Every finding on record at Meadowbrook Care Center

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for 2 (Resident #1 and #2) of 4 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 grabbed Resident #2's right arm during an altercation on 03/25/2026 at 12 p.m. in the doorway of Resident #1's room, where the residents' wheelchairs had become entangled. This failure could place residents at risk for emotional distress, fear and decreased quality of life.Findings included: Record review of Resident #1 face sheet dated 05/05/2026 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnosis included cerebral infarction (a stroke caused by a blockage in blood vessels supplying the brain due to lack of oxygen), depression, and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment and had no physical or verbal behavioral symptoms. Record review of the care plan reviewed and updated on 12/31/2025 indicated Resident #1 had impaired cognition or thought processes related to difficulty in making decisions. The goal was she would maintain current level of cognitive function through the next review date. Interventions included communicating with resident/family regarding resident's capabilities and monitor/report to physician any changes in cognitive function. Record review of the Provider Investigation Report dated 04/01/2026 indicated an incident categorized as abuse occurred on 03/25/2026. The incident involved Resident # 1 in the doorway of her room where MA A witnessed Resident #1 grab Resident #2's right arm. An assessment was conducted on Resident #1 and there were no injuries, marks or bruises as a result of the incident. Resident # 1 was placed on 1 on 1 monitoring and a referral was made to psychiatric services. The administrator and an officer from the Van Alstyne police department interviewed Resident #1 on 03/25/2026 at 3:30 p.m. and according to her, Resident #2 propelled herself to the doorway of Resident #1 and attempted to enter her room. Resident #2 began yelling obscenities at Resident #1 and propelled herself towards the doorway. In an attempt to stop Resident #2 from entering the room, Resident #1 grabbed Resident #2's arm while arguing with her about entering the room. Subsequently their wheelchairs became entangled and the CMA came and separated them from each other. During an interview on 05/05/2026 at 1:22 p.m. Resident #1 stated she was doing fine and she did get upset with another resident who tried to come in her room and she didn't want her there. She stated she is not afraid of any residents and feels safe in the facility. In an interview on 05/05/2026 at 1:40 p.m. MA A stated she had not seen Resident #1 get upset or try to hurt another resident. She immediately separated them and took Resident #2 to DON's office to be assessed for injuries. Resident # 1 was put on 1:1. Record review of Resident #2's face sheet dated 05/05/2026 indicated she was an [AGE] year-old female who was admitted on [DATE]. Her diagnosis included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills), mood disorder (a condition characterized by persistent and intense emotional state that disrupts daily functioning), insomnia and high blood pressure. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment and had no verbal or physical behavioral symptoms noted. Record review of the care plan initiated on 05/05/2026 indicated Resident #2 had a communication problem related to dementia that makes it difficult to express needs and understand others. The goal was she would use available methods to communicate her needs and participate in activities to the best of her ability with support from staff. Interventions included encourage to participate in activities to reduce isolation and staff will give her time to respond and avoid rushing when trying to communicate. Record review of the Provider Investigation Report dated 04/01/2026 indicated an incident categorized as abuse occurred on 03/25/2026. After the incident occurred, the residents were immediately separated, a referral to psych services was made and Resident # 2 was moved to another room on the other side of the facility. A head-to-toe assessment was completed by the DON for Resident #2 and there were no injuries, marks or bruises that were sustained. The administrator and an officer from the Van Alstyne police department interviewed Resident #2 on 03/25/2026 at 3:40 p.m. She was happily sitting up in her bed watching TV. Due to her cognitive impairment, she was unable to articulate exactly what had transpired or who it transpired with. However, it appeared that Resident #2 was aware that an incident of some sort led to her being moved to another room. Resident #2 was not interviewed as she had been discharged to a memory care unit. In an interview on 05/05/2026 at 3:50 p.m. the DON stated that her expectation was if resident to resident abuse occurred, staff were to separate the residents, make sure both are safe and report it to the administrator. She stated the risk to the residents was the situation could further escalate. In an interview on 05/05/2026 at 3:55 p.m. the Administrator stated she expected the staff to separate the residents, closely supervise the aggressor and provide 1:1 and assess for injuries. She stated the risk to the residents if they were not separated was more harm or an increase in harm. Review of the policy Abuse, Neglect and Exploitation dated 09/01/2023 revealed the following, The facility will implement policies and procedures to prevent and prohibit all types of abuse, the identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accident hazards for one of ten residents (Resident #1) reviewed for accidents.The facility failed to ensure CNA A used a transfer aid when she transferred Resident #1 from her bed to wheelchair, which resulted in her falling and obtaining a fracture to her left hip.On 01/30/2026 at 2:00 pm, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/31/2026, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could place residents at risk for serious injury, harm, impairment, or death.Findings included:Record review of Resident #1's Face Sheet, dated 01/29/2026, reflected the resident was a 78 -year-old female, admitted [DATE], diagnoses included muscle weakness, unsteadiness of feet, lack of coordination, convulsion (involuntary movement of the muscles), and history of fall.Record review of Resident #1's Quarterly MDS Assessment, dated 11/17/2025, reflected the resident had moderate (resident may need additional support and monitoring) impairment in cognition with a BIMS score of 12. Section GG - Functional Abilities reflected the resident required partial/moderate assistance for sit to stand and chair/bed-to-chair transfer. The resident was not coded for mechanical lift.Record review of Resident #1's Comprehensive Care Plan, dated 12/10/2025, reflected the resident was at risk for falls related to unsteady gait, history of falls, muscle weakness, and cognitive impairment and one of the interventions was the resident would be assisted with walking, transfers, or toileting as needed, based on the resident's current ability. The Comprehensive Care Plan did not specify the kind of transfer was required for Resident #1.Record review of Resident #1's Comprehensive Care Plan, dated 12/10/2025, reflected the resident had a diagnosis of osteoporosis (brittle bones), placing them at increased risk for bone fractures (broken bones), chronic pain, loss of mobility, and independence and one of the interventions was to provide assistance with transfers and ambulation as needed (e.g., supervision, limited assistance, extensive assistance). The Comprehensive Care Plan did not specify the kind of transfer required for Resident #1.Record review of Resident #1's Comprehensive Care Plan, dated 12/10/2025, reflected the resident required varying levels of staff assistance for ADLs . placing them at risk for decreased independence, impaired dignity, and functional decline and one of the interventions was use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation. The Comprehensive Care Plan did not specify the kind of transfer required for Resident #1.Record review of Resident #1's Physician Order reviewed on 01/29/2026 reflected no order on how the resident should be transferred.Record review of Resident #1's Nursing Progress Notes, dated 01/11/2026, reflected, CNA called @10:50 a.m. for nursing assistance . During the transfer attempted resident lost balance and landed on both knees while the upper body remained leaning on the bed . Resident c/o severe pain 10/10 to the left hip area. Resident requested to be transferred to . hospital. 911 was called, resident was transferred onto a stretcher and transported to the hospital with EMT for further evaluation. The Dr . and DON notified, Resident's daughter . notified as well.Record review of Resident #1's Nursing Progress Notes, dated August 2025 to January 2026, reflected that there was no documentation that the resident refused the sit-to-stand.Record review of Resident #1's Physician/Practitioner Progress Notes, dated 01/02/20206, reflected, Patient currently stable, will maintain on strict fall precaution . monitor closely.Record review of Resident #1's Fall Risk Assessment, dated 01/02/2026, reflected the resident was a high risk for falls with a score of 32.Record review of Resident #1's PT Therapy Progress Notes, dated 08/22/2025, reflected, Pt requires use of sit to stand (a mobility aid used to help an individual transition safely from sitting to standing). Has difficulty raising RLE during transfer. Precautions: Fall risk due to weakness and delays in righting responses, declines in safety awareness.Record review of Resident #1's PT Therapy Progress Notes, dated 09/09/2025, reflected, Pt has increased anxiety with all sit to stand activities . Precautions: Fall risk due to weakness and delays in righting responses (automatic responses that help maintain postural stability), declines in safety awareness.Record review of Resident #1's PT Therapy Progress Notes, dated 10/04/2025, reflected, Pt requires use of sit to stand machine majority of time . Precautions: Fall risk due to weakness and delays in righting responses, declines in safety awareness.Record review of Resident #1's Medical Records, dated 01/11/2026, reflected, Pre surgical diagnosis: Closed (broken bone that did not break through the skin) intertrochanteric (hip bones) fracture of the left hip . Post surgical diagnosis: Closed intertrochanteric fracture of the left hip.Record review of the in-service provided after the fall incident, dated 01/12/2026, reflected, Incidents and Accidents . Policy: It is the policy of this facility for staff to utilize Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . The purpose of incident reporting can include . Assuring that appropriate and immediate interventions are implemented and corrective actions are taken.Record review of the facility's in-service reviewed on 01/29/2026 reflected no in-service for safe transfer and handling during transfer of the residents was done after Resident #1 fell.During an interview on 01/29/2026 at 8:41 a.m., Resident #1 stated she fell a couple of weeks ago but was not sure of the exact date. She said she knew it was Sunday because she wanted to attend church that was why she asked to be changed and transferred to her wheelchair. She said after she was changed, the CNA put her wheelchair beside her bed and started to transfer her. She said she was not sure if her knees buckled or she felt dizzy and when she knew it she was kneeling on the floor. She said, at first, she did not feel any pain even when the staff sat her down on the floor but when they asked if she could be repositioned, that was when she felt severe pain on her hips. She said it happened so fast the CNA was not able to catch her. She said the aide did not use a transfer aid to transfer her. She said she requested to go to the hospital and had to have surgery.During an interview on 01/29/2026 at 8:47 a.m., Resident #1's roommate stated Resident #1 was sent to the hospital after she fell. She said the curtain was pulled and she really did not see what happened. She said all she knew was she was being transferred to her wheelchair and then all of a sudden there was a commotion.During an interview on 01/29/2026 at 9:18 a.m., CNA A stated Resident #1 fell on a Sunday, 01/11/2026. CNA A said RN B told her Resident #1 wanted to get up for church service and wanted to be cleaned and changed. She said after changing Resident #1, she got the wheelchair, placed it close to the bed, and started to transfer the resident. She said the resident said, give me your hand, so she extended her hand, and Resident #1 used it to help herself stand up. She said Resident #1 was heavy and her left leg was weak. She said she noticed the weak leg was not turning and moving. She said the resident tried to reach for the armrest of the wheelchair, became dizzy and fell knee first on the floor. CNA A said she screamed for help and RN B came to the room. She said while the resident was still kneeling on the floor, RN B assessed the resident and the resident said she was not in pain. She said RN B and herself tried to see if the resident could sit on the wheelchair, but it was hard because the resident's legs were weak. She said RN B kept on asking the resident if she was in pain while they were trying to reposition her. She said she went out of the room to call the Weekend Supervisor for assistance. She said RN B, the Weekend Supervisor, and herself carefully sat the resident on the floor. She said the resident did not complain of pain when repositioned. She said they tried to reposition her again, that was when the resident complained of pain so they stopped and both RN B started to call and the Weekend Supervisor started making calls. She said the resident was a one-person assist for transfer and she should have used a gait belt for transfer, especially since she knew Resident #1 had weakness to one side. She said the gait belt was to secure the resident. She said Resident #1 would always say not to rush her because her left leg was weak. She said she never rush the resident.During a telephone interview on 01/29/2026 at 10:23 a.m., the Weekend Supervisor stated she did not witness the incident. She said RN B told her Resident #1 had fallen and they were not able to get her up. She said she went with RN B and saw Resident #1 sitting on the floor. She said she asked the resident if she was having any pain and Resident #1 denied pain. The Weekend Supervisor said she told Resident #1 they would attempt to reposition her because she was too close to the bed. The Weekend Supervisor said, at that point, Resident #1 said she was having pain in her left hip. She said they stopped and RN B called 911. She said she asked CNA A what happened and CNA A said she went to transfer the resident and one of the resident's knees gave out. She said she was not sure on Resident #1's mode of transfer but if she was a one-person assist, CNA A must use a gait belt to help transfer. She said the gait belt would provide an extra support because it would give CNA A something to hold on to. She said Resident #1 told her that at first she thought her knee popped when she fell.During a telephone interview on 01/29/2026 at 10:33 a.m., RN B stated she was making rounds when she heard CNA A calling for help from Resident #1's room. She said upon entering the room, she saw the resident kneeling on the floor beside her bed. She said she did not know exactly what time it happened nor what happened. She said she asked CNA A what happened and CNA A told her she thought the resident lost her balance. RN B said Resident #1 was heavy and she called the Weekend Supervisor for assistance. She said the three of them put the resident on the floor from the kneeling position. She said the resident was not complaining of any pain when she was lowered to the floor. She said the Weekend Supervisor assessed the resident and asked her if it was ok to get her up. She said, at that point, Resident #1 complained of pain scale of 10/10 in the hip area and requested to be sent to the hospital. She said she called 911 and then notified MD, DON, and responsible party. She said if CNA A used a gait belt, there would be a possibility the resident would not have fell on her knees. She said the DON told her to educate CNA A about safe transfers.During an interview on 01/29/2026 at 11:21 a.m., the DON stated the Weekend Supervisor called to let her know they called 911 for Resident #1. She said she was told that the resident fell when CNA A was transferring her. She said the resident had left leg pain but the Weekend Supervisor could not tell whether it was the knee or the hip. She said Resident #1was sent to the ER and that afternoon, they learned from the daughter of the resident, Resident #1 had a fracture that required surgery. She said Resident #1 had a rod inserted to her hip. She said RN B notified her Resident #1 had a fracture. The DON said she asked RN B to educate CNA A about transfers. She said she told RN B to make a statement about the incident. The DON said, prior to the 01/11/2026 incident, Resident #1 was a one person assist and staff were supposed to use a gait belt to have an extra level of support. She said since the resident had a diagnosis of weakness and unsteady gait, the staff should be more careful with transferring. She said she did an in-service about accidents and hazards but not about safe transfers. She said it did not know why she did not do an in-service about safe transfers. She said she was responsible in making sure that the residents were transferred safely and appropriately.During an interview on 01/29/2026 at 11:43 a.m., the Administrator stated she was notified of the incident after Resident #1 was already in the hospital. She said she was told she fell while attempting to transfer from chair to wheelchair. She said that her understanding was Resident #1 was self-transferring, which was why it was reported to the state. She said later she learned Resident #1 fell during transfer. She said the DON did an in-service about accidents and hazards but did not in-service about safe transfers. She said CNA A should have used a gait belt when she transferred Resident #1.During an interview on 01/30/2026 at 6:30 a.m., CNA E stated she knew Resident #1 fell two Sundays ago because the resident told her. CNA E said Resident #1told her CNA A did not use a machine when she was transferred. She said prior to the fall incident, the resident's mode of transfer was the use of sit to stand. She said the resident did not refuse the use of sit-to-stand everytime she would use it to transfer her. She said when the resident was admitted , she was not walking and was already using the wheelchair. She said therapy worked with her and was able to take a few steps. CNA E said Resident #1 had weakness and was started on using a mechanical lift. She said all the aides knew about the resident's mode of transfer. She said they did not have an in-service about safe transfer when Resident #1 had a fall during transfer.During an interview on 01/30/2025 at 6:51 a.m., LVN S stated she knew Resident #1 fell and was sent out for further evaluation. She said she was told during shift report Resident #1 sustained a fractured o hip when she fell during a staff assisted transfer. LVN S said prior to incident, she was not sure if the resident was a sit to stand. She said CNA A should have used a gait belt for safety measures regardless if the resident could transfer by herself or not. She said, if Resident #1 used a mechanical shift, the CNA should have used the machine because there was a reason why she was ordered to do so. During an interview on 01/30/2026 at 7:27 a.m., the MDS Nurse stated when Resident #1 first came to the facility, she was on skilled nursing (a level of care designed for individuals with complex medication that needed a high level of care), and the mode of transfer was stand and pivot. She said before the fall, the mode of transfer was a sit to stand. She said she heard from their morning meeting, after the fall, that the resident's knees buckled and she went down to her knees. She said CNA A was transferring the resident when she fell on her knees. She said transfer aids could be in the form of gait belts and mechanical lifts.During an interview on 01/30/2026 at 7:44 a.m., the DON stated she knew there was a recommendation from therapy about changing Resident #1's mode of transfer from stand and pivot to sit-to-stand but did not know if there was a final decision about the matter and failed to follow up. she said, if she could remember it right, the recommendation was done during one of the departmental meetings but said she could not remember the exact date. She said when they interviewed CNA A, CNA A said she transferred the resident using her hands to guide the resident. She said the term transfer aids meant Hoyer lifts, sit-to-stands, and gait belts.During an interview on 01/30/2026 at 8:03 a.m., CNA D stated she knew that Resident #1 fell during a transfer. She said Resident #1 told her about the fall and according to the resident, CNA A was beside her but was not able to catch her. She said the resident's mode of transfer was sit-to-stand since around September of 2025. CNA D said she talked to therapy about the resident not moving during transfer and unable to turn. During an interview on 01/30/2026 at 8:23 a.m., Resident #1 stated that she must have misjudged how far she was from the bed or she sat down too soon and ended up on the floor, kneeling beside the bed. She said CNA A did not use a gait belt nor a machine. She said the other CNAs used a machine when they transferred her. She said, after the fall, she had pain where she did not have before. She said after the fall, her movements were limited and she became anxious when trying to move. She said she did not want to fall and had surgery but it happened. During a interview on 01/30/2026 at 8:42 a.m., the Weekend Supervisor stated she did not see a sit to stand machine when she entered Resident #1's room nor in the hallway. She said she was not aware that the resident's mode of transfer was sit to stand. She said whatever was the resident's mode of transfer, the staff should have used it to protect the resident. She saidDuring an interview on 01/30/2026 at 8:58 a.m., the DOR stated Resident #1 was first admitted to the facility for skilled nursing. She said the resident was wheelchair bound during admission. She said before Resident #1 fell, her mode of transfer was the use of sit-to-stand machine due to weakness. The DOR said she gave the recommendation to the nursing department and, from there, she did not know how they transferred Resident #1. During a interview on 01/30/2026 at 9:21 a.m., RN B stated she was PRN and was not always in the facility. She said they usually use a gait belt to transfer Resident #1. She said she was sure CNA A did not use a gait belt because she saw the gait belt hanging on the wall when she entered the room. She said if the resident required sit-to-stand, then the machine should have been used. She said she did not see machine inside the room or in the hallway. During an interview on 01/30/2026 at 10:26 a.m., the Administrator stated she knew they talked about Resident #1's change in mode of transfer but did not know that it was implemented. She said the resident refused to transferred via sit-to-stand. The administrator said examples of transfer aids would be Hoyer lift, sit-to-stand, gait belts, and sliding board.During an interview on 01/30/2026 at 10:41 a.m., RN C stated she knew Resident #1 used a sit-to-stand because it was discussed during one of their morning meetings. She said the DON and the Administrator were always present during the morning meeting. She said she could remember the therapy department recommended sit-to-stand it was deemed that it would be safer for the resident. She said she knew about it and other nurses also knew about it. She said CNA A also knew that the resident was being transferred via sit-to-stand because she saw CNA A used the machine. She said Resident #1 did not refuse sit-to-stand.During an interview on 01/30/2026 at 11:09 a.m., the Social Worker stated she participated during the morning team meetings. She said she heard on one of their morning meetings, with the therapy department, about changing Resident #1's mode of transfer. She said she was not sure the exact date of the recommendation. She said it was also during their morning meeting that she heard about the fall during their meeting. During a telephone interview on 01/30/2026 at 11:27 am, CNA A stated she knew Resident #1 was a sit to stand before she fell. She said she used sit-to-stand on her when she was on the other hall but when she was transferred to the present room, she never used the sit-to-stand. She said she did not use the sit-to-stand on the day of the fall. CNA A did not reply when asked why she did not use the sit-to-stand.During a telephone interview on 01/30/2026 at 11:39 a.m., the NP T stated he documented on Resident #1's progress notes for strict fall precautions because of the resident's impaired balance. He said he was notified about the fall. He said some fall precautions included lowering the bed, place near the nurse's station, mat on the floor, and monitor medications.Record review of the facility's in-service, dated 01/12/2026, reflected an in-service about Incidents and Accidents. There was no in-service done for after the fall reflected no in-service for safe transfers and using appropriate transfer.This was determined to be an Immediate Jeopardy (IJ) on 01/30/2026 at 2:22 p.m the Administrator was notified. The Administrator was provided with the IJ template on 01/30/2026 at 2:26 p.m.The following Plan of Removal submitted by the facility was accepted on 01/31/2026 at 12:01 p.m.Facility: [Facility Name]Date: 01/30/2026Problem: F689 Accidents and Hazards Plan of RemovalOn 01/29/2026, an investigation survey was initiated at the facility. On 01/30/2026, the surveyor provided Immediate Jeopardy (IJ) for SNF notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. F-689- Free of Accident Hazards/Supervision/Assistive Devices (F689 - The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.1. Immediate Actions Taken for Those Residents IdentifiedAction: Resident #1 immediately evaluated by nursing staff. Care plan updated to reflect current transfer status. Resident requires a sit to stand lift. Order placed in the electronic medical administration record for mechanical lift transfers. Physical Therapy referral placed in the electronic medical administration record for evaluation and treatment. Person(s) Responsible: Director of Nursing (DON), Regional Nurse Consultant, and/or Designee Date: 01/30/2026 by 5 p.m. Action: All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy. Staff members will be educated prior to working their next shift. Staff who are not present will receive education via the telephone prior to working their next shift. All new hires and agency staff will receive education before providing resident care. Person(s) Responsible: Director of Nursing (DON), Regional Nurse Consultant, and/or Designee Date: 01/31/2026 by noon Action: 1:1 education provided to Director of Nursing on following recommendation made by therapy on resident transfers and discussing those residents in clinical meeting Monday thru Friday and weekly during the center Standards of Care Meeting. Person(s) Responsible: Regional Nurse Consultant Date: 1/30/2026 by 10:00 p.m. 2. How the Facility Identified Other Possibly Affected Residents:Action: The DON and designee(s) reassessed all residents using the Fall Risk Assessment Tool and the MOS Nurse ensured all residents identified as at risk for falls had safety measures, as well as resident specific interventions, added to their care plans. Responsible Person(s): Director of Nursing (DON) and MOS Nurse Date: 1/31/2026 by noonAction: The MOS Nurse will ensure the safety measures and resident specific interventions that were added to the care plans were also reflected on the electronic and paper medical record so that the CNAs had access to this information. Responsible Person(s): MOS Nurse Date: 1/31/2026 by noon Action: The DON and designee(s) instructed the CNAs to review the updated paper medical record prior to their next shift. Responsible Person(s): Director of Nursing (DON), Regional Nurse Consultant, and/or MOS Nurse Date: 1/31/2026 by noon Action: 100% audit of all residents requiring assistance with transfers conducted to ensure accuracy of transfer status and updated care plans. Person(s) Responsible: Director of Nursing (DON), Regional Nurse Consultant, and/or Designee Date: 01/30/2026 by 10 p.m. Action: 100% audit of all therapy recommendations from August 1, 2025, to current reviewed and followed Person(s) Responsible: Director of Nursing (DON), Regional Nurse Consultant, and/or Designee Date: 01/31/2026 by noon 3. Measures that were put into Place/System Changes to remove the immediacy, and what date these actions occurred:Action: Policy on Safe Resident Handling/Transfers reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care. Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Regional Nurse Consultant, and/or Designee Date: 01/30/2026 at 3:30 p.m. policy reviewed with no changes made Action: The DON or designee will audit new admissions daily to ensure the Fall Risk Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the Kardex (gives a brief overview of each patient). Responsible Person(s): Director of Nursing (DON) Date: Ongoing x 60 daysAction: The Regional Nurse Consultant will review all falls within 72 hours for three months to ensure an RCA has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the paper and electronic care plan chart Responsible Person(s): Regional Nurse Consultant Date: Ongoing x 60 days Action: The DON or designee will review all falls at the daily stand up meeting with the IDT for three months to ensure appropriate fall interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been updated. Responsible Person(s): Director of Nursing (DON) Date: Ongoing x 60 days Action: Interdisciplinary team will review all audit results in QAPI weekly for 8 weeks, then monthly for 4 months. Any identified trends will result in additional training. Person(s) Responsible: Administrator, Director of Nursing (DON) and/or Rehab Director Date: Ongoing QAPI-Action: Medical Director notified of the deficient practice/lJ and Plan of Removal. Person(s) Responsible: DON, Administrator, and/or Designee Date: 01/30/2026Immediate Interventions:1. Resident #1 evaluated, care plan updated of the current transfer status, order and Physical Therapy placed in electronic medical record.2. All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy. All new hires and agency staff will receive education before providing resident care.3. Director of Nursing in-serviced on following recommendation made by therapy on resident transfers and discussing those residents in clinical meeting.4. The Fall Risk Assessment of all the residents were re-assessed.5. Safety measures and resident specific interventions that were added to the care plans were also reflected on the paper and electronic medical record so that the CNAs had access to this information.6. The CNAs were instructed to review the updated paper medical record prior to their next shift.7. Audit of all residents requiring assistance with transfers conducted to ensure accuracy of transfer status and updated care plans.8. Audit of all therapy recommendations reviewed and followed.9. Audit new admissions daily to ensure the Fall Risk Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions11. All falls will reviewed within 72 hours to three months to ensure an RCA has been conducted.12. Interdisciplinary team will review all audit results in QAPI weekly for 8 weeks, then monthly for 4 months.Monitoring:1. On 01/30/2026, Resident #1's intervention updated and reflected the resident's current transfer status.2. On 01/30/2026, Resident #1's care plan reflected the resident's current transfer status.3. On 01/30/2026, Staff received an education pertaining to Safe Resident Handling/Transfer as evidenced by a signed Education Page with twenty-eight signatures. Fifteen staff were educated face-to-face while thirteen staff educated via phone call. The education was inclusive of all three shifts and various disciplines.4. Fall Prevention Program under Basic Restorative Skills included on the Nurse Aide Competency for new hires.5. The DON was in-serviced by RCN on 01/30/2026 about following recommendations done by the therapy department.6. Audit of fall risk assessment of all residents provided.7. Copy of paper Kardex provided.8. Transfer status of all residents provided.9. Audit of therapy recommendations provided.10. Copy of risk assessment for two new admission provided.11. Ad-Hoc QAPI sign-in, dated 01/30/2026, with nine signatures provided.Staff Monitoring:During an interview on 01/31/2026 at 12:36 p.m., LVN L she was in-serviced about transfers and safe handlings of the residents before she began her shift. She said the in-service talked about making sure the appropriate transfers needed by a specific resident.During an interview on 01/31/2026 at 1:10 p.m., CNA D stated she had an in-service about safe transfer and the use of the transfer aids like Hoyer lift, sit-to-stand, and gait belt. She said she was also provided a Kardex with an updated mode of transfer for all residents. She said she also had a check off about transfer.During an interview on 01/31/2026 at 1:20 p.m., CNA E stated the staff had an in-service about safe resident handling/transfer. She said residents whose mode of transfer were stand and pivot should use a gait belt. She said the DON provided the in-service and the DOR provided a visual education. She said the education included Hoyer lifts and sit-to-stand. She said she had a check-off on how to put on the gait belt, how to operate the Hoyer lift and sit-to-stand. She said she was also reminded to make sure that the machine were in good condition before using and to clean after using. During an interview on 01/31/2026 at 1:27 p.m., the DOR stated she conducted a training with the CNAs and Nurses about gait belts, Hoyer lifts, and sit-to-stand were given. She said she also provided visual education with the staff that were not present the night before. She said she also provided a virtual training with the therapists so they would be confident in case they would be transferring the residents. She said the goal was to make sure safe measures when transferring were in place. During an interview on 01/31/2026 at 1:34 p.m., the MDS Nurse said the DON in-serviced the staff about proper means of transferring alongside the DOR. She said if the resident was a one person assist, the staff must use a gait belt and must check if too loose or too tight. She said she was educated on how to operate the Hoyer lift and the sit-to-stand. She said the DON instructed them to check the Kardex always to make sure the right transfer would be done. She said they were told that, if ever in doubt about what kind of transfer, ask the nurse.During an interview on 01/31/2026 at 1:42 p.m., the Weekend Supervisor stated they had an in-service about different kinds of transfers and safe handling. She said the machines should be checked before using. She said the DON called her last night for the in-service and also that morning.During an interview on 01/31/2026 at 1:49 p.m., the Activity Director stated she participated in the in-service about safety of residents during transfer. She said she did not do transfers but the in-service was good food for the brain just in case extra help was needed.During an interview on 01/31/2026 at 1:56 p.m., the BOM stated she was in-serviced about transferring the resident safely and not transferring if not trained. She said the DON and the DOR showed them how to use the gait belt and the machines like the Hoyer lift and the sit-to-stand.During an interview on 01/31/2026 at 2:08 p.m., HK Y stated he did not do transfers but was educated on what to do if he saw a resident on the floor. He said he needed to call the nurses in case a resident fell.During a telephone interview on 01/31/2026 at 2:16 p.m., CNA A said she was in-serviced about safe transfer and handling of the residents. She said she needed to make sure that she was following how the residents were transferred to ensure resident safety.During a telephone interview on 01/31/2026 at 2:23

