Every finding on record at Memphis Convalescent Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings included:Observation of the freezer on 09/23/25 at 9:54 AM revealed the following:1. (1) gallon bag of purple unidentified food with no label or date.2. (1) container of lime sherbert, with visible freezer burn, the lid not secured tightly, and an expiration date of 09/09/2025.3. (1) bag of ready to eat hamburger patties stored open to air, out of the original packaging, with ice crystal present, and no label or date.4. (1) large zip top bag of brown frozen liquid, no label or date5. (1) large bag of meat, no label or date.6. (1) large zip top bag of raw chicken legs and wings, no label.7. (1) large clear bag of pancakes removed from the original packaging with no label or date. In an interview on 09/24/25 at 9:55 AM, DC B stated she had worked at the facility since August 2025, and everyone was responsible for labeling and dating food. She stated a possible negative outcome for not labeling and dating food could be that residents could get sick.In an interview on 09/24/25 at 10:15 AM, DA A stated she had worked at the facility for a long time and everyone who worked in the kitchen was responsible for labeling and dating food. She stated a possible negative outcome for not doing that could be a resident could become sick.In an interview on 09/25/25 at 8:26 AM, the DM stated it was everyone's responsibility to label and date food and ensure expired items were thrown away. She stated if food was not labeled or dated then residents could get bad food and get sick. The DM stated she was responsible for ensuring her staff were following policy.Record Review of Food Storage and Supplies dated 2012 revealed the following:Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. If a frozen food item does not have an expiration date or a dated shipping label it will be dated when received or removed from original packaging. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria . foods with spoilage characteristics should not eaten. Record review of FDA Food Code revision January 18, 2023, revealed the following: 3-302.12 Food Storage Containers identified with common name of food.Working containers holding food or food ingredients that are removed from their original packages shall be identified with the common name of the food. 3-302.11 Packaged and Unpackaged food, Separation, Packaging and segregation.Food shall be protected from cross contamination by storing food in packages, covered containers or wrappings.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The medication cart had an inulin bottle that was expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings include: During an observation on 09/24/2025 at 8:46 AM of the facility's only medication cart (with LVN D present) a bottle of Novolog insulin with the date it was opened/ accessed 8/07/25 (48 days prior to this review). The insulin was one of seven insulins present in the medication cart. All other inulin medications were still within the correct use date. During an interview on 09/24/2025 at 8:50 AM LVN D reported the Novolog insulin bottle was marked opened on 8/07/25, had been accessed and used, and that it should have expired in 28 days. LVN D reported if the inulin medication was expired the resident could have an allergic reaction or received a medication which would not be effective and could affect the resident's treatment. LVN D reported the night nurse from the previous shift reported to her she had checked all the insulins but obviously she had not and she (LVN D) would have to report this to the administrator to be delt with and she (LVN D) would replace the expired insulin bottle right now. LVN D also reported she had been trained by the previous DON on the proper storage of all medications and the previous DON no longer worked for the facility During an interview on 09/25/2025 at 9:54 AM the Corporate RN reported that the previous DON and ADON resigned last week. The Corporate RN reported that all insulins should be marked with the date of when they were opened and when they should expire. The expiration date depended on the type of insulin, and their pharmacy has provided them with literature that was on the medication cart of when each type of insulin should expire after it was opened. The Corporate RN reported if a staff member used an insulin that was expired then that resident would not get the full capacity of the medication.Record review of the facility provided Insulin Storage Guidelines: undated, revealed the following:Brand: NovologExpiration date after opening: 28 days Record review of the facility provided policy titled Expired Medications with Shortened Expiration Dates undated, revealed the following: Procedure:2. The Director of Nursing or other authorized personnel will delegate to the appropriate personnel the task of ensuring that all outdated or expired medications ae removed from the medication cart.4. In the event that a medication has a shortened expiration date once opened the medication (open-dated) will be labeled with the date opened.

Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (09/19/2025) of the last 90 days reviewed.The facility did not have an RN working in the facility for 1 (09/19/2025) of the last 90 days reviewed. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advanced care skills available to assist in their care needs.Findings included: Record review of the facility's last 90 days (06/25/2025-09/24/2025) of RN coverage provided by the Corp RN revealed the facility had no RN working in the facility for the following date: 09/19/2025. During an interview on 09/24/2025 at 2:23 PM, the Corp RN acknowledged there was no RN coverage on 09/19/2025 after the DON resigned two days prior. The Corp RN stated she was not aware of the vacancy in coverage and had she known, she could have provided RN services that days. She further stated she did not believe there was a negative outcome from the lack of RN coverage, as she was available by phone. During an interview on 09/25/2025 at 10:12 AM, the ADM stated the DON had just recently resigned and she didn't realize there was no RN coverage on 09/19/2025. The ADM, being an RN, also stated she had a doctor's appointment on that day and was not at work. The ADM stated administration personnel were responsible for ensuring licensed staff coverage. The ADM said she did not feel there was a negative outcome because she was always available by phone if issues arose. During a confidential interview on an undisclosed date and time, the staff stated that a negative outcome for not having an RN on staff every day would be that if a major clinical issue came up in the facility, the correct treatment might not be given. A policy for RN coverage was requested on 09/24/2025 at 2:23 PM and 09/25/2025 at 1:15 PM but was not provided.