident #1 out because her left leg was twisted and propped up on a pillow. She said she asked LVN C did she know of Resident #1's injuries and LVN C said no. She said LVN C said she had not seen Resident #1 since 10:30 p.m. on 03/06/26 when she was in her wheelchair. She said LVN C said CNA A told her at 5:15 a.m. that Resident #1's legs were swollen and she told her to prop up it up with a pillow and she would look at it after she was done with another resident. She said after the police arrived, LVN B said she was notified of the edema at approximately 5:15 a.m. but was doing trach care on another resident. She said LVN C said CNA A pulled the cover back and she saw the edema on the left foot but she did not see the whole left leg. LVN B said she believed Resident #1 was dropped. She said the Kardex has the information related to resident care and if they required a Hoyer. She said all Hoyer transfers required 2 persons. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. Record review of the facility's policy Unexplained Injuries dated 2023 indicated 1. Observations of any unexplained injuries shall be reported immediately to the resident's nurse. 2. Care and treatment shall be provided to the resident as needed. This includes physician notification and implementation of physician orders or facility protocols. An incident report form shall be completed. An injury should be classified as an injury of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: i. The extent of the injury or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or iii. The number or injuries observed at one particular point in time or iv. The incidence of injuries over time. Relevant information shall be documented in the resident's medical record, including but not limited to: a. Physical assessment findings, including objective descriptions of the injury. b. Risk factors and conditions that could cause or predispose someone to similar signs and symptoms. c. Notification of physician and his/her response. d. Actions taken to meet the resident's immediate needs and implementation of physician orders. E. Notification of resident representative. The facility took the following actions to correct the noncompliance prior to surveyor entrance: Record review of the facility-wide skin assessments dated 03/07/26 indicated no new or abnormal findings. Record review of the facility environmental and safety rounds dated 03/07/26 indicated no hazards or abnormal findings identified. Record review of resident safe surveys dated 03/07/26 indicated residents reported they felt safe in the facility environment. Record review of staff education indicated they were trained on abuse, neglect, and exploitation policies from 03/07/26 through 03/10/26. Record review of mechanical lift competencies indicated they were completed with nursing staff 03/07/26 through 03/10/26. Record reviews of electronic records of residents indicated no issues identified with assessments. Record review of an AD HOC QAPI meeting dated 03/07/26 indicated the interdisciplinary team included the Medical Director, DON, Administrator, the police were notified, SW, and Regional Nurse. The facility identified LVN B reported to the abuse coordinator Resident #1 had swelling, discoloration and bruising to her lower and upper extremities. Resident #1 had skin tears to both arms. There were no abnormal reports on 03/06/26 for Resident #1. Resident #1 was sent out to hospital for further evaluation and treatment. LVN C was suspended pending the investigation. The facility would continue to monitor the residents daily. The facility implemented staff training and competency testing/demonstration to include abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment. In-services: Record review of in-services initiated on 03/07/26 through 03/10/25 were conducted for all direct care staff by the DON in person and/or via phone. All staff who were not present for in-services were not permitted to work their assignment until in-serviced. All new hires would be in-serviced during facility orientation. All agency staff would be in-serviced prior to working their floor assignment. Record review of an In-Service Training Report that included falls, documentation, stop and watch alert tool in PCC, and documentation, the abuse coordinator and staff to report, abuse, neglect immediately to the abuse coordinator (the Administrator), conducted by the DON from 03/07/26 through 03/10/26, indicated 100% of staff were trained. Record review of the staff training for skin assessment, pain assessments, and competencies conducted by the ADON on 03/07/26 through 03/10/26 indicated 100% of nursing staff were trained. Record review of the facility's incident reports from 03/07/26 through 03/18/26 indicated there were no concerns related to resident injuries. Staff interviews conducted on 03/17/26 and 03/18/26 with staff who worked all shifts (6:00 a.m.-6:00 p.m., 6:00 p.m. - 6:00 a.m., 7:00 a.m. - 7:00 p.m., and 8:00 .m. - 4:30 p.m. (LVN K, LVN B, LVN L, LVN O, LVN P, LVN R, and ADON) indicated they were aware of the facility's abuse prevention and reporting policy, were aware the Administrator was the Abuse Coordinator and were to report any suspicion or allegation of abuse or neglect immediately. They were aware all changes of condition should be reported immediately to the charge nurse, documented, and assessed. Nursing staff indicated they had received training and passed competency tests from 03/07/26 through 03/10/26 on resident assessment and pain assessments. During an interview on 03/17/26 at 12:00 p.m., the Administrator said facility-wide skin assessments were completed with no new or abnormal findings, environmental and safety rounds were conducted with no hazards or abnormal findings identified, resident safe surveys conducted and residents reported they felt safe in the facility environment, staff education provided on abuse, neglect, and exploitation policies, mechanical lift competencies were completed with nursing staff, re-education was provided to staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations. The Administrator said an Ad Hoc QAPI meeting was conducted to review the incident and identify opportunities for system improvement. She said the facility was conducting impromptu observations and skills knowledge of Hoyer lift transfers and resident assessments. She said she, the DON and ADON were conducting reviews of resident records for assessments upon review of the daily 24 hour reports. She said there were no problems identified since 03/07/26. During an interview on 03/18/26 at 3:32 p.m., the DON said all staff who were trained abuse, neglect, and exploitation policies, mechanical lift, the role of the Facility Abuse Coordinator, incident and accident reporting, assessment and documentation requirements, and charting expectations. Staff that were trained over the phone were tested for competence or had to demonstrate competency prior to working their scheduled shift. She said all staff passed the testing and demonstrations. She said there were no concerns noted. She said staff would be retrained as necessary if there were problems observed. She said staff were monitored daily and impromptu knowledge checks were conducted. She said the 24-hour reports were reviewed daily and resident charts were reviewed for required charting. The Medical Director was notified of the Immediate Jeopardy on 03/18/26 by the Administrator. On 03/18/26 at 1:28 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/06/26 and ended on 03/10/26. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 11 (Resident #1) residents reviewed for accidents. The facility failed to ensure CNA A performed a 2 person Hoyer lift transfer for Resident #1. CNA A transferred Resident #1 from wheelchair to bed, Resident #1 sustained a fractured left tibia (shin bone) and fibula (calf bone), avulsion injuries (skin torn away from its normal attachment) to her bilateral upper extremities, a large bruise on her back and a scratch to her forehead on 03/06/26. Resident #1 required surgical intervention. The noncompliance was identified as PNC (past noncompliance). The IJ began on 03/06/26 and ended on 03/10/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.Findings included: Record review of Resident #1's face sheet dated 03/17/26 indicated she was an [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (form of dementia), cerebral infarction (stroke), dementia (decline in cognitive function), and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she had clear speech and sometimes was able to make herself understood and sometimes understood others. She had severe cognitive impairment (BIMS-4). She utilized a wheelchair for mobility. She was dependent for all ADLS and transfers. Record review of Resident #1's care plan dated 12/26/23 (revised 11/28/25) indicated she had limited physical mobility or was at risk for decline related to Alzheimer's, and limited ROM to right arm and hand. Interventions included: Total assist for all ADLS (revised 07/15/25) and Resident #1 was non weight bearing and was a Hoyer lift X2 by staff at all times with transfers (revised 11/20/25). Record review of Resident #1's Kardex (electronic care record utilized by care staff) dated 03/17/26 indicated Resident #1 was non weight bearing and was a Hoyer lift X2 by staff at all times with transfers. Record review Resident #1's daily note dated 03/06/26 at 1:56 p.m., completed by LVN B indicated no edema present. There were no injuries noted. Record review of Resident #1's daily note dated 03/06/26 at 11:24 p.m., and signed on 03/07/26, completed by LVN C indicated edema present. Location and grade were not noted. There were no signs or symptoms of pain or discomfort this PM. There were no injuries noted. Record review of Resident #1's progress note dated 03/07/26 at 8:33 a.m., completed by LVN B indicated she was asked by LVN C to look at Resident #1. Upon entering the room, LVN B pulled back the covers and discovered discoloration to arms and legs and resident having pain when being touched. LVN B immediately called the administrator and completed a full head to toe assessment and pain assessment. Resident #1 was not able to tell LVN B what happened. LVN B obtained a verbal order from MD to transfer Resident #1 to hospital for further evaluation. RP was notified. Record review of Resident #1's progress note dated 03/07/26 at 9:07 a.m., completed by LVN B, indicated Resident #1 had skin tears and bruising. Resident #1 was lying in bed with the sheets pulled up. A full head to toe assessment was completed. Resident #1 had bilateral bruising to both arms right side and right thigh. Left lower extremity swelling and discoloration. There were 4 skins tears. The right forearm had swelling with a knot. There was a scratch on her forehead. Resident #1 was not able to articulate what happened. The MD was notified with new order to send to hospital for continuation of care. The RP, DON and Administrator were notified. There was no progress notes completed by LVN B on 03/06/26 or 03/07/27. Record review of hospital records dated 03/07/26 indicated Resident #1 was to the hospital out of concern for bruising on her extremities. There was a small 2 cm linear abrasion over the right superior forehead, obvious deformities of the left lower extremity, severe hematoma (trauma or injury to blood vessels to the right upper extremity along the distal brachium (lower arm), elbow and forearm, bilateral upper extremity contusion (bruise) with avulsion injuries around both wrists. CAT scan indicated displaced comminuted fractures (bone is broken into three or more pieces and the pieces have moved apart creating a gap) of the distal shafts of the left tibula and fibula and soft tissue swelling. Concern for elder abuse was noted. Resident was placed in cast. Orthopedic surgeon consulted for possible surgery following stabilization. These are life threatening diagnosis. Patient was treated with morphine. At the time of the investigation the surgical records were not available for review. Record review of the facility investigation dated 03/12/26 indicated: On 03/07/2026 at approximately 06:40 AM, the Facility Abuse Coordinator was notified Resident #1 was observed with bruises, and skin tears to her upper extremities. Swelling and discoloration was also noted to her left leg. The abnormalities were identified by day shift nurse LVN B. Review of facility documentation revealed no reported or documented falls or incidents on the prior shift that would explain the injuries. Facility nursing staff were unable to determine or identify how the injuries occurred. LVN B stated she was notified by the night nurse LVN C that Resident #1 had Edema. LVN B immediately went to assess the resident. LVN B was also the day shift nurse for 03/06/2026 from 6:00 am to 6:00 pm. LVN B stated that Resident #1 did not have any skin tears or abnormalities when she left her prior day shift at 6:00 pm. Prior to transferring to the hospital, the resident was interviewed by facility nursing staff. The resident, who is cognitively impaired but able to answer simple questions, was asked whether she had fallen or if anyone had harmed her. The resident responded no. Resident #1 was immediately assessed by nursing staff. A full head-to-toe assessment was completed, which confirmed the presence of bruising, swel1ing, and skin tears. Due to the unknown origin of the injuries and the need for further evaluation, the resident was transferred to (named hospital) for continuation of care. The physician (MD), responsible party (RP), police department, and Ombudsman were notified immediately. As part of the investigation, staff statements were collected from employees who had contact with the resident within the previous 72 hours. Staff interviews did not reveal any reports of falls, injuries, or incidents involving the resident. No staff member was able to identify the cause of the abnormalities observed. Alert and oriented residents who reside on the 100 hall were interviewed and asked if they noticed or heard anything out of the ordinary for the night of 03/06/2026 into 03/07/2026, no abnormal reporting.Documentation review showed that the resident received a shower on 03/06/2026 (time not indicated). The shower aide reported that at the time of care the resident did not have visible bruising, swelling, or skin tears. Additionally, the resident had been seen in person by the facility physicians on both 03/05/2026 and 03/06/2026, with no new or abnormal findings documented during those visits.CNA A who worked the night shift of 03/06/2026 to 03/07/2026 reported that at approximately 10:30 PM she was notified that the resident remained in her chair and needed to be placed in bed. Resident #1 was dependent for transfers, and her care plan and Kardex identify her as a two-person transfer using a mechanical Hoyer lift. CNA A stated that she transferred the resident to bed using the Hoyer lift; however, she acknowledged that she performed the transfer alone without a second staff member present, which is contrary to facility policy. CNA A acknowledged she had been trained that Hoyer lifts required two staff members for safe operation but did not provide a reason for performing the transfer alone. CNA A denied dropping the resident, denied finding the resident on the floor, and denied knowledge of any incident occurring prior to or during her shift.CNA A further stated that after placing the resident in bed, she requested assistance from the 600 Hall CNA E to help reposition the resident in bed. She stated she noticed bruising on the resident's arms and inquired about it. She reported she was told by CNA A that the bruising and skin tears were old and that the nurse had already been notified.The 100 Hall nurse LVN C acknowledged to the facility Director of Nursing and Administrator that she had been notified around approximately 5:00 AM that the resident's leg appeared bruised. The nurse stated she was providing care to another resident at the time and did not go to assess the resident following notification.Due to concerns identified during the investigation, CNA A and LVN C assigned to the resident's hall were immediately suspended pending investigation. Following further review, the nurse was terminated for failure to assess and document a resident after being notified of a change in condition. CNA A resigned effective immediately during questioning regarding the circumstances surrounding the resident's injuries.Additional investigative actions included:Facility-wide skin assessments completed with no new or abnormal findings.Environmental and safety rounds conducted with no hazards or abnormal findings identified.Resident safe surveys conducted, with residents reporting they feel safe in the facility environment.Staff education provided on abuse, neglect, and exploitation policies.Mechanical lift competencies completed with nursing staff.Targeted staff interviews conducted with employees who had direct contact with the resident within the previous 72 hours, specifically addressing whether abnormalities were observed and whether they were reported appropriately.Re-education provided to staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations. Record review of the police report dated 03/07/26 at 1:00 p.m., completed by PD E indicated he was dispatched to the facility in reference to injury to elderly. He observed Resident #1 laying in bed but she had no verbal response to PD E. He observed purple and red bruising on both hands, fresh blood in the area of the bruising. Dried blood was observed on the sheets. He observed her left leg and it was bruised, coloration of purple, turned in opposite of normal direction, and inflamed. Observations of the pictures provided by the police department on 03/19/26 at 8:30 a.m. indicated the following: purple and red bruising on both hands fresh blood in the area of the bruising, dried blood on the sheets, and the left leg was bruised, purple, turned in opposite of normal direction, and inflamed. Record review of CNA A's personnel records indicated her date of hire was 01/23/26. She resigned 03/07/26. She was trained and completed competencies that included safe resident transfers on 01/23/26 and 02/02-03/26. She was trained on fall prevention on 02/03/26. She had access to the facility electronic records and Kardex information. Record review of LVN C's personnel records indicated her date of hire was 11/03/09. She signed she was trained and completed competencies on 11/20/25 that included performing physical assessments/evaluations, documenting change of condition and monitoring pain. During an interview on 03/16/26 at 5:13 p.m., PD E said he arrived at the facility in reference to injury to elderly. He observed Resident #1 laying in bed but she had no verbal response to him (PD E). He observed purple and red bruising on both hands, fresh blood in the area of the bruising. Dried blood was observed on the sheets. He observed her left leg and it was bruised, coloration of purple, turned in opposite of normal direction, and inflamed. He said the case was handed to PD D for investigation of abuse to an elderly person. During an interview on 03/17/26 at 12:00 p.m., the Administrator said she was the Facility Abuse Coordinator. She said on 03/07/26 at approximately 6:40 a.m., she was notified that Resident #1 was observed with bruises, skin tears to her upper extremities, and swelling and discoloration of her left leg. The injuries were identified by LVN B. She said they were not able to determine how the injuries occurred. She said LVN B was notified by the night nurse, LVN C, that Resident #1 had edema and LVN B immediately went to assess Resident #1. LVN B was also the day shift nurse for 03/06/26 from 6:00 a.m. to 6:00 p.m. She said LVN B stated Resident #1 did not have any skin tears or abnormalities when she left her prior day shift at 6:00 p.m. Resident #1 was asked whether she had fallen or if anyone had hurt her. Resident #1 responded no. Resident #1 was assessed with bruising, swelling and skin tears. Due to the unknown origin of the injuries and the need for further evaluation, the resident was transferred to the hospital for continuation of care. The MD, RP, police department, and Ombudsman were notified immediately. Staff interviews did not reveal any reports of falls, injuries, or incidents involving Resident #1. No staff member was able to identify the cause of the observed injuries. She said Resident #1 received a shower on 03/06/26, before the lunch meal. The shower aide (CNA G) reported Resident #1 did not have visible bruising, swelling, or skin tears. Resident #1 was seen by the facility physicians on both 03/05/26 and 03/06/26, with no new or abnormal findings documented during those visits. She said CNA A worked the night shift of 03/06/26 to 03/07/26. She said CNA A reported at approximately 10:30 p.m. on 03/06/26 she was notified Resident #1 remained in her chair and needed to be placed in bed. Resident #1 was dependent for transfers, and her care plan and Kardex identified her as a two-person transfer using a mechanical Hoyer lift. CNA A stated that she transferred Resident #1 to bed using the Hoyer lift alone, without a second staff assist. She said CNA A acknowledged she had been trained Hoyer lifts required two staff for safe operation but did not provide a reason for performing the transfer alone. CNA A denied dropping the resident, denied finding the resident on the floor, and denied knowledge of any incident occurring prior to or during her shift. She said CNA A requested assistance from CNA F to help reposition Resident #1 in bed. She said CNA F noticed bruising on Resident #1's arms and inquired about it. CNA F said CNA A reported the bruising and skin tears were old and that the nurse had already been notified. The Administrator said LVN C acknowledged she had been notified around approximately 5:00 a.m. on 03/07/26 that the Resident #1's leg appeared bruised. LVN C stated she was providing care to another resident at the time and did not go to assess the resident following notification. CNA A and LVN B were immediately suspended pending investigation. She said LVN B was terminated for failure to assess and document a resident after being notified of a change in condition. CNA A resigned during questioning of Resident #1's injuries. She spoke with Resident #1's family member, who reported Resident #1 had sustained a break in her leg in multiple places. She said the facility was unable to determine the exact cause of the injuries. She said Resident#1's roommate was not interviewable and did not provide any information regarding the incident. She said all staff were trained with Hoyer transfer during orientation, annually, and as needed, were aware two staff were required, and were aware the information was located in the Kardex. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. During an interview on 03/17/26 at 2:09 p.m., CNA A said she arrived at the facility on 03/06/26 at 6:30 p.m. She said she started on Hall 500 and used a Hoyer lift to transfer Resident #5. She said she did not ask anyone to help. She said CNA H directed her to work on hall 100 and put Resident #1 to bed. She said she took the Hoyer she previously used on Resident #5 and went to Resident #1's room and transferred Resident #1 to her bed from her wheelchair. She said when she changed Resident #1 and took off her sweater she found the skin tears on her arms by her wrists. She said she went to the nurse and asked if this resident was the resident who was always black and blue and the nurse said no. She said she put a gown on Resident #1 and told the nurse Resident #1 appeared in pain. She said the nurse said Resident #1 would be screaming if she was in pain. She said she did not ask for help. She said she did not notice any skin tears or bruises before she completed the Hoyer lift transfer without assist from a second staff. She said when she provided incontinent care for Resident #1 she noticed there was bruising on the left leg. She said she told her supervisor (CNA H) and the supervisor said it was always like that. She said the supervisor did not check Resident #1's leg. She said she asked LVN C to check Resident #1's leg. She said LVN C said it was edema and to elevate her leg. She said her leg was already on a pillow so she got a sheet and added it to the pillow for more elevation. She said she did not drop Resident #1 when she did the Hoyer transfer or when she provided incontinent care. She said she was aware Resident #1 was two person Hoyer lift. She said she was not trained in the facility with the Hoyer lift. She said she did not check the Kardex because she did not have access to the electronic system. During an interview on 03/17/26 at 5:48 p.m., Family Member I said on 03/07/26, Resident #1 had numerous skin tears and bruises on her arms. She had a large bruise on her back and a scratch on her right forehead. He said she had a broken left tibia and fibula that required surgery. He said metal rods were placed in each bone. He said he was very upset Resident #1 had sustained injuries and was not assessed by the nurse timely. He said he believed the staff transferred Resident #1 without a second staff and dropped her during the transfer and did not report the incident to the nurse. He said he was extremely upset Resident #1 was in her bed from 11:00 p.m. on 03/06/26 until 6:40 a.m. on 03/07/26 with injuries and pain and not assessed or sent to hospital. He said Resident #1 would not return to the facility and was admitted to a different facility for care. During an interview on 03/18/26 at 9:20 a.m., CNA F said she did not know what happened to cause injuries to Resident #1. She said CNA A asked her to assist to pull Resident #1 up in her bed at approximately 11:00 p.m. on 03/06/26. She said she noticed the skin tears on both of Resident #1's arms and asked CNA A what happened. She said CNA A said the skin tears were there already and the nurse was aware. She said the skin tears looked bloody but were not bleeding. She said she did not see Resident #1's legs because they were covered with the sheet. She said she did not provide any care to Resident #1 and did not assist with the Hoyer transfer from wheelchair to the bed. She said she had been trained and was aware all Hoyer lift transfers were supposed to be completed with 2 staff. She said the information was available in the Kardex. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. During an interview on 03/18/26 at 10:23 a.m., LVN C said she saw Resident #1 in her wheelchair at approximately 10:30 p.m. She said Resident #1 was in her room. She said she looked over Resident #1 while she was in her wheelchair because Resident #1's Medicare charting was due. She said she did not see anything wrong with Resident #1. She said there were no bruises or skin tears. She said she asked CNA H to have CNA A put Resident #1 in bed. She said she saw CNA A go to Resident #1's room with the Hoyer lift. She said she saw CNA A walk past the nurse station and then she came back with CNA E and assumed it was to assist with the Hoyer lift to transfer Resident #1 from her wheelchair to her bed. She said she checked Resident #1 at 1:00 a.m. and Resident #1 was sleeping. She said she did not pull covers back because Resident #1 was sleeping and she did not want to wake her. She said he saw Resident #1 again at 3:00 a.m. and she was still sleeping. She said she was doing rounds at 5:00 a.m. and CNA A was changing Resident #1. She said the door to Resident #1's room was closed and she did not observe Resident #1 at 5:00 a.m. She said CNA A asked her to look at Resident #1's foot at approximately 5:10 a.m. or 5:15 a.m. She said CNA A rolled back the blanket on Resident #1's left foot and she saw the edema. She said she told CNA A to elevate Resident #1's leg and she continued to provide care to other residents. She said she checked Resident #1's chart to see if there was any prior documentation of the edema because CNA A said the edema was already known. She said she did not find any documentation of the edema. She said she asked LVN B to witness while she completed an assessment of Resident #1. She said she always had a witness for skin assessments. She said she and LVN B went to Resident #1's room and LVN B pulled back the covers and observed Resident #1's left leg was bruised and there was skin tears on both arms. She said the top layer of skin was missing from the skin tears and there were no skin flaps. She said Resident #1 was turned towards her (LVN C) and LVN B observed a cantaloupe sized bruise on her back. Resident #1 also had a scratch on her face. She said when Resident #1 was touched or moved she grimaced and moaned in pain. She said LVN B immediately called the Administrator to report the injuries. She said the Administrator called the police nd the police arrived very quickly and asked for statements. She said CNA A had already left. She said the MD was notified and EMS arrived to transfer Resident #1 to hospital for evaluation. She said she did not provide care or use the Hoyer lift to transfer for Resident #1. She said she did not properly assess Resident #1 when she was informed of the edema. She said she was not informed of any bruises or skin tears. She said not properly assessing a resident could lead to further decline of health and resident would not receive timely care. She said all Hoyer lift transfers are supposed to be with 2 person assist. She said risks of not having 2 person could include injuries and death. During an interview on 03/18/26 at 3:05 p.m., LVN B said she observed Resident #1 on 03/06/26 ad Resident #1 had no injuries when she left the faciity on [DATE] at 6:00 p.m. She said Resident #1 wore a dress and had no edema or bruises on her legs. She said she arrived at the facility on 03/07/26 at 6:00 a.m. and received report. She said there was no report of any issues or concerns related to Resident #1 She said LVN C asked her to assess Resident #1 at approximately 6:40 a.m. She said she pulled back Resident #1's covers and was shocked and immediately called the Administrator. She said Resident #1 was in the same condition the day before. She said Resident #1 had fresh skin tears on both her arms that had no skin flaps with purple and red bruises. She said there was a scratch on her right forehead. She said Resident #1's left leg was bruised and purple. She said there was fresh blood on her gown and blankets. She said Resident #1 showed pain with grimace and frown when she was moved and touched. She said the police arrived and told her to tell the administrator Resident #1 needed to go to the hospital. She said she told the administrator she had to send Resident #1 out because her left leg was twisted and propped up on a pillow. She said she asked LVN C did she know of Resident #1's injuries and LVN C said no. She said LVN C said she had not seen Resident #1 since 10:30 p.m. on 03/06/26 when she was in her wheelchair. She said LVN C said CNA A told her at 5:15 a.m. that Resident #1's legs were swollen and she told her to prop up it up with a pillow and she would look at it after she was done with another resident. She said after the police arrived, LVN B said she was notified of the edema at approximately 5:15 a.m. but was doing trach care on another resident. She said LVN C said CNA A pulled the clover back and she saw the edema on the left foot but she did not see the whole left leg. LVN B said she believed Resident #1 was dropped. She said the Kardex has the information related to resident care and if they required a Hoyer. She said all Hoyer transfers required 2 persons. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. During an interview on 03/18/26 at 3:34 p.m., CNA G said Resident #1 was brought to the shower room in the shower chair on 03/06/26 before the lunch meal was served. She said she had no bruises or skin tears nd there was no injury to her left leg. She said she was brought back to her room and transferred back to her bed with the Hoyer lift and two staff. CNA G said she was trained on Hoyer lift transfers and all required 2 person. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. During an interview on 03/18/26 at 3:39 p.m., CNA H said she assisted with transferring Resident #1 with the Hoyer lift on 03/06/26. She said Resident #1 did not have any bruises, skin tears or leg injuries. She said she came back to work late in the evening on 03/06/26 because there was call-ins and she had to find staff to work. She said she saw Resident #1 was still in her wheelchair at approximately 10:30 p.m. She said she advised CNA A to put Resident #1 to bed. She said CNA A was scheduled to work the 100 hall where Resident #1 was and there was no reason she should have been using the Hoyer to put another resident to bed. She said CNA A did not report any injuries or bruises to her on 03/06/26. She said all staff were trained on Hoyer lift transfers and were to find the Kardex information upon hire and annually. She said residents were at risk of injuries if they were not transferred with 2 staff as required with the Hoyer. Record review of the facility's Safe Resident Handling/Transfers policy dated 2023 indicated Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used.3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. The facility took the following actions to correct the noncompliance prior to surveyor entrance: Record review of the facility-wide skin assessments dated 03/07/26 indicated no new or abnormal findings. Record review of the facility environmental and safety rounds dated 03/07/26 indicated no hazards or abnormal findings identified. Record review of resident safe surveys dated 03/07/26 indicated residents reported they felt safe in the facility environment. Record review of staff education indicated they were trained on abuse, neglect, and exploitation policies from 03/07/26 through 03/10/26. Record review of mechanical lift competencies indicated they were completed with nursing staff 03/07/26 through 03/10/26. Record reviews of electronic records of residents indicated no issues identified with assessments. Record review of an AD HOC QAPI meeting dated 03/07/26 indicated the interdisciplinary team included the Medical Director, DON, Administrator The police were notified, SW, and Regional Nurse. The facility identified LVN B reported to the abuse coordinator Resident #1 had swelling, discoloration and bruising to her lower and upper extremities. Resident #1 had skin [NAME] to both arms. There were no abnormal reports on 03/06/26 for Resident #1. Resident #1 was sent out to hospital for further evaluation and treatment. LVN C was suspended pending the investigation. The facility would continue to monitor the residents daily. The facility implemented staff training and competency testing/demonstration to include abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment. In-services:Record review of in-services initiated on 03/07/26 through 03/10/25 were conducted for all direct care staff by the DON in person and/or via phone. All staff who were not present for in-services were not permitted to work their assignment until in-serviced. All new hires would be in-serviced during facility orientation. All agency staff would be in-serviced prior to working their floor assignment. Record review of an In-Service Training Report that included falls, documentation, stop and watch alert tool in PCC, and documentation, the abuse coordinator and staff to report, abuse, neglect immediately to the abuse coordinator (the Administrator), conducted by the DON from 03/07/26 through 03/10/26, indicated 100% of staff were trained. Record review of the staff training for skin assessment, pain assessments and competencies conducted by the ADON on 03/07/26 through 03/10/26 indicated 100% of nursing staff were trained. Record review of the facility's incident reports from 03/07/26 through 03/18/26 indicated there were no concerns related to resident injuries. Observation on 03/17/26 at 12:40 p.m. indicated CNA G and CNA H were able to use the Hoyer correctly for the transfer of Resident #5. There was no observed concerns. Observations conducted on 03/17/26, 03/18/26, and 03/19/26 indicated no observed hazards related to resident transfers. Interviews conducted with Resident #4 and Resident #5 who required a Hoyer lift transfer indicated they felt safe. They indicated they were transferred with Hoyer lift and always had two staff. Staff interviews conducted on 03/17/26 and 03/18/26 with staff who worked all shifts (6:00 a.m.-6:00 p.m., 6:00 p.m. - 6:00 a.m., 7:00 a.m. - 7:00 p.m., and 8:00 .m. - 4:30 p.m. (LVN K, LVN B, CNA E, CNA H, LVN L, CNA G, CNA H, CNA M, CNA N, LVN O, LVN P, CMA Q, LVN R, LVN S, CNA T, CNA U, and ADON) indicated they were aware of the facility policy for Hoyer lift transfers, had received training and had demonstrated competencies. They were aware of the facility's abuse prevention and reporting policy, were aware the Administrator was the Abuse Coordinator and were to report any suspicion or allegation of abuse or neglect immediately. They were aware all changes of condition should be reported immediately to the charge nurse, documented, and assessed. Nursing staff indicated they had received training and passed competency tests from 03/07/26 through 03/10/26 on resident assessment and pain assessments. During an interview on 03/17/26 at 12:00 p.m., the Administrator said facility-wide skin assessments were completed with no new or abnormal findings, environmental and safety rounds were conducted with no hazards or abnormal findings identified, resident safe surveys conducted and residents reported they felt safe in the facility environment, staff education provided on ab[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of nine residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2 took her morning medications and the medications were not left in her room, unsecured, on her bedside table on 02/10/26. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.Findings included: Record review of Resident #2's face sheet, dated 01/11/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included delusional disorder (a type of serious mental illness characterized by holding one or more firm, false beliefs) and schizophrenia (mental health condition that affects everything from how you think, to how you feel, and how you behave). Record review of Resident #2's quarterly MDS assessment, dated 02/08/26, reflected she had a BIMS score of 14, which indicated her cognition was intact, and she was independent for functional abilities. Record review of Resident #2's Care Plan, on 02/11/26, reflected no evidence that Resident #2 could self-administer her medications or keep medications in her room. Record review of Resident #2's Medication Administration Record, dated printed 02/11/26, reflected four different medications (six tablets) were signed off as given that morning of 02/10/26 (exact times were not listed). During an observation and interview on 02/10/26 at 10:02 AM, a small medication cup was sitting at Resident #2's bedside and Resident #2 stated they (the medications) have not been here long.I need to take them. She immediately sat up, grabbed the medications, and took them herself. She stated she must have been asleep, and they were not able to wake her up. She stated medications were not left on her bedside table often. During an interview with RN A on 02/11/26 at 10:21 AM, she stated the medication administration process was to check the medication administration record to verify the resident, and the medications that were to be administered. She stated she would stay until the resident took the medication. She stated medications should not be left in the room. She stated at times, residents would not want to take them immediately and would be upset, but they had to say no and stay in the room until the resident took the medication. She stated the failure could cause a different resident to pick up the medications, the medications could end up in the wrong hands, or the resident might miss a dose. She stated registered nurses, licensed vocation nurses, and medication aides were responsible for medication administration. During an interview with LVN B on 02/11/26 at 11:06 AM, she stated she would pull up the medication administration record to verify medications and the residents. If she did not know the resident, she would compare the picture in the record to the resident and ask them to state their name. LVN B stated she would never leave medication with the residents; that is a big no. She stated, I tell them I can't leave meds with them. LVN B stated registered nurses, licensed vocational nurses, and medication aides were responsible for medication administration. She stated the failure could be the resident could miss a dose. During an interview with the DON on 02/11/26 at 01:02 p.m., she stated nurses or medication aides passed medications. She stated they looked at the medication administration record to verify medications, and popped them out into a cup. She stated the staff go to the bedside, and verify the correct resident, right medication, and right route. She stated medications were never to be left with a resident and they knew that. She stated that failure could cause the residents to not receive their medications or someone else might get them. She stated all staff have been in-serviced on medication administration. Related trainings were requested by email from the Administrator on 02/11/26 at 02:11 p.m.; none were received upon exit. Record review of the facility's policy Medication Administration, dated February 2023, reflected Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.16. Observe resident consumption of medication. Record review of the facility's policy Medication Storage, dated February 2023, reflected It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 5 of 10 (Resident #1, #2, #3, #4, #5) reviewed for misappropriation and exploitation. 1.The facility failed to ensure Resident #1 was free from exploitation when the former BOA accepted cash payment for Resident #1's June, July, August, and [DATE] payments (totaling $3,440.00), with only $2,184.00 deposited within a facility account on [DATE] (after BOA termination date) leaving $1,256.00 unaccounted for. 2. The facility failed to ensure Residents #2, #3, and #4 were free from exploitation when the former BOA created and cashed checks for Residents #2, #3, and #4 for personal need items without authorization from the resident or resident representative and no personal need items were provided to the residents involved. 3. The facility failed to ensure Resident #5 was free from exploitation when the former BOA made a money order (provided to her for Resident #5's October payment) out to herself and deposited it into her personal account for $925.00 without authorization from the resident or resident representative. This failure could place residents at risk of not having access to their funds. The findings included: Record review of Resident #1's admission Record, dated [DATE], indicated an [AGE] year-old male, admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including myocardial infarction (blood flow decreases or stops in one of the blood vessels of the heart causing tissue death), diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and dementia (loss of cognitive functioning). Record review of Resident #1's quarterly MDS Assessment, dated [DATE], indicated a BIMS score of 14 indicating he was intact cognitively. This MDS indicated Resident #1 usually made himself understood and understood others. He required assistance for self-care of dressing, and bathing and was independent with mobility. Record review of Resident #1's care plan, dated [DATE], indicated Resident #1 had an impaired cognitive function/dementia or impaired thought process and communication problems related to hearing. Interventions included clear communications, to ask yes or no questions, staff identification and make eye contact, keep routine consistent, allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, reduce environmental noise, and use alternative communication tools as needed.Record review of Resident #1's payment receipts indicated the following cash payment of $360.00 on [DATE], $354.00 on [DATE], $364.00 on [DATE], $364.00 on [DATE], $354.00 on [DATE], and $1,644.00 on [DATE] for social security overpayment. Payment receipts indicated cash payments were received from Resident #1's family member and received by former BOA.Record review of a letter dated [DATE], addressed to Resident #1 from the SSA indicated Resident #1 was overpaid $1,644.00 from [DATE] through [DATE] because resident was living in a medical care facility and was requested the overpayment be paid back. Record review of a deposit slip (provided by former BOA), dated [DATE] indicated $2,184.00 was deposited to the facility's bank. Money orders associated with the deposit identified three money orders, one in the amount of $1,000.00, one in the amount of $900.00, and one in the amount of $284.00, all paid to the nursing facility for Resident #1.During an interview with Resident #1's family member, on [DATE] at 12:47 p.m., he said he was Resident #1's responsible party and was responsible for making Resident #1's monthly payments to the facility. He said he made cash payments to the former BOA for Resident #1's monthly payment. He said he made the following cash payments in 2025: June for $360.00, July for $354.00, August made two payments for $364.00 each, and September for $354.00. He said he also made a cash payment of $1,644.00 on [DATE] for the facility to pay back the SSA for the overpayment received in [DATE] through [DATE] because resident was living in a medical care facility. He said the former BOA took the cash payments and provided him with a payment receipt with each payment and told him she would pay the balance due to SSA for the overpayment. He said he received a second request from SSA about the overpayment balance after he had made the payment to the former BOA for payment submission and he contacted the facility with his concerns. He said he provided the facility with a copy of the payment receipts and bank statements showing the cash withdrawals. He said he went to the bank to make a cash withdrawal and went to the facility and made the monthly payment. He said the facility administrator and regional business office informed him the misappropriation of the resident's funds would be reported to the state, local police, and investigated. He said the facility investigated the incident and reported to him his cash payment was not deposited into the facility bank account and was unable to be located or reconciled. He said the facility credited Resident #1's account for his monthly payments involved in this incident and reimbursed Resident #1 the $1,644.00 for the payment to SSA for the overpayment due. He said he took the reimbursement check and paid the SSA for the amount due. He said the facility handled the incident professionally and admirably, but he was upset with the former BOA and contacted local law enforcement regarding pressing charges as well. During an interview on [DATE] at 2:44 p.m., the Administrator said she did not know the former BOA was misappropriating resident's funds. She said Resident #1's family member notified her on [DATE] that he had received a collection call from corporate billing regarding payments that he claimed were paid to the former BOA. She said Resident #1's family member stated the payments in question were paid in cash to former BOA along with a payment for a SSA overpayment. She said Resident #1's family member said he had handwritten receipts and bank transactions showing his payment records. She said she requested Resident #1's family member bring his payment receipts, banking transactions and SSA overpayment letter to the facility for review. She said she immediately notified the regional business office associate, regional support team, state agency, and local police department. She said the regional business office associate, support team, and herself immediately began to investigate the alleged misappropriation. She said the former BOA turned in a letter of resignation on [DATE]. She said she accepted the letter and advised the former BOA it was effective immediately on [DATE]. She said the evidence collected during the investigation indicated the former BOA misappropriated Resident #1's funds. She said the facility reimbursed or credited Resident #1 for the cash payments. 2. Record review of Resident #2's admission Record, dated [DATE], indicated a [AGE] year-old female, admitted on [DATE] and readmitted [DATE]. Resident #2 had diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia (loss of cognitive functioning). Record review of Resident #2's quarterly MDS Assessment, dated [DATE], indicated a BIMS score of 05 indicating she was severely impaired cognitively. She usually made herself understood and sometimes understood others. She was dependent on staff for self-care and mobility. Record review of Resident #2's care plan, dated [DATE], indicated Resident #2 had an impaired cognitive function/impaired thought process and communication problems related to dementia and stroke. Interventions included clear communication, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, allowing adequate time to respond, repeat as necessary, do not rush, and request clarification from the residents to ensure understanding.Record review of furniture store invoice, dated [DATE], indicated a solid wood bed side nightstand was ordered/purchased for Resident #2 and delivered [DATE] between 9:00 a.m. - 4:00 p.m. with a total due of $497.94. Record review of Resident #2's RFMS withdrawal record dated [DATE] created by former BOA, indicated $500.00 was withdrawn from the account for personal needs items on [DATE]. Resident #2's name was signed on an authorized signature line.During an interview on [DATE] at 1:25 p.m., Resident #2 was resting in bed. She was well groomed with no foul odor. She did not respond appropriately to interview questions. Resident #2's room observation indicated no personal needs items of solid wood bedside nightstand noted in her room. During an interview on [DATE] at 1:35 p.m., housekeeping staff identified the nightstand in Resident #2's room as a standard issued nightstand table issued by the facility. During an interview on [DATE] at 1:08 p.m., Resident #2's responsible party said he did not authorize funds to be removed from Resident #2 account to purchase furniture on [DATE] and that Resident #2 had Alzheimer's disease and she was not cognitively able to make financial decisions and was not able to sign her name. He said Resident #2 never received any new furniture in June or July of 2025 from the alleged purchase. He said the facility contacted him regarding the incident and reimbursed Resident #2 the $500.00.Record review of Resident #3's admission Record, dated [DATE], indicated a [AGE] year-old female, who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses including chronic systolic heart failure (condition in which the heart's main pumping chamber (left ventricle) is weak), right sided hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) following a stroke, speech and swallowing difficulties following a stroke, diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated [DATE], indicated a BIMS score of 15 indicating she was intact cognitively. She usually made herself understood and usually understood others. She required assistance for self-care of dressing, and bathing and was independent with mobility once up in wheelchair. Record review of Resident #3's care plan, dated [DATE], indicated Resident #3 had an impaired cognitive function related to stroke. Interventions included clear communication, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, allowing adequate time to respond, repeat as necessary, do not rush, and request clarification from the residents to ensure understanding.Record review of furniture store invoice dated [DATE], indicated a solid wood five drawer chest, solid wood bed side end table, wall decoration, and tall decorative lamp was ordered/purchased for Resident #3 and estimated delivery in two weeks, deliver Monday-Friday between 8:00 a.m. - 5:00 p.m. with total due of $2,276.30. Record review of Resident #3's RFMS withdrawal record dated [DATE], created by former BOA, indicated that $2,300.00 was withdrawn from Resident #3's account for personal needs items on [DATE]. Resident #3's name was signed on an authorized signature line.During an observation and interview on [DATE] at 2:15 p.m., Resident #3 was observed sitting in her bed in her room. She was well groomed with no foul odor. She was alert and oriented and answered interview questions appropriately. She denied requesting or authorizing a purchase for furniture in the amount of $2,276.30 in May of 2025, she furthermore denied that the signature she observed on the withdrawal record was hers. She said she did not sign the withdrawal record or give anyone permission to sign the withdrawal record. She said she did not receive any new furniture in May, June or [DATE]. She said the furniture in her room was from the facility and if she wanted or needed it replaced, she would speak with housekeeping or the maintenance department. She said if she wanted to purchase large items, she asked her family to make the purchases not the facility. Observations indicated no solid wood five drawer chest, solid wood bedside end table, wall decoration, and tall decorative lamp noted in her room. She said the facility notified her regarding the incident, ongoing investigation, police notification and her rights to press charges. She said the facility reimbursed the $2,300.00.Record review of Resident #4's admission Record, dated [DATE], indicated a [AGE] year-old male, who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses including cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), multiple contractures (chronic loss of joint mobility) of the hands, fingers, wrist, shoulder, elbows, and knees, and intellectual disabilities (condition that affects a person's ability to learn and function at an expected level). Resident #4 expired at the facility under hospice care on [DATE].Record review of Resident #4's quarterly MDS Assessment, dated [DATE], indicated he was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. He sometimes made himself understood and rarely/never understood others. He was dependent on staff for self-care and mobility. Record review of Resident #4's care plan, dated [DATE] indicated Resident #1 had an impaired cognitive function related to cerebral palsy. Interventions included clear communication, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, allowing adequate time to respond, repeat as necessary, do not rush, and reality orientation during care.Record review of a furniture store invoice, dated [DATE], indicated a solid wood tall chest of drawer, solid wood bedside end table was ordered/ purchased for Resident #4 and estimated delivery in about two weeks, deliver Monday-Friday between 8:00 am - 5:00 pm with a total due of $2,143.33. Record review of Resident #4's RFMS withdrawal record dated [DATE] created by former BOA, indicated $2,150.00 was withdrawn from account for personal needs items on [DATE]. Resident #2's name was initialed on an authorized signature line with -two2 staff members (CMA B and LVN A) signatures noted.During an interview on [DATE] at 1:15 p.m., MA B said Resident #4 had contractures in his hands, wrist and fingers and was unable to hold a pen for a signature, so he could not have signed a document. MA B reviewed Resident #4's withdrawal record from [DATE] and said that Resident #4 did not sign the document because he was unable to hold a pen and MA B's signature on the form was forged because that was not her signature and her name was spelled wrong. During an interview on [DATE] at 1:25 p.m., LVN A said Resident #4 had contractures in his hands, wrist and fingers and was unable to hold a pen for a signature, so he could not have signed a document. LVN A reviewed Resident #4's withdrawal record from [DATE] and said Resident #4 did not sign the document because he was unable to hold a pen and LVN A's signature on the form was forged because that was not her signature.An attempted telephone interview on [DATE] at 1:30 p.m. with Resident #4's responsible party was unsuccessful left message and no return call back received.During an interview on [DATE] at 2:50 p.m., the Administrator said during the facility audit of all resident's funds they identified three additional questionable invoices and sales receipts from what appeared to be a local furniture store. She said Residents #2, #3, and #4 had invoices from this furniture store and withdrawals from each respective resident's trust fund account related to personal need items on the invoice dates. She said she contacted the telephone number identified on the invoices and the individual who answered stated they had no affiliation with a furniture store or the BOA. She said she visited the local furniture location in person and provided a copy of the invoices and the store manager confirmed the invoices and sales receipt she presented were not from that furniture store, salesperson's listed on the documents were not a current or former employee, the invoice numbers were not be found in the database and the equipment description was not correct. She said after collecting this information, she and the IT department searched former BOA's computer and found false invoices, logos and sales receipt templates, created and stored on the former BOA's work computer matching the invoices utilized as Resident #2, #3, and #4's furniture store invoices/receipts. She said after collecting this evidence she felt the former BOA fabricated fraudulent invoices and withdrew the money from the residents' personal funds. She said the administrator had to approve or sign the check for the withdrawal and she was not the active administrator during the time in question. During an interview on [DATE] at 5:46 p.m., the former interim Administrator said she recalled the former BOA presenting her invoices and a check requiring a signature for purchasing residents' furniture or personal need items to lower their account balance. She said she signed the checks under the assumption the funds withdrawn would be used for residents' personal need items. She said she did not recall the names of the residents or what personal need items were identified on the invoices/receipts. 3. Record review of Resident #5's admission Record, dated [DATE], indicated a [AGE] year-old male, who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia (loss of cognitive functioning).Record review of Resident #5's quarterly MDS Assessment, dated [DATE], indicated a BIMS score of 05 indicating he was severely impaired cognitively. He made himself understood and usually understood others. His vision was severely impaired and was dependent on staff for self-care and mobility. Record review of Resident #5's care plan, dated [DATE] indicated Resident #1 had an impaired cognitive function related to dementia. Interventions included clear communication, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, allowing adequate time to respond, repeat as necessary, do not rush, and reality orientation during care.Record review of money orders signed by Resident #5's responsible party indicated she purchased two money orders dated [DATE] for $925.00 each. One money order indicated it was made out to the facility and the second money order indicated it was made out to the former BOA, and the former BOA endorsed the back of the money order and indicated deposit only into the same account number that the employee paycheck was direct deposited. Record review of BOA's personnel file indicated the account number on the facility direct deposit authorization slip dated [DATE] for the employee's paycheck to be deposited was the same account number for Resident #5's money order to be deposited. During an interview with Resident #5's family member, on [DATE] at 12:56 p.m., she said she was contacted by the collections department in early [DATE] regarding the payment for [DATE] and she had already made the payment via money order to the former BOA. She said she gave the former BOA two money orders for $925.00 in [DATE] for Resident #5's [DATE] and [DATE] payments. She said the former BOA told her to leave the money orders blank and she would fill them out for her. She said she provided the facility copies of the money order receipts and bank information showing where the money orders were deposited. She said the former BOA made one of the money orders out to herself and that was very upsetting because she thought the former BOA was so nice and helpful. She said she was still contemplating if she was filing charges on the former BOA but was aware the facility reported the incident to the authorities. She said the facility credited Resident #5's account for his October monthly payment of $925.00.In a telephone interview on [DATE] at 11:49 a.m. the local police department said the department was investigating the misappropriation of property/exploitation of elderly incidents reported by the facility and it was an oncoming investigation so they could only provide public information. The police department said the case was being reviewed by the local district attorney's office for possible charges to be filed. The police department said the facility was helpful in the investigation and reported any new concerns as they arose in the case.During an interview on [DATE] at 11:00 a.m., the corporate BOM said she was the interim BOM since the former BOA resigned. She said she trained the former BOA and was overseeing her performance weekly via in person or remotely. She said accounts receivable was monitored closely. She said the former BOA was instructed to discourage cash payment and, if accepted, to make deposits at least weekly and all money orders were to be filled out completely prior to accepting. She said cash payments and money orders could not be scanned for a remote deposit, so they had to be physically taken to the out-of-town bank for deposit. She said during the audit it was noted that no physical deposits were made to the out-of-town bank from [DATE] until [DATE], the former BOA's last day of employment. She said she was involved with the investigation and review of all residents' accounts and was continuing to run reports, verifying deposits and reconciling. She said looking back the former BOA always volunteered to contact residents or family members regarding debt collections during the AR meetings. She said she informed the former BOA that personal items needed could be purchased for residents to spend their accounts down but the resident or resident's responsible party had to consent to the personal need items. She said for resident personal need items that the former BOA should have written a check for the purchase, and she should not have been cashing a check for the purchase of items. She said if check was not an acceptable payment, then the resident or resident responsible party would have to consent, approve and witness the cash withdrawal and all purchase receipts kept, signed and copied for proof of purchase. She said she and the corporate management, and facility administrator were currently working on running reports, auditing outstanding debts and working with residents or responsible parties to identify any unreconciled accounts or misappropriation of funds. During an interview on [DATE] at 11:20 p.m., the former BOA said when she resigned on [DATE] the administrator took it effective immediately and she was escorted to her car. She said a few days later ([DATE]) she discovered a facility money bag in the glovebox of her car that she had forgotten to deposit. She said it had $2,184.00 cash in it, so she took it to the out-of-town bank and made the cash deposit. She said the cash was for Resident #1's payments. She said she had a copy of the deposit slip to provide to the investigator but denied notifying the facility of the cash found or the deposit. She said she did not recall the furniture purchases for Residents #2, #3, #4 but assisted residents with getting personal need items to spend down their accounts and would create checks to be cashed once approved by the administrator for those purchases. She denied making any falsified documents (invoices or purchase receipts) on her work computer and said the work computer was password protected for security purposes. She said she did take the second blank money order provided by Resident #5's family member, made it out to herself, and deposited it into her personal account because she was late on rent and had all intentions of paying back the money but resigned and terminated at the same time. She said the cash found in her car glovebox was cash, but she took the cash to the local post office for money orders to be purchased to identify who the payments were for on the money order. She denied knowing where the remaining $1,256.00 of Resident #1's cash payment was located. During an interview on [DATE] at 1:45 p.m., the Administrator said her expectations were all residents remain free from misappropriation of property or exploitation. She said she was not aware the former BOA made a bank deposit after her termination date and that the employee denied having any items belonging to the facility to return. She said the former BOA's desk was searched by herself, corporate staff and HR representative for a receipt book, and it was unable to be located. She said during the continued audits the facility had discovered an unreconciled bank deposit on [DATE] and was working with the bank to reconcile the deposits. She said the former BOA was terminated on [DATE] and should not have been making facility deposits after her termination date. She said when the misappropriation/exploitation was identified, she notified authorities, trained staff, and sent resident statements to all residents and responsible parties and requested that any discrepancies be reported to her immediately. She said if there were any identified discrepancies, the facility asked residents or responsible parties make an appointment, bring in receipts, money order receipts, bank statements or any evidence identifying the payment, payment method and date. She said this was an ongoing audit and she was currently working with another resident to identify if her funds were misappropriated. She said a new process was put in place and if cash was accepted (discouraging this type of payment) there were two witnesses during any handling of cash and residents, or resident representatives signed receipts if facility made purchases. She said money order payments were not accepted without the payor line filled out completely. She said all physical payments received were provided a receipt with two witness signatures. She said residents involved in the current misappropriation allegations were reimbursed for their loss or their accounts were credited. She said during the ongoing audits if the evidence collected identified that the resident's funds were misappropriated or exploited the facility would reimburse the resident. She said she or the corporate business office manager was responsible for all business office responsibilities currently and required witnesses for all financial transactions. She said she was keeping the local police department, ombudsman, medical director and state authorities aware of any new misappropriation or exploitation found during the ongoing audit. She said she felt the former BOA misappropriated the resident's funds/exploited the residents' and, for the safety of the residents, staff were informed she and the local police were to be notified if the former BOA attempted to enter the facility. Record review of the facility's policy titled Abuse, Neglect and Exploitation revised in 2023 indicated; Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. II. Employee Training A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves . IV. Identification of Abuse, Neglect and Exploitation. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 17 residents reviewed for care plans. (Residents #4 & #54) 1. The facility did not have a care plan to address Resident #4's hospice care. 2. The facility did not have a care plan to address Resident #54's indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) or catheter care. These failures could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: 1. Record review of the face sheet dated 08/20/25 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or postured due to abnormal brain development often before birth) and muscle wasting and atrophy (waste away, especially because of degeneration of cells). Record review of a significant change MDS dated [DATE] indicated Resident #4 had severely impaired cognition, was dependent for all ADLs, and was receiving hospice care. Record review of the care plan last updated 07/15/25 did not indicate that Resident #4 was under the care of hospice. Record review of a physician order dated 07/21/25 indicated Resident #4 was admitted to hospice services. During an observation and interview on 08/18/25 at 9:27 a.m., Resident #4 was in bed with his family member at bedside. Resident #4 was not responding to verbal or touch stimuli from his family member. The family member said the facility had called him that morning because of Resident #4's change of condition and hospice had determined he was actively dying. During an interview on 08/20/25 at 1:11 p.m., the DON said that while the facility was without an MDS Nurse that she and the ADON were responsible for writing new care plans. She said they learn of new or changed treatments and orders in the morning meeting by reviewing the 24-hour report, new orders, and incident reports. She said she reviewed Resident #4's care plan and there was no care plan for hospice care. She said it was just overlooked. She said the possible negative outcome of not having a care plan for hospice services could be the resident not receiving the appropriate care. During an interview on 08/20/25 at 1:35 p.m., the Administrator said the former MDS Nurse last day was 07/21/25. She said the DON and ADON were responsible for creating care plans until another MDS Nurse could be trained. She said she and the DON searched Resident #4's care plan for a hospice care plan and one had not been created. She said the care plan was just missed. She said there was no negative outcome for Resident #4 not having a hospice care plan because he had hospice serves in place, the order for the service, and had received the ordered care. 2. Record review of a face sheet dated 08/20/25 indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included chronic diastolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should) and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) with hyperglycemia (high blood sugar). Record review of a significant change MDS dated [DATE] indicated Resident #54 had a BIMS score of 11 indicating she had moderate cognitive impairment, was dependent for most ADLs, and was incontinent of urine and bowel. Record review of a care plan last dated 07/08/25 indicated Resident #54 had no care plan to address her indwelling urinary catheter. Record review of a physician order dated 07/30/25 indicated Resident #54 was to have an indwelling urinary catheter in place related to urinary retention. During an observation and interview on 08/19/25 at 8:35 a.m., Resident #54 was lying in bed in her room with her catheter bag hanging on the bed below bladder level. She said she had the catheter because she was having trouble urinating without it. During an interview on 08/20/25 1:11 a.m., the DON said she had reviewed Resident #54's care plans and that there was no care plan for her catheter or catheter care. She said the possible negative outcome for not having a care plan for the catheter and care could be the resident not receiving the appropriate care. During an interview on 08/20/25 1:35 p.m., the Administrator said she expected resident care plans were to be complete and address all needs, goals, and interventions for each resident. She said there was no negative outcome for Resident #54 not having a catheter care plan because the resident had the catheter and receiving the care required to maintain the catheter. Record review of the facility's undated Comprehensive Care Plans policy indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 6 residents (Resident #25) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #25. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings included: Record review of Resident #25's face sheet dated 08/18/25, indicated he was a [AGE] year-old male readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide resulting in dangerously low oxygen levels in the blood) and heart failure (condition in which the heart does not pump blood as well as it should). Record review of Resident #25's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 12 which indicated moderately impaired cognition. The assessment indicated medical diagnoses of respiratory failure, chronic obstructive pulmonary disease and heart failure and received oxygen therapy on during the last 14 days while a resident in the facility. Record review of Resident #25's care plan with a target date of 10/10/25 indicated he received oxygen therapy related to shortness of breath with interventions including oxygen setting at 2-4 liters per minute per nasal canula (a think flexible tube that delivers supplemental oxygen through your nose) per physician order. Record review of Resident #25's Physicians Order Summary dated 08/18/25 indicated he was prescribed oxygen at 2-4 liters per minute humidified oxygen by nasal canula continuously with an order date of 04/11/25. During an observation and interview on 08/18/25 at 08:55 a.m., Resident #25 was lying in bed with oxygen per nasal canula set at 4 liters/minute to an oxygen concentrator with two black filters. The oxygen concentrator filters were covered with a light gray powdery substance. Resident #25 said he wore his oxygen all the time and the facility changed his oxygen tubing and cleaned the filters sometimes, but he was not sure when the last time they were cleaned. During an observation and interview on 08/20/25 at 8:00 a.m., Resident #25 was lying in bed with oxygen per nasal canula set at 4 liters/minute to an oxygen concentrator with two black filters. The oxygen concentrator filters were covered with a light gray powdery substance. Resident #25 said he wore his oxygen all the time and the facility changed his tubing and cleaned the filters sometimes, but he was not sure when the last time they were cleaned. During an interview on 08/20/25 at 8:32 a.m., RN A said she was providing care for Resident #25 on 08/20/25 and 08/19/25. She said Resident #25's oxygen concentrator filters were dirty and should have been changed or cleaned. RN A said she was responsible for ensuring the oxygen concentrator filters were clean and the ADON was the back up to double check. She said she was educated on ensuring oxygen concentrator filters were cleaned but she overlooked them. RN A said the resident risk of dirty oxygen concentrator filters was possible contamination. During an interview on 08/20/25 at 8:35 a.m., the DON said the Maintenance Director was responsible for ensuring oxygen concentrator filters were cleaned and the ADON was the back up to double check. She said the charge nurses inspected oxygen concentrators daily to ensure the oxygen concentrator filters were clean, the oxygen tubing and the humidifier bottles (oxygen can be drying to your nose so some patients use a humidifier bottle to moisten the oxygen you breath) were changed weekly and dated. The DON said the Maintenance Director, ADON and charge nurses were educated on cleaning filters on oxygen concentrators. She said Resident #25's oxygen concentrator filters were overlooked. She said the resident risk of soiled oxygen concentrator filters was potentially the oxygen concentrator may not be as effective as it should be. The DON said her expectation was charge nurses inspect the oxygen concentrators daily to ensure the filters were clean and tubing changed weekly and dated, the Maintenance director clean the filters as needed and ADON ensure the concentrator filters were cleaned as needed. During an interview on 08/20/25 at 8:40 a.m., the Administrator said the Maintenance Director was responsible for ensuring oxygen concentrator filters were cleaned and the ADON was the back up to double check. She said the charge nurses inspected the oxygen concentrators daily to ensure concentrator filters were clean. She said the Maintenance director, ADON and charge nurses were educated on cleaning filters on oxygen concentrators. She said Resident #25's oxygen concentrator filers were overlooked. She said the resident risk of soiled oxygen concentrator filters was potentially the oxygen concentrator may not be as effective as it should be. She said her expectation was charge nurses inspect the oxygen concentrators daily to ensure the filters were clean, tubing changed weekly and dated and humidifier bottles not empty, dated and changed weekly, the Maintenance director clean the filters as needed and the ADON ensure the oxygen concentrator filters were cleaned as needed. During an interview on 08/20/25 at 8:48 a.m., the ADON said the Maintenance director was responsible for ensuring oxygen concentrator filters were cleaned or changed monthly and as needed. She said she was the backup and checked daily and let the Maintenance director know when a patient's oxygen concentrator filters needed to be cleaned or changed. The ADON said she was educated on cleaning filters on oxygen concentrators. She said Resident #25's oxygen concentrator filters were overlooked. The ADON said the resident risk of dirty oxygen concentrator filters was potentially improper air flow to the concentrator. During an interview on 08/20/25 at 8:55 a.m., the Maintenance Director said he was responsible for ensuring oxygen concentrator filters were cleaned or changed monthly and as needed. He said the ADON was the backup and let him know when a patient's oxygen concentrator filters needed to be cleaned or changed. He said he was educated on cleaning filters on oxygen concentrators. The Maintenance Director said Resident #25's oxygen concentrator filters were overlooked. He said the resident risk of an oxygen concentrator with dirty filters was potentially improper air flow to the concentrator. Record review of an undated facility in-service, titled, Cleaning Oxygen Concentrator Filters indicated, .Oxygen concentrator filters remove dust, dirt, and particles from the air before it reaches the resident. Keeping filters clean ensures: Safe and effective infection risk. Longer equipment life. Reduced breakdowns ad malfunctions. Cleaning Frequency Reusable filters: Weekly or as recommended by the manufacturer. Signs the Filter Needs Cleaning or Replacement Visible dust buildup. Reduced oxygen flow . Filter looks gray, brown or damaged. Record Review of a facility policy dated 2023, titled, Oxygen Concentrator indicated, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device.