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for eight (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of twenty-nine residents reviewed for accuracy of assessments.The facility failed to ensure Resident #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's Comprehensive MDS Assessments accurately reflected the residents were using mechanical lifts. This failure could place residents at risk for not receiving care and services needed to meet their needs, diminished function of health, and regression in their overall health.Findings included:1. Record review of Resident #1's Face Sheet, dated 01/29/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included muscle weakness, unsteadiness of feet, lack of coordination, convulsion (sudden, irregular movement), and history of fall.Record review of Resident #1's Comprehensive MDS Assessment, dated 11/17/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift (a device used to lift, transfer, or position an individual with limited mobility).Record review of Resident #1's Comprehensive Care Plan, dated 11/23/2025, reflected the resident was at risk for falls related to unsteady gait, history of falls, muscle weakness, and cognitive impairment. The Comprehensive Care Plan also reflected, with revision date, 12/31/2025, staff were to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation for ADLs. The plan did not indicate what transfer aid to use.Record review of Resident #1's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand (a mobility device that helps an individual with some strength but limited endurance to safely move from a seated position to a standing position).During an interview on 01/29/2026 at 8:41 a.m., Resident #1 stated some staff would transfer her using a machine. She said she used the machine last year, but she could not remember the exact date.2. Record review of Resident #2's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included muscle weakness and lack of coordination.Record review of Resident #2's Comprehensive MDS Assessment, dated 12/02/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needed little support) with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #2's Comprehensive Care Plan, dated 01/07/2026, reflected the resident was at risk for falls related to muscle weakness and one of the interventions was to be assisted with transfers via mechanical lift ( used to transfer an individual with limited mobility) as needed.Record review of Resident #2's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for mechanical lift.3. Record review of Resident #3's Face Sheet, dated 01/30/2026, reflected an [AGE] year-old female, admitted [DATE], diagnoses included muscle weakness and lack of coordination.Record review of Resident #3's Comprehensive MDS Assessment, dated 01/02/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #3's Comprehensive Care Plan, dated 01/07/2026, reflected the resident was at risk for falls related to muscle weakness and one of the interventions was to transfer with Hoyer lift to wheelchair.Record review of Resident #3's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for mechanical lift.During an interview on 01/31/2026 at 11:45 a.m., Resident #3 stated the staff transferred her using a machine. She said before lifting her up, the staff would hook the sling to the machine and then the machine would raise her from the bed to her wheelchair.During an observation on 01/31/2026 at 11:48 a.m., revealed CNA D and CNA E transferred Resident #3 using a mechanical lift. The CNAs placed the mechanical lift's sling under the resident, hooked the ends of the mechanical lift's sling to the Hoyer lift, and transferred the resident to her wheelchair.4. Record review of Resident #4's Face Sheet, dated 01/30/2026, reflected an [AGE] year-old male, admitted [DATE], diagnoses included muscle weakness, unsteadiness of feet, and lack of coordination.Record review of Resident #4's Comprehensive MDS Assessment, dated 12/10/2025, reflected the resident had severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #4's Comprehensive Care Plan, dated 10/15/2025, reflected the resident was at risk for falls and one of the interventions was the resident would be assisted with transfer. The Comprehensive Care Plan also reflected that the resident required varying levels of staff assistance for ADLs and one of the interventions was to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation. The plan did not indicate what transfer aid to use.Record review of Resident #4's Physician Order reviewed on 01/30/2026 reflected the resident did not have an order for sit-to-stand.During an interview on 01/31/2026 at 10:28 a.m., Resident #4 stated if he remembered it right, he started using the sit-to-stand around October of 2025 because his legs were not that strong anymore.During an observation on 01/31/2026 at 10:31 a.m., CNA D and CNA E transferred Resident #4. The CNAs pushed the sit-to-stand machine inside the resident's room, put the waist strap around the resident's waist, hooked the waist strap to the hook of the sit-to-stand and transferred the resident to his wheelchair.5. Record review of Resident #5's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old male, admitted [DATE], diagnoses included muscle weakness, lack of coordination, and repeated falls.Record review of Resident #5's Comprehensive MDS Assessment, dated 11/16/2025, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #5's Comprehensive Care Plan, dated 11/19/2025, reflected the resident was not care planned for a Hoyer lift.Record review of Resident #5's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand.6. Record review of Resident #6's Face Sheet, dated 01/30/2026, reflected an [AGE] year-old male, admitted [DATE], diagnosis included repeated fall.Record review of Resident #6's Comprehensive MDS Assessment, dated 11/12/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #6's Comprehensive Care Plan, dated 11/19/2025, reflected the resident was not care planned for Hoyer lift.Record review of Resident #6's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for mechanical lift.7.Record review of Resident #7's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves) and contracture (tightening or shortening of the muscles).Record review of Resident #7's Comprehensive MDS Assessment, dated 11/25/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #7's Comprehensive Care Plan, dated 12/09/2025, reflected the resident was at risk for falls and one of the interventions was the resident would be assisted with transfer. The Comprehensive Care Plan also reflected staff were to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation for ADLs. The plan did not indicate what transfer aid to use.Record review of Resident #7's Physician Order reviewed on 01/30/2026 reflected the resident did not have an order for Hoyer lift.8. Record review of Resident #8's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old male, admitted [DATE], diagnoses included muscle wasting and lack of coordination.Record review of Resident #8's Comprehensive MDS Assessment, dated 11/24/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #8's Comprehensive Care Plan, dated 12/09/2025, reflected the resident required varying levels of staff assistance for ADLs and one of the interventions was to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation. The plan did not indicate what transfer aid to use.Record review of Resident #8's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand.During an interview on 01/30/2026 at 7:27 a.m., the MDS Nurse stated she was the one doing the residents' MDSs. She said she was not able to code that Residents #1, #2, #3, #4, #5, #6, #7, and #8 were using mechanical lifts because she did not see the orders for mechanical lifts. She said the MDS was a tool to identify the needs of the residents with regards to their care. She said, in order to provide the appropriate care, the residents should be assessed thoroughly to provide the current status of the residents so they would be care planned accordingly. She said the MDS gave the overall picture of the resident, and it was like puzzle pieces that needed to be put together. She said the MDS was for reimbursement but also to assess the residents' needs. During an interview on 01/30/2026 at 7:44 a.m., the DON stated the resident's MDS should reflect their mode of transfer because sometimes the MDS was the basis of what should be included in the care plan. She said she already coordinated with the MDS Nurse to fix the issue.During an interview on 01/30/2026 at 10:26 a.m., the Administrator stated if the MDS Assessment needed to reflect that residents were using a mechanical lift, then the residents' MDS should display it. She said she knew the DON and the MDS Nurse already started fixing the issue.Record review of the facility policy, Comprehensive Assessment and the Care Delivery Process Nursing Services Policy and Procedure Manual for Long-Term Care revised December 2016 revealed Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans . 2. Assessment and information . a. Assess the individual . (1) Gather relevant information from multiple sources . (a) Observation; (b) Physical assessment; (c) Symptom or condition-related assessments; (d) Resident and family interview . (h) Evaluations from other disciplines.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that 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 a resident for six (Residents #1, #4, #5, #6, #7, and #8) of twenty-nine residents reviewed for care plans. The facility failed to ensure Residents #1, #4, #5, #6, #7, and #8 were care planned for the transfer mode used on 01/29/2026.This failure could place residents at risk of not receiving the necessary care needed during transfer. Findings included:Record review of Resident #1's Face Sheet, dated 01/29/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included muscle weakness, unsteadiness of feet, lack of coordination, convulsion, and history of fall.Record review of Resident #1's Comprehensive MDS Assessment, dated 11/17/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #1's Comprehensive Care Plan, dated 11/23/2025, reflected the resident was at risk for fall related to unsteady gait, history of falls, muscle weakness, and cognitive impairment. The Comprehensive Care Plan also reflected, with revision date, 12/31/2025, staff were to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation for ADLs. The plan did not indicate what transfer aid to use.Record review of Resident #1's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand.During an interview on 01/29/2026 at 8:41 a.m., Resident #1 stated some staff would transfer her using a machine. She said she had been using the machine last year, but she could not remember the exact date.2. Record review of Resident #4's Face Sheet, dated 01/30/2026, reflected an [AGE] year-old male, admitted [DATE], diagnoses included muscle weakness, unsteadiness of feet, and lack of coordination.Record review of Resident #4's Comprehensive MDS Assessment, dated 12/10/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #4's Comprehensive Care Plan, dated 10/15/2025, reflected the resident was at risk for fall and one of the interventions was the resident would be assisted with transfer. The Comprehensive Care Plan also reflected that the resident required varying levels of staff assistance for ADLs and one of the interventions was to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation. The plan did not indicate what transfer aid to use.Record review of Resident #4's Physician Order reviewed on 01/30/2026 reflected the resident did not have an order for sit-to-stand.During an interview on 01/31/2026 at 10:28 a.m., Resident #4 stated if he remembered it right, he started using the sit-to-stand around October of last year because his legs were not that strong anymore.During an observation on 01/31/2026 at 10:31 a.m. revealed CNA D and CNA E were about to transfer Resident #4. The CNAs pushed the sit-to-stand machine inside the resident's room, put the waist strap around the resident's waist, hooked the waist strap to the hook of the sit-to-stand and transferred the resident to his wheelchair.3. Record review of Resident #5's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old male, admitted [DATE]., diagnoses included muscle weakness, lack of coordination, and repeated falls.Record review of Resident #5's Comprehensive MDS Assessment, dated 11/16/2025, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #5's Comprehensive Care Plan, dated 11/19/2025, reflected the resident was not care planned for Hoyer lift.Record review of Resident #5's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand.4. Record review of Resident #6's Face Sheet, dated 01/30/2026, reflected an [AGE] year-old male, admitted [DATE], diagnosis included repeated fall.Record review of Resident #6's Comprehensive MDS Assessment, dated 11/12/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #6's Comprehensive Care Plan, dated 11/19/2025, reflected the resident was not care planned for Hoyer lift.Record review of Resident #6's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for Hoyer lift.5. Record review of Resident #7's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old female, admitted [DATE], diagnoses included multiple sclerosis and contracture.Record review of Resident #7's Comprehensive MDS Assessment, dated 11/25/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #7's Comprehensive Care Plan, dated 12/09/2025, reflected the resident was at risk for fall and one of the interventions was the resident would be assisted with transfer. The Comprehensive Care Plan also reflected staff were to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation for ADLs. The plan did not indicate what transfer aid to use.Record review of Resident #'7s Physician Order reviewed on 01/30/2026 reflected the resident did not have an order for mechanical lift.6. Record review of Resident #8's Face Sheet, dated 01/30/2026, reflected a [AGE] year-old male, admitted [DATE]., diagnoses included muscle wasting and lack of coordination.Record review of Resident #8's Comprehensive MDS Assessment, dated 11/24/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift.Record review of Resident #8's Comprehensive Care Plan, dated 12/09/2025, reflected the resident required varying levels of staff assistance for ADLs and one of the interventions was to use adaptive equipment (e.g., utensils, transfer aids, non-skid footwear) to enhance participation. The plan did not indicate what transfer aid to use.Record review of Resident #8's Physician Order reviewed on 01/29/2026 reflected the resident did not have an order for sit-to-stand.During an interview on 01/30/2026 at 7:27 a.m., the MDS Nurse stated she was responsible for the care plans. She said care plans should be in place so the staff knew the interventions and goals for the resident and would be consistent in terms of the care provided. She said if the residents were using a mechanical lift for transfer, then their care plan should reflect that. She said she was not able to do Resident #1's, #4's, #5's, #6's, #7's, and #8's care plan for transfer via mechanical lifts because the was no orders. She said they already made an audit of the care plans of the residents and updated them accordingly.During an interview on 01/30/2026 at 7:44 a.m., the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. She said the care plan should be in place so that the staff providing care would be on the same page. She said the care plan was important because it reflected the resident's problem lists, goals, and interventions. She said they already updated the care plans of the residents using mechanical lifts and also put the physician orders for them. During an interview on 01/30/2026 at 10:26 a.m., the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the DON and the MDS Nurse already put the care plans for the resident using mechanical lifts. She said the care plan should reflect the specific transfer need of the residents.Record review of the facility's policy title, Comprehensive Care Plans, dated revised 10/01/2025, reflected, Policy: 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 . Policy Explanation and Compliance Guidelines . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for seven (Resident #1, #2, #16, #20, #22, #24, and #25) of seventeen residents reviewed for privacy and confidentiality.1. The facility failed to ensure a list of hospice residents (Residents #2, #22, #24) was not left on top of the CNA's cubicle unattended on 07/01/2025.2. The facility failed to ensure MA B did not leave Resident #16's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for potassium on top of the medication cart unattended on 07/01/2025.3. The facility failed to ensure RN A did not leave Resident #25's order for wound care on top of treatment cart unattended on 07/02/2025.4. The facility failed to ensure MA C did not leave the names of the medications to be re-ordered for Resident #20 and Resident #25 on top of the medication cart unattended on 07/02/2025. 5. The facility failed to ensure CNA F and CNA G would close Resident #1's door while doing transfer via mechanical lift (a device used to lift, transfer, or position an individual with limited mobility), did not perform ADLs in the hallway, and did not reposition the resident in the hallway on 07/02/2025.These failures could place the residents at risk of not having their personal privacy maintained during transfer and ADLs and their medical information exposed to unauthorized individuals.Findings included: 1. Record review of Resident #2's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves). Record review of Resident #2's Quarterly MDS Assessment, dated 06/06/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #2's Care Plan, dated 06/09/2025, reflected the resident required hospice due to terminal illness of multiple sclerosis and one of the approaches was to report decline in condition to hospice agency.Record review of Resident #22's Face Sheet, dated 07/01/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #22's Quarterly MDS Assessment, dated 05/14/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #22's Care Plan, dated 05/13/2025, reflected the resident required Hospice due to terminal illness of chronic obstructive pulmonary disease and one of the approaches was to report decline in condition to hospice agency.Record review of Resident #24's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with coronary artery disease (heart disease caused by plaque buildup in the arteries). Record review of Resident #24's Quarterly MDS Assessment, dated 06/06/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #24's Care Plan, dated 06/13/2025, reflected the resident required Hospice due to terminal illness of coronary artery and one of the approaches was to call hospice for any concerns.Observation on 07/01/2025 at 8:44 AM revealed a piece of paper was on top of a cubicle on the hallway. On the piece of paper were names of residents who were on hospice.Observation and interview on 07/01/2025 at 9:12 AM, RN A stated the list of residents on hospice should not be left in the hallway because those were medical information and a HIPAA (law protecting health information aimed to ensure confidentiality) violation. RN A took the paper from the cubicle and said she would place it somewhere in the nurse's station. 2. Record review of Resident #16's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting. Record review of Resident #16's Quarterly MDS Assessment, dated 04/29/2025, reflected the resident had severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident had muscle wasting. Record review of Resident #16's Care Plan, dated 05/01/2025, reflected the resident had nine or more medications required and one of the approaches was to monitor laboratory results.Record review of Resident #16's Physician Order, dated 12/90/2020, reflected potassium chloride 20 meq 1 tablet Once A DayObservation on 07/01/2025 at 8:45 AM revealed Resident #16's blister pack was on top of the medication cart. The blister pack had the resident's name, name of medication, the prescription number, the name of the medical doctor, and the instruction on how to take the medication, and the name of the resident's pharmacy.In an interview on 07/01/2025 at 10:45 AM, MA B stated different facilities had different policies with regards to leaving the blister packs on top of the medication cart and said she had been doing it at other facilities, and it was not an issue. When asked if the medical information about the resident exposed, she said she should have flipped it before leaving her cart unattended so others would not know what medications Resident #16 was taking.3. Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with non-pressure chronic ulcer (wound on the skin caused by prolonged pressure to specific area of the body) to left heel. Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had non-pressure chronic ulcer of left heel. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had surgical wound to left foot and one of the approaches was to change the dressing as ordered.Record review of Resident #25's Physician Order, dated 05/31/2025, reflected Daily Wound Treatment: Clean Left Ankle with Wound Cleanser, Apply Collagen and Dry Dressing Daily.Observation on 07/02/2025 at 10:44 AM revealed RN A was about to do Resident #25's wound care. She prepared the things needed for wound care and entered inside the resident's room. She left the MAR opened and the resident's treatment flowsheet was visible. The order for the resident's wound care was visible to others. On the flowsheet was the resident's name, code status, wound care orders, time of treatments, name and phone number of the resident's physician, medications that the resident was allergic to, diagnosis and the resident's date of birth .In an interview on 07/02/2025 at 10:55 AM, RN A stated she should have closed the MAR's binder before going inside Resident #25's room to perform wound care because the medical information and the order for wound care for the resident was exposed. She said she saw it while she was doing wound care but was already in the middle of the process and it was already too late for her to close the binder. She said it was a HIPAA violation and the information should be confidential.4. Record review of Resident #20's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #20's Quarterly MDS Assessment, dated 04/28/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had depression. Record review of Resident #20's Care Plan, dated 04/28/2025, reflected the resident had depression and one of the approaches was administer medication as ordered.Record review of Resident #20's Physician Order, dated 05/05/2025, reflected mirtazapine tablet 7.5 mg Once A Day Antidepressants.Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's Disease (movement disorder). Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had Parkinson's Disease. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had Parkinson's and one of the approaches was to provide drug therapy.Record review of Resident #25's Physician Order, dated 03/27/2025, reflected amantadine HCl capsule 100 mg Twice A Day for Parkinsonism.Observation on 07/02/2025 at 3:59 PM revealed a re-order form for medications was on top of a medication cart. On the form were posted two stickers showing Residents #20 and #25's names and the medications to be re-ordered for them. Observation and interview on 07/02/2025 at 4:00 PM revealed RN A also saw the re-order form and flipped it. She said the staff should have flipped it so the medications of the residents were not showing.Observation and interview on 07/02/2025 at 4:01 PM revealed MA C was exiting one of the residents room and saw RN A flipped the re-order form on top of her cart. she said she had been flipping the form the whole day but forgot to do so for that particular moment. She said the said those were medical information and should not be seen by unauthorized individuals.5. Record review of Resident #1's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with contracture and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was dependent on staff for transfer, bed mobility, and personal hygiene.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident required assistance with ADLs and the approaches were to transfer times 2 with mechanical lift, assist with bed mobility, and assist with ADL care.Record review of Resident #1's Physician Order, dated 10/18/2016, reflected Transfer with assist of 2 staff and Hoyer lift.Observation on 07/02/2025 at 10:20 AM revealed CNA F and CNA G were about to transfer Resident #1 from bed to wheelchair via mechanical lift. Both CNAs washed their hands, put on their gloves, and proceeded with transfer. They did not close the resident's door when they were performing the transfer and the procedure could be seen from the hallway. Both CNAs hooked the loops of the mechanical sling, which was under the resident, to the sling attachment of the mechanical lift, and started to raise the resident. CNA G then went to the resident's wheelchair and CNA F started to maneuver the mechanical lift towards the wheelchair using its remote control. They lowered the resident to her wheelchair, unhooked the mechanical sling, and ushered the resident to the hallway. It was observed that the resident did not have a roommate and the other bed inside the room was parallel to the wall and perpendicular to the resident's bed rendering a square-shaped space inside the room. In the hallway CNA F started to clean the resident's face and combed her hair and asked CNA G to reposition the resident.In an interview on 07/02/2025 at 10:35 AM, CNA F stated the door should had been closed when they were transferring Resident #1 to her wheelchair to provide privacy and dignity. He said he also should had cleaned the resident's face, combed her hair, and repositioned the resident inside her room with the door closed. He said Resident #1 might be embarrassed because other residents or visitors might see how she was being transferred and that she needed somebody else to clean her face and comb her hair. He said he would make sure to close the door every time he would do a transfer and do all the ADLs and repositioning inside the room with the door closed as well. In an interview on 07/02/2025 at 11:44 AM, CNA G stated the door should be closed when Resident #1 was transferred and her ADLs should had been done inside the room to provide privacy.In an interview on 07/02/2025 at 2:28 PM, the DON stated the door should be closed when transferring the residents to provide privacy. She said ADLs such as cleaning the face, combing the hair, and repositioning the residents should be done inside the room and not in the hallway for the same reason. She said privacy should be provided during care to avoid awkwardness. She said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. The DON stated medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have made sure the MAR was closed before going inside the resident's room, the blister pack and the re-order form were flipped, and the list of hospice resident was not exposed. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors will be able to see it. She said all staff, including her, were expected to provide full privacy during care and confidentiality of all the residents' personal and medical information. The DON stated she would start an in-service about privacy and confidentiality of the residents' information.In an interview on 07/02/2025 at 2:52 PM, the ADON stated all transfers and ADLs should be done in the privacy of the residents' room so other staff, other residents, or even the visitors would not see the care being provided. She said it did not matter if the residents care or not, the door should be closed to ensure the residents would not be embarrassed. The ADON said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during care and to secure the medical information of the residents.to the residents. She said she would coordinate with the DON to do an in-service about privacy during care and confidentiality of medical records.In an interview on 07/02/2025 at 3:13 PM, The Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment and that the medical information of the residents were safeguarded to prevent embarrassment or unlawful use of their information. She said the expectation was for the staff to be mindful about privacy and confidentiality. She said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality.Record review of the facility's policy, SAFEGUARDING PROTECTED HEALTH INFORMATION Health Information Management Policies and Procedures revised 03/01/2013 revealed POLICY: Health Information Management (HlM staff will set up access controls and physical safeguards to prevent prohibited uses and disclosure of Protected Health Information (PHI) . 2. SAFEGUARDS FOR WRITTEN PHI . A. Active Records on Nursing Unit . 1) Active Medical Records are stored in an area or manner that secures the records from unauthorized access . 3) Active Medical Record are not left unattended or unsecured on the nurses' station desk or other areas where patients/residents, visitors and unauthorized individuals could easily view the records . 4) Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI are not left open.Record review of the facility's policy, PRIVACY AND SECURITY Resident Rights revised 11/01/2017 revealed POLICY: The Facility staff will provide the patient/resident with his/her right to privacy . 2. Staff . D. Closes privacy curtains or doors as appropriate during treatment or daily care.