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 (Resident #5) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #5 for the use of CPAP on her 09/01/25 quarterly MDS. This failure could result in residents not receiving correct care and services. Findings include: Record review of Resident #5's face sheet printed 09/23/25 revealed she was a [AGE] year-old female resident admitted to the facility originally on 06/22/23 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and sleep apnea (a common disorder that causes your breathing to stop or get very shallow). Record review of Resident #5's last MDS was a quarterly assessment completed 09/01/25 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision/touching assistance with most of her activities of daily living. Section O - Special Treatments, Procedures, and Programs: Resident #5 was not marked as having any Non-invasive Mechanical Ventilation. Record review of Resident #5's care plan with admission date of 07/05/23 revealed the following: Focus: RESIDENT REQUIRES THE USE OF CPAP/BIPAP R/T SLEEP APNEA Facility has ordered several different masks and resident has not been happy with any of them. Date Initiated: 12/12/2023. Revision on: 07/31/2025. Interventions/Tasks: RESIDENT WILL USE DEVICE AS ORDERED. Date Initiated: 12/12/2023. Revision on: 12/12/2023. Record review of the clinical record for Resident #5 revealed an Order Summary Report with active orders as of 09/23/25 with the following order:- O2- OXYGEN- CPAP- O2 CPAP/BIPAP MASK @ 11% at bedtime related to SLEEP APNEA, UNSPECIFIED (G47.30) O2 OXYGEN CPAP VIA MASK SETTINGS @ 11 EVERY NIGHT AT BEDTIME. Phone Active 06/22/2023. Record review of the Treatment Administration Record 08/19/25 to 09/01/25 for Resident #5 revealed she received her CPAP therapy at 8:00 PM 11 times during the MDS required 14-day look back period. During an interview on 09/24/2025 at 1:41 PM Resident #5 reported she had CPAP up until about 6 months ago when she started having trouble with the machine and the company went bankrupt, and she could not get a replacement. Resident #5 reported she was having trouble with her mask and the tubing so the Dr said, let's just scrap the whole thing and start over. Resident #5 reported the facility had been trying to get all her records to include her previous 4 sleep studies from the hospital and they were scheduling a new sleep study. During an interview on 09/24/2025 at 1:59 PM the Administrator reported Resident #5 was on CPAP therapy and had a history of often refusing to wear her CPAP mask. The Administrator reported that was documented in Resident #5's care plan and she has been offered several different types of masks and she has not been wearing them on a regular basis. During an interview on 09/25/2025 at 9:32 AM the MDS Coordinator reviewed Resident #5 last MDS and reported Resident #5 was not marked for CPAP therapy due to the MDS did not require the facility to address her CPAP therapy on the comprehensive assessment. When the surveyor asked the MDS coordinator to review the RAI instructions the MDS Coordinator reported she had misunderstood the instructions and the CPAP or BiPAP were to be addressed as non-invasive mechanical intervention. The MDS coordinator reported that she interviewed Resident #5 who told her she never used a CPAP and that was why the MDS coordinator did not address CPAP therapy on the quarterly MDS assessment. The RRC (present for the conversation) reviewed Resident #5's chart and verified Resident #5 was documented on the 14-day look back period as receiving her CPAP therapy but not every night. Both the MDS Coordinator and the RRC discussed Resident #5 and both reported Resident #5 had a history of frequently changing her story and her condition. The RRC reported not addressing the CPAP therapy would not have affected the reimbursement rate on the older version of the MDS assessment but the new one was a different story. The MDS Coordinator reported not addressing the CPAP therapy on the MDS would not affect the resident care because they still get the same care. During an interview on 09/25/2025 at 9:58 AM the Corporate RN reported the previous DON and ADON resigned effective last week. The Corporate RN reported she expects MDS assessments to accurately reflect a resident's status so there would be a continuum of care and everyone would be on the same page, so the residents' care would be consistent. The Corporate RN reported the facility would follow the RAI manual for completion of all MDS assessments. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 (RAI Manual) revealed the following: SECTION O: SPECIAL TREATMENTS, PROCEDURES, ANDPROGRAMSSteps for Assessment O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closingby delivering slightly pressurized air through a mask or other device continuously or viaelectronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables theindividual to support their own spontaneous respiration by providing enough pressure whenthe individual inhales to keep their airways open, unlike ventilators that breathe for theindividual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here.This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure dented cans were not in circulation. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure refrigerated foods were properly stored, labeled, and dated. 5. The facility failed to ensure expired foods were disposed of timely. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on [DATE] @ 9:32 AM revealed the following: 1. (1) bag of what appeared to be chicken breasts, no label or received/use by date. 2. (1) frozen ham, no date or label. Observation of the refrigerator on [DATE] at 9:40 AM revealed the following: 1. (1) box of what appeared to be whole cucumbers, no label or date. 2. (1) whole cantaloupe, no label or date. 3. (1) ,d+[DATE] cantaloupe, covered in plastic wrap, no label or date. 4. (3) 5-pound tubs of sour cream, no received by or open date. 5. (1) box of what appeared to be bread loaves, open to air, no label or date. 6. (1) box of cream cheese, no received on/use by date. 7. (1) bell pepper in a sack, no label or date. 8. (1) sack full of limes, no label or date. 9. (1) pitcher of red liquid, half full, no label or date. Observation of walk-in pantry on [DATE] at 9:50 AM revealed the following: 1. (8) bottles of lemon juice, all unopened with expiration dates of [DATE]. 2. (1) box of crunchy taco shells, unopened with expiration date of [DATE]. 3. (11) packages of mini marshmallows, unopened with expiration dates of [DATE]. 4. (1) opened package of mini marshmallows, opened and in a zip top bag with no date or label, with expiration date of [DATE]. 5. (6) packages of brown gravy mix with expiration dates of [DATE]. 6. (1) can of tropical fruit salad, dented, with cans that were in circulation. In an interview on [DATE] at 12:05 PM, [NAME] B stated that whoever unpacked boxes was responsible for labeling and dating the food with the date it was received into the kitchen. She stated that everyone was responsible for putting labels/dates on food and throwing away expired food. In an interview on [DATE] at 3:30 PM, [NAME] A stated a possible negative outcome for giving bad or expired food to residents was they would not know that the food was spoiled. She stated that it was not good to give expired canned food to anyone, because residents could get sick. In an interview on [DATE] at 3:31 PM, [NAME] C stated that it was everyone's responsibility to check that food was labeled and dated properly. He stated that a possible negative outcome of food not being labeled and dated was not knowing when food was cooked or when it expired. In an interview on [DATE] at 7:38 AM, DM stated that everyone was responsible for making sure that food was labeled and dated, and that expired food was to be thrown out. She stated a possible negative outcome for not labeling, dating, and throwing away expired food would be that they could serve contaminated food to residents which could make them sick. She stated that dating and labeling was important so they would know when food was expired. Record Review of facility policy dated 2012 titled Storage Refrigerators revealed in part: .5. Food must be covered when stored, with a date label identifying what is in the container . Record Review of facility policy dated 2012 titled Food Safety, revealed in part: .2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly . .7. Dented or otherwise damaged cans will not be used. Dented cans will be stored in a separate location and returned to the food vendor for credit. Record review of U.S. Food and Drug Administration's Food Code version [DATE] revealed in part: . Food . shall be labeled as specified . Label information shall include: (1) The common name of the FOOD .