Based on interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 4 (Resident #1 Resident #2, Resident #3 and Resident #4) of 10 residents reviewed for medications. The facility failed to administer Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 10 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 11 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 1 dose in [DATE] for Resident #2.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 5 doses in [DATE] for Resident #3.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 3 doses in [DATE] for Resident #3.The facility failed to hold Nifedipine (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 1 dose in [DATE] for Resident #4. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Resident #1Record review of Resident #1's face sheet indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses to include: Parkinson's disease (progressive disorder that affects the nervous system, and the parts of the body controlled by the nerves), low blood pressure, anxiety disorder, dementia (loss of cognitive functioning) and vitamin deficiency. Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down) and he was moderately impaired cognitively with a BIMS score of 12. He used a manual wheelchair independently for mobility and required setup or clean-up assistance with transfer to and from a bed to wheelchair. Record review of Resident #1's Comprehensive Care Plan last revised [DATE], indicated he had hypotension related to low BP. Goal: resident will be free of s/s of hypotension. Interventions: encourage adequate fluid intake and healthy diet, give medications per orders, and monitor/document/ report prn any s/s causative factors; dehydration, allergic reactions, orthostatic or postural hypotension, trauma, septicemia (bloodstream infection), blood loss, post prandial hypotension (blood pressure drops after you eat a meal).Record review of Resident #1's physicians' orders indicated: check BP every 8 hours and administer midodrine per order as required according to bp result every 8 hours for maintaining healthy bp related to Hypotension, and Midodrine oral tablet 2.5 mg give 1 tablet by mouth every 8 hours as needed for hypotension, give for SBP less than 90 or DBP less than 60 order dated [DATE]. Record review of Resident #1's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 109/58, [DATE] at 6:00 a.m. BP 120/52, [DATE] at 2:00 p.m. BP 70/40, [DATE] at 6:00 a.m. BP 100/58, [DATE] at 2:00 p.m. BP 98/52, [DATE] at 10:00 p.m. BP 122/56, [DATE] at 10:00 p.m. BP 178/56, [DATE] at 2:00 p.m. BP 80/55, [DATE] at 2:00 p.m. BP 133/55, and [DATE] at 10:00 p.m. BP 128/59.Record review of Resident #1's MAR for [DATE] indicated Midodrine was not given on: [DATE] at 10:00 p.m. BP 109/58 by LVN B, [DATE] at 6:00 a.m. BP 120/52 by LVN C, [DATE] at 2:00 p.m. BP 70/40 by LVN D, [DATE] at 6:00 a.m. BP 100/58 by LVN E, [DATE] at 2:00 p.m. BP 98/52 by LVN D, [DATE] at 10:00 p.m. BP 122/56 by LVN F, [DATE] at 10:00 p.m. BP 178/56 by LVN B, [DATE] at 2:00 p.m. BP 80/55 by LVN D, [DATE] at 2:00 p.m. BP 133/55 by LVN D, and [DATE] at 10:00 p.m. BP 128/59 by LVN B.Record review of Resident #1's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 148/47, [DATE] at 2:00 p.m. BP 121/57, [DATE] at 10:00 p.m. BP 131/58, [DATE] at 10:00 p.m. BP 112/46, [DATE] at 2:00 p.m. BP 113/48, [DATE] at 10:00 p.m. BP 100/59, [DATE] at 10:00 p.m. BP 108/57, [DATE] at 2:00 p.m. BP 105/54, [DATE] at 2:00 p.m. BP 147/45, [DATE] at 2:00 p.m. BP 98/53 and [DATE] at 2:00 p.m. BP 75/84.Review of Resident #1's MAR for [DATE] indicated Midodrine was not given on: [DATE] at 10:00 p.m. BP 148/47 by LVN B, [DATE] at 2:00 p.m. BP 121/57 by LVN D, [DATE] at 10:00 p.m. BP 131/58 by LVN E, [DATE] at 10:00 p.m. BP 112/46 by LVN B, [DATE] at 2:00 p.m. BP 113/48 by LVN G, [DATE] at 10:00 p.m. BP 100/59 by LVN B, [DATE] at 10:00 p.m. BP 108/57 by LVN B, [DATE] at 2:00 p.m. BP 105/54 by LVN E, [DATE] at 2:00 p.m. BP 147/45 by RN H, [DATE] at 2:00 p.m. BP 98/53 by LVN E and [DATE] at 2:00 p.m. BP 75/84 by RN H.During an interview on [DATE] at 11:30 a.m., Resident #1 said he received his medications as prescribed, and they monitored his BP routinely. Resident #1 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #1 said he did have a history of falling but it was because he tried to ambulate without assistance. Resident #2Record review of Resident #2's face sheet indicated he was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: high blood pressure, end stage renal disease (last stage of long-term kidney disease), diabetes, dementia, anxiety and depression. Record review of Resident #2's annual MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of hypertension (condition in which the force of the blood against the artery walls is too high) and orthostatic hypotension, and he was cognitively intact with a BIMS score of 15. He used a manual wheelchair for mobility but was totally dependent on staff for mobility and assistance with transfer to and from a bed to wheelchair.Record review of Resident #2's Comprehensive Care Plan last revised [DATE], indicated he had hypertension related to lifestyle choices. Goal: resident will remain free of complications related to hypertension. Interventions: Administer Midodrine if SBP is less than 110 and DBP is less than 60, Give PRN Hydralazine per MD orders if SBP is over 160 or DBP is over 110 and Monitor/record use/side effects of medication. He has hypotension. Goal: resident will remain free from signs and symptoms of hypotension. Interventions: . Educate resident/family/caregivers to change position slowly going from lying, sitting to standing, encourage adequate fluid intake and a healthy diet. and give medications as ordered. Monitor for side effects and effectivenessRecord review of Resident #2's physicians' orders indicated: Midodrine oral tablet 5 mg give 1 tablet by mouth every 12 hours as needed for SBP <100 or DBP <60 related to orthostatic hypotension; order dated [DATE].Record review of Resident #2's MAR for [DATE] indicated on [DATE] at 7:00 p.m. BP reading of 125/54 and Midodrine 5mg 1 tablet was not given by LVN L as needed for SBP <100 or DBP <60 related to orthostatic hypotension.During an interview on [DATE] at 9:00 a.m., Resident #2 said he received his medications as prescribed, and they monitored his BP routinely. Resident #2 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #2 said staff checked his BP frequently because he went out to dialysis, and it caused his BP to drop. He said he was to be administered Midodrine if his BP reading was low but did not recall his BP being low enough for the Midodrine to be administered. Resident #3Record review of Resident #3's face sheet indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses to include: sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), osteomyelitis of vertebra (infection in the vertebrae in the spine), paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), depression, atrial fibrillation (type of irregular heartbeat) and bed confinement status. Record review of Resident #3's admission MDS assessment dated [DATE], indicated he had active diagnoses in the last 7 days of atrial fibrillation or other dysrhythmias, (abnormal or irregular heartbeats) and he was cognitively intact with a BIMS score of 14. He was bedfast and dependent on staff for mobility.Record review of Resident #3's Comprehensive Care Plan last revised [DATE], indicated he had hypotension. Goal: resident will remain free of complications related to hypotension. Interventions: . Encourage adequate fluid intake and a healthy diet and give medications as ordered. Monitor for side effects and effectiveness.Record review of Resident #3's physicians' orders indicated: Midodrine oral tablet 5 mg give 3 tablets by mouth three times a day for hypotension, hold for systolic BP greater than 120.Record review of Resident #3's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 2:00 p.m. BP 130/79, [DATE] at 2:00 p.m. BP 126/74, [DATE] at 2:00 p.m. BP 129/68, [DATE] at 2:00 p.m. BP 122/65, and [DATE] at 2:00 p.m. BP 130/75. Record review of Resident #3's MAR for [DATE] indicated Midodrine was not held on: [DATE] at 2:00 p.m. BP 130/79 by LVN J, [DATE] at 2:00 p.m. BP 126/74 by LVN D, [DATE] at 2:00 p.m. BP 129/68 by LVN J, [DATE] at 2:00 p.m. BP 122/65 by LVN D, and [DATE] at 2:00 p.m. BP 130/75 by LVN J.Record review of Resident #3's MAR for [DATE] Blood Pressure monitoring indicated: [DATE] at 10:00 p.m. BP 128/74, [DATE] at 2:00 p.m. BP 174/94, and [DATE] at 9:00 a.m. BP 157/74.Review of Resident #3's MAR for [DATE] indicated Midodrine was not held on: [DATE] at 10:00 p.m. BP 128/74 by LVN L, [DATE] at 2:00 p.m. BP 174/94 by LVN K, and [DATE] at 9:00 a.m. BP 157/74 by RN H.During an interview on [DATE] at 11:45 a.m., Resident #3 said he received his medications as prescribed, and they monitored his BP routinely. Resident #3 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if he did have any, he would notify the nursing staff. Resident #4Record review of Resident #4's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses to include: high blood pressure, dementia, chronic pain and muscle weakness. Record review of Resident #4's Quarterly MDS assessment dated [DATE], indicated she had active diagnoses in the last 7 days of hypertension, and she was able to make herself-understood and usually understood others. No BIMS score was identified. She used a manual wheelchair independently for mobility and required maximum assistance with transfer to and from a bed to wheelchair.Record review of Resident #4's Comprehensive Care Plan last revised [DATE], indicated she was on medication for hypertension related to lifestyle choices. Goal: resident will remain free of complications related to hypertension. Interventions: . give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. per MD order hold medication if SBP (systolic blood pressure) is less than 110, DBP (diastolic blood pressure) or pulse is less than 60.Record review of Resident #4's physicians' orders indicated: Nifedipine ER Oral Tablet Extended Release 24Hour 60 mg give 1 tablet by mouth one time a day related to hypertension; hold if SBP <110, DBP <60, order dated [DATE].Record review of Resident #4's MAR for [DATE] indicated on [DATE] at 8:00 a.m. Nifedipine ER 60 mg 1 tablet by mouth one time a day related to hypertension; hold if SBP <110, DBP <60 was administered by MA N with a blood pressure reading of 112/50. During an interview on [DATE] at 11:45 a.m., Resident #4 said she received her medications as prescribed, and they monitored her B/P routinely prior to administering BP medication. Resident #4 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if she did have any, she would notify the nursing staff.Record review of facility incidents for June and [DATE] did not indicate Resident #1, Resident #2, Resident #3, and Resident #4 had falls or incidents related to the medication errors.During an interview on [DATE] at 8:00 a.m., MA N observed checking BP prior to administer BP medications and said she checked resident's BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low. She said if the resident's BP was low, she held the medication, documented on the MAR and reported it to the resident's charge nurse. She said that the charge nurses administered medications for hypotension but if she was responsible for administering those, she would do the same process, check the BP, review and administer the medication if within acceptable parameter. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in [DATE].During an interview on [DATE] at 11:57 a.m., LVN D said depending on the time, a medication aide or nurse administered the resident's medications. She said the resident's blood pressure should be checked each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury.During an interview on [DATE] at 2:00 p.m., LVN K said depending on the time, a medication aide or nurse administered the resident's medications. She said the resident's blood pressure should be checked each time the blood pressure medication was due, and orders/MAR reviewed for parameters. She said the blood pressure protocol ordered by the physician should be followed. She said residents were at risk for hypotension symptoms (dizziness, lightheadedness, drowsy, and unresponsiveness) if medications were not administered for hypotension or if hypertension medications were administered when BP was low (out of parameters). During an interview on [DATE] at 2:45 p.m., RN H, said the BP reading of 75/84 was an error, and she did administer Resident #1's Midodrine on [DATE] for low blood pressure. She said she typically looked at the medication and parameters before administering, but she did not remember why she had not looked at the parameters on [DATE] and hold the Midodrine when BP reading was 147/45. RN H said if the blood pressure dropped too low Resident #1 could have had dizziness, passed out, or even possibly died. She stated she had been in-serviced recently regarding blood pressures, parameters and medication administration during her recent orientation. During an interview on [DATE] at 9:00 a.m., LVN L said she checked resident's BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low and medications to administer if BP was low. She said she checked the BP, reviewed and administered the medication if within acceptable parameters. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, it could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in [DATE].During an interview on [DATE] at 9:45 a.m., LVN M, said the LVNs administered Resident #1's BP medications due to his hypotension and staff checked his blood pressure every 8 hours and as needed. She said standard facility protocol was if systolic BP was less than 120 to administer the Midodrine but was unsure what to do if the diastolic BP was low. LVN M said she would probably hold the Midodrine or call the physician for clarification if the systolic BP was above 120 but the diastolic BP was below 60. She said she took the BP prior to medication administration and would review the MAR/orders to clarify parameters if medication was to be administered or held. She said she would contact the physician if she was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. LVN M said if the blood pressure dropped too low Resident #1 could have dizziness, unresponsiveness, or even possibly die. She stated she had been in-serviced recently regarding blood pressures, parameters and medication administration during her recent in-service.During an interview on [DATE] at 12:30 p.m., the DON said she expected her nurses and medication aides to follow physicians' orders. She stated she expected them to read the MAR and follow parameters. The DON stated that anytime a resident's blood pressure was high or low she would expect staff to look to see if the resident had any standing PRN orders. She said if a resident's blood pressure was low and the blood pressure medication was administered, it could cause blood pressure to bottom out. She said if a resident's blood pressure was low and medications to increase blood pressure were not administered, it could cause blood pressure to remain low or drop. She said the resident could experience symptoms of hypotension including syncope (fainting or passing out), confusion, and even death. During an interview on [DATE] at 1:15 p.m., the Administrator said she expected her staff to following physicians' orders and to be competent enough to notice a high or low blood pressure and to check the orders for parameters. Record review of a facility's Medication Administration policy dated 2024, indicated Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents, for 1 of 10 residents (Resident #2) reviewed for abuse. 1. The facility failed to ensure residents were free from abuse. *On 03/29/25 HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. 2. The facility failed to ensure allegations of abuse were reported to the Abuse Coordinator Immediately. *HSK B wrote a concern form and left it in the mailbox outside of the HR door on 03/29/25 about the witnessed verbal exchange between Resident #2 and HSK A. 3. The facility failed to report allegations of abuse to HHSC within two hours of being notified of the abuse allegation. *The Administrator did not report the allegation of verbal abuse on 03/31/25. The Administrator reported the allegations of verbal abuse to HHSC on 04/01/25. 4. The facility failed to implement measures to protect residents and prevent additional abuse incidents during the investigation when they did not immediately suspend HSK A. *HSK A continued to work in the facility 03/29/25, 03/30/25, 03/31/25. She was suspended on 04/01/25 and returned to work on 04/03/25, while the investigation was ongoing and continued to work on 04/04/25 and 04/05/25. *The facility confirmed the allegation of abuse on 04/07/25 but did not terminate HSK A until 04/09/25 after being directed to by their corporate management. An Immediate Jeopardy (IJ) was identified on 05/08/25 at 2:30 p.m. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 05/09/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. I. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; . Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (persistent worry and fear about everyday situations), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and cerebral infarction (stroke). Record review of Resident #2's annual MDS assessment dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate cognitive impairment (BIMS-8). Record review of Resident #2's care plan dated 05/08/25 indicated Resident #2 had a psychosocial well-being problem related to verbal aggression while interacting with staff. Interventions included initiate referrals as needed or increase social relationships, provide a safe environment, and and when conflict arises residents to a calm safe environment. Record review of a facility investigation dated 04/07/25 and completed by Administrator L indicated the incident occurred on 03/29/25 at 1:00 p.m. and was reported to HHS on 04/01/25 at 12:00 p.m. The AP was identified and confirmed as HSK A. The witness was identified as HSK B. The allegation was noted as HSK A was being verbally aggressive with Resident #2 over the purchase of cigarettes. HSK A was suspended during the investigation. HSK B was in-serviced on timely reporting of abuse allegation on 04/01/25. The findings were confirmed. The facility's investigation included documentation completed by Administrator L: 3/31/2025 HSK A communicated with the administrator that she bought cigarettes for a resident and she did not want the residents to share them. I let HSK A know that she should not purchase cigarettes for the residents, if the residents want cigarettes they are to ask their family to purchase them or our activity director, when she goes shopping. 4/1/2025 - On April 1, 2025 HSK A was not working in the facility. The administrator called her at home to discuss the argument that HSK A got into at the facility on 3/29/2025. HSK A was suspended until the investigation could be completed. HSK A was in serviced on abuse, conflict resolution, resident rights and purchasing items for residents 4/3/2025- HSK A returned to work and met with AIT II regarding incident that occurred on 3/29/2025. Abuse, conflict resolution, residents rights and purchasing items for residents was discussed again. was returned to her duties on the floor. The resident safe surveys included with the investigation did not address verbal abuse by staff. Record review of an Employee Concern Form dated 03/29/25 at 1:00 p.m., completed by HSK B indicated At 1:00 p.m. smoke time I was giving Resident #4 her two cigarettes and I told Resident #2 you don't have any did you call someone and she said yeah I still waiting. Couple of minutes goes by and Resident #2 goes I'm not hiding anymore give me a cigarette talking to Resident #4. HSK A turns and goes not if its the cigarettes a bought I am not buying you cigarettes to just hand them out. I said well Resident #2 when you have cigarettes and Resident #4 don't don't share with her if that's the case. That's not fair to you. HSK A gives she share with her just not the cigarettes I bought. She can do whatever she wants with the cigarettes she buys with her money. HSK A started to get loud and angry. Resident #2 had enough and told HSK A to shut up. HSK A got out of her chair and tells Resident #2 to make her shut up. You will have to get out of your chair to shut me up. Then Resident #3 told HSK A to calm down. After that HSK A left. Resident #2 said I wish I can punch her and then looked at Resident #4 and goes I want to punch you for not having my back and then Resident #2 started to cry and shake. Record review of a Service Recovery Opportunity form dated initially dated 3/31/25, (the date was amended by Administrator L on 04/01/25), completed by Administrator L on 04/05/25 indicated HSK A became verbally abusive with Resident #2 about cigarettes. HSK A was suspended during the investigation. This was the first time HSK A had an argument with a resident. HSK A was inserviced on abuse, managing conflict and resident rights. HSK A confirmed she got upset with with Resident #2. Record review of a progress note dated 04/01/25 at 10:01 a.m., completed by the SW indicated On April 1, 2025, I spoke with Resident #2 regarding the incident between she and HSK A. Resident #2 said, She apologized to me for being upset and me crying. She said, And I apologized to her for what I said. Resident #2 could not recall what she said to HSK A or what HSK A said to her. She said, I know she had never talked to me like that before. She said, I don't recall what she said, but its not the way we normally talk. Resident #2 said, my mind is not that good and I can't recall. Resident #2 continued talking to me and she eventually recalled that the incident was about the sharing of cigarettes. Resident #2 said that she asked Resident #4 for a cigarette and HSK A said no because she had purchased the cigarettes with her own money. So, Resident #2 was upset that she could not get a cigarette because she and Resident #4 shares cigarettes. She said, she (HSK A) was going on about everything under the moon. She said that she told HSK A to hush and leave her alone. She don't recall what HSK A said. Resident #2 was upset with Resident #4 for not standing up for her. She said, I was crying and Resident #4 gave me the cigarette when HSK A left. Resident #2 told me that she is not scared of HSK A. She said, She is my friend and we apologized. She feels safe here at the facility and she knows who to report abuse too. She said HSK A is a good person. Record review of a progress note dated 04/07/25 at 4:02 p.m., completed by the SW indicated On April 7, 2025, I asked Resident #2 about the interaction between her and HSK A on smoke break. Resident #2 at first said she didn't recall what it was about, but they both apologized and it's over. I inquired further and Resident #2 said, She went off on a rampage. She did not want Resident #4 to share her cigarettes with me. Resident #2 told me that HSK A purchases cigarettes for Resident #4 using her own money (HSK A's money), so she did not want Resident #4 to share the cigarettes with her. Resident #2 said, HSK A and I kept going back and forth I told HSK A to shut up. Resident #2 did not recall what HSK A said, but I told her what the witness reported. She said yes, HSK A did say make me. Resident #2 said she cried because HSK A had never spoken to her like that before. She said, We are friends and both have apologized. I thought this was over. I explained that anytime there is an incident between staff and a resident we must make sure that the resident is safe, and no harm is caused. Resident #2 said, I'm okay, HSK A and I have made up. It's over. Record review of HSK's time record indicated she worked 03/29/25, 03/30/25, 03/31/25, 04/03/25, 04/04/25/, and 04/05/25. During an interview on 05/07/25 at 10:00 a.m., Administrator L said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHS C within 2 hours. She said the facility was reporting on 04/01/25 an allegation of verbal abuse by HSK A towards Resident #2 on 03/29/25. She said HSK B witnessed the verbal abuse on 03/29/25 and put a note under the HR door but did not report the incident immediately to her (Administrator L) as required. She said HSK A was suspended when the facility was made aware of the incident on 03/31/25. She said the verbal abuse was confirmed. She said AIT TT was out on FML. During an interview on 05/07/25 at 12:46 p.m., Administrator L said the allegations of abuse was reported on 04/01/25. She said she did not report on 03/31/25 because she was working on the investigation and she could not give a logical reason for not reporting. She said HSK A was supposed to be suspended pending the facility investigation. She said HSK A worked work on 03/30/25, 03/31/25, 04/03/25, 04/04/25/, and 04/05/25. HSK A did not respond to a call from the surveyor on 05/07/25 at 2:35 p.m. During an interview on 05/07/25 at 2:45 p.m., Resident #2 said HSK A made her upset and spoke to her with a mean tone about borrowing cigarettes. She said she wanted her to shut up and HSK A said she (Resident #2) would have to get up from her wheelchair to make her shut up. She said she felt sad and upset when HSK spoke to her. She said at the time it was abuse but they had made up and there was no further problems. She said HSK A was not working at the facility anymore. She said she was o.k. and no other staff ever spoke to her with a mean or mad tone. During an interview on 05/08/25 at 10:55 a.m., HR HH said she found a concern form written by HSK B, under her office door, on 03/31/25. She said she scanned the form and emailed it to Administrator L. She said she followed up with the Administrator L on 04/01/25 (but she did not recall what time) and that was when Administrator L realized the form had a second page where the verbal abuse was documented. She said Administrator L then reported the allegations of abuse to HHSC. She said the facility's protocol would include immediate suspension for staff. She said confirmed allegations of abuse could result in disciplinary action that could include termination. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 11:13 a.m., HSK Director II said she arrived to work on 03/31/25 and HSK B handed her a copy of the concern form she had left under the HR office door. She said she (HSK B) did not want to report the incident. She said she read the form and then went to Administrator L's office with HSK B. She said all staff were trained on abuse. She said HSK B said she did not know she should call the Administrator. She said HSK A's employment was handled by the administrator. She said she was not told to suspend HSK A. She said HSK worked her regular scheduled day rotation. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 12:56 p.m., HSK B said the incident of verbal abuse occurred on 03/29/25 during the 1:00 p.m. smoke break. She said the staff were advised residents were not supposed to share their cigarettes. She said HSK A had bought cigarettes for Resident #4. She said HSK A told Resident #4 not to share, that she was only buying for Resident #4. Resident #2 said she wished HSK A would shut up. HSK A got up form her chair and told Resident #2 she would have to get out of her chair to make her shut up. She said Resident #3 told HSK A to calm down. She said Resident #2 said she wished she could punch HSK A in the face. Resident #2 was upset and crying. She said she did not report the incident immediately to the abuse coordinator/Administrator L, the DON, or her supervisor. She said HSK A continued to work after the incident. She said she was scared of what HSK A would do if she knew she had reported. She said she was trained on abuse and reporting. She said residents were at risk of further abuse if it was not reported immediately. During an interview on 05/09/25 at 10:10 a.m., Resident #3 said HSK A was having words with Resident #2 over some cigarettes. He said HSK A was disrespectful and angry. He said they called each other BITCH. He said HSK A said if Resident #2 got up from her chair she would whoop her ass. He said he told HSK A she should not talk to her elders like that. He said he was not interviewed about the incident. He said he had not heard HSK A speak to residents that way before. During an interview on 05/09/25 at 12:29 p.m., Resident #4 said HSK A and Resident #2 were arguing about cigarettes. She said HSK A had purchased the cigarettes for her (Resident #3) and was mad because Resident #4 was going to share with Resident #2). She said HSK A said she wanted to whoop Resident #2's ass because she was arguing with her. She said she knew HSK A all her life and she had a temper. She said she never heard HSK A talk to residents that way before. She said she would report abuse to the Administrator or the DOM immediately. During an interview on 05/09/25 at 12:40 p.m., Administrator L said she did not conduct interviews with Resident #3 or Resident #4. She said she thought the SW would have conducted the interviews when she did the safe surveys. During an interview on 05/09/25 at 1:03 p.m., the SW said she was not sure if she wrote interviews down for Resident #3 or Resident #4. She said she remembered talking to Resident #4 but not Resident #3. She said Resident #4 did not report HSK A said she wanted to whoop Resident #2's ass. She said she would have reported the allegation to the Administrator immediately. During an interview on 05/09/25 at 1:18 p.m., HSK B said she did not hear HSK A say she wanted to whoop Resident #2's ass. She said she would still be scared to report if she did hear the threat. During an interview on 05/09/25, at 1:51 p.m., Administrator L said she was retrained on abuse on 05/08/25. She said not following the facility policy for abuse prevention, reporting, and investigation placed the residents were at risk for re-occurrence of abuse or the incident could have escalated. This was determined to be an Immediate Jeopardy on 05/08/25 at 2:30 p.m. The Administrator was notified and provided with the IJ template on 05/08/25 at 3:35 p.m. and a Plan of Removal was requested. The facility's plan of removal was accepted on 05/09/25 at 12:41 p.m. and included the following: Immediate actions after incident- Housekeeping Staff A Terminated: Although the staff member was terminated on 4/9/25, this was confirmed and documented today (5/8/25) as part of the facility's response to the identified IJ. -Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator on 3-31-25 and 5-8-25. -Safe surveys on 10 residents completed on 4-1-25. All residents were presented with a safe survey on 5/9/2025 with no concerns. -Notification to the Medical Director and Ombudsman occurred on 5/8/25. Notification provided by Administrator. Resident Safety Review - 5/8/2025 -Resident #2 was assessed 5-1-25 for psychological needs by MD and was stable. --Resident #2 reassessed for psychological needs on 5-8-25 and was stable per MD. -Monitoring for emotional distress will be performed each shift for 72 hours and documented in resident's electronic medical record. -Resident assessed with PHQ9 on 5-7-25 and no depression identified. Systemic Corrections as of 5/8/25: -Policy Re-Education: Today, all department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education Performed by: Regional Nurse. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. It reinforced that all staff are required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensures no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within an 2 hour period of learning of the allegation. We reviewed the latest provider letter (PL 2024-14) This provider letter provides guidance or reporting incidents to HHS, most importantly, reporting abuse immediately, but not later than two hours after the incident occurs or suspected. -Ad Hoc QAPI performed 5-8-25 Staff In-Service - 5/8/2025 - Completed by Admin or designee -All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via (named online training portal) or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.(Abuse coordinator phone number is posted around the facility) It emphasized that any failure to report can result in disciplinary action. The training also outlined steps for immediately removing suspected abusers from duty to protect residents, thereby addressing the urgency of response. -A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced on 5/8/2025 via care feed or in person. Monitoring and Oversight Initiated 5/8/25: -Abuse Coordinator Duties Reinforced: The Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up. -Leadership Review Process: A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented on 5/8/25 to review all allegations of abuse and ensure prompt interventions. -Reporting Compliance Audit: A retrospective review of all abuse allegations from the past 30 days was initiated on 5/8/25, no abuse allegations reported in the last 30 days, confirm compliance and identified any gaps. Audit will be completed by: Administrator. Staff Accountability on 5/8/25: -Supervisory Staff Counseling: Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff on 5-8-25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. -Disciplinary Action Initiated: Disciplinary procedures for involved parties have been initiated per HR guidelines, effective 5/8/25. Sustained Prevention Measures (Beginning 5/8/25): -Ongoing Monthly Abuse Training: Scheduled for the second week of each month, beginning in May for three months. -The Administrator and DON, or designee, will review all reportable 3 times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. On 05/09/24 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of HSK A's personnel file indicated she was terminated on 04/09/25, this was confirmed and documented on 05/08/25. Record review of HSK B's training record indicated she was in-serviced and educated on timely reporting by Administrator on 03/31/25 and 05/08/35. Record review of safe surveys indicated all cognitive residents were presented with a safe survey on 05/09/25 with no concerns identified. Record review of Resident #2's assessments indicated Resident #2 was assessed 05/01/25 for psychological needs by MD JJ and was stable. Resident #2 reassessed for psychological needs on 05/08/25 and was stable per MD JJ. Resident #2 was assessed with PHQ9 on 05-07-25 and no depression was identified. Record review of staff training indicated as of 05/08/25: -Policy Re-Education: All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI by RN KK. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. All staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensured no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within a 2 hour period of learning of the allegation. The latest provider letter (PL 2024-14) was reviewed. Record review of staff in-service dated 05/08/25 and 05/09/25 indicated all facility staff, including nursing, therapy, dietary, housekeeping, and administration were trained by the the Administrator or the DON or through online portal on on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person). The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods by directly notifying the Abuse Coordinator in person or via phone. (Abuse coordinator phone number was posted around the facility). It emphasized that any failure to report could result in disciplinary action. The training outlined steps for immediately removing suspected abusers from duty to protect residents and addressed the urgency of response. Record review of post-training exams indicated all staff trained passed with a required 100% passing score. Staff unable to attend the in-service would not be permitted to work until training was completed. Record review of the facility's Reporting Compliance Audit dated 05/08/25 indicated no abuse allegations reported in the previous 30 days. Record review of staff counselling indicated the Administrator/Abuse Coordinator was counselled and educated on policy requirements by corporate staff on 05/08/25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. Disciplinary procedures were initiated per HR guidelines, effective 05/08/25. Record review of a resident list reflected 100% resident rounds was initiated on 05/08/25 and completed on 05/09/25 to determine if further allegations of abuse were alleged. No additional concerns were identified. During interview conducted on 05/08/25 and 05/09/25, there were no additional incidents of abuse reported by residents. Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, indicated they would report to the Administrator or DON immediately. During interviews conducted on 05/09/25 between 12:50 p.m. and 2:50 p.m. indicated (Administrator L, DON, ADON, SW, CNA D, Receptionist O, BOA S, CMA/CNA T, MR U, CNA BB, CNA CC, DA LL, PTA MM, LS NN, RN OO, CNA PP, RN QQ, LVN RR, HSK SS ) from all shifts (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m., 8:00 a.m.-4:00/5:00 p.m., and 3:00 p.m. -11:00 p.m.) were in-serviced on and could verbalize understanding of in-service on immediate notification of allegations to facility abuse coordinator or designee when not in facility or available, investigating allegations of abuse and neglect, reporting of abuse neglect and misappropriation, and notification of proper local and state entities. During an interview on 05/09/25 at 2:10 p.m. the DON was able verbalize understanding of in-service on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. She said all staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. She said this ensured no delay in response, removing the immediacy of the risk. During an interview on 05/09/25 at 1:51 p.m., Administrator L indicated she was retrained on 05/08/25 on the facility's abuse and reporting policy and the most current provider letter. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. The Administrator was notified the Immediate Jeopardy was removed on 05/09/25 at 2:50 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 10 residents (Resident #2) reviewed for reporting allegations of abuse. The facility failed to ensure allegations of abuse were reported to the Abuse Coordinator Immediately. HSK B wrote a concern form and left it in the mailbox outside of the HR door on 03/29/25 about the witnessed verbal exchange between Resident #2 and HSK A. The facility failed to report allegations of abuse to HHSC within two hours of being notified of the abuse allegation. The Administrator did not report the allegation of verbal abuse on 03/31/25. The Administrator reported the allegations of verbal abuse to HHSC on 04/01/25. An Immediate Jeopardy (IJ) was identified on 05/08/25 at 2:30 p.m. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 05/09/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (persistent worry and fear about everyday situations), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and cerebral infarction (stroke). Record review of Resident #2's annual MDS assessment dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate cognitive impairment (BIMS-8). Record review of Resident #2's care plan dated 05/08/25 indicated Resident #2 had a psychosocial well-being problem related to verbal aggression while interacting with staff. Interventions included initiate referrals as needed or increase social relationships, provide a safe environment, and and when conflict arises residents to a calm safe environment. Record review of a facility investigation dated 04/07/25 and completed by Administrator L indicated the incident occurred on 03/29/25 at 1:00 p.m. and was reported to HHS on 04/01/25 at 12:00 p.m. The AP was identified and confirmed as HSK A. The witness was identified as HSK B. The allegation was noted as HSK A was being verbally aggressive with Resident #2 over the purchase of cigarettes. HSK A was suspended during the investigation. HSK B was in-serviced on timely reporting of abuse allegation on 04/01/25. The findings were confirmed. The facility's investigation included documentation completed by Administrator L: 3/31/2025 HSK A communicated with the administrator that she bought cigarettes for a resident and she did not want the residents to share them. I let HSK A know that she should not purchase cigarettes for the residents, if the residents want cigarettes they are to ask their family to purchase them or our activity director, when she goes shopping. 4/1/2025 - On April 1, 2025 HSK A was not working in the facility. The administrator called her at home to discuss the argument that HSK A got into at the facility on 3/29/2025. HSK A was suspended until the investigation could be completed. HSK A was in serviced on abuse, conflict resolution, resident rights and purchasing items for residents 4/3/2025- HSK A returned to work and met with AIT II regarding incident that occurred on 3/29/2025. Abuse, conflict resolution, residents rights and purchasing items for residents was discussed again. was returned to her duties on the floor. The resident safe surveys included with the investigation did not address verbal abuse by staff. Record review of an Employee Concern Form dated 03/29/25 at 1:00 p.m., completed by HSK B indicated At 1:00 p.m. smoke time I was giving Resident #4 her two cigarettes and I told Resident #2 you don't have any did you call someone and she said yeah I still waiting. Couple of minutes goes by and Resident #2 goes I'm not hiding anymore give me a cigarette talking to Resident #4. HSK A turns and goes not if its the cigarettes a bought I am not buying you cigarettes to just hand them out. I said well Resident #2 when you have cigarettes and Resident #4 don't don't share with her if that's the case. That's not fair to you. HSK A gives she share with her just not the cigarettes I bought. She can do whatever she wants with the cigarettes she buys with her money. HSK A started to get loud and angry. Resident #2 had enough and told HSK A to shut up. HSK A got out of her chair and tells Resident #2 to make her shut up. You will have to get out of your chair to shut me up. Then Resident #3 told HSK A to calm down. After that HSK A left. Resident #2 said I wish I can punch her and then looked at Resident #4 and goes I want to punch you for not having my back and then Resident #2 started to cry and shake. Record review of a Service Recovery Opportunity form dated initially dated 3/31/25, (the date was amended by Administrator L on 04/01/25), completed by Administrator L on 04/05/25 indicated HSK A became verbally abusive with Resident #2 about cigarettes. HSK A was suspended during the investigation. This was the first time HSK A had an argument with a resident. HSK A was inserviced on abuse, managing conflict and resident rights. HSK A confirmed she got upset with with Resident #2. Record review of a progress note dated 04/01/25 at 10:01 a.m., completed by the SW indicated On April 1, 2025, I spoke with Resident #2 regarding the incident between she and HSK A. Resident #2 said, She apologized to me for being upset and me crying. She said, And I apologized to her for what I said. Resident #2 could not recall what she said to HSK A or what HSK A said to her. She said, I know she had never talked to me like that before. She said, I don't recall what she said, but its not the way we normally talk. Resident #2 said, my mind is not that good and I can't recall. Resident #2 continued talking to me and she eventually recalled that the incident was about the sharing of cigarettes. Resident #2 said that she asked Resident #4 for a cigarette and HSK A said no because she had purchased the cigarettes with her own money. So, Resident #2 was upset that she could not get a cigarette because she and Resident #4 shares cigarettes. She said, she (HSK A) was going on about everything under the moon. She said that she told HSK A to hush and leave her alone. She don't recall what HSK A said. Resident #2 was upset with Resident #4 for not standing up for her. She said, I was crying and Resident #4 gave me the cigarette when HSK A left. Resident #2 told me that she is not scared of HSK A. She said, She is my friend and we apologized. She feels safe here at the facility and she knows who to report abuse too. She said HSK A is a good person. Record review of a progress note dated 04/07/25 at 4:02 p.m., completed by the SW indicated On April 7, 2025, I asked Resident #2 about the interaction between her and HSK A on smoke break. Resident #2 at first said she didn't recall what it was about, but they both apologized and it's over. I inquired further and Resident #2 said, She went off on a rampage. She did not want Resident #4 to share her cigarettes with me. Resident #2 told me that HSK A purchases cigarettes for Resident #4 using her own money (HSK A's money), so she did not want Resident #4 to share the cigarettes with her. Resident #2 said, HSK A and I kept going back and forth I told HSK A to shut up. Resident #2 did not recall what HSK A said, but I told her what the witness reported. She said yes, HSK A did say make me. Resident #2 said she cried because HSK A had never spoken to her like that before. She said, We are friends and both have apologized. I thought this was over. I explained that anytime there is an incident between staff and a resident we must make sure that the resident is safe, and no harm is caused. Resident #2 said, I'm okay, HSK A and I have made up. It's over. Record review of HSK's time record indicated she worked 03/29/25, 03/30/25, 03/31/25, 04/03/25, 04/04/25, and 04/05/25. During an interview on 05/07/25 at 10:00 a.m., Administrator L said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHS C within 2 hours. She said the facility was reporting on 04/01/25 an allegation of verbal abuse by HSK A towards Resident #2 on 03/29/25. She said HSK B witnessed the verbal abuse on 03/29/25 and put a note under the HR door but did not report the incident immediately to her (Administrator L) as required. She said HSK A was suspended when the facility was made aware of the incident on 03/31/25. She said the verbal abuse was confirmed. She said AIT TT was out on FML. During an interview on 05/07/25 at 12:46 p.m., Administrator L said the allegations of abuse was reported on 04/01/25. She said she did not report on 03/31/25 because she was working on the investigation and she could not give a logical reason for not reporting. She said HSK A was supposed to be suspended pending the facility investigation. She said HSK A worked work on 03/30/25, 03/31/25, 04/03/25, 04/04/25/, and 04/05/25. HSK A did not respond to a call from the surveyor on 05/07/25 at 2:35 p.m. During an interview on 05/07/25 at 2:45 p.m., Resident #2 said HSK A made her upset and spoke to her with a mean tone about borrowing cigarettes. She said she wanted her to shut up and HSK A said she (Resident #2) would have to get up from her wheelchair to make her shut up. She said she felt sad and upset when HSK spoke to her. She said at the time it was abuse but they had made up and there was no further problems. She said HSK A was not working at the facility anymore. She said she was o.k. and no other staff ever spoke to her with a mean or mad tone. During an interview on 05/08/25 at 10:55 a.m., HR HH said she found a concern form written by HSK B, under her office door, on 03/31/25. She said she scanned the form and emailed it to Administrator L. She said she followed up with the Administrator L on 04/01/25 (but she did not recall what time) and that was when Administrator L realized the form had a second page where the verbal abuse was documented. She said Administrator L then reported the allegations of abuse to HHSC. She said the facility's protocol would include immediate suspension for staff. She said confirmed allegations of abuse could result in disciplinary action that could include termination. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 11:13 a.m., HSK Director II said she arrived to work on 03/31/25 and HSK B handed her a copy of the concern form she had left under the HR office door. She said she (HSK B) did not want to report the incident. She said she read the form and then went to Administrator L's office with HSK B. She said all staff were trained on abuse. She said HSK B said she did not know she should call the Administrator. She said HSK A's employment was handled by the administrator. She said she was not told to suspend HSK A. She said HSK worked her regular scheduled day rotation. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 12:56 p.m., HSK B said the incident of verbal abuse occurred on 03/29/25 during the 1:00 p.m. smoke break. She said the staff were advised residents were not supposed to share their cigarettes. She said HSK A had bought cigarettes for Resident #4. She said HSK A told Resident #4 not to share, that she was only buying for Resident #4. Resident #2 said she wished HSK A would shut up. HSK A got up form her chair and told Resident #2 she would have to get out of her chair to make her shut up. She said Resident #3 told HSK A to calm down. She said Resident #2 said she wished she could punch HSK A in the face. Resident #2 was upset and crying. She said she did not report the incident immediately to the abuse coordinator/Administrator L, the DON, or her supervisor. She said HSK A continued to work after the incident. She said she was scared of what HSK A would do if she knew she had reported. She said she was trained on abuse and reporting. She said residents were at risk of further abuse if it was not reported immediately. During an interview on 05/09/25 at 10:10 a.m., Resident #3 said HSK A was having words with Resident #2 over some cigarettes. He said HSK A was disrespectful and angry. He said they called each other BITCH. He said HSK A said if Resident #2 got up from her chair she would whoop her ass. He said he told HSK A she should not talk to her elders like that. He said he was not interviewed about the incident. He said he had not heard HSK A speak to residents that way before. During an interview on 05/09/25 at 12:29 p.m., Resident #4 said HSK A and Resident #2 were arguing about cigarettes. She said HSK A had purchased the cigarettes for her (Resident #3) and was mad because Resident #4 was going to share with Resident #2). She said HSK A said she wanted to whoop Resident #2's ass because she was arguing with her. She said she knew HSK A all her life and she had a temper. She said she never heard HSK A talk to residents that way before. She said she would report abuse to the Administrator or the DOM immediately. During an interview on 05/09/25 at 12:40 p.m., Administrator L said she did not conduct interviews with Resident #3 or Resident #4. She said she thought the SW would have conducted the interviews when she did the safe surveys. During an interview on 05/09/25 at 1:03 p.m., the SW said she was not sure if she wrote interviews down for Resident #3 or Resident #4. She said she remembered talking to Resident #4 but not Resident #3. She said Resident #4 did not report HSK A said she wanted to whoop Resident #2's ass. She said she would have reported the allegation to the Administrator immediately. During an interview on 05/09/25 at 1:18 p.m., HSK B said she did not hear HSK A say she wanted to whoop Resident #2's ass. She said she would still be scared to report if she did hear the threat. During an interview on 05/09/25, at 1:51 p.m., Administrator L said she was retrained on abuse on 05/08/25. She said not following the facility policy for abuse prevention, reporting, and investigation placed the residents were at risk for re-occurrence of abuse or the incident could have escalated. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. I. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; . This was determined to be an Immediate Jeopardy on 05/08/25 at 2:30 p.m. The Administrator was notified and provided with the IJ template on 05/08/25 at 3:35 p.m. and a Plan of Removal was requested. The facility's plan of removal was accepted on 05/09/25 at 12:41 p.m. and included the following: Immediate actions after incident- Housekeeping Staff A Terminated: Although the staff member was terminated on 4/9/25, this was confirmed and documented today (5/8/25) as part of the facility's response to the identified IJ. -Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator on 3-31-25 and 5-8-25. -Safe surveys on 10 residents completed on 4-1-25. All residents were presented with a safe survey on 5/9/2025 with no concerns. -Notification to the Medical Director and Ombudsman occurred on 5/8/25. Notification provided by Administrator. Resident Safety Review - 5/8/2025 -Resident #2 was assessed 5-1-25 for psychological needs by MD and was stable. --Resident #2 reassessed for psychological needs on 5-8-25 and was stable per MD. -Monitoring for emotional distress will be performed each shift for 72 hours and documented in resident's electronic medical record. -Resident assessed with PHQ9 on 5-7-25 and no depression identified. Systemic Corrections as of 5/8/25: -Policy Re-Education: Today, all department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education Performed by: Regional Nurse. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. It reinforced that all staff are required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensures no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within an 2 hour period of learning of the allegation. We reviewed the latest provider letter (PL 2024-14) This provider letter provides guidance or reporting incidents to HHS, most importantly, reporting abuse immediately, but not later than two hours after the incident occurs or suspected. -Ad Hoc QAPI performed 5-8-25 Staff In-Service - 5/8/2025 - Completed by Admin or designee -All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via (named online training portal) or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.(Abuse coordinator phone number is posted around the facility) It emphasized that any failure to report can result in disciplinary action. The training also outlined steps for immediately removing suspected abusers from duty to protect residents, thereby addressing the urgency of response. -A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced on 5/8/2025 via care feed or in person. Monitoring and Oversight Initiated 5/8/25: -Abuse Coordinator Duties Reinforced: The Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up. -Leadership Review Process: A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented on 5/8/25 to review all allegations of abuse and ensure prompt interventions. -Reporting Compliance Audit: A retrospective review of all abuse allegations from the past 30 days was initiated on 5/8/25, no abuse allegations reported in the last 30 days, confirm compliance and identified any gaps. Audit will be completed by: Administrator. Staff Accountability on 5/8/25: -Supervisory Staff Counseling: Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff on 5-8-25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. -Disciplinary Action Initiated: Disciplinary procedures for involved parties have been initiated per HR guidelines, effective 5/8/25. Sustained Prevention Measures (Beginning 5/8/25): -Ongoing Monthly Abuse Training: Scheduled for the second week of each month, beginning in May for three months. -The Administrator and DON, or designee, will review all reportable 3 times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. On 05/09/24 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of HSK A's personnel file indicated she was terminated on 04/09/25, this was confirmed and documented on 05/08/25. Record review of HSK B's training record indicated she was in-serviced and educated on timely reporting by Administrator on 03/31/25 and 05/08/35. Record review of safe surveys indicated all cognitive residents were presented with a safe survey on 05/09/25 with no concerns identified. Record review of Resident #2's assessments indicated Resident #2 was assessed 05/01/25 for psychological needs by MD JJ and was stable. Resident #2 reassessed for psychological needs on 05/08/25 and was stable per MD JJ. Resident #2 was assessed with PHQ9 on 05-07-25 and no depression was identified. Record review of staff training indicated as of 05/08/25: -Policy Re-Education: All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI by RN KK. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. All staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensured no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within a 2 hour period of learning of the allegation. The latest provider letter (PL 2024-14) was reviewed. Record review of staff in-service dated 05/08/25 and 05/09/25 indicated all facility staff, including nursing, therapy, dietary, housekeeping, and administration were trained by the the Administrator or the DON or through online portal on on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person). The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods by directly notifying the Abuse Coordinator in person or via phone. (Abuse coordinator phone number was posted around the facility). It emphasized that any failure to report could result in disciplinary action. The training outlined steps for immediately removing suspected abusers from duty to protect residents and addressed the urgency of response. Record review of post-training exams indicated all staff trained passed with a required 100% passing score. Staff unable to attend the in-service would not be permitted to work until training was completed. Record review of the facility's Reporting Compliance Audit dated 05/08/25 indicated no abuse allegations reported in the previous 30 days. Record review of staff counselling indicated the Administrator/Abuse Coordinator was counselled and educated on policy requirements by corporate staff on 05/08/25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. Disciplinary procedures were initiated per HR guidelines, effective 05/08/25. Record review of a resident list reflected 100% resident rounds was initiated on 05/08/25 and completed on 05/09/25 to determine if further allegations of abuse were alleged. No additional concerns were identified. During interview conducted on 05/08/25 and 05/09/25, there were no additional incidents of abuse reported by residents. Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, indicated they would report to the Administrator or DON immediately. During interviews conducted on 05/09/25 between 12:50 p.m. and 2:50 p.m. indicated (Administrator L, DON, ADON, SW, CNA D, Receptionist O, BOA S, CMA/CNA T, MR U, CNA BB, CNA CC, DA LL, PTA MM, LS NN, RN OO, CNA PP, RN QQ, LVN RR, HSK SS ) from all shifts (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m., 8:00 a.m.-4:00/5:00 p.m., and 3:00 p.m. -11:00 p.m.) were in-serviced on and could verbalize understanding of in-service on immediate notification of allegations to facility abuse coordinator or designee when not in facility or available, investigating allegations of abuse and neglect, reporting of abuse neglect and misappropriation, and notification of proper local and state entities. During an interview on 05/09/25 at 2:10 p.m. the DON was able verbalize understanding of in-service on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. She said all staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. She said this ensured no delay in response, removing the immediacy of the risk. During an interview on 05/09/25 at 1:51 p.m., Administrator L indicated she was retrained on 05/08/25 on the facility's abuse and reporting policy and the most current provider letter. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. The Administrator was notified the Immediate Jeopardy was removed on 05/09/25 at 2:50 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan to prevent suicide or self harm after she said she wanted to kill herself on 10/23/24. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. While the immediacy was removed on 05/08/25 at 4:55 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for self-harm or death. Findings included: Record review of Resident #1's face sheet dated 05/07/25 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction affecting right dominant side, diabetes (high blood sugar), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worrying), mood disorders (mental illness), persistent mood (affective) disorders (continuous long-term for of depression), and insomnia(sleep disorder). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others. She was cognitively intact (BIMS-13). Her psychiatric/mood disorders included anxiety, depression and bipolar disorder (mental health disorder). Record review of Resident #1's care plan dated 08/24/24 indicated she had antidepressant medication related to major depressive disorder and insomnia. Interventions included administer medications as ordered, arrange psych consult, follow up as indicated, monitor/document/report PRN any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. There was no care plan related to major depressive disorder, suicidal thoughts or self-harm after the 10/23/24 incident. Record review of Resident #1's progress note dated 10/23/24 at 12:17 p.m., completed by LVN FF indicated Resident #1 asked if the facility had helium in the building. LVN FF asked Resident #1 why she needed helium. Resident #1 stated, So I can end it now. I just want to kill myself. My family member UU don't want anything to do with me, My family member only comes when I need something. I just want to die. Nothing to live for. LVN FF stayed with Resident #1. The SW and DON were notified. Record review of Resident #1's progress note dated 10/23/24 at 12:37 p.m., completed by the SW, indicated Resident #1 she just wanted to end it, because of her family member XX not wanting to speak with her or with the family member YY. The SW asked Resident #1 if she had a plan and Resident #1 said no, she just want to end it all. Resident #1 agreed to go to the behavior hospital due to her mood. Spoke with the DON and informed Resident #1 would go on 15 minute watch until SW was able to contact (named psychiatry) for assessment. (Named psychiatry) notified and waiting for call back. Record review of Resident #1's progress note dated 10/23/24 at 1:37 p.m., completed by LVN FF indicated (named psychiatry) on-call called facility and was given report on Resident #1's condition. (Named psychiatry) on-call stated, have SW call back and set up tel psych visit. SW notified. 15 minute checks continue. Record review of Resident #1's progress note dated 10/23/24 at 2:01 p.m. completed by SW indicated Tele-health visit attempted with on-call psychiatrist. Left message for return call. Record review of Resident #1's progress note dated 10/23/24 at 14:28, completed by LVN GG indicated LVN GG was doing 2:00 p.m. monitoring check when he noticed Resident #1 with an object in her left hand. LVN GG noticed Resident #1 had blood coming from her right wrist area. LVN GG took away the object and notified the charge nurse. The DON and ADON were notified. Resident #1 had sliced right wrist with the object. DON cleansed right wrist area and the wounds were superficial. LVN GG and and staff will continue to monitor Resident #1. Record review of Resident #1's progress note dated 10/23/24 at 2.29 p.m., completed by LVN GG indicated while the DON and ADON were giving care, Resident #1 allowed LVN GG to remove and look for sharp objects. A pencil, pen and mirror were removed from the room. Record review of Resident #1's progress note dated 10/23/24 at 2:49 p.m., completed by the DON, indicated she observed Resident #1 with small amount of blood on sheets. She assessed Resident #1's right wrist and noted two superficial cuts approximately 1 to 1.5 inches in length and less than 0.1 mm deep. The cuts were not bleeding. The DON asked Resident #1 what happened and Resident #1 stated she just wanted to the pain to stop. The DON asked Resident #1 what pain she was referring to (physical or emotional) Resident #1 stated the pain in her bladder. LVN C stated she had changed Resident #1's catheter earlier (time noted at 12:13 p.m. per progress note) due to complaints of discomfort. Resident #1 stated that it helped but the pain was back. Upon assessing resident cath noted small amount of urine in collection bag. Palpation of abdomen completed. Resident noted with tenderness. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine flowed from suprapubic site. Resident #1 refused to have suprapubic cath re-placed back but did allow the DON to straight cath her at suprapubic site. Approximately 500 ml drained from bladder. Bladder palpated with no s/s discomfort and Resident #1 stated it does feel better. The DON and ADON spoke with Resident #1 about why she had cut herself. Resident first stated because of the pain in her bladder but upon conversation with the resident, she revealed she was having issues with her family member YY . Resident #1 stated that her family was upset with her for calling her family member YY her babies. The DON and ADON attempted to re-assure Resident #1 that although her family was upset at the moment, they would resolve their issues and her family member YY would want her to be around. Resident #1 was tearful during conversation. The DON explained to Resident #1 she would be sent to ER for evaluation not only of her mental health but also of her urinary retention. Resident #1 agreeable to go to hospital since they would be assessing her bladder. Resident #1 left in room with 1:1 sitter pending ems arrival to facility. Record review of Resident #1's progress note dated 10/23/24 at 2:29 p.m. indicated the DON assessed Resident #1 for other marks or cuts. All other skin intact. Resident #1 denied cutting self anywhere else. Record review of Resident #1's progress note dated 10/23/24 at 2:45 p.m., completed by ADON indicated Staff notified ADON & DON of Resident #1's attempt to self-harm. Upon arrival to room observed x2 staff at bedside: one nurse applying pressure to right wrist, second nurse at foot of bed. DON cleaned with NS and band aide applied to area. Resident #1 complained of pain to lower quadrant of abdomen and suprapubic catheter. Suprapubic catheter removed. Placed with 1:1 sitter. Call placed to 911 for transport to ER due to attempt to self-harm and complaint pain d/t urinary retention. Record review of Resident #1's progress note dated 10/23/24 at 2:42 p.m., completed by the DON indicated EMS arrived at facility. ADON informed EMS of Resident #1's situation. Resident #1 in room with 1:1 sitter. The DON and CNA D assisted resident to change gown and pullup. During resident changing full body skin assessment performed no redness, cuts, scratches or open areas noted except area previously noted to right wrist that was covered with clean dry dressing. Resident no longer tearful. Resident laughing with staff. Resident #1 asked EMTs if they had handcuffs because she wanted to cuff herself to her [positioning] rail so she wouldn't have to go anywhere. When the EMTs told her they were not police so they did not have cuffs she said ok and stood to transfer to stretcher. Resident #1 left with EMS. Record review of Resident #1's progress note dated 10/23/24 at 3:23 p.m., completed by the SW indicated the SW spoke with (named psychiatry provider) and informed the (named psychiatry provider) Resident #1 was transferred to ER and behavioral health due to self harm. Record review of Resident #1's progress note dated 10/23/24 at 6:33 p.m., completed by the SW indicated the hospital psychiatrist asked if Resident #1 was aware that she was going to behavioral hospital, because she was not wanting to go. He stated that resident was competent and a mental health warrant would need to be filed. The SW spoke with Resident #1 and she said, she wants to sleep in her own bed. SW explained due to her trying to harm herself it was our recommendation that she went to the behavioral hospital. She said that she only did it because she thought no one cared. SW asked if she still believed that, she answered, 'No. SW encouraged Resident#1 to go to Behavioral Hospital to get the help she needed. Resident #1 agreed to go to the behavioral hospital. Record review of Resident #1's progress note dated 11/05/25, completed by LVN E indicated Resident #1 returned to the facility in stable condition. Record review of Resident #1's behavioral hospital records dated 11/01/25 indicated she was admitted on [DATE]. Her admitting diagnoses included bi-polar disorder, current episode depressed, severe, without psychotic features. Resident #1 stated she had nothing to live for because family was not involved with her. Resident #1 indicated she had past history 4 suicide attempts b OD on pills. Resident #1 indicated she recently cut her right wrist for attention. Record review of Resident Monitoring Tool dated 10/23/24 indicated: -1:00 p.m. asking for helium -1:15 p.m. asking for helium -1:30 p.m. asking for DON -1:45 p.m. asking for helium -2:00 p.m. cut her wrist -2:15 p.m. one on one -2:30 p.m. one on one -2:45 p.m. one on one Record review of psychological services dated 11/26/25 completed by LCSW M indicated .ongoing conflict with family member UU and family member XX continued to wear on her. Sadness surrounding family betrayal.Plan: follow up next session on things discussed . Record review of the facility's staff training for Depression dated 10/23/24 indicated: What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident states they want to harm themselves or they want to die: -Notify the charge nurse -Charge nurse should evaluate the resident: -Ask the resident what they said to the employee reporting the self harm/ideation -Ask the resident if they have intention to harm themselves -If the resident states they have intention to harm themselves, ask the resident how they plan to harm themselves. -If resident has no plan, initiate 15 minute checks to monitor resident then notify MD or psych services if following, social worker and DON/ADON -If resident has a plan, initiate 1:1 with resident (have a staff member remain with the resident) then notify MD or psych services (if following), social worker and DON/ADON. What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident is observed harming or attempting to harm themselves. -Intervene and ensure the resident is safe -Stay with the resident and have another staff member notify the charge nurse, social worker or DON/ADON immediately. -Charge Nurse will call 911. During an interview on 05/07/25 at 10:00 a.m., the DON said on 10/23/24, Resident #1 asked LVN FF if the facility had helium because she wanted to end her life. She said Resident #1 was placed on 15 monitoring per the facility policy at the time of the incident because she did not have a plan to hurt herself. She said a room sweep to check for items she might use to herself was not completed. She said LVN GG was conducting a 15 minute check and found Resident #1 attempted to cut her right wrist with microblade razor on 10/23/24. She said staff was trained on the facility policy at the time that included 15 minute checks if the resident did not have a plan. She said she attended a corporate DON meeting in November of 2024 and the facility's policy was changed to 1-1 supervision after suicide threat or attempts. She said she believed all staff were trained on the updated policy after Resident #1 attempted to cut her wrist. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 11:55 a.m., Resident #1 said when she asked for helium, she wanted to kill herself because of her family problems and she was very sad. She said when she when she cut her wrist, she used a microblade razor she had ordered off (named on-inline shopping provider). She said no one was listening to what she was saying. She said her family did not support her. She said she received the therapy she needed at the behavior hospital. She said she no longer had any plans to harm herself. During an interview on 05/07/25 at 12:07 p.m., LVN GG said he was completing a 15 minute check on Resident #1 and found her with blood on her wrist. He said she had a razor in her left hand. He said he removed the razor and called for assistance. He said He said he could not recall a room search was completed for additional dangerous objects. He said he did not complete the facility's depression training. He said he could not recall training on the facility's updated suicide policy. He said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:12 p.m., the DON said Resident #1's care plan should include behaviors. She said Resident #1's care plan should address self-harm from the incident on 10/23/24. She said the SW reviewed behavior and psychiatric care plans quarterly and updated them as required. She said the IDT meeting minutes should be located in Resident #1's progress notes but was not able to locate any documentation regarding updating Resident #1's care plan. During an interview on 05/07/25 at 1:36 p.m., the SW said she was advised Resident #1 requested helium to end her life. She said Resident #1 was upset due to family stress. She said Resident #1 was placed on 15 minute checks. She said she was not sure why Resident #1 was placed on 1-1 supervision. She said Resident #1 asked for helium but could not access helium. She said she could not recall being trained on depression or suicide prevention. She said she did not recall reviewing Resident #1's care plan for follow-up care. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:52 p.m., previous Administrator J said Resident #1's care plan should have been updated by the previous MDS coordinator. He said the incident was discussed in the morning meeting and the previous MDS coordinator was aware of the incident. He said weekly IDT meeting were held to discuss acute incidents that required a care plan. He said he was unaware the care plan was not updated. Record review of the facility's policy Care plan Revisions Upon Status Change dated 2023 indicated The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. B. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal (POR) submitted by the facility was accepted on 05/08/25 at 12:24 p.m.: Resident-Specific Interventions - 5/7/2025 - Completed by DON or designee -Resident #1's care plan was updated to reflect resident centered behavioral health status, including the initiation of a psychiatric virtual visit and ongoing behavioral observations. Facility-Wide Audit - 5/7/2025 - Completed by Social Worker, DON, ADON -A 100% audit of current residents using the PHQ-9 screening tool began on 5/7/2025 and will be completed by 9:00 PM. PHQ-9 is a clinically validated screening tool used to assess and monitor depression severity in individuals. No other residents identified as high risk for suicide or behavioral health needs via the PHQ-9 screening tool, question 9. -Care plans are being updated, if warranted by the PHQ- 9 screening tool, to reflect PHQ-9 results and ensure individualized, resident-centered care. Staff Training - 5/7/2025 -Nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse. Training will be completed by 9:00 PM. QAPI Review - 5/7/2025 -An ad-hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, and the interdisciplinary team to evaluate current systems related to care planning and suicide prevention. Local ombudsmen notified. -QAPI will continue to review care plan compliance and quality monthly. Ongoing Monitoring - Effective 5/7/2025 -The Director of Nursing or designee will monitor the 24-hour report (generated through Point Click Care based on progress notes entered into the residents chart) and PHQ-9 completion daily for 14 days then 5 times per week for 3 months for any depression or suicidal thoughts and care plans will be updated as needed. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Monitoring of the Plan of Removal included the following: Record review of Resident #1's care plan dated 05/07/25 indicated Resident #1 had diagnoses of major depressive disorder, insomnia, and history of suicidal thoughts/self harm. Interventions included administer medications as ordered, conduct depression questionnaire on 05/07/25. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. If the resident expresses suicidal thoughts or ideas, staff will be assigned one-on-one care, and the Primary Physician and Abuse Coordinator will be notified immediately for further intervention(s) and guidance. If the resident expresses suicidal thoughts or ideas, staff will inspect the immediate area/room for items that could be used for self-harm and remove such items if found upon inspection. Record review of Residents #2, #3, #4, #5, #6, #7, #8, #9, and #10's care plans indicated no concerns. Record review of the facility audit completed by the DON, ADON, and SW for all residents dated 05/07/25 indicated there were no additional residents identified that required care plan updates. Record review of Staff Training dated 05/07/25 indicated nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse. During an interview on 05/08/25 at 3:52 p.m., the ADON said resident care plans would be updated as needed for acute events. She said the acute events would be reviewed in morning meeting During an interview on 05/08/25 at 3:48 p.m., the SW said she would review and update resident care plans as directed by the DON or designee. During an interview on 05/08/25 at 4: 22 p.m. the DON said she or her designee would monitor the 24 hour report daily and update resident care plans as needed. She said she would conduct weekly audits to ensure updated care plans were maintained. She said and identified issues would be address at the weekly IDT meeting. Interviews conducted on 05/08/25 from 2:55 p.m. through 4:54 p.m. with staff (Administrator L, LVN E, LVN P, MDS/LVN V), indicated they were aware of the facility's policy and protocols for care plans and care plan revisions. The Administrator was informed the Immediate Jeopardy was removed on 05/08/25 at 4:55 p.m. The facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after Resident #1 expressed suicidal ideations on 10/23/24. Resident #1 was placed on 15 minute monitoring. She attempted to cut her right wrist with a microblade razor (used for face shaving) between the 15 minute monitoring checks. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. While the immediacy was removed on 05/08/25 at 4:55 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or even death. Findings include: Record review of Resident #1's face sheet indicated she was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction affecting right dominant side, diabetes (high blood sugar), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worrying), mood disorders (mental illness), persistent mood (affective) disorders (continuous long-term for of depression), and insomnia(sleep disorder). Record review of Resident #1's annual MDs assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others. She was cognitively intact (BIMS-13). Her psychiatric/mood disorders included anxiety, depression and bipolar disorder (mental health disorder). Record review of Resident #1's care plan dated 08/24/24 indicated she had antidepressant medication related to major depressive disorder and insomnia. Interventions included administer medications as ordered, arrange psych consult, follow up as indicated, monitor/document/report PRN any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. There was no care plan related to major depressive disorder, suicidal thoughts or self-harm. Record review of Resident #1's progress note dated 10/23/24 at 12:17 p.m., completed by LVN FF indicated Resident #1 asked if the facility had helium in the building. LVN FF asked Resident #1 why she needed helium. Resident #1 stated, So I can end it now. I just want to kill myself. My family member UU don't want anything to do with me, My sister only comes when I need something. I just want to die. Nothing to live for. LVN FF stayed with Resident #1. The SW and DON were notified. Record review of Resident #1's progress note dated 10/23/24 at 12:37 p.m., completed by the SW, indicated Resident #1 she just wanted to end it, because of her family member XX not wanting to speak with her or with the great grand children. The SW asked Resident #1 if she had a plan and Resident #1 said no, she just want to end it all. Resident #1 agreed to go to the behavior hospital due to her mood. Spoke with the DON and informed Resident #1 would go on 15 minute watch until SW was able to contact (named psychiatry) for assessment. (Named psychiatry) notified and waiting for call back. Record review of Resident #1's progress note dated 10/23/24 at 1:37 p.m., completed by LVN FF indicated (named psychiatry) on-call called facility and was given report on Resident #1's condition. (Named psychiatry) on-call stated, have SW call back and set up tel psych visit. SW notified. 15 minute checks continue. Record review of Resident #1's progress note dated 10/23/24 at 14:01, completed by SW indicated Tele-health visit attempted with on-call psychiatrist. Left message for return call. Record review of Resident #1's progress note dated 10/23/24 at 14:28, completed by LVN GG indicated LVN GG was doing 2:00 p.m. monitoring check when he noticed Resident #1 with an object in her left hand. LVN GG noticed Resident #1 had blood coming from her right wrist area. LVN GG took away the object and notified the charge nurse. The DON and ADON were notified. Resident #1 had sliced right wrist with the object. DON cleansed right wrist area and the wounds were superficial. LVN GG and and staff will continue to monitor Resident #1. Record review of Resident #1's progress note dated 10/23/24 at 2.29 p.m., completed by LVN GG indicated while the DON and ADO were giving care, Resident #1 allowed LVN GG to remove and look for sharp objects. A pencil, pen and mirror were removed from the room. Record review of Resident #1's progress note dated 10/23/24 at 2:49 p.m., completed by the DON, indicated she observed Resident #1 with small amount of blood on sheets. She assessed Resident #1's right wrist and noted two superficial cuts approximately 1 to 1.5 inches in length and less than 0.1 mm deep. The cuts were not bleeding. The DON asked Resident #1 what happened and Resident #1 stated she just wanted to the pain to stop. The DON asked Resident #1 what pain she was referring to (physical or emotional) Resident #1 stated the pain in her bladder. LVN C stated she had changed Resident #1's catheter earlier (time noted at 12:13 p.m. per progress note) due to complaints of discomfort. Resident #1 stated that it helped but the pain was back. Upon assessing resident cath noted small amount of urine in collection bag. Palpation of abdomen completed. Resident noted with tenderness. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine flowed from suprapubic site. Resident #1 refused to have suprapubic cath re-placed back but did allow the DON to straight cath her at suprapubic site. Approximately 500 ml drained from bladder. Bladder palpated with no s/s discomfort and Resident #1 stated it does feel better. The DON and ADON spoke with Resident #1 about why she had cut herself. Resident first stated because of the pain in her bladder but upon conversation with the resident, she revealed she was having issues with her family member YY. Resident #1 stated that her family was upset with her for calling her great family member YY her babies. The DON and ADON attempted to re-assure Resident #1 that although her family was upset at the moment, they would resolve their issues and her great-grandchildren would want her to be around. Resident #1 was tearful during conversation. The DON explained to Resident #1 she would be sent to ER for evaluation not only of her mental health but also of her urinary retention. Resident #1 agreeable to go to hospital since they would be assessing her bladder. Resident #1 left in room with 1:1 sitter pending ems arrival to facility. Record review of Resident #1's progress note dated 10/23/24 at 2:29 p.m. indicated the DON assessed Resident #1 for other marks or cuts. All other skin intact. Resident #1 denied cutting self anywhere else. Record review of Resident #1's progress note dated 10/23/24 at 2:45 p.m., completed by ADON indicated Staff notified ADON & DON of Resident #1's attempt to self-harm. Upon arrival to room observed x2 staff at bedside: one nurse applying pressure to right wrist, second nurse at foot of bed. DON cleaned with NS and band aide applied to area. Resident #1 complained of pain to lower quadrant of abdomen and suprapubic catheter. Suprapubic catheter removed. Placed with 1:1 sitter. Call placed to 911 for transport to ER due to attempt to self-harm and complaint pain d/t urinary retention. Record review of Resident #1's progress note dated 10/23/24 at 2:42 p.m., completed by the DON indicated EMS arrived at facility. ADON informed EMS of Resident #1's situation. Resident #1 in room with 1:1 sitter. The DON and CNA D assisted resident to change gown and pullup. During resident changing full body skin assessment performed no redness, cuts, scratches or open areas noted except area previously noted to right wrist that was covered with clean dry dressing. Resident no longer tearful. Resident laughing with staff. Resident #1 asked EMTs if they had handcuffs because she wanted to cuff herself to her [positioning] rail so she wouldn't have to go anywhere. When the EMTs told her they were not police so they did not have cuffs she said ok and stood to transfer to stretcher. Resident #1 left with EMS. Record review of Resident #1's progress note dated 10/23/24 at 3:23 p.m., completed by the SW indicated the SW spoke with (named psychiatry provider) and informed the (named psychiatry provider) Resident #1 was transferred to ER and behavioral health due to self harm. Record review of Resident #1's progress note dated 10/23/24 at 6:33 p.m., completed by the SW indicated the hospital psychiatrist asked if Resident #1 was aware that she was going to behavioral hospital, because she was not wanting to go. He stated that resident was competent and a mental health warrant would need to be filed. The SW spoke with Resident #1 and she said, she wants to sleep in her own bed. SW explained due to her trying to harm herself it was our recommendation that she went to the behavioral hospital. She said that she only did it because she thought no one cared. SW asked if she still believed that, she answered, 'No. SW encouraged Resident#1 to go to Behavioral Hospital to get the help she needed. Resident #1 agreed to go to the behavioral hospital. Record review of Resident #1's progress note dated 11/05/25, completed by LVN E indicated Resident #1 returned to the facility in stable condition. Record review of Resident #1's behavioral hospital records dated 11/01/25 indicated she was admitted on [DATE]. Her admitting diagnoses included bi-polar disorder, current episode depressed, severe, without psychotic features. Resident #1 stated she had nothing to live for because family was not involved with her. Resident #1 indicated she had past history 4 suicide attempts b OD on pills. Resident #1 indicated she recently cut her right wrist for attention. Record review of Resident Monitoring Tool dated 10/23/24 indicated: -1:00 p.m. asking for helium -1:15 p.m. asking for helium -1:30 p.m. asking for DON -1:45 p.m. asking for helium -2:00 p.m. cut her wrist -2:15 p.m. one on one -2:30 p.m. one on one -2:45 p.m. one on one Record review of psychological services dated 11/26/25 completed by LCSW M indicated .ongoing conflict with family member UU and family member XX continued to wear on her. Sadness surrounding family betrayal.Plan: follow up next session on things discussed . Record review of the facility's staff training for Depression dated 10/23/24 indicated: What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident states they want to harm themselves or they want to die: -Notify the charge nurse -Charge nurse should evaluate the resident: -Ask the resident what they said to the employee reporting the self harm/ideation -Ask the resident if they have intention to harm themselves -If the resident states they have intention to harm themselves, ask the resident how they plan to harm themselves. -If resident has no plan, initiate 15 minute checks to monitor resident then notify MD or psych services if following, social worker and DON/ADON -If resident has a plan, initiate 1:1 with resident (have a staff member remain with the resident) then notify MD or psych services (if following), social worker and DON/ADON. What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident is observed harming or attempting to harm themselves. -Intervene and ensure the resident is safe -Stay with the resident and have another staff member notify the charge nurse, social worker or DON/ADON immediately. -Charge Nurse will call 911. During an interview on 05/07/25 at 10:00 a.m., the DON said on 10/23/24, Resident #1 asked LVN FF if the facility had helium because she wanted to end her life. She said Resident #1 was placed on 15 monitoring per the facility policy at the time of the incident because she did not have a plan to hurt herself. She said a room sweep to check for items she might use to herself was not completed. She said LVN GG was conducting a 15 minute check and found Resident #1 attempted to cut her right wrist with microblade razor on 10/23/24. She said staff was trained on the facility policy at the time that included 15 minute checks if the resident did not have a plan. She said she attended a corporate DON meeting in November of 2024 and the facility's policy was changed to 1-1 supervision after suicide threat or attempts. She said she believed all staff were trained on the updated policy after Resident #1 attempted to cut her wrist. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 11:55 a.m., Resident #1 said when she asked for helium, she wanted to kill herself because of her family problems and she was very sad. She said when she when she cut her wrist, she used a microblade razor she had ordered off (named on-inline shopping provider). She said no one was listening to what she was saying. She said her family did not support her. She said she received the therapy she needed at the behavior hospital. She said she no longer had any plans to harm herself. During an interview on 05/07/25 at 12:07 p.m., LVN GG said he was completing a 15 minute check on Resident #1 and found her with blood on her wrist. he said she had a razor in her left hand. He said he removed the razor and called for assistance. He said he could not recall a room search was completed for additional dangerous objects. He said he did not complete the facility's depression training. He said he could not recall training on the facility's updated suicide policy. He said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 12:52 p.m., the DON said she was not able to locate records of staff straining related to the facility updated policy for suicide prevention. During an interview on 05/07/25 at 1:12 p.m., the DON said Resident #1's care plan should include behaviors. She said Resident #1's care plan should address self-harm from the incident on 10/23/25. She said care plans were reviewed quarterly and updated. During an interview on 05/07/25 at 1:36 p.m., the SW said she was advised Resident #1 requested helium to end her life. She said Resident #1 was upset due to family stress. She said Resident #1 was placed on 15 minute checks. She said she was not sure why Resident #1 was placed on 1-1 supervision. She said Resident #1 asked for helium but could not access helium. She said she could not recall being trained on depression or suicide prevention. She said she was not aware of any changes related to the facility's suicide protocols. She said she did not recall reviewing Resident #1's care plan for follow-up care. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:52 p.m., previous Administrator J said Resident #1 was not placed on 1-1 supervision on 10/23/24 after she asked if the facility had helium and indicated she wanted to end her life. He said he believed the facility spoke to the psych doctor and Resident #1 did not have an active plan. He said he could not recall if the facility conducted a search of Resident #1's room to ensure there were no items she could harm herself with. He said he believed the Medical Director recommended 15 minute checks until she was cleared by psychiatrist or they had different recommendations. He said after the incident on 10/23/24, the facility changed the policy to anytime there was an outcry, the resident would be placed on 1-1. He said he believed all the staff were trained on the facility's new suicide prevention policy. He said Resident #1's care plan should have been updated by the previous MDS coordinator. He said the incident was discussed in the morning meeting and the previous MDS coordinator was aware of the incident. He said weekly IDT meeting were held to discuss acute incidents that required a care plan. He said he was unaware the care plan was not updated. During an interview on 05/08/25 at 10:25 a.m., Activity Director K said said she did not have helium in the facility currently. She said she believed it was more than 6 months since she had a tank. She said she would keep them in her office and use it to blow up balloons. She said she did not lock her office and anyone could access the helium if they knew it was available in her office and they knew how to access it it and turn it on. Record review of the facility's Suicide Prevention policy dated 2024 indicated: It is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide. Definitions: Suicide - is defined as a death from injury, poisoning, or suffocation where there is evidence that the death was self-inflicted. Suicidal Ideation - is defined as self-reported thoughts about engaging in suicide-related behaviors. Policy Explanation and Compliance Guidelines:1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. 2. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal ideation and any orders received from the resident's physician. 4. The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record. 6. If the resident requires inpatient psychiatric services, State specific guidelines and requirements will be followed. 7. All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Record review of the facility's Accidents and Supervision policy dated 2023 indicated: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully h. Facility-based interventions may include, but are not limited to: i. Educating staff ii. Repairing the device/equipment iii. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. An Immediate Jeopardy was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal was submitted by the facility and accepted on 05/08/25 at 12:34 p.m. Supervision and Accident Prevention Resident Safety Review - 5/7/2025 -All residents identified as high risk for suicide or behavioral health needs, via the PHQ-9 screening tool, question 9, were immediately placed on 1-1, room searched, notified physician, RP notified, and initiated mental health consultation. -Question 9 - Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way? -0 - not at all -1 - Several days -2 - More than half the days -3 - Nearly every day -Adjustments were made as needed, and care plans were updated accordingly. -Resident #1 received a PHQ-9 assessment, a room safety search, and a virtual psychiatric visit, all completed by 9:00 PM on 5/7/2025. Staff In-Service - 5/7/2025 - Completed by Admin or designee -All facility staff, including nursing, therapy, dietary, housekeeping, and administration, completed training on suicide prevention, including immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, and immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, provided by the Director of Nursing or designee, completed by 10:00 p.m. on 5/7/2025. -A post-training exam with a required 100% passing score was administered. Staff unable to attend the in-service will not be permitted to work until training is completed. Ongoing Monitoring - Effective 5/7/2025 -The Director of Nursing or designee will conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Monitoring: Record review and interviews of completed: Observation on 05/08/25 from 3:00 p.m. through 4:45 p.m. of 10 resident rooms indicated no hazardous items noted. Record review of the facility wide resident safety review dated 05/07/25 indicated there were no additional residents identified and high risk for suicide of unmet behavioral health needs. Record review of Resident #1's PHQ-9 assessment, a room safety search, and a virtual psychiatric visit, indicated all were completed by 9:00 PM on 05/07/25. There were no concerns identified. Record review of Resident #1's care plan dated 05/07/25 indicated Resident #1 had diagnoses of major depressive disorder, insomnia, and history of suicidal thoughts/self harm. Interventions included administer medications as ordered, conduct depression questionnaire on 05/07/25. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. If the resident expresses suicidal thoughts or ideas, staff will be assigned one-on-one care, and the Primary Physician and Abuse Coordinator will be notified immediately for further intervention(s) and guidance. If the resident expresses suicidal thoughts or ideas, staff will inspect the immediate area/room for items that could be used for self-harm and remove such items if found upon inspection. Record review of staff in-service dated 05/07/25 indicated facility staff, including nursing, therapy, dietary, housekeeping, and administration, completed training on suicide prevention, including immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, and immediate search for hazards and hazardous items. Record review of staff post-training exams indicated all staff passed with a required 100% passing score. Staff unable to attend the in-service would not be permitted to work until training and testing was completed. During an interview on 05/08/25 at 1:51 p.m., Administrator L said the facility would conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. Any discrepancies would be be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/08/25 at 4:22 p.m., the DON said she would conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. Any discrepancies would be be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Interviews conducted on 05/08/25 from 2:55 p.m. through 4:54 p.m. with staff (Administrator L, DON, ADON, SW, LVN E OTR N, Receptionist O, LVN P, Dietary Director Q, LS R, BOA S, CMA T, Medical Records U, MDS/LVN V, ST W, CNA X, CNA AA, CMA BB, CNA DD, CNA EE), who represented all shifts on all days of the week (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m., 8:00 a.m.-4:00/5:00 p.m., and 3:00 p.m. -11:00 p.m.) indicated they were aware of the facility's policy and protocols for suicide prevention that included immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, and immediate search for hazards and hazardous items. The Administrator and DON were informed the Immediate Jeopardy was removed on 05/08/25 at 4:55 p.m. the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure the rights of residents to be free from abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse by HSK A. On 03/29/25 HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (persistent worry and fear about everyday situations), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and cerebral infarction (stroke). Record review of Resident #2's annual MDS assessment dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate cognitive impairment (BIMS-8). Record review of Resident #2's care plan dated 05/08/25 indicated Resident #2 had a psychosocial well-being problem related to verbal aggression while interacting with staff. Interventions included initiate referrals as needed or increase social relationships, provide a safe environment, and and when conflict arises residents to a calm safe environment. Record review of a facility investigation dated 04/07/25 and completed by Administrator L indicated the incident occurred on 03/29/25 at 1:00 p.m. and was reported to HHS on 04/01/25 at 12:00 p.m. The AP was identified and confirmed as HSK A. The witness was identified as HSK B. The allegation was noted as HSK A was being verbally aggressive with Resident #2 over the purchase of cigarettes. HSK A was suspended during the investigation. HSK B was in-serviced on timely reporting of abuse allegation on 04/01/25. The findings were confirmed. Record review of an Employee Concern Form dated 03/29/25 at 1:00 p.m., completed by HSK B indicated At 1:00 p.m. smoke time I was giving Resident #4 her two cigarettes and I told Resident #2 you don't have any did you call someone and she said yeah I still waiting. Couple of minutes goes by and Resident #2 goes I'm not hiding anymore give me a cigarette talking to Resident #4. HSK A turns and goes not if its the cigarettes a bought I am not buying you cigarettes to just hand them out. I said well Resident #2 when you have cigarettes and Resident #4 don't don't share with her if that's the case. That's not fair to you. HSK A gives she share with her just not the cigarettes I bought. She can do whatever she wants with the cigarettes she buys with her money. HSK A started to get loud and angry. Resident #2 had enough and told HSK A to shut up. HSK A got out of her chair and tells Resident #2 to make her shut up. You will have to get out of your chair to shut me up. Then Resident #3 told HSK A to calm down. After that HSK A left. Resident #2 said I wish I can punch her and then looked at Resident #4 and goes I want to punch you for not having my back and then Resident #2 started to cry and shake. Record review of a Service Recovery Opportunity form dated initially dated 3/31/25, (the date was amended by Administrator L on 04/01/25), completed by Administrator L on 04/05/25 indicated HSK A became verbally abusive with Resident #2 about cigarettes. HSK A was suspended during the investigation. This was the first time HSK A had an argument with a resident. HSK A was inserviced on abuse, managing conflict and resident rights. HSK A confirmed she got upset with with Resident #2. Record review of a progress note dated 04/01/25 at 10:01 a.m., completed by the SW indicated On April 1, 2025, I spoke with Resident #2 regarding the incident between she and HSK A. Resident #2 said, She apologized to me for being upset and me crying. She said, And I apologized to her for what I said. Resident #2 could not recall what she said to HSK A or what HSK A said to her. She said, I know she had never talked to me like that before. She said, I don't recall what she said, but its not the way we normally talk. Resident #2 said, my mind is not that good and I can't recall. Resident #2 continued talking to me and she eventually recalled that the incident was about the sharing of cigarettes. Resident #2 said that she asked Resident #4 for a cigarette and HSK A said no because she had purchased the cigarettes with her own money. So, Resident #2 was upset that she could not get a cigarette because she and Resident #4 shares cigarettes. She said, she (HSK A) was going on about everything under the moon. She said that she told HSK A to hush and leave her alone. She don't recall what HSK A said. Resident #2 was upset with Resident #4 for not standing up for her. She said, I was crying and Resident #4 gave me the cigarette when HSK A left. Resident #2 told me that she is not scared of HSK A. She said, She is my friend and we apologized. She feels safe here at the facility and she knows who to report abuse too. She said HSK A is a good person. Record review of a progress note dated 04/07/25 at 4:02 p.m., completed by the SW indicated On April 7, 2025, I asked Resident #2 about the interaction between her and HSK A on smoke break. Resident #2 at first said she didn't recall what it was about, but they both apologized and it's over. I inquired further and Resident #2 said, She went off on a rampage. She did not want Resident #4 to share her cigarettes with me. Resident #2 told me that HSK A purchases cigarettes for Resident #4 using her own money (HSK A's money), so she did not want Resident #4 to share the cigarettes with her. Resident #2 said, HSK A and I kept going back and forth I told HSK A to shut up. Resident #2 did not recall what HSK A said, but I told her what the witness reported. She said yes, HSK A did say make me. Resident #2 said she cried because HSK A had never spoken to her like that before. She said, We are friends and both have apologized. I thought this was over. I explained that anytime there is an incident between staff and a resident we must make sure that the resident is safe, and no harm is caused. Resident #2 said, I'm okay, HSK A and I have made up. It's over. Record review of HSK's time record indicated she worked 03/29/25, 03/30/25, 03/31/25, 04/03/25, 04/04/25, and 04/05/25. During an interview on 05/07/25 at 10:00 a.m., Administrator L said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHS C within 2 hours. She said the facility was reporting on 04/01/25 an allegation of verbal abuse by HSK A towards Resident #2 on 03/29/25. She said HSK B witnessed the verbal abuse on 03/29/25 and put a note under the HR door but did not report the incident immediately to her (Administrator L) as required. She said HSK A was suspended when the facility was made aware of the incident on 03/31/25. She said the verbal abuse was confirmed. HSK A did not respond to a call from the surveyor on 05/07/25 at 2:35 p.m. During an interview on 05/07/25 at 2:45 p.m., Resident #2 said HSK A made her upset and spoke to her with a mean tone about borrowing cigarettes. She said she wanted her to shut up and HSK A said she (Resident #2) would have to get up from her wheelchair to make her shut up. She said she felt sad and upset when HSK spoke to her. She said at the time it was abuse but they had made up and there was no further problems. She said HSK A was not working at the facility anymore. She said she was o.k. and no other staff ever spoke to her with a mean or mad tone. During an interview on 05/08/25 at 12:56 p.m., HSK B said the incident of verbal abuse occurred on 03/29/25 during the 1:00 p.m. smoke break. She said the staff were advised residents were not supposed to share their cigarettes. She said HSK A had bought cigarettes for Resident #4. She said HSK A told Resident #4 not to share, that she was only buying for Resident #4. Resident #2 said she wished HSK A would shut up. HSK A got up form her chair and told Resident #2 she would have to get out of her chair to make her shut up. She said Resident #3 told HSK A to calm down. She said Resident #2 said she wished she could punch HSK A in the face. Resident #2 was upset and crying. During an interview on 05/09/25 at 10:10 a.m., Resident #3 said HSK A was having words with Resident #2 over some cigarettes. He said HSK A was disrespectful and angry. He said they called each other BITCH. He said HSK A said if Resident #2 got up from her chair she would whoop her ass. He said he told HSK A she should not talk to her elders like that. He said he was not interviewed about the incident. He said he had not heard HSK A speak to residents that way before. During an interview on 05/09/25 at 12:29 p.m., Resident #4 said HSK A and Resident #2 were arguing about cigarettes. She said HSK A had purchased the cigarettes for her (Resident #3) and was mad because Resident #4 was going to share with Resident #2). She said HSK A said she wanted to whoop Resident #2's ass because she was arguing with her. She said she knew HSK A all her life and she had a temper. She said she never heard HSK A talk to residents that way before. She said she would report abuse to the Administrator or the DON immediately. During an interview on 05/09/25 at 1:18 p.m., HSK B said she did not hear HSK A say she wanted to whoop Resident #2's ass. During an interview on 05/09/25, at 1:51 p.m., Administrator L said she was retrained on abuse on 05/08/25. She said not following the facility policy for abuse prevention, reporting, and investigation placed the residents were at risk for re-occurrence of abuse or the incident could have escalated. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . I. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.

Based interview and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to thoroughly investigate after HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. This failure could place residents at risk of not having allegations of abuse, neglect or exploitation investigated properly to prevent re-occurrence. Findings included: Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (persistent worry and fear about everyday situations), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and cerebral infarction (stroke). Record review of Resident #2's annual MDS assessment dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate cognitive impairment (BIMS-8). Record review of Resident #2's care plan dated 05/08/25 indicated Resident #2 had a psychosocial well-being problem related to verbal aggression while interacting with staff. Interventions included initiate referrals as needed or increase social relationships, provide a safe environment, and and when conflict arises residents to a calm safe environment. Record review of a facility investigation dated 04/07/25 and completed by Administrator L indicated the incident occurred on 03/29/25 at 1:00 p.m. and was reported to HHS on 04/01/25 at 12:00 p.m. The AP was identified and confirmed as HSK A. The witness was identified as HSK B. The allegation was noted as HSK A was being verbally aggressive with Resident #2 over the purchase of cigarettes. HSK A was suspended during the investigation. HSK B was in-serviced on timely reporting of abuse allegation on 04/01/25. The findings were confirmed. The facility investigation did not include interviews with other residents. The resident safe surveys included with the investigation did not address verbal abuse by staff. Record review of an Employee Concern Form dated 03/29/25 at 1:00 p.m., completed by HSK B indicated At 1:00 p.m. smoke time I was giving Resident #4 her two cigarettes and I told Resident #2 you don't have any did you call someone and she said yeah I still waiting. Couple of minutes goes by and Resident #2 goes I'm not hiding anymore give me a cigarette talking to Resident #4. HSK A turns and goes not if its the cigarettes a bought I am not buying you cigarettes to just hand them out. I said well Resident #2 when you have cigarettes and Resident #4 don't don't share with her if that's the case. That's not fair to you. HSK A gives she share with her just not the cigarettes I bought. She can do whatever she wants with the cigarettes she buys with her money. HSK A started to get loud and angry. Resident #2 had enough and told HSK A to shut up. HSK A got out of her chair and tells Resident #2 to make her shut up. You will have to get out of your chair to shut me up. Then Resident #3 told HSK A to calm down. After that HSK A left. Resident #2 said I wish I can punch her and then looked at Resident #4 and goes I want to punch you for not having my back and then Resident #2 started to cry and shake. Record review of a Service Recovery Opportunity form dated initially dated 3/31/25, (the date was amended by Administrator L on 04/01/25), completed by Administrator L on 04/05/25 indicated HSK A became verbally abusive with Resident #2 about cigarettes. HSK A was suspended during the investigation. This was the first time HSK A had an argument with a resident. HSK A was inserviced on abuse, managing conflict and resident rights. HSK A confirmed she got upset with with Resident #2. Record review of a progress note dated 04/01/25 at 10:01 a.m., completed by the SW indicated On April 1, 2025, I spoke with Resident #2 regarding the incident between she and HSK A. Resident #2 said, She apologized to me for being upset and me crying. She said, And I apologized to her for what I said. Resident #2 could not recall what she said to HSK A or what HSK A said to her. She said, I know she had never talked to me like that before. She said, I don't recall what she said, but its not the way we normally talk. Resident #2 said, my mind is not that good and I can't recall. Resident #2 continued talking to me and she eventually recalled that the incident was about the sharing of cigarettes. Resident #2 said that she asked Resident #4 for a cigarette and HSK A said no because she had purchased the cigarettes with her own money. So, Resident #2 was upset that she could not get a cigarette because she and Resident #4 shares cigarettes. She said, she (HSK A) was going on about everything under the moon. She said that she told HSK A to hush and leave her alone. She don't recall what HSK A said. Resident #2 was upset with Resident #4 for not standing up for her. She said, I was crying and Resident #4 gave me the cigarette when HSK A left. Resident #2 told me that she is not scared of HSK A. She said, She is my friend and we apologized. She feels safe here at the facility and she knows who to report abuse too. She said HSK A is a good person. Record review of a progress note dated 04/07/25 at 4:02 p.m., completed by the SW indicated On April 7, 2025, I asked Resident #2 about the interaction between her and HSK A on smoke break. Resident #2 at first said she didn't recall what it was about, but they both apologized and it's over. I inquired further and Resident #2 said, She went off on a rampage. She did not want Resident #4 to share her cigarettes with me. Resident #2 told me that HSK A purchases cigarettes for Resident #4 using her own money (HSK A's money), so she did not want Resident #4 to share the cigarettes with her. Resident #2 said, HSK A and I kept going back and forth I told HSK A to shut up. Resident #2 did not recall what HSK A said, but I told her what the witness reported. She said yes, HSK A did say make me. Resident #2 said she cried because HSK A had never spoken to her like that before. She said, We are friends and both have apologized. I thought this was over. I explained that anytime there is an incident between staff and a resident we must make sure that the resident is safe, and no harm is caused. Resident #2 said, I'm okay, HSK A and I have made up. It's over. During an interview on 05/07/25 at 10:00 a.m., Administrator L said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHS C within 2 hours. She said the facility was reporting on 04/01/25 an allegation of verbal abuse by HSK A towards Resident #2 on 03/29/25. She said HSK B witnessed the verbal abuse on 03/29/25 and put a note under the HR door but did not report the incident immediately to her (Administrator L) as required. She said HSK A was suspended when the facility was made aware of the incident on 03/31/25. She said the verbal abuse was confirmed. HSK A did not respond to a call from the surveyor on 05/07/25 at 2:35 p.m. During an interview on 05/07/25 at 2:45 p.m., Resident #2 said HSK A made her upset and spoke to her with a mean tone about borrowing cigarettes. She said she wanted her to shut up and HSK A said she (Resident #2) would have to get up from her wheelchair to make her shut up. She said she felt sad and upset when HSK spoke to her. She said at the time it was abuse but they had made up and there was no further problems. She said HSK A was not working at the facility anymore. She said she was o.k. and no other staff ever spoke to her with a mean or mad tone. During an interview on 05/08/25 at 12:56 p.m., HSK B said the incident of verbal abuse occurred on 03/29/25 during the 1:00 p.m. smoke break. She said the staff were advised residents were not supposed to share their cigarettes. She said HSK A had bought cigarettes for Resident #4. She said HSK A told Resident #4 not to share, that she was only buying for Resident #4. Resident #2 said she wished HSK A would shut up. HSK A got up form her chair and told Resident #2 she would have to get out of her chair to make her shut up. She said Resident #3 told HSK A to calm down. She said Resident #2 said she wished she could punch HSK A in the face. Resident #2 was upset and crying. She said she was scared of what HSK A would do if she knew she had reported. She said she was trained on abuse and reporting. She said residents were at risk of further abuse if it was not reported immediately. During an interview on 05/09/25 at 10:10 a.m., Resident #3 said HSK A was having words with Resident #2 over some cigarettes. He said HSK A was disrespectful and angry. He said they called each other BITCH. He said HSK A said if Resident #2 got up from her chair she would whoop her ass. He said he told HSK A she should not talk to her elders like that. He said he was not interviewed about the incident. He said he had not heard HSK A speak to residents that way before. During an interview on 05/09/25 at 12:29 p.m., Resident #4 said HSK A and Resident #2 were arguing about cigarettes. She said HSK A had purchased the cigarettes for her (Resident #3) and was mad because Resident #4 was going to share with Resident #2). She said HSK A said she wanted to whoop Resident #2's ass because she was arguing with her. She said she knew HSK A all her life and she had a temper. She said she never heard HSK A talk to residents that way before. She said she would report abuse to the Administrator or the DOM immediately. During an interview on 05/09/25 at 12:40 p.m., Administrator L said she did not conduct interviews with Resident #3 or Resident #4. She said she thought the SW would have conducted the interviews when she did the safe surveys. During an interview on 05/09/23 at 1:03 p.m., the SW said she was not sure if she wrote interviews down for Resident #3 or Resident #4. She said she remembered talking to Resident #4 but not Resident #3. She said Resident #4 did not report HSK A said she wanted to whoop Resident #2's ass. She said she would have reported the allegation to the Administrator immediately. During an interview on 05/09/25 at 1:18 p.m., HSK B said she did not hear HSK A say she wanted to whoop Resident #2's ass. She said she would still be scared to report if she did hear the threat. During an interview on 05/09/25, at 1:51 p.m., Administrator L said she was retrained on abuse on 05/08/25. She said not following the facility policy for abuse prevention, reporting, and investigation placed the residents were at risk for re-occurrence of abuse or the incident could have escalated. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; .