Based on observation, interview and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 15 resident rooms on the [NAME] Hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8) reviewed for environment.The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8 were thoroughly cleaned and sanitized.This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 07/01/25 at 10:13 AM of resident room [ROOM NUMBER] reflected a mini fridge with brown stains on the bottom of the inside of it. The room floor had thick dark dirt stains along the edges and corners of the floor. The bathroom floors had dark stains along the corners of the floor and behind the toilet. The bathroom sink had stains inside the bowl of the sink. The air vent had black dirt on the vents. An observation on 07/01/25 at 10:16 AM of resident room [ROOM NUMBER] reflected a mini fridge with brownish and reddish stains on the bottom of the inside of it. The room floor had thick dark dirt stains along the edges, behind the bed, and corners of the floor. The inside resident door had red stains on the bottom portion of the door. An observation on 07/01/25 at 10:19 AM of resident room [ROOM NUMBER] reflected the air conditioning unit filters had thick dust in them. The air vents had black dirt on the vents. The room floor had thick dark dirt stains along the edges and corners of the floor. The bathroom floor had dark reddish stains behind the toilet and the bathroom had a strong unpleasant odor. The bathroom wall near the door had brown stains streaking down the bathroom tile and door frame. An observation on 07/01/25 at 10:24 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges, near a resident bed, and corners of the floor. A wall near a resident's bed had large scrapings. The air vent had black dirt on the vents. An observation on 07/01/25 at 10:27 AM of resident room [ROOM NUMBER] reflected a mini fridge with brownish and reddish stains on the bottom of the inside of it and on the floor in front of the fridge. The room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:29 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:33 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:35 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. In an interview on 07/03/25 at 09:16 AM, Housekeeping J stated he was responsible for cleaning the rooms on the [NAME] side of the facility. He stated he was supposed to clean the floor, air vents, bathrooms, and wipe down the walls. He stated he did not clean the resident mini fridges in the rooms unless they asked him to. He was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, #6, #7, and #8. He stated he normally cleaned the areas observed. He did not state why the areas of concern were not cleaned. He stated not cleaning the rooms and the hallway floors could result in germs being spread. In an interview on 07/03/25 at 9:21 AM, the Maintenance/Housekeeping Director, stated he was responsible for supervising the staff on cleaning the facility. He stated staff was responsible for cleaning the floors, empty the trashcans, dust the vents, clean the bathrooms, wiping down the walls, and the hallway floors. He stated the nursing staff was responsible for checking the mini fridges in the resident rooms but they could clean them if needed. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8. He stated he currently did not have a working buffer to thoroughly clean the floors. He stated he was responsible for repairing any damaged walls. He stated during Angels rounds, staff was responsible for checking the rooms for cleanliness and he also checked rooms for cleanliness multiple times a week. He stated if the rooms and halls were not thoroughly cleaned it could result in health issues for the residents. In an interview on 07/03/25 at 9:45 AM, the Administrator stated she had met with the Maintenance/Housekeeping Director, and he had briefed her on the concerns observed. She was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8. She stated her staff cleaned the rooms and they typically were told by others that they had a clean facility. She stated they completed Angel rounds daily and one of the areas observed was the cleanliness of the resident rooms. She stated it was the entire staff's responsibility to clean the resident refrigerators in the resident rooms. She stated she expected the housekeeping staff to thoroughly clean the resident rooms and hall floors. She stated not cleaning the areas mentioned could present sanitary concerns. Record review of the facility's policy on Environment That Preserves Dignity-Resident Right For (2017) reflected The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #51) of ten residents reviewed for pharmaceutical services. 1. The facility failed to ensure MA B did not leave Resident #51's medications inside the resident's room for the resident to take unsupervised on 07/01/2025 2. The facility failed to ensure MA C did not put her personal beverage on the medication cart while passing medications on 07/02/2025. 3. The facility failed to ensure that there was no expired nasal sprays inside the medication room on 07/02/2025. These failures could place the residents at risk of not receiving medications as ordered by the physician. Findings included: 1. Record review of Resident #51's Face Sheet, dated 07/01/2021, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #51's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #51's Comprehensive Care Plan, dated 06/20/2025, reflected the resident had a decline in her ability to ambulate and one of the approaches was to provide supplements and vitamins as ordered. Record review of Resident #51's Physician's Order, dated 06/24/2025, reflected provitalize 2 capsules Once A Day. Record review of Resident #51's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 07/01/2025 at 8:54 AM revealed Resident #51 was in her bed finishing her breakfast. It was observed that there was a small cup on her overbed table with two yellow capsules. The resident said it was left by her nurse for her to take and she was done with the rest of the pills. The resident said she would take the capsules after she was done with breakfast. In an interview on 07/01/2025 at 9:12 AM, RN A stated Resident #51's medication should not be left with the resident for her to take unsupervised. She said staff should have made sure the medications were swallowed and there was no issue while taking the medication. She said the resident might not take the pills or hide them or choke on them and nobody was there to initiate help. In an interview on 07/01/2025 at 10:45 AM, MA B stated she was inside Resident #51's room waiting for the resident to finish her medications. She said a CNA called her for assistance so she stepped out of the room and forgot to go back. She said she should have told the staff that she could not be distracted when she was administering medications. She said the resident might throw the medication or hide them. She said she would check if the resident already took the medications. She said the two yellow capsules were provitalize, a probiotic. 2. Observation on 07/02/2025 at 7:15 AM revealed MA C's personal tumbler was on top of the medication cart that she was using to pass medications. Observation and interview on 07/02/2025 at 12:27 PM revealed MA C's personal tumbler was still on top of the medication cart that she was using to pass medications. She said she always had her tumbler every time she passed medications and nobody told her she could not put it there. In an interview on 07/03/2025 at 9:12 AM, MA C stated the DON already explained to her why she could not have her personal tumbler on the cart when passing medications. She said it could be an infection control issue or could create clutter on the medication cart. She was told that only required supplies and medications should be on the medication cart. 3. Observation on 07/02/2025 at 8:15 AM revealed during inspection of the medication room, three bottles of nasal spray were dated 05/25. Observation and interview on 07/02/2025 at 8:16 AM, RN A stated the nasal sprays were expired and should not be inside the medication room. She said they were supposed to be disposed so they would not be used for the residents. She said the ADON was responsible in auditing the medication room but she would sometimes help in the checking the med room. She said they missed the three expired nasal sprays. She said the expired nasal sprays might be less effective or could cause adverse reactions. RN A took the three bottles of nasal spray and showed them to the DON. In an interview on 07/02/2025 at 2:28 PM, the DON stated a staff should never leave the medications at the bedside for the resident to take later unsupervised. She said the staff must ensure the resident took the medications before leaving the room. She said the resident could hoard or hide the pills to avoid taking them. She said the residents could overdose on hoarded pills. She said the staff should have told the staff that asked for assistance that she was passing meds and could not be distracted. She said there should be no expired medications inside the medication room or inside the medication carts. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects. She said she already talked to MA C that she could not put any personal items on the medication carts. She said aside from the risk of cross contamination, some residents might take it and drink the content. She said the expectations were for the staff not to leave any medication inside the room for the residents to take unsupervised, for the medication room to be audited thoroughly for expired medications, and no personal beverages were in any cart. The DON said she would do an in-service pertaining to all the issues mentioned and would closely monitor the staffs' compliance. In an interview on 07/02/2025 at 2:52 PM, the ADON stated she was the one responsible for auditing the medication room for what to order and for expired medications. She said it was an oversight on her part that she missed seeing the expired nasal sprays. She said she already checked the medications inside the medication room to see if there were other expired medications. She said expired medications lose their effectiveness and would not address the medical needs of the residents. She said medications were not left with the residents to take unsupervised. She said the staff administering the medications should stay with the resident until the resident was done taking them. She said the resident might not take them or someone else might, like another resident or a visitor. She said the resident might aspirate while taking the medications and nobody was with her. She said if somebody asked for help, the staff could help after the resident was done taking the medications. She said no personal beverages should be on the carts because aside from being a clutter that might contribute to medication error, staff might bring some microorganism from their home to the medication cart. She said she would coordinate with the DON to do an in-service about not leaving the medications with the residents and not distracting the staff that was passing medications. In an interview on 07/02/2025 at 3:13 PM, The Administrator stated she was made aware of the issues about the expired medications in the medication room and personal beverages on the cart, and the staff leaving the resident's medications for the resident to take alone. She said if the pills were left unattended, the resident might not take them or the pills might not be taken on time. She said she would coordinate with the DON and the ADON to do an in-service about not leaving the medications with the resident during med pass, not disturbing the staff that was passing meds, make sure there no expired medications in the med room, and no personal beverages on the carts. Record review of the facility's policy, MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures revised 01/15/2025 revealed 2. Nursing services . E. educate staff . that during medication pass . the medication aide . is not to be interrupted . 5. person authorized . prepares, administer . the medications . 8. The authorized staff member must remain with the resident while the medication is swallowed. Do not leave the medication in a resident room without order to do so . Preparing for the Medication Pass . F. No employee beverages should be on the medication/treatment cart . Security and Safety Guidelines . 15. Outdated medication is destroyed or returned to the pharmacy.

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to place a lid on top of the trashcan to avoid air borne contaminants. The facility failed to ensure prepared food in the refrigerator was labeled and dated when stored. The facility failed to ensure foods located in the freezer were sealed from air-borne contaminants. The facility failed to ensure all foods stored in the freezer and refrigerator were labeled and dated when stored. The facility failed to dispose of expired foods in the dry storage area. The facility failed to ensure kitchen equipment was cleaned. The facility failed to ensure the kitchen and dining area was cleaned and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 07/01/25 from 8:34 AM to 8:47 AM in the facility's only kitchen revealed: One large trashcan, located in the dining room, was full of trash and did not have a lid on it. A large air vent, located in the dining room, had black and reddish stains on the vents. One microwave, located in the dining room, had brownish stains all over the inside walls of it. One brown serving cart, located in the dining room, had stains, trash, and food particles all over the top of it. One zip locked bag of fruits, located in the refrigerator, was not labeled with the stored date. One gallon of Asian Sesame Dressing, located in the refrigerator, was not labeled with the stored date. One large box of French toast, located in freezer, was not sealed from air-borne contaminants. One large box of frozen waffles, located in freezer, was not sealed from air-borne contaminants. One large bag of frozen ground beef, located in the freezer, was not labeled with the date the item was stored. One ice scoop was sitting on a tray in the dining area, and not covered from air-borne contaminants. One blue ice scoop holder, located on a wall next to the ice machine, had brownish dirt particles on the inside bottom of it. Four bags of flour tortillas, located in the dry storage area, had a best by date of 6/25/25, and were not discarded. One white refrigerator, located in the dry storage area had black stains on the inside of it. One bag of frozen biscuits, located in the freezer, was dated 12/19 with a use by date of 1/13/25 was not discarded. In an interview on 7/02/25 at 12:10 PM, the Dietary manager stated the kitchen was cleaned daily and they used a cleaning schedule. He stated the microwave was scheduled to be cleaned twice a week. He stated he ensured the trashcans always had lids on them and he had forgotten to place the lid back on the trashcan. He stated he labeled and dated the food when it was stored and if food came in on the weekend, the cooks would label and date the foods. The Dietary Manager stated he was responsible for ensuring food in the freezer were sealed, foods were labeled and dated, and ensured foods were discard when it expired. He stated he had new cooks, and they were still learning so he took on these responsibilities. He stated residents could potentially get sick if these issues were not resolved. In an interview on 07/03/25 at 9:45 AM, the Administrator stated she had spoken with the Dietary Manager about the concerns observed in the kitchen area. She was also shown pictures of the concerns observed in the kitchen area. She stated her expectation was for the kitchen and kitchen equipment to be clean, expired foods to be discarded, and the foods to be properly labeled and dated. She stated not addressing the concerns observed could result in residents getting sick. Record review of the facility's policy on Food Safety in Receiving and Storage (06/20/23), revealed Foods will be received and stored by methods to minimize contamination and bacterial growth. Refrigerated, ready-to-eat Time/Temperature Control for Safety Foods are properly covered, labeled, dated with use-by-date, refrigerated immediately. Record review of the facility's policy on Sanitation & Food Safety in Food and Nutrition Services (06/20/2023), revealed The Certified Dietary Manager will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. Infection control sanitation practices are followed to minimize the risk of contamination of food and prevent foodborne illness. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #1 and Resident #7) of fifteen residents reviewed for dignity.1. The facility failed to ensure CNA F properly covered Resident #1 while repositioning the resident in the hallway on 07/02/2025.2. The facility failed to ensure CNA D did not stand in front of Resident #7 while assisting the resident to eat during lunchtime on 07/01/2025.These failures could place the residents at risk of not having their right to a dignified existence maintained.Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with contracture (tightening or shortening of the muscles) and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was dependent on staff for dressing and personal hygiene.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident had contractures and one of the approaches was to assist with repositioning.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident was experiencing weakness and one of the approaches was to assist with ADLs.Observation on 07/02/2025 at 10:29 AM revealed after Resident #1 was transferred to her wheelchair, CNA F pushed the resident's wheelchair to the hallway. In the hallway, CNA F asked CNA G for assistance in repositioning the resident. The resident was facing the hallway, did not have any cover on her lower part of the body, and half of her thighs were visible. CNA G asked CNA F if she would get a blanket to cover the resident, but CNA F said to finish repositioning the resident first. Both CNAs repositioned the resident and placed some pillows under the resident's arms.In an interview on 07/02/2025 at 10:35 AM, CNA F stated he should have covered Resident #1 or pulled her clothes while repositioning her in the hallway to provide dignity and so that her brief would not be visible to other residents, staff, or visitors. He said the resident had the right to be treated with dignity and one of his duties was to provide it.Observation and interview on 07/02/2025 at 1:38 PM revealed Resident #1 was in the lobby eating snacks. When asked if it was ok with her when the staff did not cover her up in the hallway, the resident did not reply.2. Record review of Resident #7's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with legal blindness (vision impairment that affects central or peripheral visions or both) and lack of coordination.Record review of Resident #7's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident was dependent on staff for eating.Record review of Resident #7's Comprehensive Care Plan, dated 05/12/2025, reflected the resident required assistance with ADLs and one of the approaches was to assist with eating.Record review of Resident #7's Physician Order, dated 05/28/2019, reflected EATING with assist of 1 staff.Observation on 07/01/2025 at 11:53 AM revealed CNA D was assisting Resident #7 for lunch in the dining area. CNA D was standing in front of the resident while she was feeding the resident. In an interview on 07/01/2025 at 12:17 PM, CNAD stated she should be sitting down when assisting somebody in the dining area. She said she assisted Resident #7 during lunch until somebody relieved her. She said, when assisting somebody during mealtimes, she should sit down so she would be face to face with the resident. She said standing up in front of the resident was not a way of showing respect and dignity and as if she was implying to the resident to hurry up. She said her mind was already on the trays on the hallway that she needed to pass. She said he ADON whispered to her that she should be sitting down but somebody already came to relieve her so she could pass the trays. Observation and interview on 07/01/2025 at 2:07 PM revealed when asked if it was ok when staff were standing up when assisting her during mealtimes, Resident #7 did not reply.In an interview on 07/02/2025 at 2:28 PM, the DON stated staff should cover the residents before ushering them in the hallway to prevent improper exposure of the resident as well as a feeling of embarrassment. She said before pushing the residents out of their rooms, the residents should be well-groomed and decent. She said the staff should sit down next to the resident when assisting them during mealtimes. She said sitting beside the resident also allowed close observation of the resident's eating habits like if the residents were swallowing the food, if there was a problem in swallowing, if the resident was pocketing the food, if the residents were choking. She said standing up behind the resident gave the impression that the staff was in a hurry. She said not covering the residents and not sitting beside the resident to assist in eating did not uphold dignity and respect. She said she already initiated an in-service about dignity specifically about sitting down when providing assistance during mealtimes. She said the expectation was for all the staff to provide all the residents a dignified existence. She said she would add to the in-service to make sure the residents were covered and decent when ushered to the hallway. In an interview on 07/02/2025 at 2:52 PM, the ADON stated the staff assisting a resident during mealtime should be sitting alongside the residents to provide dignity. She said sitting beside the residents would allow better observation of the residents' needs during mealtime. She also said sitting beside the resident encouraged interaction and promoted safety when eating. She said she saw CNA D standing up while assisting Resident #7 during lunch and told her she needed to sit down. She said when ushering the residents in the hallway, the staff must make sure the residents were appropriately covered to prevent embarrassment. She said the expectation was for the staff to provide dignity, not only during mealtime but every time the staff provide care to the residents. She said the DON already started an in-service about dignity.In an interview on 07/02/2025 at 3:13 PM, The Administrator stated the expectation was for the staff to always have in mind that the residents have the right for a dignified existence and it should be provided during all interactions with the residents, not just in the dining room and in the hallway. She said both incidents were disrespectful and a dignity issue. She said she would collaborate with the DON and the ADON to re-educate the staff about the importance of dignity.Record review of the facility's policy, ENVIRONMENT THAT PRESERVES DIGNITY Resident Rights revised 11/01/2017 revealed POLICY: The Facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #22) reviewed for accident prevention. The facility failed to ensure Resident #22's fall mat was place alongside his bed for fall prevention. This failure could prevent the resident from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #22's Face Sheet, dated 07/01/25, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated falls, and dementia (memory loss). Record review of Resident #22's Quarterly MDS assessment, dated 05/14/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis included quadriplegia (paralysis of lower extremity). Record review of Resident #22's Comprehensive Care Plan, dated 05/14/25, reflected the resident was a fall risk and two of the interventions was to be ensure a fall mat placed alongside the resident's bed. An observation on 07/02/25 at 9:45 AM of Resident #22 revealed the resident lying in bed sleeping. There was a bed side table positioned over him and the fall mat was folded and leaning against the foot of his bed. In an interview and observation on 07/02/25 at 9:48 AM, the ADON observed the resident's fall mat folded up and leaning against the foot of Resident #22's bed. She stated she had confirmed with the DON that the resident had a recent fall and required the fall mat to be placed alongside the resident's bed while he was lying in it to prevent him from injuring himself if he fell. She stated Hospice may have provided care to the resident and had forgotten to remove the bedside table and place the fall mat alongside the bed. In an interview on 07/02/25 at 11:22 AM, the DON stated she had spoken with the ADON about Resident #22 not having the fall mat placed alongside his bed after he had finished his breakfast. She stated she thought Hospice had forgotten to place the fall mat back alongside the resident's bed. She was advised that the resident was observed earlier in the morning eating his breakfast and was later observed with the bedside table still over his bed while he was lying in it and the fall mat leaning against the foot of the bed. She stated the fall mat should have been placed alongside the resident's bed to assist in preventing him from injuring himself if he fell out of the bed. She stated the resident was a fall risk. Record review of the facility's policy Fall Management (5/05/23) reflected The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #6's t-tube (used to receive medications by breathing in mist through the mouth) for breathing treatment was properly stored when not in use on 07/01/2025 and that there was a sign outside the resident's room to indicate that oxygen was in use on 07/01/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #6's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #6's Quarterly MDS Assessment, dated 05/13/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and was on oxygen therapy. Record review of Resident #6's Comprehensive Care Plan, dated 06/30/2025, reflected the resident had chronic obstructive pulmonary disease and the approaches were to administer albuterol hfa (medication used for breathing treatment) prn and oxygen as ordered. Record review of Resident #6's Physician's Order, dated 06/30/2024, reflected albuterol sulfate HFA aerosol inhaler 90 mcg/actuation PRN for shortness of breath. Record review of Resident #6's Physician's Order, dated 05/09/2025, reflected O2 at 2 liters per minute via nasal cannula continuous every day. Observation and interview on 07/01/2025 at 8:32 AM revealed Resident #6 was sitting in his recliner, awake and with was on oxygen therapy. A nebulization machine was noted on top of the resident's side table with a t-tube connected to it. The t-tube was not bagged. The resident said the last time he had a breathing treatment was before he was sent out to the hospital and that was a week ago. He said he had been using oxygen even before he was admitted to the facility. Observation and interview on 07/01/2025 at 10:23 AM, RN A stated Resident #6's order for the breathing treatment was as needed. She said, if she was not mistaken, the last time the resident used the breathing treatment was before his last hospitalization a week ago. She said the resident used a t-tube instead of the breathing mask during the breathing treatment. She said if the resident was not using the t-tube, it should be inside a clean plastic bag to ensure cleanliness for the next use. She went inside the resident's room and saw the t-tube on the table. She disconnected the breathing mask and threw it in the trash can and said she did not notice it when she did her morning round. She said she would get another one and make sure it was inside the plastic bag to prevent any respiratory infection. In an interview on 07/02/2025 at 2:28 PM, the DON stated Resident #6's t-tube should be inside a plastic bag when the resident was using it to prevent cross contamination and possible infection. She said no one even knew how long it was on the side table not bagged. She said the expectation was for any breathing paraphernalia be bagged. She said she would initiate an in-service about bagging storing any breathing paraphernalia properly. In an interview on 07/02/2025 at 2:52 PM, the ADON stated the t-tube should be stored properly to prevent cross contamination and respiratory infections. she said whoever administered the breathing treatment was responsible in cleaning it and storing it in a plastic bag. She said the expectation was for the staff to bag the t-tube when not in use and replace it if seen not bagged. She said she would coordinate with the DON to do an in-service about the issue. In an interview on 07/02/2025 at 3:13 PM, The Administrator stated they were vigilant in reminding the staff to bag the respiratory paraphernalia that the residents were using to prevent respiratory infection. She said she would coordinate with the DON and the ADON on how to deal with the issue. Record review of the facility's policy RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 05,2023 revealed POLICY: The Facility ensures the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice . PROCEDURES . 6. Infection control practices including standard and transmission-based precautions are . B. Handling of equipment, including cleaning, storage . 8. Respiratory Care [NAME] elements . A. Oxygen Therapy . 2) safety precautions.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for two (Resident #2 and Resident #25) of sixteen residents reviewed for medication storage. 1. The facility failed to ensure #Resident #2's anti-fungal powder was not left on top of the resident's side table on 07/01/2025. 2. The facility failed to ensure Resident #25 did not have a bottle of eyedrops on her overbed table on 07/01/2025. These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects. Findings included: 1. Record review of Resident #2's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depressive disorder (persistent feeling of sadness or loss of interest) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09 (resident may need additional support and monitoring). The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #2's Comprehensive Care Plan, dated 06/09/2025, reflected the resident took an antidepressant and one of the approaches was to monitor the resident's mood and response to medication. Record review of Resident #2' Physician Order, dated 11/10/2022, reflected Anti-fungal powder to affected area. Record review of Resident #2's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 07/01/2025 at 8:50 AM revealed Resident #2 was in her bed, awake. It was observed that there was an antifungal powder on the resident's side table. When asked if she was using it, the resident just shrugged her shoulders. 2. Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar that could potentially have an effect on the eye sight). Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had diabetes mellitus and one of the approaches was to monitor potential signs and symptoms . blurry eyes. Record review of Resident #25's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Record review of Resident #25's Physician orders on 07/01/2025 reflected no order for eye drops. Record review of Resident #25's Physician Order, dated 12/23/2024, reflected RESIDENT MAY NOT SELF-ADMINISTER MEDICATIONS Observation and interview on 07/01/2025 at 10:08 AM revealed Resident #25 was in her bed, awake. It was observed that there was a container of eyedrops on the resident's overbed table. She said she was using it every morning because her eyes were dry when she woke up. She said the eyedrops had always been on top of her table. She said she did not know if the staff saw it or knew about it but it had been on her table. Observation and interview on 07/01/2025 at 10:23 AM, RN A stated the eyedrops should not be inside Resident #25's room unless she had an assessment that she could administer it herself. She said if the resident needed eyedrops, the staff should be the one administering it and it should be stored inside the cart. She went inside Resident #25's room and talked to the resident. She said she would also call the doctor to get an order for the eyedrops. RN A then went to Resident #2's room and saw the anti-fungal powder on the side table. She said she did not know who left it on the side table. She took the anti-fungal from the side table and said she would put it inside the cart because it was a medicated powder. She said she did not see the eyedrops and the anti-fungal powder when she made her morning round. In an interview on 07/02/2025 at 2:28 PM, the DON stated no medications should be stored inside the resident's room. She said if Resident #25 needed eyedrops, the staff should be the one administering it to ensure proper use of the medication and there should be an order for. She said the anti-fungal powder is a form of medication and should be in the cart. She said whoever applied it should have not left it in Resident #2's side table because the resident, other confused residents, or a visitor might accidentally ingest it and could result in allergic reactions or other adverse outcomes. She said the expectations were for the staff to always scan the residents' rooms to make sure the residents were not storing any medications and for staff to put the medicated powder back to the medication cart. She said she would do an in-service for all the issues mentioned and would closely monitor the staffs' compliance. In an interview on 07/02/2025 at 2:52 PM, the ADON stated no medications should be stored inside the residents' rooms because the residents might administer them incorrectly and there should be physician orders for such medications as well. She said the medicated powder should be stored in the cart and not inside the room because it had chemicals that could be toxic when consumed. She said the expectation was for the staff to be compliant with the policies regarding medication storage to ensure a safe medication administration. She said she would coordinate with the DON to do an in-service about medication storage. In an interview on 07/02/2025 at 3:13 PM, The Administrator stated she was made aware of the issues about medication inside the residents' rooms. She said the expectation was for the staff to be mindful with all the discussed medication storage issues to ensure safety of the residents. She said she would coordinate with the DON and the ADON on what to so the issues mentioned would not happen again. Record review of the facility policy, MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures revised 05/05/2023 revealed 2. Nursing services . 5. person authorized . prepares, administer . the medications . Security and safety Guidelines . 3. The medication cart is locked when not in use and in direct line insight.