48491 Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #4, Resident #11, and Resident #22) of 12 residents reviewed for accuracy of assessments. 1. On Resident #4's MDS the facility inaccurately coded Resident #4 as receiving anticoagulant medication. 2. On Resident #11's MDS the facility inaccurately coded Resident #11 as receiving anticoagulant medication. 3. On Resident #22's MDS the facility inaccurately coded Resident #22 as receiving anticoagulant medication. These failures could place residents at risk of being inaccurately assessed and therefore not receiving necessary care. Findings Included: 1. Record review of Resident #4's admission record dated 08/05/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and high blood pressure. Record review of Resident #4's quarterly MDS revealed a completion date of 06/13/24. Section C revealed a BIMS of 8 which indicated moderately impaired cognition. Section N question N0415E revealed Resident #4 was receiving anticoagulant medication. Record review of Resident #4's care plan completed on 06/13/24 revealed Resident #4 was on anticoagulant therapy. Record review of Resident #4's active order summary report dated 08/05/24 revealed no order for anticoagulant medication. The report did reveal the following order: Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth at bedtime related to CHRONIC ATRIAL FIBRILLATION . Record review of Resident #4's completed, struck out, discontinued orders since her admitted revealed no order for anticoagulant medication. 2. Record review of Resident #11's admission record dated 08/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), high blood pressure, and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #11's quarterly MDS revealed a completion date of 05/21/24. Section C revealed a BIMS of 14 which indicated intact cognition. Section N question N0415E revealed Resident #11 was receiving anticoagulant medication. Record review of Resident #11's care plan completed on 05/22/24 revealed Resident #11 was on anticoagulant therapy. Record review of Resident #11's active order summary report dated 08/05/24 revealed no order for anticoagulant medication. The report did reveal the following order: Aspirin Tablet 81 MG Give 1 tablet by mouth one time a day related to OTHER SEQUELAE OF OTHER CEREBROVASCULAR DISEASE . Record review of Resident #11's completed, struck out, discontinued orders since her admitted revealed no order for anticoagulant medication. 3. Record review of Resident #22's admission record dated 08/04/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, high blood pressure, peripheral vascular disease (blood circulation disorder), and colon cancer. Record review of Resident #22's Admission MDS revealed a completion date of 05/14/24. Section C revealed a BIMS of 15 which indicated intact cognition. Section N question N0415E revealed Resident #22 was receiving anticoagulant medication. Record review of Resident #22's care plan completed on 05/21/24 revealed Resident #22 was on anticoagulant therapy. Record review of Resident #22's active order summary report dated 08/04/24 revealed no order for anticoagulant medication. The report did reveal the following order: Aspirin 81 Oral Tablet Delayed Release (Aspirin) Give 81 mg by mouth one time a day related to PERIPHERAL VASCULAR DISEASE . Record review of Resident #22's completed, struck out, discontinued orders since her admitted revealed no order for anticoagulant medication. During an interview on 08/06/24 at 09:13 AM ADM stated MDS LVN was responsible for completing MDS assessments on residents of the facility. She said MDS assessments affected facility funding as well as direct resident care plans. ADM stated having an inaccurate MDS could therefore negatively impact the care a resident received. During an interview on 08/06/24 at 09:15 AM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. When asked if aspirin should be coded as an anticoagulant in section N of the MDS she said it should. She stated, I was not coding aspirin as anticoagulant, and someone told me I needed to be doing that. MDS LVN could not remember who told her to code aspirin as anticoagulant. When she was shown a passage in the RAI which indicated aspirin was not to be coded as anticoagulant, she said, Hmmm. Okay, I guess they were wrong. Good to know! MDS LVN could not think of a negative outcome for residents if aspirin was inaccurately coded as an anticoagulant. During an interview on 08/06/24 at 09:24 AM DON stated having an inaccurate MDS could negatively impact resident care because the care plan was based on the MDS. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . N041 5: High-Risk Drug Classes: Use and Indication . N041 5E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Tips and Special Populations . Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as NO41 5E, Anticoagulant.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of for 4 of 5 anonymous residents observed for 3 (August 4, 5, and 6 of 2024) of 3 days and reviewed for quality of life. The facility failed to ensure activities provided, met residents' needs or desires. The facility failed to ensure activities were being provided on the weekends. These failures could place residents at risk of boredom and a decline in their quality of life. Findings included: Record review of facility's activities calendar for August 2024 revealed chronicle/devotions scheduled at 10 AM every morning of the month. In addition to this activity, each Saturday and Sunday of the month had table game of choice scheduled for 10:15 AM. Saturdays had bingo scheduled for 2 PM and Sunday's had dominoes scheduled for 2 PM. Observation on 08/04/24 at 10:00 AM, while walking into the dining room, observed scheduled activity of chronicle/devotions not going on. During an observation and interview on 08/04/24 at 10:43 AM, an anonymous resident's room did not have an activity calendar in it. She stated residents did not get activity calendars for their rooms each month, but that there was an activity calendar for the whole facility outside the dining room on the wall. Observation on 08/04/24 at 12:45 PM of activity calendar for the month of August 2024 on wall outside of the dining room revealed the same activities repeated each week. Observation on 08/04/24 at 2:30 PM, revealed a scheduled activity of domino's was not happening in the dining room. During an interview on 08/05/24 at 10:39 AM, 4 of 5 anonymous residents stated they do not get activity calendars for their rooms, and if they want to know what was happening for the day, they must go and view the big calendar outside the dining room. Residents stated that they did not have any activities yesterday, which was Sunday August 04, 2024 and that there was no one in the facility to run activities on the weekends. Residents stated that the AD does not spend enough time with residents and that they have suggested to her that they want new games, but nothing had happened. One resident stated that on Friday, August 