Based on interview and record review, the facility failed to ensure pharmacy procedures to ensure an accurate accounting of all controlled drugs and the licensed pharmacist failed to ensure the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 4 medication carts reviewed for narcotic counts. (300 Hall Nurse Cart and 200/500 Halls Medication Aide Cart) The facility did not ensure staff were conducting accounting of Controlled Drugs at shift change on the 300 Hall Nurse Cart and 200/500 Halls Medication Aide Cart. The Pharmacy Consultant did not ensure the Controlled Drugs - Count Record forms had signatures of the staff indicating the Controlled Drugs were reconciled. These failures could place residents at risk for misappropriation and drug diversion. Findings included: Record review of the June 2024 Controlled Drugs - Count Record form on the 300 Hall Nurse Cart indicated: *on the day shift the nurse going off shift did not sign the form on 1st, 5th, 6th, 10th, 12th, 13th, 19th, 20th, and 21st; *on the night shift the nurse going off shift did not sign the form on the 14 th ; *on the night shift the nurse coming on shift did not sign on 4th, 5th, 8th, 11th, 12th, 13th, 18th, and 19th; and *there were no signatures on the day shift on the 14th and 20th; and *there were no signatures on the night shift on the 20th. Record review of the June 2024 Controlled Drugs - Count Record form on the 200/500 right side Halls Medication Aide Cart indicated: *on the day shift the Medication Aide coming on shift did not sign on 4th, 5th, 10th, 18th, 19th, 21st, 22nd, 23rd, and 24th; and *on the night shift the Medication Aide going off shift did not sign on 4th, 5th, 8th, 10th, 18th, 19th, 21st, 22nd, 23rd, 24th, and 25th. Record review of the Consultant Pharmacist Activity Report dated 06/18/24 indicated Special Notes/Activities: The medication room and carts were reviewed There was no indication on the report of missing signatures on the Controlled Drugs - Count Record forms on the medication aide or the nurse carts. During an interview on 06/25/24 at 12:40 p.m., MA C indicated if the narcotics were not counted then the medications could be missing and because the sheet was not signed as to who had the cart they would not know who would be accountable for missing medications. During an interview on 06/25/24 at 01:09 p.m., MA D indicated she was not trained on the cart count sheet. During an interview on 06/25/24 at 12:39 p.m., the DON indicated she expected staff to count the narcotics on the medication carts. She indicated if the counts were not done then there could be a drug diversion and she would not know who would be accountable for missing medications. During an interview on 06/25/24 at 12:39 p.m., the DON indicated the no signature could indicated the narcotic counts were not done. Pharmacy Consultant was at the facility a few days ago and reviewed the medication aides and nurse carts. She indicated there was no report of any issues with the count sheets. During a phone interview on 06/25/24 at 01:50 p.m., the Pharmacy Consultant indicated she was supposed to check the signature count to ensure the staff are counting medications between shifts before they hand off the keys. She said she did not notice the missing signatures on the cart count sheets. She said the possible negative outcome could be a drug diversion. Record review of a Controlled Substances policy revised April 2019 indicated Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: .4. Access to controlled medications remains locked at all times and access is recorded. .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. .12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together Record review of a Pharmacy Services - Role of the Consultant Pharmacist policy revised April 2019 indicated Policy Interpretation and Implementation: 5. The consultant pharmacist will provide specific activities related to medication regimen review including: d. review of medication storage areas at least monthly, and medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and expired medications;

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 2 of 2 medications reviewed for security. The facility did not ensure clonidine (medication to treat elevated blood pressure) and a Fentanyl patch (narcotic opioid pain medication) medication was stored securely when it was left unattended at the nursing station. This failure could place residents at risk for harm by misappropriation of property and drug diversion. Findings included: During an observation on 06/23/24 at 12:28 p.m. of the nurse station, a card of clonidine (medication to treat elevated blood pressure) and a Fentanyl (narcotic opioid pain medication) patch were left on the desk unattended by a nurse or medication aide and accessible to staff, residents, and visitors. During an interview on 06/23/24 at 12:30 p.m., the Administrator was shown the card of clonidine and Fentanyl patch were on the desk of the nurse station unattended by a nurse or medication aide. He said medications were not to be left at the nurse station unattended by the staff as they could be removed by anyone walking by. During an interview on 06/23/24 at 12:32 p.m., LVN B indicated she had the card of clonidine to put on the cart and was reordering the Fentanyl patch when she got up to leave the nurse station. She said she should not have left the medications at the desk. During an interview on 06/25/24 at 02:09 p.m. during the exit, the DON indicated she was aware of the medications being left at the nurse station and medications were not to be left to where anyone could get them. Record review of a Controlled Substance policy revised April 2019 indicated Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: .3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. 4. Access to controlled medications remains locked at all times and access is recorded

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's needs identified in the comprehensive assessment for 1 of 20 residents reviewed for following physician orders. (Resident #27) The facility did not apply Resident #27's hand splint as ordered by the physician This failure could place the residents at risk of a decline in their range of motion. Findings included: Record review of physician orders dated June 2024 indicated Resident #27, admitted [DATE], was an [AGE] year-old female with diagnoses of muscle wasting and atrophy and cerebral infarction (a condition that occurs when blood flow to the brain is disrupted causing the brain tissue to die). The orders indicated the resident was to have a resting hand splint to the right upper extremity to prevent contracture. The hand splint was to be removed every night. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #27 had a BIMs of 4 (Severe cognitive impairment), had an impairment in ROM to one side of the upper extremities and was dependent for personal hygiene and toileting. Record review of a care plan revised 02/16/24 indicated Resident #27 had limited physical mobility or was at risk for a decline in mobility related to a limited range of motion to the right arm/hand. Record review of an ADL task sheet dated June 2024 for Resident #27 indicated the CNAs were to apply a resting hand splint to the resident's right upper extremity each morning and remove each night to prevent contractures. During observations, Resident #27 had her right hand clenched tightly with the fingers and thumb positioned inward towards the palm of the hand but opened it when asked. The resident did not have a splint to the right hand: *on 06/23/24 at 10:48 a.m., *on 06/24/24 at 8:33 a.m., *on 06/25/24 at 2:42 p.m., and *on 06/25/24 at 9:44 a.m. During observation and interview on 06/25/24 at 9:44 a.m., Resident #27 was sitting in the common area with her right hand closed tightly. The surveyor asked the resident to open her hand and the resident was able to straighten all fingers out. The DON said the resident was supposed to have a splint in her hand as ordered. She said the possible negative outcome could be the resident's hand could become contracted. She said her expectation was for the resident to have the splint in her hand as ordered. During observation and interview on 06/25/24 at 9:53 a.m., upon entering Resident #27's room, the DON retrieved the resident's splint from the top of the chest of drawers and said here it is. The DON said the splint was not applied as ordered. She said it was the CNA's responsibility to make sure the splint was applied. During an interview on 06/25/24 at 10:50 a.m., CNA E said she worked on Hall 600, where Resident #27 resided. She said she was not aware she was supposed to apply the splint to Resident #27's right hand and no one had told her she was supposed to until then. She said she did look at the aide assignment sheet for the resident and did see the splint was to be applied to the right hand but she did not ever see a hand splint so she did not apply it. She said the possible negative outcome of not applying the splint would be the resident's hand could get to the point of not opening and she would not be able to use it. Review of the Prevention of the decline in Range of Motion policy dated 2023 indicated The facility in collaboration with the medical director, director of nurses and as appropriate, physical/ occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #272) reviewed for enteral feeding. The facility failed to ensure LVN A verified placement of Resident #272's G-tube by checking for tube placement before enteral administration of water and medications. The facility failed to ensure LVN A administered the flushes and medications using gravity. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, aspiration, and possible injury. Findings included: Record review of Resident #272's physician orders dated June 2024 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dysphagia (difficulty or discomfort swallowing). Orders indicated he was NPO (nothing by mouth), was to receive all feedings and medications via G-tube (a tube inserted through the stomach that brings nutrition directly to the stomach) and tube placement was to be verified before each use by change in the incremental marking on tube, documented tube length, gastric residual volume, or by pH of aspirate. Record review of a care plan dated 06/21/24 indicated Resident #272 had a feeding tube. Interventions included to administer enteral feeding, medications, and water flushes as ordered. During an observation and interview during medication administration on 06/24/24 at 09:30 a.m., LVN A did not check placement of Resident #272's G-tube prior to administration of water flushes and medications through the G-tube. LVN A flushed the tube with water, she drew up the medications individually with the syringe, administered the medications using the plunger in the syringe, drew up the water between medications using the syringe, flushed the water using the plunger in the syringe, then did the final flush of the tube with water. LVN A said she would not have done anything different in the procedure. During an interview on 06/25/24 at 10:35 a.m. the DON indicated staff should follow the policy for gastrostomy tube placement check and flushes/medications should be administered via gravity. She indicated the flushes and medications should be done via gravity and not pushed through the syringe with the plunger. She indicated injury could occur from pushing fluids or medications through the gastrostomy tube. Record review of the Confirming Placement of Feeding Tubes policy and procedure revised November 2018 indicated Purpose: The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication.Steps in the Procedure: .To Confirm Placement of an Existing Feeding Tube at the Bedside: 1. Use one of the following methods to test whether the tube is properly positioned: a. Observe for symptoms of elevated gastric residual volume (GRV - Please see GVR Policy), or: (1) A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach; (2) Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. b. Observe and check the pH of aspirate: (1) Fasting stomach contents will have a clear and colorless or grassy green and brown appearance. (2) Fluids from the pleural space may have a pale yellow, serous appearance. (3) Post-pyloric/small bowel contents can be bile-stained, light to dark yellow or greenish-brown. (4) Fasting stomach acid will have a pH of 5 or less. (5) Fluid from the pleural space will have a pH of 7 or higher. (6) A pH of 5 or less suggests that the tube is placed in the stomach. However, a pH of 6 or greater is not definitive of placement outside the stomach. 2. If the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 3. When correct tube placement has been verified, flush tubing with at least 30 mL water (or prescribed amount) Record review of the Administering Medications through an Enteral Tube policy and procedure revised November 2018 indicated Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube Steps in the Procedure: 6. Verify placement of feeding tube: a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 10. Administer each medication separately. 11. Reattach syringe (without plunger) to the end of the tubing. 12. Administer medication by gravity flow: a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly. c. Begin flush before the tubing drains completely. 13. If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm purified water (or prescribed amount). 15. Quickly clamp the tubing when the flush is complete. Remove syringe

Based on interview and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 2 of 3 residents reviewed for parenteral care and services: The facility failed to ensure there was documentation of the insertion of hydrodermoclysis (fluids infused into the subcutaneous tissue for hydration) clysis, monitoring of the site and the infusion and discontinuation of therapy. for Residents #1 and #2. This failure could affect residents with parenteral care and services, placing them at risk of peripheral edema, leakage, or fluid overload from hypodermoclysis hydration infusion. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was admitted on [DATE], was a [AGE] year-old male with diagnoses including acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing lack of oxygen supply), fracture right femur (broken upper leg), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and stroke (damage to the brain from interruption of its blood supply). Record review of MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. He required extensive assistance in performing all activities of daily living (ADLs). He was in-continent to bowel and bladder. Record review of care plan for Resident # 1 indicated Focus: Resident had a cerebral vascular accident and goals that Resident will be free from signs and symptoms of complications of stroke including dehydration through review date. Record review of Resident #1's physician orders dated [DATE], indicated an order for Dextrose-NACl Intravenous Solution ,d+[DATE].45% (Dextrose w/ Sodium Chloride) inject 3 liters subcutaneously (via clysis) one time only for dehydration until [DATE]. Record review of Resident #1's progress notes dated [DATE] - [DATE], MARs for [DATE] indicated no documentation of the clysis needle being inserted, no monitoring/assessment of infusion, the site or discontinuing of the hydration. During an observation and interview on [DATE] at 8:45 a.m., revealed Resident #1 was lying in bed, fall mat by bed. He was clean and well-groomed with no unpleasant odors. Water was available at bedside, and he did not show any visible signs of dehydration. Resident #1 was not able to recall the hydration infusion he received in [DATE]. There was no infusion at the time of the observation. During an interview on [DATE] at 9:00 a.m., LVN A recalled administering Resident #1 hypodermoclysis (subcutaneous) hydration therapy, she said Resident #1 was bad about pulling the subcutaneous needle out and that the therapy would have to be restarted. She said staff would have to stay with the resident while he was receiving his infusion. LVN A said that the procedure was supposed to be documented in the progress notes or MAR every shift, the type of fluid, location of needle, insertion site assessment, monitoring infusion, and starting or discontinuing the infusion. LVN A felt the treatment benefits the residents if they were mildly dehydrated and stated, she was comfortable and competent in performing the procedure. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was admitted [DATE], was [AGE] years old and had diagnoses including cellulitis of left lower limb (a bacterial skin infection), acute embolism (blood clot or air bubble in artery), and thrombosis (blood clot) of other specified deep vein of left lower extremity, dementia (loss of cognitive functioning), developmental disorder of scholastic skills (conditions characterized by a significant discrepancy between an individuals perceived level of intellect and their ability to acquire new language and other cognitive skills), cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 expired on [DATE]-23 Record review of MDS dated [DATE], he was alert with a Brief Interview for Mental Status (BIMS) score of 2 which indicated he was severely cognitively impaired. He required extensive assistance in performing most activities of daily living (ADLs) and supervision with eating and locomotion. He was in-continent to bowel and bladder. Record review of care plan for Resident # 2 indicated Focus: Resident is receiving IV fluids for peripheral line/PICC line/midline/central line) in the right/left arm). Decrease PO intake Date initiated [DATE]. Goals: Resident will be compliant with IV fluids thru next review. Resident will tolerate IV fluids with no complications thru next review. Record review of Resident #2's physician orders dated [DATE] indicated to infuse Sodium Chloride 0.9%, use 40 ml/hr intravenously one time for dehydration for 2 days x 2 Liters NS via clysis (1st Liter via emergency drug kit ekit) [DATE] to [DATE]. Record review of MAR and TARs [DATE] for Resident #2 indicated no documentation of insertion of the needle for the clysis, monitoring/assessment of parenteral care or discontinuation of therapy. Record review of Resident #2's progress notes for ,d+[DATE], did not include documentation of insertion of the needle, monitoring of hypodermoclysis (subcutaneous) infusion, site care or management/monitoring. During an interview on [DATE] at 3:09 p.m., LVN C said she knew she was supposed to document insertion of the clysis needle and monitoring. She said she made sure Resident #2 had the order and just made the mistake and did not document about the administration or insertion of the clysis. During an interview on [DATE] at 3:45 p.m., LVN B said she had been checked off on inserting the clysis needle. She said the insertion was supposed to be documented, the site monitored and documented, and when the hydration is stopped, it should be documented in the medical record. During an interview on [DATE] at 8:10 p.m., LVN D said she discontinued Resident #2's clysis for hydration about 30 minutes into her shift on [DATE].She said she should have documented the discontinuation and what the site looked like. During an interview on [DATE] at 10:20 a.m., the DON said that all staff were trained upon hire and annually on the Hypodermoclysis - Subcutaneous Hydration therapy, this training/in-service included purpose, general guidelines, equipment/supplies needed, steps in procedure, documentation, and reporting. The DON and ADM stated their expectations were for staff administering subcutaneous hydration therapy to be trained and competent and to document the procedure following the facility policy in the resident's medical records. Negative outcome regarding improper or lack of documentation regarding subcutaneous hydration therapy could reflect inaccurate assessment of resident and possible complications at subcutaneous insertion site (peripheral edema, leakage of fluid, or fluid overload) - DON acknowledges that one of the reason they utilized clysis (subcutaneous) infusions for hydration therapy was the lack of potential serious complications like fluid overload and infected IV sites, states it was also easier for the residents. Record review of facility policy revised [DATE] indicated Hypodermoclysis - Subcutaneous Hydration . Purpose: . The purpose of this procedure is to provide guidelines for administration of subcutaneous hydration to the resident as ordered. General guidelines: . 2. Hypodermoclysis is a method of hydration that does not require an intravenous catheter for delivery. 3. Hypodermoclysis involves using small needles to deliver isotonic fluids (0.9 NS, lactated ringers, D%W) slowly into the subcutaneous tissue. 4. This system is designed for short-term, preventative hydration or for mild dehydration. 5. Hypodermoclysis is NOT for antibiotics, narcotics, or fluids with electrolytes (KCL, magnesium, etc.). 6. Sites for needle placement are the abdomen, stomach, and front or side of thighs. Less commonly used sites are the upper arm or upper back shoulder area. 7. The fluids infused into the subcutaneous tissue where it is absorbed slowly. While the fluid is absorbed, a fluid wheal will form. This is normal and is not an infiltration of fluids. 8. Hypodermoclysis reduces the chance of the following complications associated with intravenous therapy: a. fluid overload, CHF; b. Phlebitis; and c. infection. 9. Physician order should include: a. type and quantity of isotonic fluid; b. Rate (determined by type of delivery set); and c. length of treatment. Steps in the procedure: 1. Review physician order. 2. Explain procedure to resident. 3. Assemble fluid and kit. 4. Wash hands. Don non-sterile gloves. 5. Prime tubing including attached needle set until all air is removed. 6. Do sterile site preparation and allow to air dry. 7. Pinch up skin or flatten skin. Insert needle strip flat into skin. 8. Secure needle strip to skin using transparent dressing. Tape tubing to skin. 9. Date dressing and tubing. 10. Start fluid and adjust flow rate. Make sure that the resident is comfortable. 11. Monitor for fluid wheal will form. This is normal and is not an infiltration of fluids. 12. If necessary, the site may be lightly massaged to help fluid absorption. 13. Observe for any signs of peripheral edema (not the fluid wheal), leakage or fluid overload. Monitor for line disconnection from skin. 14. If the site needs to be changed, the whole set including needles are changed as one piece. Contact pharmacy for new set. No new order is needed. Documentation . 1. Document the following in the resident's medical record upon insertion: a. procedure; b. type of fluids; and c. dressing and tubing. 2. Document the change date on the medication administration record. 3. Document the following in the resident's medical record every shift: a. the type of fluids being infused, location of needle placement, type of antiseptic used to clean skin; b. intake and output totals; c. time fluid bag was started and discontinued; d. condition of skin where needles are inserted, any leakage, peripheral edema (not fluid wheal), statement from resident regarding how they are tolerating treatment; e. date and time of tubing and needle strip site change and reason for changing site (leakage, skin irritation, 72 hour site change); and f. Any communication with physician about problems, laboratory values. Reporting . 1. Report to physician or supervisor any information about treatment. 2. Report to oncoming shift nurses the type of treatment. Needle insertion site any complications, and any objective information concerning treatment.

Based on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 2 of 3 residents reviewed for intravenous fluids. (Resident #39 and 82) *The facility failed to change Resident #39 and 82's midline catheter dressing in accordance with the resident's plan of care. (Midline catheter is an ultrasound guided catheter inserted in the upper arm peripheral veins for IV access) This failure could place residents at risk of not receiving the appropriate IV care and services. Findings included: 1. Record review of physician orders dated April 2023 indicated Resident #39, admitted [DATE], was [AGE] years old with diagnoses of emphysema and COPD (chronic obstructive pulmonary disease). Record review of a physician order dated 04/13/23 for Resident #39 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. Resident #39 was to receive Cefepime HCL (hydrochloride) Intravenous solution 1 GM/50 ml. Use 1 GM intravenously every 12 hours for pneumonia for 7 days. Record review of Resident #39's TAR (treatment administration record) for April 2023 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. There was no indication Resident #39's midline catheter site dressing had been changed since insertion on 04/15/23 and was not scheduled to be changed until 04/23/23. Record review of Resident #39's quarterly MDS dated [DATE] gave no indication of midline IV or IV antibiotics, as this MDS was completed prior to new orders. Observation and interview on 04/17/23 at 8:30 a.m., Resident #39 had a right upper arm midline IV with an undated, soiled transparent dressing. A piece of dried, blood-tinged gauze was under the transparent dressing. Resident #39 said the midline IV was put in a few days ago and was receiving antibiotics. He denied any pain or swelling at site. Observation and interview on 04/17/23 at 12:49 p.m., LVN C said Resident #39's midline IV was inserted 04/15/23. She said the transparent dressing was not signed and dated and it should be. She said RNs are responsible for changing the midline IV dressing weekly. LVN C said Resident #39's IV dressing needed to be changed because it had dried blood under it. She said nursing staff needed to be able to always assess the IV site, and Resident #39's site could not be assessed because of the dried, blood-stained gauze. She added a soiled dressing such as the one on Resident #39 could potentially cause an infection. LVN C said the site was to be assessed for signs of infection, which included redness, warmth, and drainage. Observation and interview on 04/18/23 at 12:00 p.m. with Regional Nurse at Resident #39's bedside. He said the midline IV catheter was inserted on 04/15/23 by an outside vendor, and the dressing site should have been dated and initialed at that time. He said the IV site should not have dried blood under the dressing, and the dressing should have been changed 24-48 hours after insertion, and it did not appear to have been changed per policy. Regional Nurse said midline IV sites should also have dressing changes when visibly soiled and PRN (as needed). He said the treatment nurse, who was an RN, was responsible for midline IV dressing changes. During an interview on 04/18/23 at 12:15 p.m., DON said her expectations were IV sites to be assessed and dressing changes performed per facility policy. She said Resident #39's midline IV site dressing should have been changed due to soiled dressing. She added this oversight could potentially lead to an infection of the site. 2. Record review of admission physician orders dated 04/10/23 indicated Resident #82, admitted [DATE], was [AGE] years old with diagnosis of Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues). Record review of a physician order dated 04/11/23 for Resident #82 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. Resident #82 was to receive cefazolin sodium (used to treat bacterial infections) intravenously. Use 2 GM intravenously every 8 hours for infection until 05/09/23. Record review of Resident #82's TAR (treatment administration record) for April 2023 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. Resident #39's midline catheter site dressing had been changed on Sunday 04/16/23, however on this date Resident #82's midline RUA dressing was compromised as it was soiled with dried blood under the transparent dressing. Record review of Resident #82's Admission MDS dated [DATE] indicated receiving IV antibiotic medications prior to admission to facility and while in the facility. Record review of Resident #82's care plan dated 04/12/23 gave indication of a midline IV access site. Resident #82's goal was to have no complications related to IV therapy through the next review. Interventions for Resident #82 included changing sterile transparent dressing per physician order and as needed if integrity of dressing is compromised (wet, loose, or soiled). Use a transparent dressing to ensure visualization of the IV site. During observation and interview on 04/19/23 at 2:00 p.m., Resident #82 was sitting in wheelchair visiting with spouse. Resident #82 had a RUA midline IV catheter with a soiled transparent dressing. His had dried blood visible through the transparent dressing. Resident #82 said his IV site dressing had been changed over the weekend. The initials and date were illegible. Resident #82 denied pain or swelling at site. He said he was receiving IV antibiotics for a skin condition. He said he did not know how long the dried blood had been under the transparent dressing. During an observation and interview on 04/19/23 at 2:10 p.m., LVN C acknowledged Resident #82's midline IV dressing was soiled and needed to be changed. She said she would notify the treatment nurse of the situation. During an interview on 04/19/23 at 10:20 a.m., the treatment nurse said she worked Monday-Friday and was responsible for all wound care including IV site dressing changes. She said on the weekends, the weekend RNs were responsible for wound care. The treatment nurse said she had worked at the facility for 2 years and had been the treatment nurse since August 2022. She said she had received training via online classes and hands-on training. She said the nursing staff were scheduled for an in-service training the following day (04/20/23). The treatment nurse said she was supposed to be notified of any new wound/IV orders. She also receives a daily computer print-out of new and/or current wounds and orders. Record review of training in-service indicated most recent in-service on wound care and dressing changes was December 2022 and provided by DON/Regional nurse. Record review of a facility policy dated revised April 2016 and titled, Midline Dressing Changes indicated: . Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings. General Guidelines. 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.

Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and drug records were in order and that an account of all controlled drugs was maintained for 1 of 18 residents (Resident #46) reviewed for pharmacy services. LVN A did not destroy the used fentanyl (scheduled II controlled medication used for severe pain) patch in a sharps container per policy and with a witness for destruction after the patch was removed from Resident #46. The facility did not ensure records for Resident #46 were complete with witness signatures for 5 days on control sheet for disposition of discarded fentanyl patch. This failure could place the residents at risk of drug diversion. Findings included: Record Review of physician orders summary dated April 2023 indicated Resident #46 admitted [DATE] and was [AGE] years old with diagnoses of chronic pain and kidney cancer. The orders indicated to apply 1 fentanyl patch 75 mcg/hour every 3 days and remove patch per schedule. Record review of the significant change MDS assessment dated [DATE] indicated Resident #46 had chronic pain and received pain medication routinely. Record review of Resident #46 medication administration record dated April 2023 indicated a fentanyl patch 75 mcg/hour was ordered every 72 hours, applied transdermal (medication absorbed through the skin) and removed after 72 hours for pain management on the following dates: *04/6/23, *04/9/23, *04/12/23, *04/15/23, *and 04/18/23. Record review of Resident #46's count sheet dated 03/31/23 indicated a fentanyl patch was applied and no witness signatures to indicate the removed used fentanyl patch was destroyed with witnesses on the following dates: *04/6/23, nurse signature was illegible, when the patch was removed and no witness signed, *04/9/23, an unnamed agency nurse signed removing patch and no witness signed, *04/12/23, LVN B signed removing patch and no witness signed, *04/15/23, LVN B signed removing patch and no witness signed, *and 04/18/23, LVN A signed removing patch and no witness signed. During an observation on 04/18/23 at 7:43 a.m., LVN A removed the fentanyl patch from Resident #46's chest and placed in the resident's trash. She removed the resident's trash bag with the used fentanyl patch in it, brought it to the soiled linen room, and placed into the trash can. The soiled linen room was not locked. During an interview on 04/18/23 at 7:52 a.m., LVN A said she was trained to throw the fentanyl patch in the trash, bring the trash bag out of the room, and dispose the fentanyl patch in the regular trash can. She said the fentanyl patch could still have medication on the patch. LVN A said she would then sign on the control sheet- sign that she placed a new patch and disposed of the old patch. LVN A denied getting another nurse to witness her dispose of the fentanyl patch for Resident #46. She said she was not trained to use the column which was labeled witness signature. During an interview and record review on 04/18/23 at 8:15 a.m., the DON said she expected the nurses who removed the used fentanyl patch to dispose it in the sharp's container with a witness and both sign the count sheet. She pointed to the count sheet for Resident #46 and said the nurse who witnessed the patch being placed in the sharp's container should have signed in column marked witness signature. The DON said the witnesses did not sign Resident #46's sheet. She said she could not read the signature of the nurse, who removed the patch on 04/06/23. The DON said the documentation on 04/09/23 was an agency nurse. During an interview on 04/18/23 at 8:18 a.m., the administrator said he agreed with the DON about the way the control medication should be handled. During an interview on 04/19/23 at 9:00 a.m., LVN B said on 04/12/23 and 04/15/23 she disposed of the used fentanyl patch in the sharp's container on the medication cart for Resident #46. LVN B said she forgot to get someone to witness her placing the patch in the sharps container and sign the control sheet. She said if they did not get a witness, they could be accused of taking the used fentanyl patches. She said they were trained to have a witness, when disposing of a used fentanyl patch. During an interview on 04/19/23 at 2:00 p.m., the DON said per the facility's policy, the nurses must have a witness to dispose of the fentanyl patch or any controlled medications to prevent drug diversion. Record review of the policy Disposal of medications dated August 2014 . indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations. E. The witnesses of the destruction