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #50) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA E changed her gloves and performed hand hygiene during Resident #50's incontinent care on 07/01/2025.2. The facility failed to ensure that CNA F changed his gloves and performed hand hygiene during Resident #1's incontinent care on 07/02/2025.These failures could place residents at risk of cross-contamination and development of infections.Findings included:1. Record review of Resident #50's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection.Record review of Resident #50's Comprehensive MDS Assessment, dated 07/02/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was incontinent for bladder and bowel.Record review of Resident #50's Comprehensive Care Plan, dated 04/27/2025, reflected the resident was incontinent of bowel and bladder and one of the approaches was to provide incontinence care. Observation on 07/01/2025 at 1:10 PM revealed CNA D and CNA E were about to provide incontinent care to Resident #50. Both CNAs washed their hands and put on a pair of gloves. CNA E went to right side of the resident while CNA D went to left side. Both CNAs unfastened the soiled brief and tucked it between the resident's legs. CNA D washed her hands and put on a new pair of gloves. CNA D started cleaning the resident's perineal area (area between the legs) using the front to back technique. After cleaning the perineal area, the resident was assisted to roll towards the right side and CNA D cleaned the resident's bottom. After cleaning the resident's bottom, CNA D rolled the pulled the soiled brief and threw it in the trash can. CNA E helped in rolling the soiled brief. CNA D washed her hands and put on a new pair of gloves. CNA D then took the brief and placed it under the resident. Since the resident was still in a side-lying position, CNA D told CNA E that they would switch places so CNA E could wash her hands and change her gloves. After switching places, instead of washing her hands and putting on a new pair of gloves, CNA E proceeded on fixing the new brief. CNA E still had the pair of gloves that she used to touch the soiled brief. After fixing the brief, they assisted the resident to roll back and fastened both ends of the brief. Both CNAs washed their hands.In an interview on 07/01/2025 at 1:18 PM, CNA E stated, realistically, it should not take that long to do incontinent care. She said there was a lot of things to do and sometimes there was no time to change gloves. when asked again if the gloves should be changed after touching something soiled and before touching the new brief, CNA E replied yes to prevent infection.2. Record review of Resident #1's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with anoxic brain damage.Record review of Resident #1's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident was incontinent of bowel and or bladder and one of the approaches was to provide incontinence care.Observation on 07/02/2025 at 10:05 AM revealed CNA F was about to transfer Resident #1 but said he would clean her up first. He washed his hands and put on a pair gloves. He then unfastened the resident's brief on both sides and pushed it between the resident's legs. Before starting incontinent care, he took a new brief, opened it, and placed it on the resident's side. He did not change his gloves before touching the new brief. He cleaned the resident's perineal area (area between the thighs) using the front to back technique. He did it six times. He changed his gloves but did not sanitize his hands before putting on the new pair of gloves. He then rolled the resident and started cleaning the resident's bottom. During the process, CNA F took the new brief beside the resident and placed it on the foot part of the bed. The new brief was facing down and the inner part of the brief was touching the bed. He continued to clean the resident's bottom and then pulled the new brief from the foot side of the bed and placed it under the resident. He did not change his gloves before touching the new brief. CNA F said he would clean the resident's bottom some more and placed the wipes on top of the new brief. After cleaning the resident's bottom some more, he rolled back the resident, and fastened the brief on both side. In an interview on 07/02/2025 at 10:35 AM, CNA F stated hand hygiene was important to prevent cross contamination and development of infection. He said he should be mindful that everytime he would touch any soiled items like a soiled brief, he should change his gloves first and sanitize in between changing of gloves. he said he was not even aware that when he put the new brief on the foot part of the bed, the inner part was touching the bed. He said he needed to mindful, as well, that everything that would be used for the residents were clean. In an interview on 07/02/2025 at 2:28 PM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom and before touching the new brief. She said placing the brief upside down rendered the brief dirty. She said with regards to CNA D, she already talked to her that changing the gloves was mandatory after cleaning the resident's bottom and before touching the new brief. she said the expectation was for the staff to proficient in preventing infection. She said she would do an in-service about infection control and hand hygiene. She said she would personally monitor the staff's adherence to the policy and procedure of infection control. In an interview on 07/02/2025 at 2:52 PM, the ADON stated the purpose of hand hygiene and changing of gloves was to prevent cross contamination and spread of infection in the facility. She said gloves should be changed after cleaning the resident's bottom. She said hands should also be sanitized before putting on a new pair of gloves. She said the expectations were for the staff to be mindful with how they take care of the residents. She said she would coordinate with the DON to do in-service regarding infection control and hand hygiene.In an interview on 07/02/2025 at 3:13 PM, The Administrator stated not changing the gloves when going from soiled to clean and not sanitizing the hands before putting on a new pair of gloves could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control and hand hygiene. She said she would coordinate with the DON and the ADON about hand hygiene and infection control.Review of the facility's policy Hand Hygiene/Handwashing Infection Prevention and Control Policies and Procedures revised May 15, 2023, reflected Policy: Hand Hygiene/Hand washing is the most important component for preventing the spread of infection . 1. Hand hygiene/hand washing is done . C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids . H. After removal of medical/surgical or utility gloves . C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure they assisted residents in obtaining routine dental care for 1 of 8 residents (Resident #3) reviewed for dental services. The facility failed to refer Resident #3 for dental services. This failure could put residents needing dental services at risk of oral complications or weight loss, resulting in a decreased quality of life. Findings included: Record review of Resident 3's Annual MDS assessment , dated 03/07/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke, non-Alzheimer's dementia, multiple sclerosis (a long-lasting disease of the central nervous system), malnutrition, and contractures. The record showed she was dependent on staff for oral care. Record review of Resident 3's Care Plan, revised on 03/07/24, reflected the resident had oral/dental problems. The plan was to obtain a dental consult. An observation and interview on 06/04/24 at 12:11 PM with Resident #3 revealed she was lying in bed with her headphones on. Her teeth were thick with some kind of yellow-brown build-up on them. She did not appear to be missing teeth, but it was difficult to tell because the teeth were so misshapen and caked with the yellow-brown build-up. The resident said she was able to eat and staff fed her. An interview on 06/05/24 at 2:45 PM with the ADON revealed she did not know when Resident #3 last saw the dentist. The ADON said she did not know the resident had a care plan to obtain a dental consult. The ADON said poor dental health could affect the resident's health and cause them to not be able to drink and eat well. An interview on 06/06/24 at 11:01 AM with the MDS nurse revealed she reviewed the care plan for Resident #3. She said she knew about the dental consult but thought the SW would see the care plan and get the referral. The MDS nurse said the SW was responsible for obtaining referrals. An interview on 06/06/24 at 11:24 AM with the SW revealed she worked part-time at the facility for the last 2 months and did the facility referrals if she knew about them. She said she did not know about the referral for Resident #3. She said Resident #3 did not have a referral to see the dentist and she did not know when the resident last saw the dentist. She said if residents did not get the referrals they needed, then their needs would not be met. ]An interview on 06/06/24 at 12:11 PM with the Administrator revealed she did not know why Resident #3 did not have a referral to see the dentist. She said if a resident did not get the referrals they needed, then they would not receive the care they needed. Review of the facility policy, Subject: Coordination of Ancillary Services, revised 2023, reflected: Policy: The Facility has a process to coordinate the care of patients and residents among the professional services involved. The Social Services department or designee coordinates ancillary medical services such as psychological services, dentistry, podiatry, optometry, audiologist and hospice as signed.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #17) of eight residents observed for infection control. The facility failed to ensure that CNA A and CNA B did not place the used bed padding on top of Resident #17's open, clean, and new brief. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #17's Face Sheet, dated 06/05/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diarrhea and urinary incontinence. Review of Resident #17's Comprehensive MDS Assessment, dated 05/09/2024, reflected Resident #17 had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment also indicated Resident #17 was always incontinent for bowel and bladder. Review of Resident #17's Care Plan, dated 05/16/2024, reflected resident required assistance with ADLs and one of the interventions was assist with all ADLs as needed. Observation on 06/05/2024 starting at 8:05 AM revealed Resident was on her bed awake. It was observed that the resident had a cloth padding placed beneath her torso. CNA A and CNA B were about to prepare the resident for her doctor's appointment. Both CNAs washed their hands and put on gloves. CNA A prepared the things needed and told Resident #17 that they would be cleaning her. CNA A positioned herself on Resident #17's left side and CNA B on the right side. CNA A unfastened the tape on both sides of the brief, rolled the front half of the brief and then pushed it between the resident's thighs. CNA A cleaned the front part of the resident using the front to back technique. CNA A then instructed and assisted the resident to turn towards CNA B. When the resident was on the side lying position, it was observed that the resident just had a bowel movement. CNA A and CNA B begun cleaning the resident's bottom. Both CNAs placed the wipes used to clean the resident's bottom on the soiled brief. Some of the soiled wipes touched the cloth padding. After cleaning the resident's bottom, CNA A took off her gloves, washed her hands, and put on new gloves. While CNA A was washing her hands, CNA B transferred to the other side, pulled the rest of the soiled brief, and threw it. CNA B rolled the padding halfway. CNA B took off her gloves, sanitized her hands, and put on new gloves. CNA A then took the new brief, opened it, placed it beside the resident's bottom, and tucked it under the used and soiled padding. The used padding was on top of the open, new brief. CNA A then instructed the resident to roll to the other side. CNA A pulled the padding and asked the resident to roll back. CNA B then fixed the new brief. In an interview with CNA A on 06/05/2024 at 8: 30 AM, CNA A stated she washed her hands before and after doing incontinent care. She said she also changed her gloves after touching the soiled items. CNA A then acknowledged that she tucked the brief under the padding. She said that during incontinent care, the soiled wipes could had touched the padding making dirty. She said she should had pulled the soiled padding first before tucking the new brief under the resident's bottom. She said the germs from the padding could transfer to the new brief and the resident could had urinary tract infection. In an interview with CNA B on 06/05/2024 at 8: 37 AM, CNA B stated she also washed her hands before and after doing incontinent care and sanitized her hands when she changed her gloves. CNA B then acknowledged that the padding touched the new brief when it was tucked under the resident. She said the padding, whether clean or not, should not the touch the clean brief to prevent cross contamination. She said the resident might catch an infection if dirty items touched the clean items. In an interview with RN C on 06/05/2024 at 8:45 AM, RN C stated the right procedure was to wash to do hand hygiene before and after any care. She said it was also important to change and sanitize the hands during the duration of any care if soiled items were touched. RN C added that any soiled items should not touch the clean items to prevent cross contamination and possible infection. She said, for the same reason, the used and soiled padding should not be placed on top of an open and clean brief because female residents were prone to urinary tract infections. She said everything soiled should had been taken away before placement of the clean item. In an interview with the Interim DON on 06/06/2024 at 7:22 AM, the Interim DON stated she was made aware about the infection control issue during incontinent care. The Interim DON said the soiled items should be removed first before placing the clean brief to prevent possible infections. She said there should be not contact between the clean items and the dirty items. The Interim DON said the DON and the ADON were responsible in making sure the staff were adhering to the infection control practices. The interim DON said the expectation was for the staff to carry out care without the possibility of cross contamination and introduction of infection. The interim DON said she would do an infection control in-service pertaining to incontinent care for all the staff. She also said she did a check off with CNA A and B about peri-care and would do spot checks for all the staff pertaining to peri-care. She concluded that she would continually remind the staff to be attentive to the procedures for infection control. In an interview with the ADON on 06/06/2024 at 7:48 AM, the ADON stated placing the soiled padding on top of the new brief could result to cross contamination because if the soiled wipes and brief touched the padding, the padding was considered not clean. The same reason applied when the used and soiled padding touched the clean brief. She continued that cross contamination could lead to infection such as urinary tract infection. The ADON said the expectation was for the staff not to put the soiled or the used padding on top of a clean brief. The ADON said they would do an in-service to correct the issue and would monitor their adherence to the procedure of separation of clean and dirty items. In an interview with the Administrator on 06/06/2024 at 8:23 AM, the Administrator stated clean and dirty items should not be touching each other to prevent infection. She said the expectation was for the staff to be mindful and do the right and proper way of care to protect the residents. The Administrator said she would collaborate with the clinicals to address the issue. Record review of CNA A and B's competency check-off for Peri-Care Competency, dated 06/06/2024, revealed Performance Criteria . 24. Apply clean undergarment. Record review of facility's procedure, Perineal Care revealed Perineal care, which includes care of the external genitalia and anal area . promotes cleanliness and prevents infection . Completing the procedure . dispose of soiled articles.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person centered careplan, and the resident's goals and preferences for 1 (Resident #1) of 6 residents reviewed for pain management. 1. The facility failed to administer Resident #1's Hydrocodone as ordered for 14.5 hours while the prescribed medication was available in the emergency kit. These failures placed residents at risk of increased pain due to not having their pain medication administered and resulted in Resident #1 enduring an extended period of time with no pain relief. Findings included: Record review of Resident #1's Minimum Data Set Assessment, dated 06/15/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognition was moderately impaired. He required extensive two-person assist for bed mobility, limited one-person assist for transfer, dressing, personal hygiene, limited two-person assist for toilet use, and supervision with one-person assist for walk in room. The resident was always continent. His diagnoses included aftercare following joint replacement surgery on right knee, pain, muscle spasm, muscle weakness, unspecified lack of coordination, unsteadiness on feet, cognitive communication deficit, and Type 2 Diabetes. Record review of the Physician's Order revealed: 06/13/23 Oxycodone/Tylenol Tablet 10-325 MG by mouth three times a day for pain. Record Review of the Care Plan, which was last updated on 06/24/23 for Resident #1, revealed the resident had a decline in ability to ambulate at prior level of functioning. Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/13/23 at 10:15 PM, for Resident #1 reflected, Late Entry: report received regarding new admission of resident. S/P (Surgical Procedure) right knew replacement, ice machine not complete so is unusable at this time, also narcotic pain medication unavailable from pharmacy at this time. - LVN A Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/13/23 at 10:30 PM, for Resident #1 reflected, c/o (complaint of) uncontrolled, extreme pain, zero pain med (medication) available, ice packs and Tylenol 650 mg given at this time with very little results. Resident assisted for comfort in bed, mostly ineffective. At 10:30 PM, checked on resident, resident complaining of increased pain, explained to resident that we can try some Tylenol and an ice pack to relieve pain, resident agreeable. N.O. (New Order) written for Tylenol 650 mg two tablets to be taken by mouth every six hours as needed, until narcotic medication available from pharmacy. At 10:45 PM, resident assisted to lay down and into position of comfort after administering Tylenol 650 mg. Ice pack prepared .a towel placed over right knee and large ice pack applied at this time. On 06/14/23 at 1:00 AM, resident continued to rest at this time without distress. Eyes closed, resp (respiratory) even, unlabored and regular. -LVN A Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/14/23 at 2:30 AM, for Resident #1 reflected, resident c/o increased extreme pain, called spouse and 24-hour pharmacy to attempt to get pain medications filled. Informed nurse that his wife will be picking him up to get pain meds then will return to facility. On 06/14/23 at 4:15 AM, resident returned to facility and was assisted into bed. Told nurse that pharmacy was closed and that his wife will return in the morning to pick up meds and bring to facility. Resident requested Tylenol 650 mg and ice pack. Staff assisted resident to position of comfort, administered PRN Tylenol 650 mg as ordered. Towel placed over right knew and large ice pack in place. At 4:45 AM, continued with frequent visual checks by nurse and C.N.A., for any pain symptoms, resident continues to rest in with eyes closed, resp even, unlabored and regular. At 5:30 AM resident continues to rest at this time, no noted pain symptoms. Eyes closed, resp even unlabored, and regular. - LVN A Review of a written statement from the DON, dated 06/14/23 reflected, I was informed in the Clinical Meeting this [NAME] at 0915, that the above resident (Resident #1) was admitted yesterday, a few minutes before 1800 and still did not have anything for pain except Tylenol I text the charge nurse (LVN A) and asked her if the resident complained of pain last night. She text back yes I charted about it. I ask her why she didn't get it out of ER box she said she was not an agent. She also stated she did all she could for the man (Resident #1) see attached nurse note. Administrator asked her why she didn't call DON for assist and stated she never thought about it. She said it should have been taken care of by prior shift. DON told her it was her responsibility on her shift that residents are taken care of and she should have notified DON of the need for pain medication and notified the doctor to send a script to our pharmacy. LVN B was interview by Administrator and DON. She stated she ordered his (Resident #1) medications shortly after the resident arrived, however, none of his medications arrived on the night delivery due to horders were not received by 6:00 PM for night delivery. Resident came in with orders for Hydrocodone, however, physician sent triplicate for Oxycodone to local pharmacy. She also stated she was not aware that you have to have a triplicate in order to get medications. She stated she did go down there and check on resident during her shift, she just did not document it. She stated she did text LVN C around 10:00 PM, but did not get a response back. LVN C stated she did not see the text until to late. DON instructed LVN B to always report immediately to DON, ADON anytime she needed something for a resident, also that the doctor has to be notified immediately of anything that is ordered for resident and if we don't have it. Employee suspended until further investigation. Review of undated written statement of interview with C.N.A. D rebealed, she was interviewed by phone by the DON on 06/16/23 at 11:00 PM. LVN B stated on the night of 06/13/23, she assisted LVN A with placing an ice pack early in the shift and knew the nurse had given him pills but did not know what kind. She also stated she checked on the resident throughout the shift and he was resting. She also stated they assisted him to the care so he could go to the pharmacy. She stated, other than that, she did not know of anything going. Review of undated written statement of interview with LVN A revealed, she did all she knew to do for Resident #1 the night that the resident was admitted from the hospital. She stated she gave him Tylenol twice during the night and repositioned him along with providing ice packs, due to the ice machine which was sent from the hospital was missing a chord. She stated the resident was in a pleasant mood and resting through most of the shift. The DON instructed LVN A to do a late entry, stating all of the care that was provided throughout the shift. LVN A stated it did not occur to her to call the DON for assistance in getting the resident stronger pain medication. The DON and Administrator informed her when she takes report it is her responsibility to make sure all residents are cared for in a timely manner, no matter what the prior shift had done. LVN A admitted she was wrong and that she had made a mistake. She was suspended until further investigation could be completed. Record review of in-services dated 06/14/23 revealed, staff were in-serviced on Abuse and Neglect and Pain Management. Observation of Resident #1 was not possible, as the resident was discharged from the facility on 06/24/23. An interview on 06/29/23 at 1:08 PM with the Administrator, revealed the Oxycodone medication was not administered to Resident #1 on the evening of 06/13/23 and night hours of 06/14/23. She stated she did not fully understand why LVN A did not access the Emergency Kit, so she could administer the Oxycodone to the resident. She stated LVN A eventually admitted that she knew what should had done, however, she was trying to prove a point, in order to invoke change. The Administrator stated LVN B was new to the facility, but not new to long term care nursing. She stated LVN B was the admitting nurse and she did submit the facility physician's orders to the pharmacy, however, it was too late for them to be delivered to the facility that night. She stated LVN B should have contacted herself or the DON, when she realized the medications would not be delivered that night. She stated she was not sure if LVN A had access to the Emergency Kit or not, however, she did know that she could have called herself or the DON for guidance on how to access it. She stated the Resident #1 did not have to be uncomfortable at all, had the nurses did what they were supposed to do. Attempts to contact LVN A and LVN B on 06/29/23 at 2:00 PM, were unsuccessful, as neither nurse returned the calls. A phone interview on 06/29/23 at 5:15 PM with Resident #1 revealed, he stated he felt fine when he arrived at the facility on 06/13/23. He stated he remembered first complaining of pain around 10:30 PM, that night. He stated he started feeling pain before then, but it was not bad enough to complain about. He stated he could not remember what time he first started to feel discomfort. He stated the nurse told him they did not have his medications and could only give him Tylenol. He stated he was fine with that. He stated his pain was at a nine when he complained to the nurse. He stated the Tylenol took it to an eight. He stated he dealt with it because he was able to fall asleep. He stated he had gotten text earlier in the evening about his prescription being ready, so he decided to go get it, since the facility did not have anything stronger than the Tylenol, however, the pharmacy was closed when he got there. He stated the nurse gave him more Tylenol when he returned to the facility and placed another ice pack on his knee. He stated he felt the staff did what they could do to accommodate him, so he did not have any complaints. He stated he did not feel neglected. He stated he was a strong man and he made it through the night and he did not have any complaints about his care that night. An interview on 06/30/29 at 10:00 AM with the DON, revealed LVN A had access to the Emergency Kit, however, she admitted ly did not access the medications needed. She stated LVN B should have called the DON or the Administrator to receive instruction as to how to gain access to the Emergency Kit. She stated Resident #1's pain could have been properly relieved had the nurses done what they had been educated to do. The DON stated the she accessed the Emergency Kit and administered Hydrocodone to the resident, after speaking with him and assessing him. His medication from the pharmacy arrived in time for the next dose. Review of an undated document entitled How to Access Narcotics from the ER Kit reflected 7. CALL DON OR ADON WITH ANY ISSUES. Review of the facility policy, Pain Management, dated 05/05/23, reflected: The purpose of this policy is to ensure that residents receive treatment and care in accordance with professional standards of practice., the comprehensive care plan, and the resident's choices, related to pain management .If the resident's pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food containers and cooking products in the kitchen and in the dry food pantry were closed, covered, or sealed properly. 2. The facility failed to ensure the facility's kitchen and dry food pantry were clean of dirt and debris. 3. The facility failed to ensure that staff covered their head and beard while conducting dietary duties. 4. The facility failed to ensure that the dishwasher worked properly. 5. The facility failed to cover the clean bowls and stored in the bowl rack. These failures could place residents at risk for cross contamination and other bacteria illnesses. Findings include: During an observation on 04/04/2023 at 9:32 AM of the initial tour of the facility's only kitchen revealed the Cook not wearing a hair or beard restraint. An observation on 04/04/2023 at 9:32 AM revealed the following food in the facility kitchen and dry food pantry not being closed, covered, or sealed properly. Box of Quick Creamy Wheat - partially opened, not in a bag and not resealed Box of Corn Starch - partially open, not in a bag and not resealed Box of Egg Noodles - opened and placed in an unsealed bag Box of Rice - opened and placed in an unsealed bag Container of Alfredo Sauce Mix - top of container was not securely fastened Bag of Corn Chips - opened and placed in another bag, which was not closed or sealed Bag of Elbow Macaroni - opened and not closed securely Bag of Fettuccine - opened and placed in a zip lock bag which was not sealed In a continued observation of the of the dry food pantry revealed the dry food pantry had dirt build-up and dried spills on the walking space of the floor and under the racks which held food. The seal of the deep freezer had condensation and a black substance present in the creases. Corn chip crumbs were scattered on the top of the deep freezer. Loose elbow macaroni was observed on top boxes and bags of food on the shelf below the shelf on which it was stored. An observation on 04/04/2023 at 9:41 AM revealed Cook B not wearing a beard covering or head covering with beard stubble hair exposing the sides of his beard from the jaw line above the lips up to his earlobe and under his chin. An interview with Cook B on 04/04/2023 at 9:41 AM revealed he ran the kitchen when on shift. He stated he had to work alone for a while until he was allowed to bring on another person to assist. He stated he cooked, cleaned, washed dishes, received deliveries, plated the food, and loaded the carts for the halls. He stated when the kitchen aide worked with him, she shared with all tasks except cooking and plating. He stated they did not have a full part time DIETARY MANAGER and they had had about 3 to 4 different DIETARY MANAGERs in about 6 to 8 months. He stated they had a part time DIETARY MANAGER, who was technically retired from the facility, however, she worked at the facility two days a week. An observation on 04/04/2023 at 9:45 AM revealed dirt and debris on the kitchen floor, under all of the raised fixtures in the kitchen. There was also dust build-up and dirt on the two, kitchen window air conditioning units. An observation on 04/04/2023 at 9:47 AM revealed a rack located on the floor, next to the counter, which held the coffee maker. The rack contained stacks of bowls which were turned upside down. The bottoms of the bowls were soiled with dried drippings from splattered coffee, which had. The number of bowls which had been soiled were too numerous to count. An observation on 04/04/2023 at 9:50 AM revealed a box which contained a bottle of cooking oil was located next to the entrance to the kitchen. The bottle of oil was exposed by a cut-out in the box. The opening of the bottle did not have a lid on it. An interview with the Cook B on 04/04/2023 at 9:50 AM revealed he had recently used it to cook, however, he had forgotten to put the lid back on it. He proceeded to place a plastic cup lid, which was used to cover the cups of beverages for the residents. This cover did not fit the opening of the cooking oil bottle, it just sat on top and was not secured in any fashion. An observation on 04/05/2023 at 11:04 AM revealed the low temperature dishwasher's thermometer read 50 degrees Fahrenheit and did not appear to be moving while it was in operation. An interview and observation on 04/05/2023 at 11:08 AM revealed Cook C stated the hot water will only stay hot if they have the hot water running from the faucet of the sink located across from the dishwasher. Which at the time of this interview, the hot water was observed to be running from the faucet at that sink. She stated the machine is old and it has been worked on several times. She stated several parts had been replaced. She stated the hot water heater had been reset and the machine was still not able to run hot water without having the hot water running from the faucet on at the sink. She stated the maintenance director instructed them to use the phone number on the dishwasher, to contact the manufacturer if the thermostat stopped working or if the water stopped getting hot. An observation on 04/05/2023 at 11:16 AM revealed after Dietary Aide raised the cover of the dishwasher 4-5 times, and each time it was raised, the temperature would go up. Dietary Aide stated by lifting the cover, it restarted the cycle which they found would increase the temperature. The thermostat did rise to 118 degrees Fahrenheit. An observation on 04/06/2023 at 10:21 AM revealed the floor of the kitchen still had the same dirt and debris present under all raised fixtures. A drinking cup and desert bowl were on the floor, under a sink adjacent to the dishwasher. The top of the dishwasher case was covered in dust, crumbs, and debris. The bracketed shelves where labels and the thickeners, container labels, litmus test strips, and other miscellaneous items were stored, was covered with dried brown splatter spots. An open container of powered food thickener was on the shelf. This open container was also observed on 04/05/23, being used when Cook A was preparing pureed chicken. There was also an open container of liquid food thickener on the shelf. The safety seal was partially opened, and it had dust build-up on it. The box which contained a bottle of cooking oil was located next to the entrance to the kitchen. The bottle of oil was exposed by a cut-out in the box. The opening of the bottle did not have a lid on it. When asked if it was being used or had recently been used, the Cook B said he forgot to put the lid back on it and proceeded to place a plastic cup lid, which was used to cover the cups of beverages for the residents. This cover did not fit the opening of the bottle, it just sat on top and was not secured in any fashion. An observation on 04/06/2023 at 10:51 AM revealed the dry food pantry's walking space of the floor had been mopped, however, dry spills and dirt build-up was still under the shelves which held the food. The open containers and packages of food were still not closed properly. An interview on 04/06/2023 at 12:06 PM revealed the DIETARY MANAGER stated if the dishwasher did not reach around 70 degrees Fahrenheit and the chemical sanitizer levels were not good, it would mean the dishes and utensils were not getting properly cleaned, which would mean they were not safe for the residents to eat from. An interview on 04/06/2023 at 1:03 PM revealed Cook B stated hair coverings are to be worn at all times. He stated he usually wore a nylon cap; however, he would get too hot while wearing it and he would take it off when he got too hot and started to sweat. He stated if head and beard coverings were not worn, hair could fall in the food. Observation and interview on 04/06/23 at 1:17 PM revealed the Dietary Aide was wearing a hair net, however, hair was uncovered around the perimeter of the cap. When the exposed hair was mentioned to her, she stated her hair did what it wanted to do and she couldn't control it. She did not attempt to correct the issue, until the ADietary Managerinistrator interceded and instructed her to do so. An interview on 04/06/23 at 1:28 PM revealed Cook B stated the maintenance guy is always working on the dishwasher. He stated it had had issues for a long time, about 3-4 years. He stated the hot water issue, with them having to turn the hot water faucet, at the sink across from the it, had been going on for about a month. An interview on 04/06/2023 at 1:43 PM revealed the ADietary Managerinistrator stated an unclean kitchen could cause cross contamination for the food being prepared for the residents. She stated the open containers of food could be contaminated with dust and insects. She stated the open containers of food thickener were unacceptable. The policy which was provided by the Dietary Manager for the facility was The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, which reflected, During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent food borne illness. Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning and texture. Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents. All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Tightly seal opened packages to prevent contamination or place food in covered containers. Clean exterior surfaces of food containers, such as cans or jars of visible soil before opening. Dishes, flatware, and glassware are free from chips, cracks, or stains. Anyone working in the kitchen during normal food production hours is expected to wear appropriate hair restraints (such as hats, hair covers or nets, beard restraints).