2nd, she came to the dining room to do creative crafting which was the 2:00 pm activity on the calendar that day, and she sat in the dining room until 2:30 pm, and when no one came, resident went back to her room. Record review on 08/04/24 at 2:57 PM of Facility Grievance Log for 2024 revealed that there were several complaints in the month of June regarding activities. Residents indicated that activities were boring, repetitive, AD was sometimes not present, and scheduled activities did not happen or were cancelled at the last minute. Record review on 08/04/24 at 3:00 PM of resident council minutes for month of July revealed under activities section: no activities offered on the weekends. During an interview on 08/05/24 at 1:08 PM, AD stated that she had worked in the facility since February 2024 and just received her certification for AD. She stated that she tried to do all the activities that are on the calendar each month and that she was aware of residents who had complained about wanting different games and more outings and she was just in the process of looking on the internet for new games to try. AD stated that there was only one time that an activity was cancelled, and it was a birthday party due to a death of a resident's family member. AD was unable to recall any other times when an activity was cancelled or not done. She stated a possible negative outcome for not having new games that were stimulating for residents could be depression and memory loss. AD stated a possible negative outcome for not conducting activities that were scheduled could be boredom and depression. During an interview on 08/05/24 at 1:29 PM, MDS LVN stated she worked weekends and that sometimes she would read the chronicle to the residents. She stated that was their daily newsletter and it was an activity that was on the calendar at 10:00 AM daily. She stated that if she did not have time to read to them, she would pass them out to residents. MDS LVN stated that there was no AD on the weekends, and it was up to nursing staff to set up games or give out activity pages to residents when they had time. During an interview on 08/05/24 at 1:50 PM, AD stated that she did not work on the weekends, and she did not know who ran the activities for her on the weekends, whoever was there she guessed. AD confirmed that dominoes were on the activity calendar every Sunday at 2:00 PM but stated she was not sure who ran that game. During an interview on 08/05/24 at 2:07 PM, ADM stated that as far as she was aware, all activities were happening on the weekends. She stated that the AD was in charge of weekend activities or the nurses. During an interview on 08/05/24 at 2:22 PM, ADM stated that the AD had been put on PIP because she left early on Friday, August 2, 2024 and did not tell anyone about it and did not do the activity that was scheduled at 2:00 PM that day. During an interview on 08/06/24 at 11:09 AM, AD stated that last Friday she had to leave early for a doctor's appointment, and she told the ADM. She stated that she did not know a resident complained about not having the 2:00 PM activity because everyone knew about her leaving. Record review of facility policy titled Resident Rights dated 11/28/16 revealed the following in part: Self-determination-The resident has the right to, and the facility must promote ad facilitate resident self-determination through support of resident choice. 1. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers or health care services consistent with his or her interests, assessments plan of care and other applicable provision of this part. 2. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. Grievances - The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Record review of facility policy titled Activity Programming dated 2011 revealed the following in part: The Activity Director and staff will provide for ongoing Activity programs. .2. Resident's or family's expressed needs and interests are included in the development of programs . .3. Activity programs are to be designed based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents . .7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week.

Based on Interview and Record Review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of six residents reviewed for transfer/discharge. The facility failed to send a discharge notice in writing to the facility's ombudsman as soon as practicable after Resident #1's discharge to home due to the facility not being able to meet Resident #1's needs. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet reflected the resident was a [AGE] year-old male, with initial admitted [DATE], readmitted [DATE] and then discharged to home on 04/23/2024. The resident had diagnoses which included: dementia (cognitive loss), schizoaffective disorder, bipolar type (mood disorder that varies by person but has mania and depression and causes distorted reality), and cocaine dependence, low back pain, muscle wasting and atrophy (breakdown of muscles), and unsteadiness on feet. Record review of Resident #1's progress notes dated 04/05/2024 revealed that resident was being readmitted to the facility from a behavioral hospital after he assaulted another resident on 03/24/24. Resident #1's family member was told by facility staff that they would not be able to keep resident in facility if another incident occurs and Resident #1's family member stated she would move him home with her if that happened. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of a three out of 15 which indicates that the resident had severe cognitive impairment. Discharge MDS dated [DATE] revealed it was an unplanned discharge with date of discharge recorded as 04/23/2024. During an interview on 05/22/2024 at 3:08 PM, the DON stated that she remembers Resident #1 coming back from a 72-hour pass with his family member on 04/23/24 and she remembers he was angry and cussing and saying he wanted to go home. DON and ADM had a meeting with Resident #1 and the family member agreed to discharge him and take him home with her. DON stated that the Ombudsman was not notified, and she did not know that the Ombudsman needed to be notified. During an interview on 05/22/2024 at 3:24 PM, ADM stated that she did not contact the Ombudsman when the discharge for Resident #1 happened. She stated that she did not think of it because Resident #1 was demanding to go home and because it was not against his will, she did not think she needed to contact the Ombudsman. ADM went on to state a possible negative outcome for not contacting the Ombudsman would be that Resident #1 would not have his rights or his appeal rights met. Record review of the facility's policy dated 11/28/2016, provided by the ADM, titled Discharge Planning Process Policy, .The final discharge summary will be available for release to authorized individuals and agencies, with the consent of the resident or the resident's legal representative. There was no mention in the policy about contacting the State Ombudsman's office.