Based on observation, interview, and record reviews, the facility failed to ensure residents have the right to be free from neglect for 1 of 9 residents (Resident #1) reviewed for neglect. The facility did not immediately or promptly respond to a call light from Resident #1's room after the resident had complaints of not feeling well that day. Facility video recording showed the call light was on for 45 minutes. Resident #1 was then found unresponsive and without a pulse in her room. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:24 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed other residents at risk of neglect. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female, admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1's oxygen was to be administered at 5 liters per minute via nasal cannula. Record review of an MDS dated [DATE], indicated Resident #1 had a BIMS of 14 indicating she was cognitively intact. She required extensive assist of one to two staff with ADLS, utilized a wheelchair for mobility, and was always incontinent of bowel and bladder. Record review of care plan dated [DATE] indicated Resident #1 was at risk for falls related to impaired mobility. Interventions included keep call light within reach and answer promptly. Record review of care plan dated [DATE] indicated Resident #1 had altered physical functioning related to [CONDITION(S)], heart disease, and diabetes. Interventions included call light within reach and answered promptly. Record review of care plan dated [DATE] indicated Resident #1 had shortness of breath upon exertion and/or inadequate oxygenation when lying flat. Interventions included administer oxygen, medications, and breathing treatments as ordered. Record review of care plan dated [DATE] indicated Resident #1 required oxygen due to shortness of breath due to respiratory failure. Resident #1 would remove O2 cannula at times and O2 SATS would drop. Interventions included check for correct placement of nasal cannula or ventimask, check oxygen saturation, and remind resident to keep oxygen cannula in place and replace oxygen when cannula is off. Record review of care plan dated [DATE] indicated Resident #1 had coronary artery disease and interventions included give all cardiac medications as ordered and monitor and report as needed any signs or symptoms of CAD. Record review of care plan dated [DATE] indicated Resident #1 had chronic respiratory failure. Interventions included administer medications as ordered and encourage sustained deep breaths. Record review of Resident #2's face sheet indicated she was a [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These individuals can learn practical life skills, which allows them to function in ordinary life with minimal levels of support.), anxiety a feeling of fear, dread, and uneasiness, [CONDITION(S)] (severe) and [CONDITION(S)] and collapse. Record review of Resident #2's MDS dated [DATE] indicated she was usually understood and usually able to understand others. She had a BIMS of 10 indicating she had moderate cognitive impairment. She required extensive assist for most ADLS, was totally dependent on 2 or more staff for transfers, and utilized a wheelchair for mobility. Record review of Resident #2's care plan dated [DATE] indicated she was at risk for falls related to impaired mobility. Interventions included assist resident as needed, encourage resident to ask for assistance, and keep call light within reach and answer promptly. Record review of Resident #2's care plan dated [DATE] indicated she had altered physical functioning related to recent hospitalization weakness. Interventions included call light would be within reach of resident and answered promptly. Record review of Resident #2's care plan dated [DATE] indicated she was at risk for skin breakdown related to incontinence of bowel and bladder and impaired mobility. Interventions included having call light available and answered promptly. Observation of video dated [DATE] from 2:20 p.m. through 3:11 p.m. for hall 500 indicated the following: 2:24 p.m. call light for Resident #1 and Resident #2 turns on 2:24 p.m. RNA P walk by 2:36 p.m. NS AA knocks on door, sticks head in and out of door and walks away (leaves call light on) 2:37 p.m. unidentified nursing student walks by, sticks head in and out of room across hall 2:44 p.m. LVN A at med cart on the same hall 2:50 p.m. ES T opens soiled linen room door, in and out of soiled linen room 2:52 p.m. AD BB walks down hall 2:55 p.m. AD BB walks back down hall towards nurse station 3:00 p.m. LVN S at med cart on the hall 3:02 p.m. LVN S leaves med cart 3:06 p.m. RN Q walks down hall to last room on right of hall (passed by Resident #1 and Resident #2's room both ways) 3:06 p.m. LVN R walks down hall to last room on right (passed by the residents' room without answering call light) 3:08 p.m. CNA B answers call light past Resident #1's room 3:09 p.m. CNA B enters Resident #1's room, call light shuts off, family member comes to door, CNA B talks to family member, CNA B leaves room to get LVN A 3:10 p.m. CNA B and LVN A enter Resident #1's room 3:11 p.m. LVN A call for LVN F and LVN R During an interview on [DATE] at 2:40 p.m., Resident #2 said she heard Resident #1 yell for her to pull the light and then she yelled again and then she did not hear Resident #1 call again. She said she couldn't see Resident #1 because the privacy curtain was pulled between them. She said the door was shut and she tried to yell for help but no one came and no one heard her yell. She said she did not know what time she pulled the call light. She said it took longer than usual for staff to come in the room. She said she was upset and crying because Resident #1 died and no one came to help her. Record review of progress note dated [DATE] at 5:00 p.m., completed by LVN CC, indicated Resident #1 experienced nausea after eating lunch. Resident #1 refused [MEDICATION(S)] because it did not help. Record review of progress note dated [DATE] at 6:30 a.m., completed by LVN A, indicated NP notified Resident #1 complained of nausea. Resident refused [MEDICATION(S)]. No new orders were given at that time. Record review of progress noted dated [DATE] at 11:00 a.m., completed by LVN A, indicated Resident #1 stated she would take [MEDICATION(S)]. Assessed vitals (were within normal limits) and notified NP in facility. NP ordered CBC and CMP tomorrow morning. Record review of progress note dated [DATE] at 12:21 p.m., completed by NP O, indicated Resident #1 was seen for complaint of nausea. Resident denied vomiting and PRN [MEDICATION(S)] was mostly effective. Resident #1 denied fever, chills, headache, dizziness, unusual shortness of breath, unusual cough chest pain, palpitations, nausea, vomiting diarrhea, unusual fatigue, or unusual weakness. The resident reported her breathing problems were no worse than normal. There was no reported chest pain, palpitations, shortness of breath, or other cardiac symptoms. The plan for nausea included continue [MEDICATION(S)] as needed and check CMP and CBC in the morning. Record review of progress note dated [DATE] at 2:03 p.m. and completed by LVN A indicated she administered Pepto Bismol to Resident #1 for loose stool and stomachache. The CNA was completing last rounds and Resident was wearing nasal cannula. Record review of progress note dated [DATE] at 3:00 p.m., completed by LVN A, indicated CNA called nurse to Resident #1's room. Resident #1 was supine and eyes were closed. Resident #1 did not have nasal cannula in place. LVN A disinfected nasal cannula, called to resident, joggled resident shoulders and arms calling her name, listened for breath sounds, and felt for pulse. The resident had no breathing and no pulse. LVN A called out for help, asked for someone to contact EMS, called for the crash cart, and began administering chest compressions. AED monitor was applied and ambu bag started and followed instruction from monitor actively administering CPR until EMS arrived. EMS arrived at approximately 3:05 p.m. EMS took over administering CPR. EMS transferred resident to hospital. Resident's family member in facility and aware of resident condition. LVN A contacted physician and DON. Record review of EMS records dated [DATE] indicated Resident #1 was in cardiac arrest. Facility staff performed CPR with AED attached. Resident #1 was apneic and pulseless. CPR taken over and Resident #1 placed on cardiac monitor with defib pads and was asystole (a state of cardiac standstill with no cardiac output and no ventricular depolarization). Record review of hospital records dated [DATE] indicated Resident #1 arrived at the ER at 3: 40 p.m. in cardio-respiratory arrest. The onset was unknown and not witnessed. The initial cardiac rhythm was asystole. Resident #1 was pronounced deceased at 4:04 p.m. Review of chest x-ray dated [DATE] at 4:00 p.m. indicated diffused pulmonary [CONDITION(S)] and/or infiltrates worse than before. Heart remains grossly enlarged. There was worsening bilateral pulmonary infiltrates and/or [CONDITION(S)]. Record review of the facility's General Working Guidelines provided by the DON on [DATE] at 1:35 p.m. indicated: ,d+[DATE] Shift 10:00am to 10:30am -200 and 500 Hall (100 watch 500 and 300 watch 200) 10:30am to 11:00am -100, 300, 600 Hall (500 hall watch 100 and R 600, 200 hall watch 300 and L600) *Halls with two aides-One aide stays on hall while other goes to lunch. ,d+[DATE] Shift 7:00pm to 7:30pm -200 and 500 Hall (100 watch 500 and 300 watch 200) 7:30pm to 8:00pm -100, 300, 600 Hall (500 hall watch 100 and R 600, 200 hall watch 300 and L600) *Halls with two aides-One aide stays on hall while other goes to lunch. ,d+[DATE] Shift 1:00am to 1:30am -100 and 500 Hall (other halls cover) 1:30am to 11:00am -100 & 300 and 600 ( other halls cover) The DON said she found them in the CNA book at the nurse station. During an interview on [DATE] at 12:47 p.m., LVN A said she last saw Resident #1 at approximately 2:00 p.m. on [DATE] when she administered medication for diarrhea. She said Resident #1's nasal cannula was off and she prompted her to put it back on. She said Resident #1 received incontinent care from CNA B at the time she administered the medication. She said Resident #1 did not complain of chest pains or breathing problems. She said she made sure the oxygen was hooked up correctly and left the room. She said she was called back to the room by CNA B and found Resident #1 with no pulse and not breathing. She said she initiated CPR and called for the crash cart. She said the AED was hooked up and CPR continued until EMS arrived and took over. During an interview on [DATE] at 1:04 p.m., CNA B said Resident #1 complained of being sick and throwing up the night before on [DATE]. She said the next morning on [DATE], she was still feeling sick and nauseated, so they called the doctor. She said she was working on a different hall when she went to check the hall Resident #1 was on. She saw her light was on but the door was shut so she assumed a staff was already in the room because Resident #1's door was usually open. She said she took care of the other two lights and saw Resident #1's room light was still on and she went in to check. She said Resident #2 was yelling she had turned on the light. She said she checked Resident #1, and she felt cold. She said she called for LVN A, who was standing at the nurse station. She said she saw Resident #1's family member walking down the hall. CNA B said LVN A came from the nurse station and she reported Resident #1 was not responding. She said LVN A did a sternum rub and called Resident #1's name and started CPR. LVN R took the crash cart to the room. CNA B said she thought she checked the lights on the hall between 2:45 p.m. and 3:15 p.m. She said all residents' lights should be answered promptly. During an interview on [DATE] at 2:19 p.m., CNA C said she had worked [DATE] 6:00 a.m. - 2:00 p.m. shift by herself and the facility wanted her to stay and work a double shift. She said she was assigned to hall 500 where Resident #1 resided. She said she would work the double shift, but she needed to take a lunch break. CNA C said she last saw Resident #1 around 2:00 p.m. when she had loose bowels and she had provided incontinent care. She said LVN A had taken in some medication for her diarrhea. She said her nasal cannula was off and LVN A told Resident #1 she needed it back on. She said it was on when she, CNA C, left the room after providing incontinent care and Resident #1 did not appear in distress. She said she took her break at approximately 2:30 p.m. She said when she returned at approximately 3:10 p.m. she saw EMS was with Resident #1 and also saw her family member in the hallway across form the room. During an interview on [DATE] at 2:26 p.m., MA I said she talked with Resident #1 around noon on [DATE]. She said Resident #1 said she was not feeling well but they did not send her to the hospital because her vital signs were good. She said the NP was at the facility and checked her vitals and ordered labs for the next day. She said she did have her nasal cannula on. She said she heard the EMS siren around 3:00 p.m. During an interview on [DATE] at 11:09 a.m., NS AA said she saw and spoke with Resident #1 on the morning of [DATE]. She said Resident #1 complained of nausea and throwing up. She said she let LVN A know and then the NP checked on Resident #1. She said she just was not feeling well. She did not complain of chest problems and she did not complain about her breathing. She had her nasal cannula on. She said Resident #1 would call to her as she passed by and she would talk to her. She said she was with another resident and then on her way out after her shift, she just peaked in to say goodbye to Resident #1. She said Resident #1 looked like she was asleep, so she shut the door and left. She said she saw the call light was on in the hall, but she did not address it because she was on her way out. During an interview on [DATE] at 10:25 a.m., NP O said he saw Resident #1 on [DATE] and she complained of nausea. He said she had [CONDITION(S)] and CHF and he asked her if any of her symptoms were worse than normal and she said they were not. He said she denied any chest pain. He said the nausea was more indicative of stomach issues. He said she had on her nasal cannula. NP O said he ordered labs for the next day. During an interview on [DATE] at 10:32 a.m., RNA P said she did not notice the light on for Resident #1 and Resident #2's room. She said she was heading to do another task and was zoned out. She said she did not hear anyone yelling from the room. She said any staff could answer a call light. During an interview on [DATE] at 10:40 a.m. RN Q said she saw the lights on but went to take care of a resident's wound care. She said as soon as staff see a light, staff were supposed to answer the light but not to turn off the light if they could not take care of the resident. During an interview on [DATE] at 10:54 a.m., LVN R said she was at the nurse station when LVN A called for help. She said she went to the Resident #1's room and Resident #1 was unresponsive. She said she ran and got the crash cart and someone else called 911. She said EMS took over CPR. She said watched the video and saw she had walked by the call light that was on. She said she was focused on completing another resident's MDS. She said she did not even see that the lights were on while walking down the hall. During an interview on [DATE] at 12:49 p.m. the Administrator said call light response was supposed to occur with as little delay as possible. He said call lights were answered one at a time. He said there should be other aides and nurses taking care of lights on the hall if one aide was on a break or busy. He said he followed the facility policy to ensure residents are free from abuse and neglect. During an interview on [DATE] at 12:49 p.m., the DON said she did not know why the call light was not answered. She said the assigned aide was taking a break. She said other aides and nurses may have been busy. She said call lights were monitored when they heard call lights and would go and watch and instruct aides and nurses as needed. She said the call light panel and the call light outside of each resident room were not able to distinguish between which resident pulled the call light. During an interview on [DATE] at 1:07 p.m., RN M said the administrator called him about the incident and based on the care that Resident #1 received that day, the orders received, and the NP saw Resident #1 it was not a reportable because he did not see a reportable situation. It was not neglect because they were meeting Resident #1's care needs. During an interview on [DATE] at 1:40 p.m., LVN S said on [DATE] she was on her second day with the facility and was in orientation. She said she did not recall if she saw the light. She said she was following LVN A and was on the left side of the hall. She said after the incident she learned that everyone could answer a call light. During an interview on [DATE] at 1:47 p.m., ES T said on [DATE] she did not notice the call lights because she was concentrating on putting the wet floor cones away. She said she was also a trained CNA and was aware that any staff could answer call lights. She said she had spoken with Resident #1 on the morning of [DATE] and the only complaint she was aware of was her mattress having a crease so she said she would order her a mattress. During an interview on [DATE] at 2:55 p.m., CNA B said she was helping another aide on a different hall with a Hoyer lift and that was the reason she could not answer the call light for hall 500. She said all the aides were told to watch hall 500 by CNA C but no one watched or answered. During an interview on [DATE] at 3:07 p.m., NA U said she worked in the facility for one year. She said she started in laundry and then trained to be an aide. She said she was on the floor as of ,d+[DATE]. She said she was assigned to hall 600 and trained on answering call lights. She said she was aware she should check to see if she could address the light or not and to let another aide or nurse know of the issue. She said on [DATE] she had just come on shift and was focused on getting all the residents on Hall 600 their ice and water. She said then she went to all the residents on hall 600 and asked them what they wanted for their supper meal. She said she put the residents to bed who wanted to go to bed. She said she did not know if the lights that were on were an emergency or not. She said she could hear the lights going off but did not go to check the lights. She said she was aware she should check the lights and ask what they needed. During an interview on [DATE] at 3:21 p.m., CNA V said she could not recall what hall she was assigned to on [DATE]. She said there was no staff for hall 200 or 500 so CNA C agreed to work a double shift. She said CNA C left for her break. She said she and CNA B used a Hoyer to get a resident ready for a shower. She said she was showering a resident for approximately 30 minutes and saw the light was on when she left the shower. She said she then heard CNA B calling for LVN A. During an interview on [DATE] at 6:09 p.m., RN W said she had not received any training specific to answering call lights after the incident on [DATE] with Resident #1. She said she was aware anyone could answer call lights. During an interview on [DATE] at 11:08 a.m., CNA B said on [DATE] when she answered the call light, Resident #1 was cold and did not respond. That is what made her do a sternum rub and then call the nurse. She said the nasal cannula was on the floor. She said Resident #1's door was usually open if she was feeling bad. The door being closed is what made her think another staff was in the room. During an interview on [DATE] at 10:05 a.m., LVN A said on [DATE] CNA B told her Resident #1 was cold and needed to be checked. She said Resident #1 did not have on her nasal cannula and she thought Resident #1 was sleeping. She said Resident #1 had no pulse and she was a little cold. She said she kept called her name and she was limp. She said there were occasions when Resident #1 would be out of it but would wake to her name. She said she did not answer the call light for Resident #1 and Resident #2's room because she was thinking a CNA was going to get the call light. She said had just finished the medication pass and was training another LVN. She had no reason why she did not answer the light. She said the expectation was to answer the light within 30 seconds or as soon as it was seen. She said she answered call lights a lot. She said the aide on that hall was on a break and anyone else could have answered. She was not aware of who should have been covering for the CNA on break. She said they did get an in-service at the time of the incident with Resident #1 to be more cognizant about answering lights. She said neglect was not giving the care a resident needed, including not answering a call light. She said there were times residents said they had been waiting when she answered lights. She said didn't remember how long they said they had to wait. She said watching the video she could not believe it went that long. It hurt to see the video. She said there was no way to tell who pulled the call light from the hall. She said Resident #2 said she turned the light on for Resident #1. She said she remembered she thought it was because Resident #1 needed to be changed. She said the bathroom call light makes a different sound and flashed but there were no different sounds from the bedroom to indicate a call was an emergency. During an interview on [DATE] at 10:27 p.m., CNA D said call lights were supposed to be answered as soon as possible. She said neglect included not answering a call light. She said Resident #1 pushed the call light a lot and probably thought she just pushed it and did not really need anything. During an interview on [DATE] at 10:34 a.m., NA E said on [DATE] Resident #1 complained of heartburn and asked her to raise the head of her bed and heat up her food. She said Resident #1 had her nasal cannula on and her call light was in reach. She said the nurses did not help to answer call lights. She said she had not asked a nurse to answer a call light. She said neglect included not doing something for a resident if they needed. She said she had heard some residents say the light was not answered for 30 minutes or a long time. She said she told LVN F about the complaint and LVN F dealt with the issue. She said she would tell the charge nurse of any complaints. During an interview on [DATE] at 10:48 a.m., CNA C said neglect was not providing care to the residents. During an interview on [DATE] at 10:56 a.m., LVN F said she was called to Resident #1's room by LVN A or CNA B. She said Resident #1's nasal cannula was on the floor. Resident #1 was lying flat on her bed. She was cool to the touch and there was no eye movement or respirations. She said she could not think of any reason the call light was not answered promptly. She said she could not recall hearing the call light at the nurse station. She said she was busy training a new nurse, answering student nurse questions, or answering phone calls. She said the aides were supposed to tell the charge nurse when they go on break and ask another aide to cover their assigned hall/rooms. She said the call lights all sound the same for the rooms and the bathrooms blink and beeps faster on the panel. She said not answering a call light would fall under the category of neglect. During an interview on [DATE] at 11:09 a.m., CNA G said she had been working in the facility for 4 years. She said neglect including seeing the call lights were on and not answering. She said she was not aware of the General Working Guidelines until [DATE]. She said she was told they were in the binder but never saw them. During an interview on [DATE] at 11:23 a.m., CNA H said she received training on answering call lights after the incident and on [DATE]. She said she received training on General Working Guidelines and who was supposed to cover on [DATE]. She said she did not recall knowing the guidelines prior to [DATE]. She said neglect included not answering a call light in a timely manner. She said letting a call light go for 45 minutes would be neglect. During an interview on [DATE] at 11:39 a.m. CNA J said on [DATE] Resident #1 complained about feeling not well and the MD said her vital signs were o.k. and was not sending her to the hospital. She said Resident #1 always had her O2 on because if she did not, she had shortness of breath. She said Resident #2 was crying and said she had been calling and yelling but no one answered the call light. She said she received training on [DATE] on the General Working Guidelines. She said she was not aware of the guidelines prior. She said was made aware of answering the call lights and taking breaks and who was supposed to cover when taking breaks on [DATE]. She said neglect was not answering a call light in a timely manner; like 5 minutes. During an interview on [DATE] at 11:59 a.m., CNA K said she had been working in the facility for 1.5 years and received training on call lights and the General Working Guidelines on [DATE]. She said she was not aware of the guidelines prior to [DATE]. During an interview on [DATE] at 12:18 p.m., NA DD said he was in class on [DATE]. He said he saw Resident #1 on the EMS stretcher. He said he received training on [DATE] to answer call lights as soon as he could and to answer them in order. He said neglect included ignoring residents and not answering the call light. He said he did not recall ever seeing nurses answer any call lights. During an interview on [DATE] at 12:30 p.m., LVN S said she was in training on [DATE], the day Resident #1 passed away. She said she was not assigned to any specific resident on that day. She said neglect was not meeting a resident's needs, like not answering a call light for 45 minutes. She said she was called on [DATE] and then signed the in-service when she come to work on [DATE]. During an interview on [DATE] at 1:03 p.m., the DON said neglect was the failure to provide goods and services. She said all incidents were reported to the administrator and the administrator decided if an incident was reportable. She said when she reviewed the video, she felt there was no failure to provide services, just needed to do better at providing care. The staff were all doing other tasks. The staff were all doing something for other residents. She said all staff have been educated in person or on phone on answering call lights, prioritizing, and abuse and neglect. During an interview on [DATE] at 1:15 p.m., the Administrator said neglect included not monitoring the residents and not providing goods and services. He said an incident would be reportable when the residents felt they were not provided goods and services. He said the incident with Resident #1 was not neglect and was not reportable because she was not refused services. He said staff were busy doing other tasks and the reason the facility did not call in the incident as a reportable incident of neglect. During an interview on [DATE] at 1:30 p.m., RN M said neglect was determined by the facility with a call to the regional director of Operations or Clinical Operations and discuss the situation. He said neglect was willfully, knowing causing harm to a resident or not following physician orders. He said an incident would be reportable once it was determined neglect had occurred. He said the facility was following physician orders, Resident #1 was seen by a physician that morning, and care was provided. He said the code was not related to the call light. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation of Property Prevention, Protection, and Response Policy and Procedures dated [DATE] indicated: The Health center Administrator is responsible for assuring the Patient's Rights of personal privacy, confidentiality, and dignity will be respected for all aspects of care and services and that patient safety, including freedom from the risk of ANEM, holds the highest priority. Neglect: The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when a facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the patient. All allegations of possible ANEM will be immediately reported to the Texas Health and Human Services by the Administrator or designee . Record review of the facility's Resident Rights policy dated 2001(revised ,d+[DATE]) indicated employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .b. be free from abuse, neglect, misappropriation of property, and exploitation . Record review of the facility's Answering the Call Light policy dated 2001 (revised ,d+[DATE]) indicated The purpose of this procedure is to ensure timely response to the resident's requests and needs. 6. Some residents may not be able to use their call light. Be sure to check these residents frequently. 7. Identify emergency call light tones, signals, and how to respond. 4. Emergency call lights will be answered with higher prioritization of all other call lights. An Immediate Jeopardy was identified on [DATE] at 2:24 p.m. due to the above failures. The Administrator and DON were notified of the Immediate Jeopardy, and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The following Plan of Removal was accepted on [DATE] at 1:36 p.m. and reflected the following: This letter represents the facility's respectful request for HHSC to accept our removal plan with immediate implementation of corrective measures placing the facility back in substantial compliance. The following measures represent the immediate action Liberty Health Care Centrex has taken to address the alleged-deficient practice and to prevent serious harm from occurring or recurring [TRUNCATED]

Based on observation, interview, and record review, the facility failed to include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advanced directive. The facility failed to implement their advance directive policy and maintain accurate code status information for 3 of 19 residents (Resident #s 7, 50, and 61) reviewed for advance directive accuracy. The facility did not ensure Resident #s 7, 50, and 61's advance directive information was complete and accurate to reflect their current code status. Residents #50 and #7's charts had conflicting code status information. Resident #61's advance directive for OOH-DNR was not signed by the physician. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed the census of 63 residents at risk of not receiving life saving measures or receiving CPR (cardiopulmonary resuscitation) against their wishes. Findings included: 1. Physician orders [REDACTED].#50, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #50 was cognitively intact (alert and oriented) and received only supervision from staff with ADLs. The advance directive care plan initiated [DATE] and reviewed on [DATE] indicated Resident #50 requested CPR and her code status was a full code. During an interview on [DATE] at 11:00 a.m., Resident #50 said she did not want CPR and had changed her code status to a DNR in [DATE]. The Standards of Care Meeting (Quality Assurance meeting), dated [DATE] indicated Resident #50's code status was reviewed and she was a DNR. There was no evidence her code status had been updated. The section for code status in the clinical record for Resident #50 contained 3 pages: *the facility's red code status page which indicated: STOP DO NOT RESUSCITATE; *the undated Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order with the resident's name on it, an unknown date and was not witnessed; and *the facility's green code status page indicated: FULL CODE. During an observation and interview on [DATE] at 10:00 a.m., LVN D said to determine a resident's code status in emergency situations, they used the color coded sheet behind the code status section in a resident's chart. She said according to Resident #50's code status, the resident was a DNR and pointed to the red color coded status page. LVN D then looked at the green code status page (Full Code) that was behind the red code status page (Stop Do Not Resuscitate). LVN D said Resident #50's code status was not clear and needed to be clarified. To make the clarification, LVN D checked Resident #50 physician's orders [REDACTED]. During an interview on [DATE] at 10:20 a.m., the social worker said she was responsible to make sure the advanced directives were completed and on the charts. She said Resident #50 requested to be a DNR at the care plan meeting in [DATE]. She said the form was sent to the physician. She said she was not sure how the OOH-DNR form got on the chart and why the green color coded status was not removed. She said and she did not follow up on the paper work required for the advanced directive for Resident #50. During an interview on [DATE] at 10:30 a.m., the DON, who had started at the facility on [DATE], said Resident #50's OOH-DNR was incomplete. She said there should not be both red and green color coded status sheets on any chart. During an interview on [DATE] at 11:20 a.m., the administrator acknowledged Resident #50's code status was not correct. He said the social worker was supposed to ensure that the advanced directives were accurate and on the chart. 2. Physician orders [REDACTED].#61, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #61's code status was a DNR on [DATE]. The care plan dated [DATE] indicated Resident #61's advance directive was a DNR. She was totally dependent on staff for all care needs. During an observation on [DATE] at 9:07 a.m., Resident #61 was in bed connected to oxygen via a [MEDICAL CONDITION] and a feeding tube for nutritional support. She was unable to communicate. The section for code status in the clinical record for Resident #61 contained the following: * A red page in front of the record which indicated Stop Do Not Resuscitate. * An Out of Hospital Do Not Resuscitate (OOH-DNR) Order dated [DATE]; however, it was not signed by the physician. During an interview [DATE] at 3:45 p.m., RN E acknowledged the physician had not signed the OOH-DNR and therefore Resident #61 should be considered a full code. 3. Physician orders [REDACTED].#7, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated his code status was DNR as of [DATE]. The care plan dated [DATE] indicated Resident #7's advance directive was a DNR. The Admission Record printed [DATE] indicated Resident #7's advance directive was both DNR and Full Code. The section for code status in the clinical record for Resident #7 indicated the following: *A green page in front of the record to indicate Full Code status. During an interview on [DATE] at 11:20 a.m., the administrator said they identified a problem with advance directives a couple of months ago and they had a plan to review code status in the IDT (interdisciplinary team) meeting. The Standards of Care Meeting (Quality Assurance meeting), dated [DATE] indicated Resident #50's advanced directive was incorrect. He said the social worker was responsible to make sure the advanced directives were completed and on the charts. He said she did not follow up on the paper work required for the advanced directive for Resident #50. He acknowledged there was a still a problem with the advance directive system. The policy dated [DATE] titled Advance Directives indicated Advance directives will be respected in accordance with state law and facility policy. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive. 16. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so the appropriate orders can be documented in the resident's medical record and plan of care. The undated policy titled Do Not Resuscitate Order indicated Our facility will not use cardiopulmonary resuscitation and related emergency measures when to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed the resident's physician on the physician's orders [REDACTED]. 2. A Do Not Resuscitate Order (DNRO) form must be completed signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. The form provided by the facility titled OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER indicated .Section A- If an adult is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. In addition, the OOH-DNR must be signed and dated by two competent adults, who have witnessed either the competent making his/her signature in section A. The administrator and DON were notified on [DATE] at 12:10 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] and included: *New DNR completed for residents #50 and #7 on [DATE]. *100% audit of all DNRs for accuracy completed [DATE]. *100% audit of all DNR and Full code orders completed [DATE]. *100% audit of all care plans for Advance Directive/ Code status on [DATE]. *In-service Nurses on verifying code status and facility policy on Advance Directives on [DATE] and ongoing. *In-service Social Worker/DNR completer on completing (out of hospital) DNRs on [DATE]. *Charts will be arranged so the code status page and DNR (if applicable) is the first page found in the chart. *Resident's Advance Care Plan will include this information (where to find the code status and DNR on chart). *Nursing staff not present for in-service will receive training prior to returning to work. On [DATE], the surveyors confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: -An In-Service report dated [DATE] indicated 22 nursing staff were in-serviced regarding verifying code status and facility policy on Advance Directives. -The social worker, 11 LVNs and 4 RNs were interviewed and said they received in-service training on [DATE] and were knowledgeable regarding advance directives, code status and knew where the code status page was located in the chart. On [DATE] at 9:45 a.m., the administrator and DON were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 63 residents.

Based on interview and record review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for 3 of 19 residents (Resident #s 7, 50 and 61) reviewed for advance directives. The facility did not ensure Resident #s 7, 50, and 61's advance directive information was complete and accurate to reflect their current code status. The facility identified a problem with advance directives; however, a plan was not developed to correct the identifed issue. Residents #50 and #7's charts had conflicting code status information. Resident #61's advance directive for OOH-DNR was not signed by the physician. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed the census of 63 residents at risk of not receiving life saving measures or receiving CPR (cardiopulmonary resuscitation) against their wishes. Findings included: During an interview on [DATE] at 11:20 a.m., the administrator said they identified a problem with advance directives a couple of months ago and they had a plan to review code status in the IDT (interdisciplinary team) meetings. The Standards of Care Meeting (Quality Assurance meeting), dated [DATE] indicated Resident #50's advanced directive was incorrect. He said the social worker was responsible to make sure the advanced directives were completed and on the charts. He said she did not follow up on the paper work required for the advanced directive for Resident #50. He acknowledged there was a still a problem with the advance directive system. 1. Physician orders [REDACTED].#50, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #50 was cognitively intact (alert and oriented) and received only supervision from staff with ADLs. The advance directive care plan initiated [DATE] and reviewed on [DATE] indicated Resident #50 requested CPR and her code status was a full code. During an interview on [DATE] at 11:00 a.m., Resident #50 said she did not want CPR and had changed her code status to a DNR in [DATE]. The Standards of Care Meeting (Quality Assurance meeting), dated [DATE] indicated Resident #50's code status was reviewed and she was a DNR. The section for code status in the clinical record for Resident #50 contained 3 pages in the following order: *the facility's red code status page which indicated: STOP DO NOT RESUSCITATE; *the undated Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order was signed by the resident on an unknown date and was not witnessed; and *the facility's green code status page indicated: FULL CODE. During an observation and interview on [DATE] at 10:00 a.m., LVN D said to determine a resident's code status in emergency situations, they used the color coded sheet behind the code status section in a resident's chart. She said according to Resident #50's code status, the resident was a DNR and pointed to the red color coded status page. LVN D then looked at the green code status page (Full Code) that was behind the red code status page (Stop Do Not Resuscitate). LVN D said Resident #50's code status was not clear and needed to be clarified. To make the clarification, LVN D checked Resident #50 physician's orders [REDACTED]. During an interview on [DATE] at 10:20 a.m., the social worker said Resident #50 requested to be a DNR at the care plan meeting in [DATE]. She said the resident signed the form and the form was sent to the physician. She said she was not sure how the OOH-DNR form got on the chart and why the green color coded status was not removed. During an interview on [DATE] at 10:30 a.m., the DON said Resident #50's OOH-DNR was incomplete. She said there should not be both red and green color coded status sheets on any chart. During an interview on [DATE] at 11:20 a.m., the administrator acknowledged Resident #50's code status was not correct. 2. Physician orders [REDACTED].#61, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #61's code status was a DNR on [DATE]. The care plan dated [DATE] indicated Resident #61's advance directive was a DNR. She was totally dependent on staff for all care needs. During an observation on [DATE] at 9:07 a.m., Resident #61 was in bed connected to oxygen via a [MEDICAL CONDITION] and a feeding tube for nutritional support. She was unable to communicate. The section for code status in the clinical record for Resident #61 contained the following: * A red page in front of the record which indicated Stop Do Not Resuscitate. * An Out of Hospital Do Not Resuscitate (OOH-DNR) Order dated [DATE]; however, it was not signed by the physician. During an interview [DATE] at 3:45 p.m., RN E acknowledged the physician had not signed the OOH-DNR and therefore Resident #61 should be considered a full code. 3. Physician orders [REDACTED].#7, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated his code status was DNR as of [DATE]. The care plan dated [DATE] indicated Resident #7's advance directive was a DNR. The Admission Record printed [DATE] indicated Resident #7's advance directive was both DNR and Full Code. The section for code status in the clinical record for Resident #7 indicated the following: *A green page in front of the record to indicate Full Code status. The policy dated [DATE] titled Advance Directives indicated Advance directives will be respected in accordance with state law and facility policy. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive. 16. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so the appropriate orders can be documented in the resident's medical record and plan of care. The undated policy titled Do Not Resuscitate Order indicated Our facility will not use cardiopulmonary resuscitation and related emergency measures when to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed the resident's physician on the physician's orders [REDACTED]. 2. A Do Not Resuscitate Order (DNRO) form must be completed signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. The form provided by the facility titled OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER indicated .Section A- If an adult is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. In addition, the OOH-DNR must be signed and dated by two competent adults, who have witnessed either the competent making his/her signature in section A. The administrator and DON were notified on [DATE] at 12:10 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] and included: *New DNR completed for residents #50 and #7 on [DATE]. *100% audit of all DNRs for accuracy completed [DATE]. *100% audit of all DNR and Full code orders completed [DATE]. *100% audit of all care plans for Advance Directive/ Code status on [DATE]. *In-service Nurses on verifying code status and facility policy on Advance Directives on [DATE] and ongoing. *In-service Social Worker/DNR completer on completing (out of hospital) DNRs on [DATE]. *Charts will be arranged so the code status page and DNR (if applicable) is the first page found in the chart. *Resident's Advance Care Plan will include this information (where to find the code status and DNR on chart). *Nursing staff not present for in-service will receive training prior to returning to work. On [DATE], the surveyors confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: -An In-Service report dated [DATE] indicated 22 nursing staff were in-serviced regarding verifying code status and facility policy on Advance Directives. -The social worker, 11 LVNs and 4 RNs were interviewed and said they received in-service training on [DATE] and were knowledgeable regarding advance directives, code status and knew where the code status page was located in the chart. On [DATE] at 9:45 a.m., the administrator and DON were informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at a widespread potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 63 resident.