Based on observation, interview and record review, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance that is palatable, attractive, and at a safe and appetizing temperature for 6 of 6 Residents (Resident #20, #6, #31, #17, #14, #35) reviewed for food and nutrition services. The facility failed to ensure the pureed chicken was prepared in a way to preserve vitamins and taste by not following required measuring when adding thickener to the pureed chicken. This failure could place residents at risk of nutrition and hydration and negatively impact the recovery from, illness or injury. Findings include: Interview on 04/05/23 at 10:30 AM at the Resident Council Meeting revealed the resident in attendance (Resident #8, #9, #11, #21, and #27) complained about the food being lukewarm and tasting very salty. Observation on 04/05/2023 at 11:55 AM revealed Cook A grabbing the powered thickener container and pouring in straight into the pot that contained the chicken and no measurement device was used. Observations and Interview attempts on 04/05/2023 at 1:00 PM of Residents #20, #6, #31, #17, #14, and #35 to obtain feedback on Pureed diet, revealed none of these residents were interviewable. Observation and interview with Dietary Manager on 04/05/2023 at 1:00 PM revealed three test trays that contained Regular Diet, Mechanical Diet, and Pureed Diet. The food temperature was hot/warm. The Dietary Manager tasted the food and stated the meat was flavorful, the egg noodles needed more butter, and the mixed vegetables were good. Her comments were the same for each texture of food. She stated the pureed chicken tasted like chicken and the pureed noodles tasted like noodles and that they also needed more butter. She stated she was pleased with the food, except for the noodles needing more butter. The test tray was observed and tested by three members of the Survey Team and all three members determined that the Regular Diet Chicken and Mechanical Diet Chicken tasted very salty. All three members tasted the Pureed Chicken and all three members agreed that it tasted nothing like chicken. The Dietary Manager was advised that Cook A was observed pouring powdered thickener straight into the pot with the chicken, without measuring it. The Dietary Manager stated there were recipes for the different pureed meals. She stated there were standard guidelines for liquids. She stated she thought there was a standard guideline for proteins. She stated they were supposed to use broth instead of water because water compromises the consistency and how the thickener reacts to the liquid. She stated the possible risk to a resident would be choking. She stated if it was too thick, they could choke and if it was too thin, they could choke. Interview with Cook B and Dietary Aide on 04/06/2023 at 10:21 AM revealed Cook B stated they usually use a scoop to measure out the thickener and they go by the guide which was printed on the containers. Cook B searched for the scooper; however, it was not where he said it should be kept. He asked the Dietary Aide where the scooper was located, and she stated she didn't know where it was either. Dietary Aide stated they did not really need it because they just add the thickener a little bit at a time, until the mixture reaches the desired consistency. She stated they have been doing it so long, they know how it is supposed to look and Cook B agreed with her. Dietary Aide then said, You have to be careful when adding the powder because if you add too much, it won't taste like food anymore and it won't be enjoyable for the person eating it. The Dietary Manager then entered and said there used to be a guideline taped to the refrigerator, however, when she retired and returned, it was no longer there. She stated she could pull it up and print it out for me if I wanted to see it. She stated they had just been adding the thickener until it reached the desired consistency. Interview on 04/06/23 at 01:14 PM with Director of Nursing revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated the risk of pureed foods not being the right consistency, would be aspiration. She stated all residents deserve to have a palliative meal. She stated the resident who are on pureed diets, have communication deficits and are not able to voice their displeasure. She stated one day, the dietitian was in the facility, and she was talking with staff at the nurses station about the taste of pureed food. She stated she does not recall them saying anything bad. Interview on 04/06/23 at 01:39 PM with the Administrator revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated if the pureed food is prepared and the cook is not using the correct amount of thickener, it could cause the resident to choke. She stated too much thickener could cause aspiration. She stated it would dilute the nutritional value of food, which would cause weight loss and/or loss of vitamin. She stated residents have a right to receive nutritional food that also tastes good. The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, reflected, Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning and texture. Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents residing on the west hall and who ate in their rooms. The facility failed to ensure that soiled laundry (sheets) were stored in a secured closed area away from residents and food carts. This deficient practice could place residents at risk of exposure to an environment that is unsanitary. Findings included: Observation of the west hallway on 02/06/2023 at 12:00 PM, revealed soiled white linen with brown spots outside in the hallway not far from uncovered food trays and ambulating residents. During an interview on 02/06/2023 at 1:30 PM, CNA A stated that she was trained to take soiled clothing, place in a plastic bag and place in soiled laundry room. During an interview on 02/06/2023 at 2:30 PM, the DON stated that it was her expectation for nursing staff to store the soiled linen in the room designated to prevent others from having access and exposure to infections. The DON said laundry will come and retrieve the soiled laundry with safe handling. During an interview on 02/06/2023 at 2:47 PM, the Maintenance Director stated staff were trained to take soiled laundry immediately to the biohazard room to prevent exposure to human fluids that can carry bacteria that was unsanitary. The Maintenance Director stated The laundry had to be handled properly to prevent access and handling that could be unsanitary and cause infections. During an interview on 02/06/2023 at 3:20 PM, the DON stated she had not noticed the soiled laundry on the hall at the same time as uncovered food, and this was unsanitary. She said she expected dining to serve food consistent with policy for maintaining sanitary conditions and soiled laundry should be stored away from residents on the hall . Record review of in-service conducted on 02/06/2023 with nursing staff addressed the policies and procedures for appropriate sanitation after personal with soiled linen. Record review of the Personal Care Area Policies - Environment dated 09/2011 Section Titled B. Soiled Laundry is 1) Handle with minimum agitation to avoid contamination of air, surfaces and persons. 2) Kept away from clothing of the person handling. 3) Bag at the point of collection and transport directly to soiled linen area. 4) Handle potentially contaminated using standard precautions.

Based on observation, interview and record review, the facility failed to store, prepare , distribute and serve food in accordance with professional stards for food service safety one (west hall) of of one halls reviewed for food sanitation. Dining staff A failed to cover resident food served on the west hall. These failures could have affected residents by possible exposure to infections and cross contamination to the residents, that could cause illness. Findings include: Observation on 02/06/2023 at 12:00 PM, resident trays was observed on a food cart residing on the west hall with 3 residents and 2 staff passing by the uncovered food located on the cart. Approximately 4 rooms down the west hall there was a laundry basket with soiled uncovered laundry. In an interview on 02/06/2023 at 12:30 PM, the Dietary Supervisor revealed that the kitchen had one staff on duty and she forgot to cover the food before taking the cart out to serve the residents She stated it was not good sanitation to serve food on the hall uncovered, as the uncovered food was exposed to pathogen's in the air that could lead to food contamination and exposure to environmental bacteria. Interview on 02/06/2023 12:46 PM, the Administrator revealed kitchen staff were expected to cover the residents food prior to serving to prevent environmental exposure to bacteria from soiled and dirty laundry. The Administrator stated she recalls having this conversation with the dining staff previously and did not realize they had not covered the food. Interview on 02/06/2023 1:22 PM, CNA A said residents were either fed in the dining room or in their rooms. CNA A said there were more residents in the dining room than normal. She stated it was very unsanitary to bring food on the hall where residents receive incontinent care and dirty laundry, this could lead to cross contamination and infections bacteria. In an interview with the DON on 02/06/2023 3:00 PM, the DON revealed she was not the Infection Preventionist (IP). The DON said she had been employed by the facility for nine months. The DON said she had several conversations with dietary about covering food prior to bringing to the hall to maintain food sanitation and prevent exposure of food that could lead to illnesses. . Record review of facility policy Meal Delivery dated 08/01/2020 revealed, Nutrition Policies and Procedures Subject: Meal Delivery Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures Procedures: # #8Nursing unit manager and Nutrition Services Director . a list for proper tray delivery order that nutrition services use to set up the carts. #9. All food and beverages are covered for hall trays, despite being transported in an enclosed cart. Pass meals promptly upon tray cart's delivery to the nursing unit.

Based on observations, interviews, and record reviews the facility failed to ensure a resident in the facility was free from physical and verbal abuse for 2 (Resident #2 and #1) of 13 residents reviewed for abuse. The facility failed to protect Resident #2 from abuse when: 1. Resident #2 made allegations of abuse to LVN K on 05/29/22 and LVN K did not report it to the ADM and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. witnessed physical and verbal abuse on 08/04/22 of Resident #2 by Resident #1 was not investigated nor reported by the facility to the State Survey Agency or law enforcement. This failure resulted in an identification if an Immediate Jeopardy (IJ) on 08/17/22 at 3:56 PM, while the IJ was removed on 08/19/22 at 2:12 PM, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm with 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. These failures could place all residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. Findings Included: Resident #2 Review of Resident #2's EHR on 08/17/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She required minimal to moderate assistance with ADLs. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. She did not have any symptoms of [CONDITION(S)]. Her mood interview reflected she had the following symptoms: feeling down, depressed, hopeless, feeling tired or having little energy, poor appetite or overeating, trouble concentrating on things, and moving or speaking so slowly that other people could notice. The behavior assessment reflected Resident #2 did not have any behavioral symptoms. Resident #2 required extensive assistance for bed mobility and limited assistance with transfers, dressing, toilet use, and personal hygiene. She required supervision for locomotion in and out of the facility and eating. Review of Resident #2's care plan dated 07/22/22 reflected she required assistance with ADLs due to dementia and left above the knee amputation. Further review reflected Resident #2 took anti-anxiety medications for worrying, anxiousness, and crying and she may display signs of mood distress such as verbalizing feeling down, depressed, or hopelessness and she took anti-depressants. Her care plan did not contain any interventions regarding safeguarding from abuse by Resident #1. Record review of the incident worksheet dated 08/04/22 reflected at 11:00 AM, indicated Resident #2 was assessed by LVN A and she had a red area to her right upper arm. Description of the incident included HSK G caught Resident #1 repeatedly hitting Resident #2 with a charger cord. Resident #2 was witnessed as saying If you weren't so stupid, I wouldn't have to hit you. Resident #2 was immediately removed from the area, and she had 2 slightly red areas to her upper right arm. The report was signed by LVN A on 08/04/22 at 11AM. Review of Resident #1's EHR on 08/17/22 reflected he was a [AGE] year-old male admitted to the facility 05/26/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE], reflected a BIMS assessment was not completed, and the staff assessment of his mental status showed his memory was ok and cognitive skills were moderately impaired. The resident mood interview was not completed as all questions were marked as no response. The staff assessment of the resident's mood reflected he had the following symptoms: feeling or appearing down, depressed, or hopeless, indicating he is a failure, poor appetite or overeating, and being short-tempered, and easily annoyed. His behavioral symptoms included physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms not directed towards others. Review of Resident #1's functional status reflected he had a functionally limited ROM to one side of his body, and he used a wheelchair for mobility. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and supervision with eating. Review of Resident #1's care plan dated 06/15/22 reflected Resident #1 may display verbal or physical behavioral symptoms such as throwing objects, cursing, yelling, swinging at, demanding, and being demeaning towards staff and Resident #2. Interventions included assessing whether the behavior endangered the resident and/or others, intervening as necessary, and the DON had educated resident that if he physically hit wife (Resident #2), the police would be called. Review of Resident #1's nurses notes reflected a note written by LVN K on 05/29/22 at 4:30 PM, reflected Staff heard [Resident #1] yelling out and cursing his wife in the room. A few minutes later staff noted [Resident #2] wheeling self out of the room and told staff that [Resident #1's] behavior is not new; he calls her all kinds of names; he hits her with any kinds of objects which he can get ahold of and [Resident #1] does not want to report this abuse she is scared that they might be kicked out like what happened at the other nursing home. In an interview on 08/17/22 at 10:35 AM, HSK G said she witnessed an incident of resident to resident abuse maybe 3 weeks ago. HSK G said she observed Resident #1 hit Resident #2 on her right upper arm with a cellphone charger cord. HSK G said she reported the abuse to LVN A. In a follow-up interview with HSK G on 08/18/22 at 2:30 PM, she said on the day she observed Resident #1 hit Resident #2 with the charger cord, she was in the room with both residents. She said Resident #1 asked Resident #2 to hand him the charger for his tablet, and when Resident #2 handed him the wrong charger, Resident #1 became upset and hit Resident #2 on the right upper arm area with the charger cord. HSK G said Resident #2 started crying and was visibly upset. HSK G said she asked Resident #2 to come out of the room with her and she immediately went and told LVN A. HSK G said she saw one red mark on Resident #2's right upper arm but could not recall if Resident #2 said anything to her. HSK G said after the incident, Resident #2 continued to go back into Resident #1's room and kept putting herself into that situation. HSK G said she had not previously witnessed physical abuse between Resident #1 and #2. HSK G said she would occasionally hear yelling from Resident #1 and #2's room and normally when Resident #1 started yelling, Resident #2 would leave the room. HSK G could not recall what was said by Resident #1 when he was yelling. HSK G said because Resident #2 used a wheelchair and Resident #1 was bed bound, Resident #2 was able to get away from the situation. In an interview on 08/17/22 at 11:15 AM, LVN A said on 08/04/22 she saw Resident #2 coming down the hallway and she was really upset and crying. She had red marks on her right arm. LVN A said Resident #2 stated she did not deserve to be hit. LVN A said DON B knew about the situation because Resident #2 was being very loud at the nurses' station and the DON's office was right across the hallway. LVN A said DON B made the decision to move Resident #2 from the room she shared with Resident #1 on 08/04/22. LVN A said she was not aware of any other instances of physical abuse between Resident #1 and #2 but she knew Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2] names and yelling at her, because Resident #2 had told her. LVN A said she did not notify the ADM who was the abuse coordinator of the abuse incident on 08/04/22 because her supervisor, DON B, was aware. LVN A completed a physical assessment of Resident #2. In an interview on 08/17/22 at 11:23 AM, the ADM said she was aware of the physical abuse between Resident #1 and Resident #2 which was witnessed by HSK G. The ADM said DON B removed Resident #2 from her room and she was placed into another room. The ADM said she was told by DON B, that Resident #1 didn't mean to hit [Resident #2] with [the charger cord]. The ADM said the incident was not reported to the state agency and said, we just removed her from him. The ADM said the incident between Resident #1 and #2 was a resident-to-resident incident and it was an oversight in being reported because it involved a husband and wife who shared a room. The ADM said she was told by DON B; Resident #2 did not have any marks on her body as a result of being hit with a charger cord. In an interview on 08/17/22 at 11:38 AM, DON B said she was told about the incident on 08/04/22 by Resident #2 and LVN A. DON B said she looked at Resident #2's arm and there was not any redness. DON B said she talked to Resident #1 and told him he can't be hitting anybody or cussing at them. DON B said Resident #1 told her he hit Resident #2 on accident. DON B said the process for reporting was basically it's reported to the ADM, but the incident on 08/04/22 was a husband and wife, and she wasn't complaining of it. DON B said even though HSK G said she observed Resident #1 hit Resident #2 with the charger cord, the incident could look like something and it isn't DON B said Resident #1 did not hurt Resident #2, but we did move her to protect her. DON B said the ADM knew about the incident on 08/04/22 because it was discussed in the morning meeting the next day, 08/05/22. DON B said she also went to the ADM's office on 08/04/22 and told her There wasn't a mark and there was no injury. DON B said there had been a previous incident involving Resident #1 and #2 a long time ago. She said Resident #1 threw something at Resident #2, but he missed. DON B could not recall if any interventions were put in place at the time of that incident or if the ADM was notified. In an observation and interview on 08/17/22 at 11:45 AM, Resident #2 was in her wheelchair in the hallway. She slowly wheeled herself into her room. She said she had a good relationship with Resident #1 and she loved him to death. She said on 08/04/22, Resident #2 hit her to her right upper arm with a charger cord because he got frustrated with her. Resident #2 said Resident #1 did not mean to hurt her and denied any verbal abuse by Resident #1. Resident #2 said there was a red mark on her arm after Resident #1 hit her with the charger cord. In an interview on 08/17/22 at 12:10 PM, Resident #1 denied hitting Resident #2 with the charging cord, and said he tapped her with it because he was frustrated with her not knowing how to plug it in. Resident #1 denied calling Resident #1 stupid or crazy. Resident #1 said LVN A lied about the incident on 08/04/22 because the nurse was a super [OBSCENITY] , and said LVN A was not in the room when the incident happened; only the HSK G was in the room. In an observation on 08/17/22 at 2:50 PM, Resident #2 was in Resident #1's room with door closed. Both residents were lying in separate beds without staff present. HHSC Surveyor's attempts to interview LVN K on 08/18/22 at 10:05, 08/18/22 at 2:02 PM, 08/19/22 at 11:02 AM were unsuccessful. In an interview on 08/18/22 at 9:50 AM, the SW said she was out sick the from 08/01/22 to 08/08/22. The SW said when there was an abuse allegation, the ADM would notify her, and she would assess the resident for distress and make referrals as needed as having the psychologist make a visit or possibly psychiatry if needed. The SW said in her absence, when there was an abuse allegation, the DON would take care of assessing residents for distress and would make referrals as needed. The SW said she was not aware of the abuse incident involving Resident #1 and #2, nor of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. The SW said all allegations of abuse should be reported straight to the ADM. The SW said since Resident #2 was also under PASSR and had a PASSR [representative] that has followed her, she would also contact Resident #2's PASSR representative. The SW said Resident #2's cognition fluctuated, and she was a resident who may always score a 15 [BIMS] but I don't think that's a true representation of what's she's able to process and communicate. In an interview on 08/18/22 at 10:08 AM, DON B said she was the DON of the facility in May 2022. DON B said she was not aware of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. DON B said ADM C was the ADM of the facility in May 2022. DON B said, The only thing I was aware of is [Resident #1] did throw something at [Resident #2], but I went and talked to him and told him he could not throw anything at his wife and told him if it happened again, we would need to take further steps. DON B said that incident occurred maybe in July 2022. DON B said in response to that incident she also told Resident #2 she needed to stay away from Resident #1. DON B said the police were not notified of the incident on 08/04/22 when Resident #1 hit Resident #2 with a charger. DON B said when she interviewed Resident #1 and #2 they both told her it was an accident , but when she interviewed HSK G, she said she felt it was purposeful. DON B said, I did not feel like he had any intent to harm her, and they had been living like this for a long time and he was mad and shaking it and he hit her, but he did not intend to hurt her. DON B said she did notify Resident #2's NP about the incident on 08/04/22. In an interview on 08/18/22 at 10:30 AM, ADM C said he worked at the facility from 07/15/15 until 05/31/22. ADM C said he did not remember being notified of abuse allegation by Resident #2 on 05/29/22 nor did he recall having a husband and wife sharing a room. ADM C said he would have expected LVN K to report the allegation of abuse to him and DON B on 05/29/22 and to make sure Resident #2 was safe by assessing Resident #1 and #2 and by moving Resident #2 to another room. ADM C said he would also expect staff to be educated to keep Resident #1 and #2 separate until decisions could be made for the health and wellbeing of both. In an interview on 08/18/22 at 10:45 AM, the MDS Nurse said I know there was an allegation of [Resident #1] hollering and cursing at [Resident #2]. He verbally curses at her and threatens her. The MDS Nurse said Resident #1's abusive behavior towards staff and Resident #2 were care planned. The MDS Nurse said she did not recall reading the note in Resident #1's chart from 05/29/22 with the allegation of verbal and physical abuse, but stated they probably told me about it, and that's why it's care planned. MDS nurse stated she did not report the abuse to ADM C, ADM D, or ADM E because the report should have come from the floor nurse or whoever witnessed. I hear about it, and when I hear about it, I care plan it. But unless I see it myself, I don't report it. We knew [Resident #1 and #2] had behaviors coming into the building from a previous facility. In an interview on 08/18/22 at 11:09 AM, PMH-NP I said she is a provider for Resident #2 but not Resident #1. PMH-NP I said she would need to review her notes and call log to check if she was notified of the incident of abuse on 08/04/22. In an interview on 08/18/22 at 11:17 AM, Psychologist H said she was notified on 08/15/22 by the SW of the assault incident from 08/04/22 involving Resident #1 and #2. Phycologist H said Resident #1 and #2 both denied the incident. Psychologist H said if she was notified on 08/04/22, she would have gone to the facility that day or within 24 hours, recommended [Resident #1 and #2] be separated, kept away from one another, and assessed [Resident #1's] safety and her mental status to see if she felt safe or was fearful. They are both their own guardians and can make their own decision. Psychologist H said she would recommend Resident #1 and #2 be in separate room, visits with the door open and someone there to watch them, and on-going supervision. She stated she would keep educating [Resident #2] on abuse, how to break the cycle, and how to identify abuse. Psychologist H said Residents #1 and #2 were probably going to have to be monitored, and not given as much privacy if we are trying to keep [Resident #2] safe. Psychologist H said she first saw Resident #1 on 07/25/22 and she was not aware of abuse allegations from 05/29/22. Psychologist H said she was aware Resident #1 would get verbally aggressive with Resident #2 and the staff. In an interview on 08/18/22 at 12:10 PM, PMH-NP I said she was not contacted by the facility staff on 08/04/22. She said DON B contacted her on 08/08/22 regarding Resident #2. She said the facility was trying to get Resident #2 out to a psychiatric hospital due to continued delusions, continued allegations of sexual assault, and auditory hallucinations. She said DON B reported to her that Resident #2 was angry, hostile, and had verbal aggression. In an interview on 08/18/22 at 3:45 PM, MD O stated he was the physician for Residents #1 and #2 and also the facility's medical director. MD O said he got a call regarding the abuse incident for Resident #1 and #2 on probably that same day in which it occurred. MD O said he was told Resident #2 got hit and the facility staff were just going to watch them. MD O said he did not give any treatment orders or orders for referrals at that time for either Residents #1 or #2. MD O said he did not remember that at all or if he was or wasn't notified about the allegation of abuse made by Resident #2 to a nurse on 05/29/22. In an interview on 08/19/22 at 11:50 AM, CNA N said she witnessed Resident #1 yelling at Resident #2 on the 3rd or 4th day they were admitted to the facility. CNA N said Resident #1 was not a nice person to Resident #2 and he would yell to her, Get out of here [OBSCENITY] . CNA N said she would bring Resident #2 out of the room and would notify ADM C. CNA N said she never witnessed physical abuse between Resident #1 and 2. CNA N said when Resident #1 would yell at Resident #2, she would cry all the time. I would talk to her and try to comfort her and distract her, go to a different environment. In an interview on 08/19/22 at 12:31 PM, MR Clerk said she witnessed Resident #1 yelling and cursing at Resident #2 on multiple occasions. The MR Clerk said there was an incident right before Resident #2 moved out of the room. She said she was standing at the door when it happened and saw [Resident #1] throw a remote at [Resident #2], but he missed, I told the nurse. The MR Clerk did not recall on which date that incident happened or which nurse she informed. The MR Clerk said Resident #1 cursed at Resident #2 all the time and said she heard Resident #1 tell Resident #2 things such as [OBSCENITY] , [OBSCENITY] you, if she wasn't so damn stupid, he wouldn't have to do[OBSCENITY]like that. The MR Clerk said she would have Resident #2 leave the room and she also told the interim ADM, ADM D. The MR Clerk said she was aware of an incident where Resident #1 hit Resident #2 with some type of cord because it was discussed during a morning meeting. The MR Clerk could not recall on which date it was discussed, or if any recommendations were made at the morning meeting and said that would be more the ADM's decision. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, dated 11/01/2017, reflected the following: The facility's leadership prohibits neglect, mental, physical and/or verbal abuse . and ensures that all violations involving abuse, neglect . are reported immediately The facility shall report immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services for where the state law provides jurisdiction in long-term care facilities) in accordance with State law through established procedures . The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse . and will implement immediate actions to safeguard the resident . The facility's Leadership will provide notification to the proper authorities . The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator) . Abuse is the willful infliction of injury . intimidation, or punishment resulting in physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . All new and current employees including volunteers receive continuous education, training, and reinforcement that identify all aspects of abuse prohibition to include . prompt reporting of allegations without fear of reprisal .role and responsibility of the Facility Abuse Coordinator . To whom the employee can report allegations of abuse . identification of persons who can fall victim to alleged or suspected abuse and identification of persons who may inflict abuse . All alleged violation concerning abuse . are reported verbally immediately to the Facility Abuse Coordinator, the Administrator, and other officials in accordance with State law . An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences . The facility maintains that all allegations of abuse . are thoroughly investigated an appropriate actions are taken . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions . Guidelines for Investigation . Immediately assess the resident/patient at the time of discovery of alleged abuse . Maintain the resident's/patient's protection during the investigation . Notify the attending physician . Conduct/make arrangements for physical/mental examination . Interview individuals with first-hand knowledge . Social Service will provide support services to the resident/patient and implement an interdisciplinary care plan . Director of Nursing or his/her designee will review the resident's medical record . Record review of the facility's policy titled Combative Resident, Care, and Safety and dated 2011 reflected the following: The facility has procedures in place to protect the health and safety of the residents, staff, visitors . Any person who identifies a resident change in behavior or an escalation of behavior which may lead to physical combativeness, reports observations to a licensed nurse . A licensed professional, e.g. nurse, social worker evaluates the resident and may intervene with behavior de-escalating techniques, if appropriate . Individuals deemed to be combative or otherwise dangerous to self or others may be placed on close observation, which may include . relocating individual to a less stimulating environment . conducting frequent checks . providing one-on-one staff member for continuous observation . redirecting attention or use of other therapeutic techniques . notification of change in condition and escalation of behaviors is made to . physician or licensed independent practitioner . family or responsible party law enforcement, emergency medical services or others may be necessary to ensure the safety and wellbeing of the combative person or persons in proximity to the situation . Combative or persons exhibiting dangerous behaviors may have treatment and care needs outside the scope of the Facility. In these cases, and to ensure the most appropriate services, the physician may order a transfer to a different level of care . An Immediate Jeopardy (IJ) was identified on 08/17/22 at 3:56 PM, due to the above failures. The ADM and the DON were notified of the IJ and the IJ template was provided on 08/17/22 at 3:56 PM. The POR was accepted on 08/19/22 at 1:10 PM and reflected: [Facility Name] Plan of Removal August 17, 2022 F600/F607/F610 Facility failed to ensure a resident was free from physical and verbal abuse 1. Resident #1 and Resident #2 no longer reside in same room. Fifteen minutes checks will be initiated by charge nurse and documented on 15 minute check form kept in medical record when Resident #2 is out of her room. If Resident #2 mobilizes onto unit where spouse resides and wishes to visit Resident #1, she will be accompanied by staff member until visit is completed and resident is no longer in Resident #1 room and will be assisted to return to her room. Facility staff will be educated on this intervention by Director of Nursing/Designee. This education will be initiated on 8/18/22 and completed by 8/19/22. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This will begin 8/18/22 and continue until Social Services Evaluation and psyche evaluations are completed and will then follow recommendations as applicable. Psyche evaluation will be completed by outside psychiatrist at first available open slot. Psyche eval request sent with urgent need. Care plan in the medical record for Resident #1 and Resident #2 updated with interventions listed above by 8/18/22 by Director of Nursing/designee. 2. Residents residing in the facility have the potential to be affected by this alleged deficient practice. Social Service Director/designee will conduct interviews with alert and oriented residents to validate that residents feel safe from abuse. This will be completed by 8/17/22 Resident #1 will be referred to psyche for evaluation by Social Services Director/designee by 8/18/22. Resident #2 will be evaluated by Social Service Director / designee to determine if any mental distress is present and documented in medical record. A psyche referral will be initiated if emotional distress is identified. There are no other spouse roommates and no other incidences of roommate altercations or dissatisfaction. 3. Administrator, Director of Nursing, nursing managers and Social Service Director will be re-educated by the clinical consultant as train the trainer regarding the Abuse Neglect Misappropriation and Exploitation policy, which includes, protecting the residents, reporting timely and investigating thoroughly. This was initiated and completed on 8/17/22. Facility staff will be re-educated by the Director of Nursing / designee on Abuse, Neglect, Misappropriation and Exploitation policy including protecting residents from abuse and if a roommate altercation occurs, room moves must be made. Residents' aggressive behaviors must be evaluated by the physician and a psych referral may be necessary. The administrator is the abuse coordinator. This re-education was initiated on 8/17/2022 will be completed by 8/18/22. Any staff member not receiving this information by this date will receive prior to next scheduled shift. This will be presented in new hire orientation and to any agency staff. 4. The Social Service Director/designee will interview a minimum of 5 residents weekly for 4 weeks to validate that residents feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Administrator and/or Director of Nursing will round Monday through Friday for 2 weeks to randomly interview residents to validate that they feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Director of Nursing will oversee the execution of this plan and the Administrator will validate compliance of this plan. Ad hoc Quality Assurance Performance Improvement Meeting held on 8/17/22 to discuss the contents of this plan. The Medical Director was notified of this Immediate Jeopardy on 8/17/22 Monitoring of the POR included: In an interview on 08/19/22 at 11:37 AM, the DON stated Resident #1 was seen by psychiatry and a recommendation was made to start on medication [MEDICATION(S)] (mood stabilizer). She said she will contact his [family member] for consent. The following record reviews were completed as follows: 1. In-services- Reporting and investigating abuse and neglect dated 08/17/22, reporting abuse dated 08/18/22, combative resident care and safety dated 08/18/22, Care Plan instructions for Resident #2 on supervision and Q15 checks dated 08/18/22. 2. Review of safety log dated 08/18/22 reflected q15minute checks were completed for Resident #2 beginning 08/18/22 at 2:45 PM. 3. Review of Resident #2's care plan dated 08/18/22 reflected Staff has noted that [Resident #1] displays physical and verbal aggression towards [Resident #2] at times . fifteen-minute checks to be initiated by the charge nurse and documented on 15-minute check form . She will be accompanied by staff member when visiting [Resident #1] until visit is completed . moved to another room away from [Resident #1] . redirect when able to . staff being empathetic with 1:1 conversation with her . Interviews with staff regarding in-services on 08/19/22 from 11:50 AM until 1:43 PM included the MDS Nurse, HSK G, LVN L, the SW, CNA N, the MR Clerk, LVN P, CNA Q, MA R, the AD, CNA S, the DON, and the ADM. All staff interviewed verified they had been in-serviced on abuse and neglect and were able to verbalize understanding of the facility's policy regarding abuse and abuse reporting. Staff interviewed were also able to verbalize understanding of the increased level of supervision for Resident #2. On 08/19/22 at 2:12 PM, the ADM and DON were notified the IJ was removed, however, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm with 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

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect of residents for 2 (Resident #2 and #1) of 13 residents reviewed for abuse and neglect. The facility failed to implement a policy and process for immediately investigating and reporting allegations of abuse and neglect to HHSC when: 1. Resident #2 made allegations of abuse to LVN K on 05/29/22 and LVN K did not report it to the ADM and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. witnessed abuse on 08/04/22 of Resident #2 by Resident #1 was not investigated nor reported by the facility to the State Survey Agency or law enforcement. An IJ was identified 08/17/22 at 3:56 PM. While the IJ was removed on 08/19/22 at 2:12 PM, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm with 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. These failures could affect all residents by placing them at risk for abuse and could lead to serious injury, harm, impairment, pain, mental anguish, or death. Findings included: Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, dated 11/01/2017, reflected the following: The facility's leadership prohibits neglect, mental, physical and/or verbal abuse . and ensures that all violations involving abuse, neglect . are reported immediately The facility shall report immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services for where the state law provides jurisdiction in long-term care facilities) in accordance with State law through established procedures . The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse . and will implement immediate actions to safeguard the resident . The facility's Leadership will provide notification to the proper authorities . The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator) . Abuse is the willful infliction of injury . intimidation, or punishment resulting in physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . All new and current employees including volunteers receive continuous education, training, and reinforcement that identify all aspects of abuse prohibition to include . prompt reporting of allegations without fear of reprisal .role and responsibility of the Facility Abuse Coordinator . To whom the employee can report allegations of abuse . identification of persons who can fall victim to alleged or suspected abuse and identification of persons who may inflict abuse . All alleged violation concerning abuse . are reported verbally immediately to the Facility Abuse Coordinator, the Administrator, and other officials in accordance with State law . An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences . The facility maintains that all allegations of abuse . are thoroughly investigated an appropriate actions are taken . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions . Guidelines for Investigation . Immediately assess the resident/patient at the time of discovery of alleged abuse . Maintain the resident's/patient's protection during the investigation . Notify the attending physician . Conduct/make arrangements for physical/mental examination . Interview individuals with first-hand knowledge . Social Service will provide support services to the resident/patient and implement an interdisciplinary care plan . Director of Nursing or his/her designee will review the resident's medical record . Review of Resident #2's EHR on 08/17/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She required minimal to moderate assistance with ADLs. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. She did not have any symptoms of [CONDITION(S)]. Her mood interview reflected she had the following symptoms: feeling down, depressed, hopeless, feeling tired or having little energy, poor appetite or overeating, trouble concentrating on things, and moving or speaking so slowly that other people could notice. The behavior assessment reflected Resident #2 did not have any behavioral symptoms. Resident #2 required extensive assistance for bed mobility and limited assistance with transfers, dressing, toilet use, and personal hygiene. She required supervision for locomotion in and out of the facility and eating. Review of Resident #2's care plan dated 07/22/22 reflected she required assistance with ADLs due to dementia and left above the knee amputation. Further review reflected Resident #2 took anti-anxiety medications for worrying, anxiousness, and crying and she may display signs of mood distress such as verbalizing feeling down, depressed, or hopelessness and she took anti-depressants. Her care plan did not contain any interventions regarding safeguarding from abuse by Resident #1. Review of Resident #1's EHR on 08/17/22 reflected he was a [AGE] year-old male admitted to the facility 05/26/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE], reflected a BIMS assessment was not completed, and the staff assessment of his mental status showed his memory was ok and cognitive skills were moderately impaired. The resident mood interview was not completed as all questions were marked as no response. The staff assessment of the resident's mood reflected he had the following symptoms: feeling or appearing down, depressed, or hopeless, indicating he is a failure, poor appetite or overeating, and being short-tempered, and easily annoyed. His behavioral symptoms included physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms not directed towards others. Review of Resident #1's functional status reflected he had a functionally limited ROM to one side of his body, and he used a wheelchair for mobility. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and supervision with eating. Review of Resident #1's care plan dated 06/15/22 reflected Resident #1 may display verbal or physical behavioral symptoms such as throwing objects, cursing, yelling, swinging at, demanding, and being demeaning towards staff and Resident #2. Interventions included assessing whether the behavior endangered the resident and/or others, intervening as necessary, and the DON had educated resident that if he physically hit wife (Resident #2), the police would be called. In an interview on 08/17/22 at 10:35 AM, HSK G said she witnessed an incident of resident to resident abuse maybe 3 weeks ago. HSK G said she observed Resident #1 hist Resident #2 on her right upper arm with a cellphone charger cord. HSK G said she reported the abuse to LVN A. In a follow-up interview with HSK G on 08/18/22 at 2:30 PM, she said on the day she observed Resident #1 hit Resident #2 with the charger cord, she was in the room with both residents. She said Resident #1 asked Resident #2 to hand him the charger for his tablet, and when Resident #2 handed him the wrong charger, Resident #1 became upset and hit Resident #2 on the right upper arm area with the charger cord. HSK G said Resident #2 started crying and was visibly upset. HSK G said she asked Resident #2 to come out of the room with her and she immediately went and told LVN A. HSK G said she saw one red mark on Resident #2's right upper arm but could not recall if Resident #2 said anything to her. HSK G said after the incident, Resident #2 continued to go back into Resident #1's room and kept putting herself into that situation. HSK G said she had not previously witnessed physical abuse between Resident #1 and #2. HSK G said she would occasionally hear yelling from Resident #1 and #2's room and normally when Resident #1 started yelling, Resident #2 would leave the room. HSK G could not recall what was said by Resident #1 when he was yelling. HSK G said because Resident #2 used a wheelchair and Resident #1 was bed bound, Resident #2 was able to get away from the situation. In an interview on 08/17/22 at 11:15 AM, LVN A said on 08/04/22 she saw Resident #2 coming down the hallway and she was really upset about it and crying. She had red marks on her right arm. LVN A said Resident #2 stated she did not deserve to be hit. LVN A said DON B knew about the situation because Resident #2 was being very loud at the nurses' station and the DON's office was right across the hallway. LVN A said DON B made the decision to move Resident #2 from the room she shared with Resident #1 on 08/04/22. LVN A said she was not aware of any other instances of physical abuse between Resident #1 and #2 but she knew Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2] names and yelling at her, because Resident #2 had told her. LVN A said she did not notify the ADM who was the abuse coordinator of the abuse incident on 08/04/22 because her supervisor, DON B, was aware. In an interview on 08/17/22 at 11:23 AM, the ADM said she was aware of the physical abuse between Resident #1 and Resident #2 which was witnessed by HSK G. The ADM said DON B removed Resident #2 from her room and she was placed into another room. The ADM said she was told by DON B, that Resident #1 did not didn't mean to hit [Resident #2] with [the charger cord]. The ADM said the incident was not reported to the state agency and said, we just removed her from him. The ADM said the incident between Resident #1 and #2 was a resident-to-resident incident and it was an oversight in being reported because it involved a husband and wife who shared a room. The ADM said she was told by DON B; Resident #2 did not have any marks on her body as a result of being hit with a charger cord. In an interview on 08/17/22 at 11:38 AM, DON B, said she was told about the incident on 08/04/22 by Resident #2 and LVN A. DON B said she looked at Resident #2's arm and there was not any redness. DON B said she talked to Resident #1 and told him he can't be hitting anybody or cussing at them. DON B said Resident #1 told her he hit Resident #2 on accident. DON B said the process for reporting was basically it's reported to the ADM, but the incident on 08/04/22 was a husband and wife, and she wasn't complaining of it. DON B said that even though HSK G said she observed Resident #1 hit Resident #2 with the charger cord, the incident could look like something and it isn't DON B said Resident #1 did not hurt Resident #2, but we did move her to protect her. DON B said the ADM knew about the incident on 08/02/22 because it was discussed in the morning meeting the next day, 08/05/22. DON B said she also went to the ADM's office on 08/04/22 and told her There wasn't a mark and there was no injury. DON B said there had been a previous incident involving Resident #1 and #2 a long time ago. She said Resident #1 threw something at Resident #2, but he missed. DON B could not recall if any interventions were put in place at the time of that incident or if the ADM was notified. In an observation and interview on 08/17/22 at 11:45 AM, Resident #2 was in her wheelchair in the hallway. She slowly wheeled herself into her room. She said she had a good relationship with Resident #1 and she loved him to death. She said on 08/04/22, Resident #2 hit her to her right upper arm with a charger cord because he got frustrated with her. Resident #2 said Resident #1 did not mean to hurt her and denied any verbal abuse by Resident #1. In an interview on 08/17/22 at 12:10 PM, Resident #1 denied hitting Resident #2 with the charging cord, and said he tapped her with it because he was frustrated with her not knowing how to plug it in. Resident #1 denied calling Resident #1 stupid or crazy. Resident #1 said LVN A lied about the incident on 08/04/22 because the nurse was a super [OBSCENITY] , and said LVN A was not in the room when the incident happened; only the HSK G was in the room. In an observation on 08/17/22 at 2:50PM, Resident #2 in Resident #1's room with door closed. Both residents were lying in separate beds without staff present. Record review if the incident worksheet dated 08/04/22 reflected at 11 AM Resident #2 was assessed by LVN A and she had a red area to her right upper arm. Description of the incident included HSK G caught Resident #1 repeatedly hitting Resident #2 with a charger cord. Resident #2 was witnessed as saying If you weren't so stupid, I wouldn't have to hit you. Resident #2 as immediately removed from the area, and she had 2 slightly red areas to her upper right arm. The report was signed by LVN A on 08/04/22 at 11AM. Review of Resident #1's nurses notes reflected a note written by LVN K on 05/29/22 at 4:30 PM which reflected, Staff heard [Resident #1] yelling out and cursing his wife in the room. A few minutes later staff noted [Resident #2] wheeling self out of the room and told staff that [Resident #1's] behavior is not new, he calls her all kinds of names; he hits her with any kinds of objects which he can get ahold of and [Resident #1] does not want to report this abuse she is scared that they might be kicked out like what happened at the other nursing home. HHSC Surveyor's attempts to interview LVN K on 08/18/22 at 10:05, 08/18/22 at 2:02 PM, 08/19/22 at 11:02 AM were unsuccessful. In an interview on 08/18/22 at 9:50 AM, the SW said she was out sick the from 08/01/22 to 08/08/22. The SW said when there was an abuse allegation, the ADM would notify her, and she would assess the resident for distress and make referrals as needed. The SW said in her absence, when there was an abuse allegation, the DON would take care of assessing residents for distress and would make referrals as needed. The SW said she was not aware of the abuse incident involving Resident #1 and #2, nor of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. The SW said all allegations of abuse should be reported it straight to the ADM. The SW said when she assessed residents after an abuse allegation, she would also make referrals as need such as having the psychologist make a visit or possibly psychiatry if needed. The SW said since Resident #2 was also under PASSR and had a PASSR [representative] that has followed her, she would also contact Resident #2's PASSR representative. The SW said Resident #2s cognition fluctuated and she was a resident who may always score a 15 [BIMS] but I don't think that's a true representation of what's she's able to process and communicate. In an interview on 08/18/22 at 10:08 AM DON B said she was the DON of the facility on May 2022. DON B said she was not aware of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. DON B said ADM C was the ADM of the facility in May 2022. DON B said, The only thing I was aware of is [Resident #1] did throw something at [Resident #2], but I went and talked to him and told him he could not throw anything at his wife and told him if it happened again, we would need to take further steps. DON B said that incident occurred maybe in July 2022. DON B said in response to that incident she also told Resident #2 she needed to stay away from Resident #1. DON B said the police were not notified of the incident on 08/04/22 when Resident #1 hit Resident #2 with a charger her. DON B when she interviewed Resident #1 and #2 they both told her it was an incident, but when she interviewed HSK G, she said she felt it was purposeful. DON B said, I did not feel like he had any intent to harm her, and they had been living like this for a long time and he was mad and shaking it and he hit her, but he did not intend to hurt her. DON B said she did notify Resident #2's NP about the incident on 08/04/22. In an interview on 08/18/22 at 10:30 AM, ADM C said he worked at the facility from 07/15/15 until 05/31/22. ADM C said he did not remember being notified of abuse allegation by Resident #2 on 05/29/22 nor did he recall having a husband and wife sharing a room. ADM C said he would have expected LVN K to report the allegation of abuse to him and DON B on 05/29/22 and to make ensure Resident #2 was safe by assessing Resident #1 and #2 and by moving Resident #2 to another room. ADM C said he would also expect staff to be educated to keep Resident #1 and #2 separate until decisions could be made for the health and wellbeing of both. In an interview on 08/18/22 at 10:45 AM, the MDS Nurse said I know there was an allegation of [Resident #1] hollering and cursing at [Resident #2]. He verbally curses at her and threatens her. The MDS Nurse said Resident #1's abusive behavior towards staff and Resident #2 were care planned. The MDS Nurse said she did not recall reading the note in Resident #1's chart from 05/29/22 with the allegation of verbal and physical abuse, but stated they probably told me about it, and that's why it's care planned. MDS nurse stated she did not report the abuse to ADM C, ADM D, or ADM E because the report should have come from the floor nurse or whoever witnessed. I hear about it, and when I hear about it, I care plan it. But unless I see it myself, I don't report it. We knew [Resident #1 and #2] had behaviors coming into the building from a previous facility. In an interview on 08/18/22 at 11:09 AM, PMH-NP I a provider for Resident #2 but not Resident #1. PMH-NP I said she would need to review her notes and call log to check if she was notified of the incident of abuse on 08/04/22. In an interview on 08/18/22 at 11:17 AM, Psychologist H said she was notified on 08/15/22 by the SW of the assault incident from 08/04/22 involving Resident #1 and #2. Phycologist H said Resident #1 and #2 both denied the incident. Psychologist H said if she was notified on 08/04/22, she would have gone to the facility that day or within 24 hours, recommended [Resident #1 and #2] be separated, kept away from one another, and assessed [Resident #1's] safety and her mental status to see if she felt safe or was fearful. They are both their own guardians and can make their own decision. Psychologist H said she would recommend Resident #1 and #2 be in separate room, visits with the door open and someone there to watch them, and on-going supervision. She stated she would keep educating [Resident #2] on abuse, how to break the cycle, and how to identify abuse. Psychologist H said Residents #1 and #2 were probably going to have to be monitored, and not given as much privacy if we are trying to keep [Resident #2] safe. Psychologist H said she first saw Resident #1 on 07/25/22 and she was not aware of abuse allegations from 05/29/22. Psychologist H said she was aware Resident #1 would get verbally aggressive with Resident #2 and the staff. In a follow-up interview on 08/18/22 at 12:10 PM, PMH-NP I said she was not contacted by the facility staff on 08/04/22. She said DON B contacted her on 08/08/22 regarding Resident #2. She said the facility was trying to get Resident #2 out to a psychiatric hospital due to continued delusions, continued allegations of sexual assault, and auditory hallucinations. She said DON B reported to her that Resident #2 was angry, hostile, and had verbal aggression. In an interview on 08/18/22 at 3:45 PM, MD O stated he was the physician for Resident #1 and #2 and also the facility's medical director. MD O said he got a call regarding the abuse incident for Resident #1 and #2 on probably that same day in which it occurred. MD O said he was told Resident #2 got hit and the facility staff were just going to watch them. MD O said he did not give any treatment orders or orders for referrals at that time for either Resident #1 or #2. MD O said he did not remember that at all or if he was or wasn't notified about the allegation of abuse made by Resident #2 to a nurse on 05/29/22. In an interview on 08/19/22 at 11:50 AM, CNA N said she witnessed Resident #1 yelling at Resident #2 on the 3rd or 4th day they were admitted to the facility. CNA N said Resident #1 was not a nice person to Resident #2 and he would yell to her, Get out of here [OBSCENITY] . CNA N said she would bring Resident #2 out of the room and would notify ADM C. CNA N said she never witnessed physical abuse between Resident #1 and 2. CNA N said when Resident #1 would yell at Resident #2, she would cry all the time. I would talk to her and try to comfort her and distract her, go to a different environment. In an interview on 08/19/22 at 12:31 PM, MR Clerk said she witnessed Resident #1 yelling and cursing at Resident #2 on multiple occasions. MR Clerk said there was an incident right before Resident #2 moved out of the room. She said she was standing at the door when it happened and saw [Resident #1] throw a remote at [Resident #2], but he missed, I told the nurse. MR Clerk did not recall on which date that incident happened or which nurse she informed. MR Clerk said Resident #1 cursed at Resident #2 all the time and said she heard Resident #1 tell Resident #2 things such as [OBSCENITY] , [OBSCENITY] you, if she wasn't so damn stupid, he wouldn't have to do[OBSCENITY]like that. MR Clerk said she would have Resident #2 leave the room and she also told the interim ADM, ADM D. MR Clerk said she was aware of an incident where Resident #1 hit Resident #2 with some type of cord because it was discussed during a morning meeting. MR Clerk could not recall on which date it was discussed, or if any recommendations were made at the morning meeting and said that would be more the ADM's decision. An Immediate Jeopardy (IJ) was identified on 08/17/22 at 3:56 PM, due to the above failures. The ADM and the DON were notified of the IJ and the IJ template was provided on 08/17/22 at 3:56 PM. The POR was accepted on 08/19/22 at 1:10 PM and reflected: [Facility Name] Plan of Removal August 17, 2022 F600/F607/F610 Facility failed to ensure a resident was free from physical and verbal abuse 1. Resident #1 and Resident #2 no longer reside in same room. Fifteen minutes checks will be initiated by charge nurse and documented on 15minute check form kept in medical record when Resident #2 is out of her room. If resident #2 mobilizes onto unit where spouse resides and wishes to visit Resident #1, she will be accompanied by staff member until visit is completed and resident is no longer in Resident #1 room and will be assisted to return to her room. Facility staff will be educated on this intervention by Director of Nursing/Designee. This education will be initiated on 8/18/22 and completed by 8/19/22. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This will begin 8/18/22 and continue until Social Services Evaluation and psyche evaluations are completed and will then follow recommendations as applicable. Psyche evaluation will be completed by outside psychiatrist at first available open slot. Psyche eval request sent with urgent need. Care plan in the medical record for Resident #1 and Resident #2 updated with interventions listed above by 8/18/22 by Director of Nursing/designee. 