Based on observation, interviews, and record reviews, the facility failed to implement its' written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: -The ADM was made aware of an allegation that AD was yelling during an activity and failed to follow policy and procedures of abuse and neglect. The facility's failure to ensure suspicions of abuse/neglect were investigated and reported to State could place all residents at risk for injuries, physical and mental decline, decrease in social gatherings, and delay of care. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is and [AGE] year-old female who was independent with touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. In an interview on 12/15/23 at 11:32 AM, Resident #1 stated BOM heard yelling and reported the incident to ADM. In an interview on 12/15/23 at 2:03 PM with BOM revealed she reported to ADM of AD yelling at someone in the activity room. No date provided. In an interview on 12/15/23 at 3:59 PM with BOM revealed 2 additional incidents at Resident Council on 11/9/23 and an encounter with a family member on 11/10/2023. In an interview on 12/15/23 at 6:14 PM with ADM revealed BOM reported an incident of AD yelling in the activity room. ADM stated by the time she reached the room, there was no yelling, and the residents were reading. In an interview on 12/16/23 at 9:10am, ADM stated a staff member or a family member who reported abuse would be no different. State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress. ADM stated a negative outcome of not reporting abuse or neglect is the facility will run into trouble with state and propagate many more abuses to occur. On 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, will report and suspend employee to do an investigation, complete investigation and report to the state. Record review of policy title, Abuse and Neglect, dated 3/29/18, states residents should not be subjected to abuse by anyone including facility staff. Under heading Definition: 3. Verbal Abuse- any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance. 6. Mental abuse- includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 10. Mistreatment- means inappropriate treatment .of a resident. Under heading C. Prevention: 1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 3. All reports of abuse or suspicion of abuse/neglect .will be investigated as per facility protocol. The facility has in place a method to identify events such as suspicious bruising of residents. 4.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. E: Reporting-Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19: A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of Long-Term Care Regulatory Provider Letter, dated 7/10/19, stated: A NF must report to HHSC the following types of incidents, in accordance with the applicable state and federal requirements: a). Abuse A table located below the Policy Details and Provider Responsibilities indicated the type of incident as abuse (with or without serious bodily injury) is to be reported immediately, but no later than two hours after the incident occurs or is suspected. On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. o Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operation [ADO] on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. o Resident safe surveys have been initiated by Administrator/ADON/MOS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [abuse hotline] [###-###-####], the ADO [Area Director of Operations] at [###-###-####], or call HHSC at [###-###-####]. o Any employees that are reported of any abuse will be suspended pending investigation. o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Monitoring of the Plan of Removal Included: An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and AD did not return to the facility. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Immediate Jeopardy (IJ) was identified on 12/16/23 at 2:30 PM. While the IJ was removed on 12/17/23 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interviews, observations, and record reviews, the facility failed to protect residents of verbal abuse and neglect for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. 1) AD verbally abused Resident #1 by yelling at her in front of residents and family members during an activity. 2) ADM failed to protect Resident #1 from verbal abuse from AD when it was reported to her by other staff members An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. This failure could affect all residents at the facility by placing them at risk for physical, mental, and emotional decline, psychosocial harm, and can lead to isolation and withdrawal from activities of enjoyment. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. In an interview on 12/15/23 at 10:19 AM, DM reported a negative outcome of abuse or neglect is the continuation of abuse or neglect. In an interview on 12/15/23 at 11:02am with Resident #1 revealed that Resident #1 stated that the AD was verbally abusive when the resident mentioned that another resident's family could assist her with picking up pizzas for the facility that are provided by a business owner in town. The AD however did not appreciate the verbal assistance from the resident and started hollering at Resident #1. Resident #1 stated that she let AD know that she was just offering help and nothing more. Resident #1 stated that the AD was sent home, for what was supposed to be a week, but AD went home on Friday afternoon and returned the following Thursday. In an interview on 12/15/23 at 11:32 AM with Resident #1 revealed AD screamed at her. Resident #1 stated that BOM heard AD scream in the activity room where an activity was being held. Resident #1 stated that BOM reported the screaming heard to ADM. Resident #1 stated AD was in a Resident Council meeting on 11/09/23 where AD was mad when item line of the Resident Council meeting was on activities. AD was upset at a comment regarding the discussion and told Resident #1 they need to discuss this in the ADM's office. Resident #1 went to ADM's office where AD interrupted the meeting. In an interview on 12/15/23 at 2:01pm with BOM revealed that she heard arguing between a resident and the AD's voice kept getting louder and louder. BOM stated that she went to go and get her abuse coordinator who is the ADM of the building. BOM stated that the ADM went down to the activity room, BOM stated that it got quiet and cannot recall what was being said when voices were raised. BOM stated that the AD was suspended for a couple of days for a completely different altercation. BOM stated that the other altercation was due to another resident's family member stating that the AD was rude to the residents. In an interview on 12/15/23 at 2:20pm with Resident #4's family member regarding any issues or altercations with the AD. Family member stated that she (AD) has never done anything to mother (Resident #4) but was just as hateful as could be to another resident, Resident #1, but since she (AD) got in trouble a couple weeks ago, she has been just as sweet as can be. Family member stated that when she pointed out to the AD that she was being hateful to the resident the AD put her hand in Family members face and said, I'm done! and walked away. Family member stated that she walked after the AD and went into the ADM's office and discussed the issue with the ADM present. The AD stated that she did not even realize what she was doing at the time of the altercation. In an interview on 12/15/23 at 3:11 PM with Resident #2 revealed that AD yelled at Resident #1 during a Resident Council meeting. In an interview on 12/15/23 at 3:32 PM with Resident #3 revealed Resident #1 had stopped going to activities and there were only three to four residents attending activities. In an interview on 12/15/23 at 4:13 PM with ADON revealed AD put in her 2 weeks' notice to resign from her position and had an argumentative attitude when doing so. In an interview on 12/15/23 at 4:23 PM with Resident #1 revealed she has attended activities one or two times. Resident #1 stated that she would rather stay in her room than be around AD. Resident #1 reported that AD told her she was going through menopause. In an interview on 12/15/23 at 6:14 PM with ADM and BOM, ADM stated that BOM reported raised voices. BOM was asked if she reported raised voices or yelling. BOM stated yelling. ADM agreed with BOM that she reported yelling. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. In an interview on 12/16/23 at 6:33am with Resident #3 stated that she just doesn't think the AD knows what she is doing. Resident #3 stated that the AD, doesn't show herself very well at times. Resident #3 stated that some residents will not come back to resident council due to the AD. In an interview on 12/16/23 at 7:59am with Resident #4 FM revealed FM, Resident #1, and AD were in a room, date unknown, and AD began yelling at Resident #1 regarding a monthly donation made to the facility. Resident #4's family member stated that the AD stated that family member does not need to be involved in getting the donation set up. AD became agitated and started yelling. AD raised her voice and stated, I will take care of it!. Resident #4's family member stated that the AD has NEVER been pleasant or nice to her (family member or Resident #1). In an interview on 12/16/23 at 8:40 AM with BOM confirmed heard yelling in the activity room. BOM reported AD does not know how to handle residents correctly and AD has not been nice or friendly. In an interview on 12/16/23 at 9:10am with ADM, ADM stated that she (ADM) meant to say loud voices. ADM was asked why she confirmed yesterday (12/15/2023) that BOM reported yelling? ADM repeated she meant to say loud voices. ADM did not answer why she agreed with the BOM previous day. ADM stated that when she went to go and investigate the altercation, she did not visualize any signs of abuse and the yelling had stopped. Record review of Resident #3's progress note, dated 11/9/23 at 11:42 AM by RN A, stated Resident #3 was crying because that activity director was arguing with another resident during resident council meeting. Record review of policy title, Abuse and Neglect, dated 3/29/18, states residents should not be subjected to abuse by anyone including facility staff. Under heading Definition: 3. Verbal Abuse- any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance. 6. Mental abuse- includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 10. Mistreatment- means inappropriate treatment .of a resident. Under heading C. Prevention: 1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 3. All reports of abuse or suspicion of abuse/neglect .will be investigated as per facility protocol. The facility has in place a method to identify events such as suspicious bruising of residents. 4.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. E: Reporting-Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19: A. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of Long-Term Care Regulatory Provider Letter, dated 7/10/19, stated: A NF must report to HHSC the following types of incidents, in accordance with the applicable state and federal requirements: a). Abuse A table located below the Policy Details and Provider Responsibilities indicated the type of incident as abuse (with or without serious bodily injury) is to be reported immediately, but no later than two hours after the incident occurs or is suspected. On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operations on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. o Resident safe surveys have been initiated by Administrator/ADON/MDS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. o The employees will protect the potential victims of A/N/E by stopping alleged behavior and removing the resident from harm. Then they will report the incident to the Abuse Coordinator immediately. o A complete investigation will be done following our Protocol/Ad Hoc QAPI - Actual/Alleged Abuse o The investigation will be evaluated by the Area Director of Operations &/or the Corporate Compliance nurse to ensure complete interviews of all possible witnesses prior to determining a conclusion. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [Abuse hotline for company] [###-###-####], the ADO [Area Director of Operations] at [###-###-####] or call HHSC at [###-###-####]. o Any employees that are reported of any abuse will be suspended pending investigation. o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Monitoring of the Plan of Removal Included: Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and did not return to the facility. An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interviews and record reviews, the facility failed to conduct a thorough investigation of all allegations of abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: -the facility reported an allegation of abuse reported by a family member and did not conduct a thorough investigation. The facility's failure to ensure allegations of abuse and neglect were thoroughly investigated could lead to continuous abuse, mental and physical decline, psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The facility's failure to ensure allegations of abuse and neglect were thoroughly investigated could lead to continuous abuse, mental and physical decline, psychosocial harm. Findings Included: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/23 at 6:14 PM with ADM revealed after BOM reported yelling in activity room, ADM went to activity room and by the time she arrived in the room, there was no