2. Residents residing in the facility have the potential to be affected by this alleged deficient practice. Social Service Director/designee will conduct interviews with alert and oriented residents to validate that residents feel safe from abuse. This will be completed by 8/17/22 Resident #1 will be referred to psyche for evaluation by Social Services Director/designee by 8/18/22. Resident #2 will be evaluated by Social Service Director / designee to determine if any mental distress is present and documented in medical record. A psyche referral will be initiated if emotional distress is identified. There are no other spouse roommates and no other incidences of roommate altercations or dissatisfaction. 3. Administrator, Director of Nursing, nursing managers and Social Service Director will be re-educated by the clinical consultant as train the trainer regarding the Abuse Neglect Misappropriation and Exploitation policy, which includes, protecting the residents, reporting timely and investigating thoroughly. This was initiated and completed on 8/17/22. Facility staff will be re-educated by the Director of Nursing / designee on Abuse, Neglect, Misappropriation and Exploitation policy including protecting residents from abuse and if a roommate altercation occurs, room moves must be made. Residents' aggressive behaviors must be evaluated by the physician and a psych referral may be necessary. The administrator is the abuse coordinator. This re-education was initiated on 8/17/2022 will be completed by 8/18/22. Any staff member not receiving this information by this date will receive prior to next scheduled shift. This will be presented in new hire orientation and to any agency staff. 4. The Social Service Director/designee will interview a minimum of 5 residents weekly for 4 weeks to validate that residents feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Administrator and/or Director of Nursing will round Monday through Friday for 2 weeks to randomly interview residents to validate that they feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Director of Nursing will oversee the execution of this plan and the Administrator will validate compliance of this plan. Ad hoc Quality Assurance Performance Improvement Meeting held on 8/17/22 to discuss the contents of this plan. The Medical Director was notified of this Immediate Jeopardy on 8/17/22 Monitoring of the POR included: In an interview on 08/19/22 at 11:37 AM, the DON stated resident #1 was seen by psychiatry and a recommendation was made to start on medication [MEDICATION(S)] (mood stabilizer). She said she will contact his daughter for consent. Reviewed the following documentation regarding the POR: 1. In-services- Reporting and investigating abuse and neglect dated 08/17/22, reporting abuse dated 08/18/22, combative resident care and safety dated 08/18/22, Care Plan instructions for Resident #2 on supervision and Q15 checks dated 08/18/22. 2. Review of safety log dated 08/18/22 reflected q15minute checks were completed for Resident #2 beginning 08/18/22 at 2:45 PM. 3. Review of Resident #2's care plan dated 08/18/22 reflected Staff has noted that [Resident #1] displays physical and verbal aggression towards [Resident #2] at times . fifteen-minute checks to be initiated by the charge nurse and documented on 15-minute check form . She will be accompanied by staff member when visiting [Resident #1] until visit is completed . moved to another room away from [Resident #1] . redirect when able to . staff being empathetic with 1:1 conversation with her . Interviews with staff regarding in-services on 08/19/22 from 11:50 AM until 1:43 PM included the MDS Nurse, HSK G, LVN L, the SW, CNA N, the MR Clerk, LVN P, CNA Q, MA R, the AD, CNA S, the DON, and the ADM. All staff interviewed verified they had been in-serviced on abuse and neglect and were able to verbalize understanding of the facility's policy regarding abuse and abuse reporting. Staff interviewed were also able to verbalize understanding of the increased level of supervision for Resident #2. On 08/19/22 at 2:12 PM, the ADM and DON were notified the IJ was removed, however, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse, have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 (Resident #2 and #1) of 13 residents reviewed for abuse and neglect. The facility failed to investigate allegations of abuse when: 1. Resident #2 made allegations of abuse to LVN K on 05/29/22 and LVN K did not report it to the ADM and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. witnessed abuse on 08/04/22 of Resident #2 by Resident #1 was not investigated nor reported by the facility to the State Survey Agency or law enforcement. An IJ was identified 08/17/22 at 3:56 PM. While the IJ was removed on 08/19/22 at 2:12 PM, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm with 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. These failures could place residents at risk for not investigating reports of abuse which could lead to serious injury, harm, impairment, pain, mental anguish, or death. Findings Included: Review of Resident #2's EHR on 08/17/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She required minimal to moderate assistance with ADLs. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a BIMS score of 15 and indicated she was cognitively intact. Review of Resident #2's MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. She did not have any symptoms of [CONDITION(S)]. Her mood interview reflected she had the following symptoms: feeling down, depressed, hopeless, feeling tired or having little energy, poor appetite or overeating, trouble concentrating on things, and moving or speaking so slowly that other people could notice. The behavior assessment reflected Resident #2 did not have any behavioral symptoms. Resident #2 required extensive assistance for bed mobility and limited assistance with transfers, dressing, toilet use, and personal hygiene. She required supervision for locomotion in and out of the facility and eating. Review of Resident #2's care plan dated 07/22/22 reflected she required assistance with ADLs due to dementia and left above the knee amputation. Further review reflected Resident #2 took anti-anxiety medications for worrying, anxiousness, and crying and she may display signs of mood distress such as verbalizing feeling down, depressed, or hopelessness and she took anti-depressants. Her care plan did not contain any interventions regarding safeguarding from abuse by Resident #1. Record review of the incident worksheet dated 08/04/22 reflected at 11:00 AM, indicated Resident #2 was assessed by LVN A and she had a red area to her right upper arm. Description of the incident included HSK G caught Resident #1 repeatedly hitting Resident #2 with a charger cord. Resident #2 was witnessed as saying If you weren't so stupid, I wouldn't have to hit you. Resident #2 was immediately removed from the area, and she had 2 slightly red areas to her upper right arm. The report was signed by LVN A on 08/04/22 at 11AM. Review of Resident #1's EHR on 08/17/22 reflected he was a [AGE] year-old male admitted to the facility 05/26/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE], reflected a BIMS assessment was not completed, and the staff assessment of his mental status showed his memory was ok and cognitive skills were moderately impaired. The resident mood interview was not completed as all questions were marked as no response. The staff assessment of the resident's mood reflected he had the following symptoms: feeling or appearing down, depressed, or hopeless, indicating he is a failure, poor appetite or overeating, and being short-tempered, and easily annoyed. His behavioral symptoms included physical behavioral symptoms, verbal behavioral symptoms, and other behavioral symptoms not directed towards others. Review of Resident #1's functional status reflected he had a functionally limited ROM to one side of his body, and he used a wheelchair for mobility. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and supervision with eating. Review of Resident #1's care plan dated 06/15/22 reflected Resident #1 may display verbal or physical behavioral symptoms such as throwing objects, cursing, yelling, swinging at, demanding, and being demeaning towards staff and Resident #2. Interventions included assessing whether the behavior endangered the resident and/or others, intervening as necessary, and the DON had educated resident that if he physically hit wife (Resident #2), the police would be called. In an interview on 08/17/22 at 10:35 AM, HSK G said she witnessed an incident of resident on resident abuse maybe 3 weeks ago. HSK G said she observed Resident #1 hist Resident #2 on her right upper arm with a cellphone charger cord. HSK G said she reported the abuse to LVN A. In a follow-up interview with HSK G on 08/18/22 at 2:30 PM, she said on the day she observed Resident #1 hit Resident #2 with the charger cord, she was in the room with both residents. She said Resident #1 asked Resident #2 to hand him the charger for his tablet, and when Resident #2 handed him the wrong charger, Resident #1 became upset and hit Resident #2 on the right upper arm area with the charger cord. HSK G said Resident #2 started crying and was visibly upset. HSK G said she asked Resident #2 to come out of the room with her and she immediately went and told LVN A. HSK G said she saw one red mark on Resident #2's right upper arm but could not recall if Resident #2 said anything to her. HSK G said after the incident, Resident #2 continued to go back into Resident #1's room and kept putting herself into that situation. HSK G said she had not previously witnessed physical abuse between Resident #1 and #2. HSK G said she would occasionally hear yelling from Resident #1 and #2's room and normally when Resident #1 started yelling, Resident #2 would leave the room. HSK G could not recall what was said by Resident #1 when he was yelling. HSK G said because Resident #2 used a wheelchair and Resident #1 was bed bound, Resident #2 was able to get away from the situation. In an interview on 08/17/22 at 11:15 AM, LVN A said on 08/04/22 she saw Resident #2 coming down the hallway and she was really upset about it and crying. She had red marks on her right arm. LVN A said Resident #2 stated she did not deserve to be hit. LVN A said DON B knew about the situation because Resident #2 was being very loud at the nurses' station and the DON's office was right across the hallway. LVN A said DON B made the decision to move Resident #2 from the room she shared with Resident #1 on 08/04/22. LVN A said she was not aware of any other instances of physical abuse between Resident #1 and #2 but she knew Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2] names and yelling at her, because Resident #2 had told her. LVN A said she did not notify the ADM who was the abuse coordinator of the abuse incident on 08/04/22 because her supervisor, DON B, was aware. In an interview on 08/17/22 at 11:23 AM, the ADM said she was aware of the physical abuse between Resident #1 and Resident #2 which was witnessed by HSK G. The ADM said DON B removed Resident #2 from her room and she was placed into another room. The ADM said she was told by DON B, that Resident #1 did not didn't mean to hit [Resident #2] with [the charger cord]. The ADM said the incident was not reported to the state agency and said, we just removed her from him. The ADM said the incident between Resident #1 and #2 was a resident-to-resident incident and it was an oversight in being reported because it involved a husband and wife who shared a room. The ADM said she was told by DON B; Resident #2 did not have any marks on her body as a result of being hit with a charger cord. In an interview on 08/17/22 at 11:38 AM, DON B, said she was told about the incident on 08/04/22 by Resident #2 and LVN A. DON B said she looked at Resident #2's arm and there was not any redness. DON B said she talked to Resident #1 and told him he can't be hitting anybody or cussing at them. DON B said Resident #1 told her he hit Resident #2 on accident. DON B said the process for reporting was basically it's reported to the ADM, but the incident on 08/04/22 was a husband and wife, and she wasn't complaining of it. DON B said that even though HSK G said she observed Resident #1 hit Resident #2 with the charger cord, the incident could look like something and it isn't DON B said Resident #1 did not hurt Resident #2, but we did move her to protect her. DON B said the ADM knew about the incident on 08/02/22 because it was discussed in the morning meeting the next day, 08/05/22. DON B said she also went to the ADM's office on 08/04/22 and told her There wasn't a mark and there was no injury. DON B said there had been a previous incident involving Resident #1 and #2 a long time ago. She said Resident #1 threw something at Resident #2, but he missed. DON B could not recall if any interventions were put in place at the time of that incident or if the ADM was notified. In an observation and interview on 08/17/22 at 11:45 AM, Resident #2 was in her wheelchair in the hallway. She slowly wheeled herself into her room. She said she had a good relationship with Resident #1 and she loved him to death. She said on 08/04/22, Resident #2 hit her to her right upper arm with a charger cord because he got frustrated with her. Resident #2 said Resident #1 did not mean to hurt her and denied any verbal abuse by Resident #1. Resident #2 said there was a red mark on her arm after Resident #1 hit her with the charger cord. In an interview on 08/17/22 at 12:10 PM, Resident #1 denied hitting Resident #2 with the charging cord, and said he tapped her with it because he was frustrated with her not knowing how to plug it in. Resident #1 denied calling Resident #1 stupid or crazy. Resident #1 said LVN A lied about the incident on 08/04/22 because the nurse was a super [OBSCENITY] , and said LVN A was not in the room when the incident happened; only the HSK G was in the room. In an observation on 08/17/22 at 2:50PM, Resident #2 in Resident #1's room with door closed. Both residents were lying in separate beds without staff present. Review of Resident #1's nurses notes reflected a note written by LVN K on 05/29/22 at 4:30 PM which reflected, Staff heard [Resident #1] yelling out and cursing his wife in the room. A few minutes later staff noted [Resident #2] wheeling self out of the room and told staff that [Resident #1's] behavior is not new, he calls her all kinds of names; he hits her with any kinds of objects which he can get ahold of and [Resident #1] does not want to report this abuse she is scared that they might be kicked out like what happened at the other nursing home. HHSC Surveyor's attempts to interview LVN K on 08/18/22 at 10:05, 08/18/22 at 2:02 PM, 08/19/22 at 11:02 AM were unsuccessful. In an interview on 08/18/22 at 9:50 AM, the SW said she was out sick the from 08/01/22 to 08/08/22. The SW said when there was an abuse allegation, the ADM would notify her, and she would assess the resident for distress and make referrals as needed. The SW said in her absence, when there was an abuse allegation, the DON would take care of assessing residents for distress and would make referrals as needed. The SW said she was not aware of the abuse incident involving Resident #1 and #2, nor of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. The SW said all allegations of abuse should be reported it straight to the ADM. The SW said when she assessed residents after an abuse allegation, she would also make referrals as need such as having the psychologist make a visit or possibly psychiatry if needed. The SW said since Resident #2 was also under PASSR and had a PASSR [representative] that has followed her, she would also contact Resident #2's PASSR representative. The SW said Resident #2s cognition fluctuated and she was a resident who may always score a 15 [BIMS] but I don't think that's a true representation of what's she's able to process and communicate. In an interview on 08/18/22 at 10:08 AM DON B said she was the DON of the facility in May 2022. DON B said she was not aware of the nurses note from 05/29/22 in which Resident #2 made an allegation of verbal and physical abuse to LVN K. DON B said ADM C was the ADM of the facility in May 2022. DON B said, The only thing I was aware of is [Resident #1] did throw something at [Resident #2], but I went and talked to him and told him he could not throw anything at his wife and told him if it happened again, we would need to take further steps. DON B said that incident occurred maybe in July 2022. DON B said in response to that incident she also told Resident #2 she needed to stay away from Resident #1. DON B said the police were not notified of the incident on 08/04/22 when Resident #1 hit Resident #2 with a charger her. DON B when she interviewed Resident #1 and #2 they both told her it was an incident, but when she interviewed HSK G, she said she felt it was purposeful. DON B said, I did not feel like he had any intent to harm her, and they had been living like this for a long time and he was mad and shaking it and he hit her, but he did not intend to hurt her. DON B said she did notify Resident #2's NP about the incident on 08/04/22. In an interview on 08/18/22 at 10:30 AM, ADM C said he worked at the facility from 07/15/15 until 05/31/22. ADM C said he did not remember being notified of abuse allegation by Resident #2 on 05/29/22 nor did he recall having a husband and wife sharing a room. ADM C said he would have expected LVN K to report the allegation of abuse to him and DON B on 05/29/22 and to make ensure Resident #2 was safe by assessing Resident #1 and #2 and by moving Resident #2 to another room. ADM C said he would also expect staff to be educated to keep Resident #1 and #2 separate until decisions could be made for the health and wellbeing of both. In an interview on 08/18/22 at 10:45 AM, the MDS Nurse said I know there was an allegation of [Resident #1] hollering and cursing at [Resident #2]. He verbally curses at her and threatens her. The MDS Nurse said Resident #1's abusive behavior towards staff and Resident #2 were care planned. The MDS Nurse said she did not recall reading the note in Resident #1's chart from 05/29/22 with the allegation of verbal and physical abuse, but stated they probably told me about it, and that's why it's care planned. MDS nurse stated she did not report the abuse to ADM C, ADM D, or ADM E because the report should have come from the floor nurse or whoever witnessed. I hear about it, and when I hear about it, I care plan it. But unless I see it myself, I don't report it. We knew [Resident #1 and #2] had behaviors coming into the building from a previous facility. In an interview on 08/18/22 at 11:09 AM, PMH-NP I, (Resident #2's provider) said she would need to review her notes and call log to check if she was notified of the incident of abuse on 08/04/22. In an interview on 08/18/22 at 11:17 AM, Psychologist H said she was notified on 08/15/22 by the SW of the assault incident from 08/04/22 involving Resident #1 and #2. Phycologist H said Resident #1 and #2 both denied the incident. Psychologist H said if she was notified on 08/04/22, she would have gone to the facility that day or within 24 hours, recommended [Resident #1 and #2] be separated, kept away from one another, and assessed [Resident #1's] safety and her mental status to see if she felt safe or was fearful. They are both their own guardians and can make their own decision. Psychologist H said she would recommend Resident #1 and #2 be in separate room, visits with the door open and someone there to watch them, and on-going supervision. She stated she would keep educating [Resident #2] on abuse, how to break the cycle, and how to identify abuse. Psychologist H said Residents #1 and #2 were probably going to have to be monitored, and not given as much privacy if we are trying to keep [Resident #2] safe. Psychologist H said she first saw Resident #1 on 07/25/22 and she was not aware of abuse allegations from 05/29/22. Psychologist H said she was aware Resident #1 would get verbally aggressive with Resident #2 and the staff. In a follow-up interview on 08/18/22 at 12:10 PM, PMH-NP I said she was not contacted by the facility staff on 08/04/22. She said DON B contacted her on 08/08/22 regarding Resident #2. She said the facility was trying to get Resident #2 out to a psychiatric hospital due to continued delusions, continued allegations of sexual assault, and auditory hallucinations. She said DON B reported to her that Resident #2 was angry, hostile, and had verbal aggression. In an interview on 08/18/22 at 3:45 PM, MD O stated he was the physician for Resident #1 and #2 and also the facility's medical director. MD O said he got a call regarding the abuse incident for Resident #1 and #2 on probably that same day in which it occurred. MD O said he was told Resident #2 got hit and the facility staff were just going to watch them. MD O said he did not give any treatment orders or orders for referrals at that time for either Resident #1 or #2. MD O said he did not remember that at all or if he was or wasn't notified about the allegation of abuse made by Resident #2 to a nurse on 05/29/22. In an interview on 08/19/22 at 11:50 AM, CNA N said she witnessed Resident #1 yelling at Resident #2 on the 3rd or 4th day they were admitted to the facility. CNA N said Resident #1 was not a nice person to Resident #2 and he would yell to her, Get out of here [OBSCENITY] . CNA N said she would bring Resident #2 out of the room, and would ADM C. CNA N said she never witnessed physical abuse between Resident #1 and 2. CNA N said when Resident #1 would yell at Resident #2, she would cry all the time. I would talk to her and try to comfort her and distract her, go to a different environment. In an interview on 08/19/22 at 12:31 PM, MR Clerk said she witnessed Resident #1 yelling and cursing at Resident #2 on multiple occasions. MR Clerk said there was an incident right before Resident #2 moved out of the room. She said she was standing at the door when it happened and saw [Resident #1] throw a remote at [Resident #2], but he missed, I told the nurse. MR Clerk did not recall on which date that incident happened or which nurse she informed. MR Clerk said Resident #1 cursed at Resident #2 all the time and said she heard Resident #1 tell Resident #2 things such as [OBSCENITY] , [OBSCENITY] you, if she wasn't so damn stupid, he wouldn't have to do[OBSCENITY]like that. MR Clerk said she would have Resident #2 leave the room and she also told the interim ADM, ADM D. MR Clerk said she was aware of an incident where Resident #1 hit Resident #2 with some type of cord because it was discussed during a morning meeting. MR Clerk could not recall on which date it was discussed, or if any recommendations were made at the morning meeting and said that would be more the ADM's decision. Record review of the facility's policy titled Combative Resident, Care, and Safety and dated 201 reflected the following: The facility has procedures in place to protect the health and safety of the residents, staff, visitors . Any person who identifies a resident change in behavior or an escalation of behavior which may lead to physical combativeness, reports observations to a licensed nurse . A licensed professional, e.g. nurse, social worker evaluates the resident and may intervene with behavior de-escalating techniques, if appropriate . Individuals deemed to be combative or otherwise dangerous to self or others may be placed on close observation, which may include . relocating individual to a less stimulating environment . conducting frequent checks . providing one-on-one staff member for continuous observation . redirecting attention or use of other therapeutic techniques . notification of change in condition and escalation of behaviors is made to . physician or licensed independent practitioner . family or responsible party law enforcement, emergency medical services or others may be necessary to ensure the safety and wellbeing of the combative person or persons in proximity to the situation . Combative or persons exhibiting dangerous behaviors may have treatment and care needs outside the scope of the Facility. In these cases, and to ensure the most appropriate services, the physician may order a transfer to a different level of care . An Immediate Jeopardy (IJ) was identified on 08/17/22 at 3:56 PM, due to the above failures. The ADM and the DON were notified of the IJ and the IJ template was provided on 08/17/22 at 3:56 PM. The POR was accepted on 08/19/22 at 1:10 PM and reflected: [Facility Name] Plan of Removal August 17, 2022 F600/F607/F610 Facility failed to ensure a resident was free from physical and verbal abuse 1. Resident #1 and Resident #2 no longer reside in same room. Fifteen minutes checks will be initiated by charge nurse and documented on 15minute check form kept in medical record when Resident #2 is out of her room. If resident #2 mobilizes onto unit where spouse resides and wishes to visit Resident #1, she will be accompanied by staff member until visit is completed and resident is no longer in Resident #1 room and will be assisted to return to her room. Facility staff will be educated on this intervention by Director of Nursing/Designee. This education will be initiated on 8/18/22 and completed by 8/19/22. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This will begin 8/18/22 and continue until Social Services Evaluation and psyche evaluations are completed and will then follow recommendations as applicable. Psyche evaluation will be completed by outside psychiatrist at first available open slot. Psyche eval request sent with urgent need. Care plan in the medical record for Resident #1 and Resident #2 updated with interventions listed above by 8/18/22 by Director of Nursing/designee. 2. Residents residing in the facility have the potential to be affected by this alleged deficient practice. Social Service Director/designee will conduct interviews with alert and oriented residents to validate that residents feel safe from abuse. This will be completed by 8/17/22 Resident #1 will be referred to psyche for evaluation by Social Services Director/designee by 8/18/22. Resident #2 will be evaluated by Social Service Director / designee to determine if any mental distress is present and documented in medical record. A psyche referral will be initiated if emotional distress is identified. There are no other spouse roommates and no other incidences of roommate altercations or dissatisfaction. 3. Administrator, Director of Nursing, nursing managers and Social Service Director will be re-educated by the clinical consultant as train the trainer regarding the Abuse Neglect Misappropriation and Exploitation policy, which includes, protecting the residents, reporting timely and investigating thoroughly. This was initiated and completed on 8/17/22. Facility staff will be re-educated by the Director of Nursing / designee on Abuse, Neglect, Misappropriation and Exploitation policy including protecting residents from abuse and if a roommate altercation occurs, room moves must be made. Residents' aggressive behaviors must be evaluated by the physician and a psych referral may be necessary. The administrator is the abuse coordinator. This re-education was initiated on 8/17/2022 will be completed by 8/18/22. Any staff member not receiving this information by this date will receive prior to next scheduled shift. This will be presented in new hire orientation and to any agency staff. 4. The Social Service Director/designee will interview a minimum of 5 residents weekly for 4 weeks to validate that residents feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Administrator and/or Director of Nursing will round Monday through Friday for 2 weeks to randomly interview residents to validate that they feel safe in their environment. Any negative response will be documented on a grievance or reported immediately to the abuse coordinator for appropriate action. The Director of Nursing will oversee the execution of this plan and the Administrator will validate compliance of this plan. Ad hoc Quality Assurance Performance Improvement Meeting held on 8/17/22 to discuss the contents of this plan. The Medical Director was notified of this Immediate Jeopardy on 8/17/22 Monitoring of the POR included: In an interview on 08/19/22 at 11:37 AM, the DON stated resident #1 was seen by psychiatry and a recommendation was made to start on medication [MEDICATION(S)] (mood stabilizer). She said she will contact his daughter for consent. Reviewed the following documentation regarding the POR: 1. In-services- Reporting and investigating abuse and neglect dated 08/17/22, reporting abuse dated 08/18/22, combative resident care and safety dated 08/18/22, Care Plan instructions for Resident #2 on supervision and Q15 checks dated 08/18/22. 2. Review of safety log dated 08/18/22 reflected q15minute checks were completed for Resident #2 beginning 08/18/22 at 2:45 PM. 3. Review of Resident #2's care plan dated 08/18/22 reflected Staff has noted that [Resident #1] displays physical and verbal aggression towards [Resident #2] at times . fifteen-minute checks to be initiated by the charge nurse and documented on 15-minute check form . She will be accompanied by staff member when visiting [Resident #1] until visit is completed . moved to another room away from [Resident #1] . redirect when able to . staff being empathetic with 1:1 conversation with her . Interviews with staff regarding in-services on 08/19/22 from 11:50 AM until 1:43 PM included the MDS Nurse, HSK G, LVN L, the SW, CNA N, MR Clerk, LVN P, CNA Q, MA R, the AD, CNA S, the DON, and the ADM. All staff interviewed verified they had been in-serviced on abuse and neglect and were able to verbalize understanding of the facility's policy regarding abuse and abuse reporting. Staff interviewed were also able to verbalize understanding of the increased level of supervision for Resident #2. On 08/19/22 at 2:12 PM, the ADM and DON were notified the IJ was removed, however, the facility remained out of compliance at a scope of pattern, and at a severity level of no actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interviews, document review, and review of policy and procedures, the facility failed to provide cardiopulmonary resuscitation (CPR) to a full-code resident when a resident experienced cardiopulmonary arrest for one (Resident #541) of four residents. In addition, the facility failed to ensure staff maintained current CPR certification. This deficient practice had the potential to affect other residents, who are a full code, by not receiving CPR if the resident experiences cardiopulmonary arrest. There were 14 residents that were a full code at the time of the survey. The census was 41. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.24 (Quality of Life) at a scope and severity of J. The Immediate Jeopardy (IJ) began on [DATE] at 5:15 AM. Resident #541 was found with no pulse or respirations by Licensed Vocational Nurse (LVN) E. LVN E was the only licensed nurse on duty. There was no registered nurse in the facility. Resident #541 was a full code. According to LVN E, emergency medical services (EMS) arrived 20 minutes after she found the resident with no pulse or respirations. LVN E, or other facility staff, never initiated CPR during this time. The Administrator was notified of the IJ and provided with the IJ template on [DATE] at 3:30 PM. A removal plan was requested. An acceptable Removal Plan was received on [DATE]. The IJ was determined to be removed on [DATE], before exit, after the survey team performed onsite verification that the Removal Plan had been implemented. Findings included: A review of a facility policy, titled, Nursing Policy and Procedures, dated [DATE], subject noted to be Resuscitation of Patients/Residents with and Without Automatic External Defibrillation (AED), the policy included, 1. Cardiopulmonary resuscitation (CPR) will be performed in the presence or absence of an automatic external defibrillator (AED). A review of a facility policy, titled, Nursing Policy and Procedures, dated [DATE], subject noted to be Emergency 911, the policy included The staff will call 911 for emergency situations. This policy only applies to residents who have determined to be a full code. Procedures listed include, 1. Qualified staff indicates the appropriate emergency procedures, i.e., oxygen, suction, CPR (with or without automatic external defibrillation [AED]). As appropriate. Etc.in accordance with patient/resident Advance Directives. A review of a facility policy, titled, Nursing Policy and Procedures, updated [DATE], subject noted to be Cardiopulmonary Resuscitation, Emergency Code Blue, the policy included, #4 The Facility ensures CPR certified healthcare providers are available immediately, 24-hours per day to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of emergency medical personnel, and subjected professional guidelines, the resident's advanced directive and physician orders. 5. The facility ensures provision of basic live support and CPR for residents who do not show obvious clinical signs of irreversible death and 1.) Who have requested CPR in their advance directives or 2.) who have not formulated an advance directive, or 3.) who do not have a valid DNR order? The facility's policy, titled, Emergency-911, dated [DATE], indicated CPR will be applied with or without an AED if a resident is full code. A review of Resident #541's face sheet revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated Resident #541 was a full code. A review of Resident #541's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 08 out of 15, indicating moderate cognitive impairment. A review of Resident #541's Baseline Care Plan, undated, with admitted noted to be [DATE], revealed there was no mention of code status. There was a note that Resident #541's plan was to return home after skilled stay on [DATE]. A review of Resident #541's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #541's Nursing Progress Notes, beginning on [DATE] through [DATE], revealed that at 2:00 AM, LVN E documented the resident was resting in bed, respirations were even and unlabored. There were no signs or symptoms of distress. The resident complained of indigestion and was medicated with a medication for indigestion. At 5:15 AM, LVN E documented the following: entered residents' room to give am (morning) meds, resident was non-responsive, not breathing, no pulse, AED (Automatic External Defibrillator) obtained, and resident hooked up to machine, [DATE] notified. Paramedics responded and advised that at that point CPR was not indicated. At their advisement, (no) further life saving measures taken. DON (Director of Nursing) notified of situation. Dayshift RN (registered nurse) arrived at facility and advised of situation. An interview on [DATE] at 9:38 PM with LVN E revealed LVN E had gone into Resident #541's room to take the resident medication. LVN E stated having been a nurse for over [AGE] years. The nurse stated it was obvious Resident #541 was deceased when LVN E turned the resident from a side lying position and the resident's leg and arm stayed in a stiff position. LVN E stated the AED was across the hall from the room. LVN E got it and hooked up Resident #541, noting the AED read, no shock advised. LVN E used a cell phone to call the DON, who said to call 911 and start CPR. LVN E stated 911 was called, and the LVN described Resident #541's condition, including the rigor mortis and the AED reading no shock. The EMS personnel answering the phone the first time said they would not be able to do anything for the resident. LVN E stated, I know I'm an LVN (and) not allowed by law to pronounce, so the nurse called the DON again and was told to call EMS back and tell them they had to come. LVN E stated it was a moral dilemma making the only ambulance in town come for someone who was obviously deceased . LVN E called them again and told them what the DON had said. LVN E stated it was only a few minutes in between the calls. LVN E stated there were no protocols at the facility for finding someone obviously deceased . When asked if CPR was ever performed, LVN E stated that also was a moral dilemma. There was no way [Resident #541] was going to be revived. LVN E stated CPR was not done. LVN E estimated the time between finding Resident #541 and EMS's arrival was about 20 minutes. During an interview on [DATE] at 3:26 PM with RN C/Former DON (FDON) at the time of Resident #541's death, RN C/FDON stated LVN E called me in a panic and said that Resident #541 was dead. RN C/FDON stated they had told LVN E the resident was a full code, that CPR needed to be started, and the AED needed to be utilized. RN C/FDON stated they were not aware that CPR was not initiated, and LVN E had not indicated the AED had already been hooked up on the call. RN C/FDON did not recall being called a second time by LVN E. RN C/FDON stated they did not feel the response was appropriate because the nurse was in a panic, so an in-service had been done on how to respond, but RN C/FDON did not know where any documentation of the in-service would be. RN C/FDON stated even if Resident #541 was dead, LVN E should have started CPR because the resident was a full code. An interview on [DATE] at 10:50 AM with the current DON revealed that if an LVN found a resident without a pulse or respirations that was full code, they should start CPR regardless of whether rigor mortis was thought to be present. The DON stated they had not known there was a concern regarding an LVN's response to a resident's death. An interview on [DATE] at 11:20 AM with the Administrator revealed the facility had completed an investigation in Resident #541's death due to the resident's family member alleging the resident was not checked during the night. Neglect was unfounded because the resident was continent and used the call light when they needed help. The Administrator stated there was no mention of the LVN not having performed CPR, so that was not investigated. The Administrator was not aware until the surveyor reported [failure to perform CPR] on this date. The Administrator also stated they had not known that 911 was called twice. The Administrator stated they would have wanted LVN to call EMS and the DON; and to start CPR since the resident was a full code. A review of the Provider Investigation Report, dated [DATE], revealed the facility did an incident investigation regarding Resident #541's death and whether or not the resident was checked during the night. LVN E and two CNAs (Certified Nursing Assistant) who worked the night of [DATE] wrote statements regarding that allegation. CNA G wrote having provided care for Resident #541 during the night and last saw the resident at 1:30 AM. CNA G documented Resident #541 requested an adult brief which was applied. CNA G's statement documented she was notified in the morning by another staff that LVN G needed help in Resident #541's room. CNA G wrote that when entering the room, she saw Resident #541 with the AED monitor on and LVN E asked for the resident's roommate to be removed from the room. CNA G did so and returned to the room and assisted LVN E with cleaning up the room. CNA G was asked by LVN E to go to the front door of the facility and wait for EMS's arrival. Continued review of the investigation report revealed LVN E's statement, I work from 10p - 6a as charge nurse. I went to Resident to check on vitals at about 2:00am since [the resident] was on a skilled stay. I woke [the resident] gently and all vitals were normal. Resident normally sleeps through the night, and I saw CNAs rounding on residents. About 5:15 am I was passing morning medications and I entered resident room to administer [their] medications and saw [the resident] lying on [their] side. [The resident] was unresponsive and I could detect no breathing. I got the AED, moved resident to [their] back and got the AED going. I called out to CNA (G) to assist me. I called DON (RN C/FDON) on my cell. After telling DON (RN C/FDON) about the situation, I called 911 per her direction. I don't think she understood I did not see any signs of life. After I got the AED going, CNA (G) entered room and I asked her to take roommate out of room. She did and returned so I helped her clean up the room and asked her to go to the front door and assist EMS when they arrived. EMS entered the room and advised CPR was not indicated and to stop life saving measures. They told me they could not pronounce, and I let them know an RN was on her way. EMS left at that point and our staff prepared Resident for funeral home. No, I have not seen any abuse or neglect Resident, or any of our residents. No, I have not seen signs of abuse or neglect either. Resident was independent and used the call light. A review of CPR certifications for the staff working on the night of [DATE] revealed all three staff had valid CPR certifications. It was noted LVN E's CPR certification had expired on ,d+[DATE]. A review of the facility employee schedule for February 2022 revealed LVN E had worked the February 5th through the 8th with an expired CPR certification. An interview on [DATE] at 10:48 AM with the Administrator revealed when asked how the facility ensured there was a staff available each shift with current CPR certification, the Administrator stated there was currently no one checking CPR, but they usually utilized at least one agency staff, and they have current CPR certification that the facility can access on the agency's website. The Administrator stated they had a system in place in 2019 but with all the COVID-19 issues, the process was not carried over. A review of a facility-provided list on [DATE] of current employees revealed there was a total of 15 staff required to maintain current CPR certification. Four of the staff were listed as not having documentation of a valid CPR certification. The four staff did not include LVN E, who received a valid CPR certification on [DATE]. The Administrator was notified of the IJ and provided with the IJ template on [DATE] at 3:30 PM. The facility's Removal Plan included: 1. Identified resident no longer resides in the facility. 2. Residents with full code status have the potential to be affected by the alleged deficient practice. An audit of licensed nurses for current CPR certification was completed by Administrator / designee on [DATE]. 3. Licensed Nurses and Certified Nursing Assistants including agency/contract will be re-educated by the Director of Nursing/ designee regarding the following: - Resuscitation Equipment will be maintained in designated crash carts in general nursing areas - Person finding resident unresponsive will not leave the resident unattended but will call for help immediately. - Licensed nurses will respond immediately to the emergency and evaluate resident and begin resuscitation effort if indicated - Nurse will direct nursing staff, either nurse or Certified Nursing Assistant to check the resident's code status found First page of each Residents Chart - Nurse will direct Certified Nursing Assistants or other staff to gather equipment (crash cart) and bring to the resident room. - Staff will call 911 and be available to assist as directed - Once resuscitation is initiated it must continue until Emergency Medical Services arrives and takes over, or resident's spontaneous efforts have returned and are adequate. - Re-education was initiated [DATE] by interim Director of Nursing with 8 staff re-educated. Clinical Service Director continued education on [DATE] with 8 staff re-educated. Any staff not receiving this information by [DATE] will receive prior to their next scheduled shift, this will include any staff on FMLA, sick days or vacation. This information will also be presented to agency staff before reporting to assigned area. 4. Licensed nurses will be interviewed daily for 5 days on each shift then weekly for 2 weeks by members of nursing management to validate that the transfer of learning regarding the expectation that a resident found unresponsive that is a full code has CPR initiated immediately upon discovery. Code status will be reviewed quarterly and with significant change to validate that code status remains accurate as part of the care planning process. The Director of Nursing /designee will randomly interview licensed nurses weekly for 3 months to validate that nurses understand the expectation that Cardiopulmonary Resuscitation is to be initiated on a resident found unresponsive that is a full code An audit of licensed nurse's CPR certification will be conducted monthly to validate current CPR certification by HR/designee. The Administrator performed an audit of February 2022 schedule of Licensed Nurses and Certified Nurse Aides to validate that the Facility has 24-hour CPR coverage. The Administrator/designee will continue to audit schedule monthly to validate 24-hour CPR coverage. An ad hoc Quality Assurance Performance Improvement Committee meeting was held on [DATE] and the medical director was notified of the immediate jeopardy and the contents of this plan. 5. The data will be presented by the Director of Nursing or Administrator to the Quality Assurance Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at the time of discovery. On [DATE], the survey team interviewed all working staff for understanding of response to a resident found without respirations and/or pulse that was a full code. All staff indicated appropriate interventions. Facility CPR certifications, gathered by the facility, were reviewed by the survey team. The nursing schedule provided by the facility, having been reviewed by the Administrator for CPR certification and 24-hour CPR coverage for the month of February 2022, was reviewed by the survey team. All in-services provided by the facility were also reviewed by the survey team. The IJ was removed on [DATE] at 6:15 PM after the survey team performed onsite verification that the Removal Plan had been implemented.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care for one (Resident #152) of 45 residents reviewed for CPR and one (RN A) of twelve staff reviewed for CPR training. RN A failed to immediately start and continuously provide CPR when she determined Resident #152 had no respirations on [DATE] at 9:00 PM. RN A left Resident #152 unattended in her room after finding her unresponsive, not breathing, with eyes fixed. Resident #152 expired at the facility on [DATE]. It was determined an Immediate Jeopardy (IJ) situation existed from [DATE] to [DATE]. The IJ was determined to have been removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could affect the residents by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #152's MDS assessment dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She required extensive assistance of two or more staff with her ADLs and had a severely impaired cognition. Review of Resident #152's Hospice Physician orders [REDACTED].#152 had a code status of Full Code, indicating she should receive immediate life saving measures including cardiopulmonary resuscitation. Review of Resident #152's physician's orders [REDACTED].#152 had a code status of Full Code, indicating she should receive immediate life saving measures including cardiopulmonary resuscitation. Review of Resident #152's clinical record revealed no documentation pertaining to a desire for a Do Not Resuscitate status, or any documentation that a Do Not Resuscitate order had been obtained for the resident. Review of Resident #152's hospice records revealed that she was admitted to hospice services on [DATE] with the [DIAGNOSES REDACTED]. Review of a written statement from RN A dated [DATE] reflected she had checked on Resident #152 at approximately 7:00 PM on the night of [DATE]. Resident #152 had taken her evening medications with applesauce. She had not noted anything unusual with the resident at that time. When RN A returned to check on Resident #152 at 8:00 PM she noted .unusual or extreme paleness, as from fear, ill health, or death . to Resident #152's face and she instructed the aides on the floor to keep Resident #152 comfortable. The note reflected she then continued treatments for other residents. RN A returned to Resident #152's room at 9:00 PM to find her un-responsive, not breathing, eyes fixed, and her skin cold to touch. Resident #152's hands and feet were mottled (blotchy, red-purplish marbling of the skin that occurs before death). RN A said she left the room to contact hospice. She noted she did not verify Resident #152's code status and thought she had a code status of DNR. A telephone interview with RN A, Resident #152's nurse on the night of [DATE] who no longer worked at the facility, was attempted on [DATE] at 10:44 AM, [DATE] at 9:50 AM, and [DATE] at 11:00 AM. RN A could not be reached. Review of Resident #152's Nurse's Note dated [DATE] at 8:00 PM written by RN A reflected, Pt (patient) is rapidly declining. Strict comfort measures being maintained. Increased SOB (shortness of breath) teaching with CNAs re(garding); increased warmth, decreased warmth, increased SOB, decreased SOB, mottling. Pt is resting able to reach out. Review of Resident #152's Nurses Note dated [DATE] at 9:00 PM written by RN A revealed Resident is deceased . (The Hospice Company) has been called. They will call family & do pronouncement. Interview conducted with LVN K on [DATE] at 3:40 PM revealed that she was the second nurse in the facility working on the night of [DATE]. She worked on another hall during her shift. She was not asked by RN A for any help with any of the residents nor did she mention any of the residents having a decline or change in condition. She said that RN A had come over to her late in the shift and told her that Resident #152 had died , and that hospice was on the way to pronounce. LVN K said that there were no other residents that had any problems that night as far as she was aware. She said that after the incident, the staff had been trained regarding CPR, emergency procedures for unresponsive residents, including residents who are exhibiting symptoms such as being pale, and also code status following this incident. She said her CPR certification was current and that the facility had a copy of her card. LVN K was able to verbalize the correct procedure for checking the code status of residents which was located in the front of the charts, this information is always accessible to all staff since the charts are located in the nurse's station. The staff were also trained over the correct actions to take for unresponsive residents. Interviews conducted with CNA L on [DATE] scheduled to work on the night shift on [DATE] did not reveal anyone except RN A to have been present in the room at the time of Resident #152's discovery. She said she was not aware that Resident #152 was declining in health, she said that she did not recall any instruction by RN A on the night of [DATE]. She said that after the incident, the facility provided education about code status and how to verify code status. She said that the facility provided CPR training to the staff. She said that if she found a resident unresponsive or pale she was supposed to report it to her nurse for follow up. In an interview on [DATE] at 11:00 AM the Administrator stated on [DATE] he was advised of Resident #152's passing and also that she had not received CPR after being found unresponsive and not breathing. On [DATE], the DON reviewed Resident #152's discharge record following her passing and notified him that she had not received CPR and her code status was a full code. He immediately called the death in to the State Survey Agency and began the investigation. Upon his interview of RN A, he discovered that she had not initiated CPR for Resident #152 because she believed the resident had a DNR code status. He stated there was no incident report filled out by RN A or any other nurse regarding Resident #152's passing. In an interview on [DATE] at 11:56 AM the Administrator stated the direct care staff were to perform CPR immediately, as soon as the staff found the resident was unresponsive or not breathing. He added the code status of the residents should be in the clinical record and he expected the code status information to be updated within 24 hours from the admission. If the resident or the family chose a DNR (Do Not Resuscitate) status for a resident, the physician still had to sign the DNR order for the status to be considered enacted. If the resident's status was undecided or the staff did not have a signed DNR document, the resident was automatically considered as full code, or an automatic resuscitation status. He said the facility provided CPR certification training for the staff members. The last training had taken place in (MONTH) of (YEAR), but he was unable to provide any documentation of the training. In an interview with the DON on [DATE] at 7:00 AM, she stated she was not working in the facility at the time of the incident. She had only been employed by the facility for one week at the time of inspection. She said it would have been her expectation that the nursing staff would have initiated CPR immediately upon validating Resident #152's code status. She said she would have expected the nursing staff to have continued performing CPR until the arrival of emergency medical services. In a telephone interview on [DATE] at 2:20 PM, Resident #152's Family Member stated she knew that Resident #152 was at risk of passing due to her health, and that was why she was on hospice. The family member said she was invited to the facility care meetings where they would discuss code status and desires for care. She said she told the facility that she did not want to prolong Resident #152's life or for the facility to perform CPR if the situation ever came up and she had no concerns about the actions the facility had taken regarding Resident #152's passing; however, she said she had not signed the DNR order at the time of Resident #152's death. Tehre was no documentation found in Resident #152's clinical record which could verify the family members wishes pertaining to code status. RN A's CPR certification record was requested from the Administrator on [DATE] at 1:00 PM, but the facility could not provide any documentation of CPR certification for RN [NAME] He said that at the time of the incident on [DATE] there was a CPR certified staff member on each shift. Review of the schedules for (MONTH) 2019 through (MONTH) 2019 reflected the facility had a CPR trained staff member every shift. The facility was able to provide evidence of the staff members CPR cards also. Review of a Corrective Action Form for RN A, dated [DATE], revealed RN A was given a final warning for failure to verify code status and failure to follow facility policy and provide CPR to Resident #152 after she was found unresponsive on [DATE]. Review of a Corrective Action Form for RN A dated [DATE], reflected RN A was terminated for reasons unrelated to the incident on [DATE]. Review of the facility's policy titled Do Not Resuscitate revised [DATE], revealed Absent any appropriate DNR Order/Identifier, Facility Staff will respond to medical emergencies with CPR measures and a Full Code will be instituted. Review of the facility's policy entitled, Cardiopulmonary Resuscitation, Emergency Code Blue revised [DATE], reflected, .3. The facility ensures provision of basic life support and CPR including: [NAME] Staff are directed to initiate CPR when cardiac or respiratory arrest occurs .2. Who have not formulated an advanced directive, or .3. Who do not have a valid DNR order. Review of The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ retrieved on [DATE] reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) (Airway - Breathing - Circulation) to minimize the time to initiation of chest compressions. Review of the Texas Board of Nursing Standards of Nursing Practice, obtained [DATE] from http://www.bon.texas.gov/rr_current/,[DATE].asp, reflected a nurse must, .(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications . Review of information regarding a nurse's duty to initiate CPR in the absence of a DNR order, obtained [DATE] from http://www.bne.state.tx.us/faq_nursing_practice.asp#t9, the BON stated, All nurses have an obligation or duty to initiate CPR for clients who require resuscitative measures (Board Rule 217.11(1)(M)). In all healthcare settings, nurses must initiate CPR immediately in the absence of a client's do-not-resuscitate/out of hospital do-not-resuscitate order. A do-not-resuscitate/out of hospital do-not-resuscitate order is a medical order that must be given by a physician; and, in the absence thereof, it is generally outside the standards of nursing practice to determine that CPR will not be initiated. The initiation of CPR does not require a physician's orders [REDACTED]. On [DATE], the Administrator was informed an Immediate Jeopardy was determined to have existed from [DATE] to [DATE]. Review of the facility's investigation report revealed the facility took the following actions to correct the noncompliance prior to the visit on [DATE]: 1. Cardiopulmonary Resuscitation reeducation started and concluded with all Licensed Nurses on [DATE]. The facility included and trained all licensed and support staff. 2. The DON, ADON, and Social Worker reviewed all facility residents' code statuses for accuracy on [DATE] with no other residents affected by not having the correct code status in their medical record. Review of in-service documentation revealed Licensed Nurses were re-educated on [DATE] by the DON and ADON on the Cardiopulmonary Resuscitation Policy and process to include the following: Resuscitation Equipment will be maintained in designated crash carts in general nursing areas. Person finding the resident unresponsive will not leave the resident unattended but will call for help immediately. Licensed nurses will respond immediately to the emergency and evaluate resident and begin resuscitation effort if indicated. Nurse will direct nursing staff, either nurse or Certified Nursing Assistant to check the resident's code status found in the resident's chart. Must have the DNR on the chart if identified as a DNR. Nurse will direct Certified Nursing Assistants or other staff to gather equipment (crash cart) and bring to the resident room. Staff will call 911 and offer assistance to the nurse. Once resuscitation is initiated it must continue until Emergency Medical Services arrives and takes over, or residents' spontaneous efforts have returned and are adequate. Review of in-service documentation dated [DATE] revealed, Licensed Nurses were re-educated by the DON and ADON on Unresponsive Residents and process to include the following: A person finding a resident unresponsive will not leave the resident unattended but will call for help immediately. The resident code status is located on the chart. If a resident is identified as DNR it must be present on the chart. The emergency cart is located next to the nurse's station on side by time clock. Understand there is AED (Automated External Defibrillator-a medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) on each hall below the kiosk. Understand that visitors should be directed out of the room, when possible, roommates should be relocated. Hallways should be clear of unnecessary furniture/equipment. Understand that if a resident is on hospice, the procedure for what to do if a resident is found unresponsiveness does not change. Understand that not all residents on hospice have a code status of DNR. Code status must be verified for every non-responsive resident. The updating of the residents' code status will be discussed in a clinical meeting for follow up and to validate implementation of the processes. Individual interviews with facility staff representing multiple shifts (LVN B, LVN C, LVN D, LVN E, LVN F, LVN K, CNA G, CNA H, CNA I, CNA J, and CNA L) on [DATE] between 11:09 AM and 1:16 PM revealed they had received in-service training and understood to initiate CPR immediately on a resident with Full Code status when he or she was unresponsive with no pulse. The staff had sufficient knowledge of their roles in an emergency situation. Staff revealed they were trained to not leave an unresponsive resident or stop compressions until the paramedics were ready to take over. Staff were trained to identify the code status in the clinical record. No concerns were noted during the interviews. ***PAST NONCOMPLIANCE*** ***NO PLAN OF CORRECTION IS REQUIRED***