yelling. In an interview on 12/16/23 at 9:10am ADM stated a staff member or a family member who reported abuse would be no different . State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress and BOM was a concerned employee. ADM stated that reportable incidents were abuse, neglect, and exploitation as well as fall with injury and injury of unknown origin. On 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, I will report and suspend the employee to do an investigation, complete investigation and report to the state. Record review of Provider Investigation Report (PIR), dated 11/13/23, was provided by ADM. Under section of assessment, dated 11/10/23, no time or name of person who completed the assessment was written in the designated spaces. Injury or adverse effect answered no. Note of psychosocial assessment completed- no adverse s/s. Treatment provided no, treatment location: In-House? No. Was the incident reported to the police? Yes. Under investigation summary, After asking Resident #1 and other resident's present, it was determined the said FM was not from this family and did not have firsthand knowledge of incident. States investigation findings were inconclusive. Provider action taken post-investigation, finish in-services, do 1:1 in-service with AD on handling difficult situations and customer service. Interviews conducted during PIR reported two negative responses from Resident #1 and Resident #4. Record review did not provide any written witness statements, staff statements, or statements by complainant. No documentation of in-services or one-on-ones provided to AD after returning to the facility from suspension. One in-service, dated 11/10/23, was signed by AD prior to her suspension from the facility. Record review of staff interviews conducted by ADO, dated 12/16/23, revealed ADO spoke with administrator, MDSC, and ADON. Stated did not interview BOM due to being placed on an action plan on 12/15/23 as ADO felt answers could be retaliation. ADO had written, I did not interview ADM or other non dept heads. This was done right after the IJ was called. The document was signed by ADO on 12/17/23. Record review of policy title, Abuse and Neglect, dated 3/29/18, section F. Investigation stated comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source. 2. After receipt of the allegation, the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria stated in Provider Letter 19-17. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). On 12/16/23 at 2:30 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 12/17/23 at 7:08 AM. It is alleged that the facility failed to establish and implement. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: Facility failed to protect residents from verbal abuse. Multiple incidents occurred between Resident #1 and Activity Director. All incidents investigated revealed witnessed verbal abuse from residents and family members. AD was suspended for five days and was allowed to return to the facility on [DATE] where she continued regular duties. o Facility Plan of Removal states: One on One in-service on Abuse Investigation with the Administrator/DON by Area Director of Operations [ADON] on 12/16/2023 3:52 pm. o Staff working with alleged perpetrator have been interviewed. o The alleged perpetrator was suspended on 12/16/2023 pending the outcome of investigation. o Resident safe surveys have been initiated by Administrator/ADON/MOS Nurse. on 12/16/2023 for all interview able residents. Those who cannot be interviewed will have a head-to-toe assessment completed. No abuse incidents have been reported. o The employees will protect the potential victims of A/N/E by stopping alleged behavior and removing the resident from harm. Then they will report the incident to the Abuse Coordinator immediately. o A complete investigation will be done following our Protocol/AD Hoc QAPI- Actual/Allege Abuse o The investigation will be evaluated by the Area Director of Operations &/or the Corporate Compliance nurse to ensure complete interviews of all possible witnesses prior to determining a conclusion. o The following in-services were initiated on 12/16/2023 by Administrator/DON/ADON/MDS Nurse: Any staff member not present or in-serviced on 12/16/2023, will not be allowed to assume their duties until in-serviced by Admin/DON/ADON/MDS Nurse. O All Staff o Abuse/Neglect o Abuse/Neglect Reporting o Who to Report Abuse/Neglect to o All staff will need to be able to articulate back on reporting any type of abuse allegation and to whom to report. The in-service includes if they believe the report was not acted upon to contact the [company name- #########] , the ADO [Area Director of Operations][#########], or call HHSC [#########] o Any employees that are reported of any abuse will be suspended pending investigation. o The medical director was notified of the immediate jeopardy situation on 12/16/2023 at 4:30 pm. Monitoring of the Plan of Removal Included: An observation on 12/17/23 at 11:25 AM revealed a photo taken from ADM phone with a text message to AD that stated AD was placed on suspension again and AD confirmed she had received it. An interview on 12/17/23 at 4:00 PM, ADO revealed company accepted AD letter of resignation effective immediately and did not return to the facility. On 12/17/23 from 11:41 PM to 2:22 PM, 23 residents were interviewed regarding safe surveys that were conducted by staff. 18 residents confirmed speaking with staff regarding safe surveys and abuse and neglect. 6 residents were unable to recall the surveys. Residents confirmed or denied knowing who to report abuse and neglect to. If they denied, safe surveys show they were educated on who the abuse coordinator is. On 12/17/23 from 12:22pm to 3:15pm, 40 employees (1 PT, 2 OT, 4 RN, 8 LVN, 11 CNA, 1 HA, 1 MDSN, 1 BOM, 7 DS, 4 HK, 2 LS, and 2 MS, 1 ADON, 1 DON, and 1 ADM) were interviewed and confirmed obtained training via phone or in person. Training attached to in-services that identified the seven areas of the Abuse/Neglect/Exploitation policy along with the types of abuse and how/who to report to. Employees that were contacted were able to state they received abuse and neglect training, knows who to report to and feels comfortable with reporting. An interview on 12/17/23 at 3:07 pm with MD revealed he was contacted on 12/16/23 regarding outcomes and plan of removal that was conducted. MD stated he was aware of in-services and additional training that would be provided prior to employee's next working shift. Record review of assessments, dated 12/16/23, revealed 23 Safe Surveys and 6 skin assessments completed. Record review of AD-HOC QAPI, dated 12/16/23, revealed ADM, DON, ADON, MD, and ADO attended AD Hoc QAPI meeting. Record review of Employee Disciplinary Report, dated 12/16/23, revealed AD had been suspended via text message from ADM. Record review of in-service for Abuse and Neglect, dated 12/17/23, revealed ADM and DON received education over policy Abuse and Neglect. Immediate Jeopardy (IJ) was identified on 12/16/23 at 2:30 PM. While the IJ was removed on 12/17/23 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services in that: The staff did not complete hand hygiene while handling or distributing food or wear proper head coverings in the kitchen. This failure can place residents at risk of cross contamination, physical decline, and weight loss. Findings Included: An observation on 12/15/23 at 10:19 AM revealed DM not wearing a hair net in the kitchen. An observation on 12/15/23 at 12:07 PM showed DS I touched her face and not practicing hand hygiene before touching the hydration cart. An observation on 12/15/23 at 12:19 PM revealed RN A handing trays to staff without practicing hand hygiene. An observation on 12/15/23 at 12:35 PM revealed DM and DS F not wearing hair nets while serving in the kitchen. In an interview on 12/15/23 at 2:29 PM, DM revealed DS F had left for the day. DM was unaware that DS F was not donning a hairnet or beard net while in the kitchen. DM stated a negative outcome could be contamination of food. An observation on 12/15/23 at 5:27 PM revealed DS H making small single size serving cups with sauerkraut and did not practice hand hygiene or wear gloves. An observation on 12/15/23 at 5:28 PM revealed DS G wearing gloves, touched faced, and continued to make food. An observation on 12/15/23 at 5:31 PM revealed DS H throwing away a box of thickener in a blue and pink container in the trash can, lifted lid with bare hand, grabbed another box and continued to make thickened tea. No hand hygiene was practiced. An observation on 12/15/23 at 5:33 PM revealed DS H grab a grey plate cover, ice cream, and silver ware with no hand hygiene practiced. An observation on 12/15/23 at 5:34 PM revealed DS G wipe nose on arm and continue serving meals. An observation on 12/15/23 at 5:35 PM revealed DS H deliver a tray after touching hair and face with no hand hygiene practiced. An observation on 12/15/23 at 5:36 PM revealed ADM walking in the kitchen with a hair net that did not cover all hair and began going through refrigerator without practicing hand hygiene. An observation on 12/15/23 at 5:37 PM revealed DS G continue making plates with no hand hygiene observed. ADM grabbed a pitcher without practicing hand hygiene. An observation on 12/15/23 at 5:37 PM revealed DS G making mechanical soft plate and did not practice hand hygiene after touching box of thickener. In an interview on 12/15/23 at 6:03 PM with DS H revealed she had just started 5 days ago. DS H revealed she has not had training in hand hygiene or official training from tenured kitchen staff. DS H stated a negative outcome could be spreading germs. In an interview on 12/15/23 at 6:06 PM with DS G revealed she had been here for two weeks, and she was trained by someone in corporate. She stated they had to wash their hands after touching anything in the kitchen and anytime handling food. DS G stated that a negative outcome of not practicing hand hygiene could be residents may get sick and it could cause harm to the resident. Record review of CDC guidelines of Handwashing: A Healthy Habit in the Kitchen, dated 7/18/22, under heading Why, When, and How to Wash Hands, stated handwashing is important when germs can easily spread. Situations include before and after preparing any food, before and after using gloves, after touching garbage, and after coughing, sneezing, or blowing your nose.

Based on observation, interview and record review, the facility failed to allow residents to organize without a staff member present, approve a staff member to aide, and demonstrate responses and rationales for changes made for 7 (#1, #4, #5, #7, #8, #9, #10, #11) of 7 residents who attended Resident Council meetings. The facility failed to include the approval of the Resident Council for decisions involving family members, approved staff, and frequency of meeting time. This failure restricted the privacy of these 8 residents and placed the residents at risk of not having the right to voice their concerns without staff being present or overhearing their concerns, conduct resident council meetings without interference, and approve changes made for the council meetings. Findings include: An observation on 12/15/23 at 12:42 PM, revealed a sign was located on each door to each hall stating: Resident Counsel Meeting- Will be moved to the 4th Thursday of the month from here on out. Thank you for your cooperation. Next meeting is December 28, 2023. An interview on 12/15/23 at 11:32 AM, Resident #1 revealed she is the resident council president. Resident #1 stated that the resident council meets every second Thursday of the month, and it was changed to the third Thursday of every month. Resident #1 stated the council was not made aware of this, the council did not approve for the meeting to move, and the AD did not know the proper protocol. Resident #1 stated the meeting held 11/9/23, the staff made family members aware they would not be allowed in council meetings and a family council will be formed. Resident #1 indicated the council did not have a voice in this decision. In an interview on 12/15/23 at 3:11 PM, Resident #2 stated they did not invite anyone, including staff, to the meeting because she had never heard of that the resident council had to. In an interview on 12/15/23 at 6:14 PM, ADM stated the council invited all the staff, but AD. ADM stated AD belongs to group who stated they run their own respected meetings and there has been no discussion with the council members. ADM stated the AD was told to move the meetings to the end of the month because they were being held in the middle of the month. ADM stated the AD told council that the meeting was moved. In an interview on 12/16/23 at 2:46 PM, Resident #4's FM reported that nobody said anything, but AD reported some residents did not want them there. Record review of Resident Advisory Council Minutes, dated 9/13/23, revealed family members were not approved to be in this month's meeting but AD was approved. Resident Council Minutes, dated 10/12/23, revealed the resident council did not want to have a private meeting and approved activity director and family members. Resident Council Minutes, dated 11/9/23, revealed activity director was approved for the meeting. Under heading ACTIVITIES: Me (regarding the Activities Director)- was noted on the top line by compliments/concerns and third line stated Resident Counsel- don't like new changes. States next month's meeting will be held on 12/14/23. Record review of Resident Rights dated 11/28/2016, line 5 stated: The resident has a right to organize and participate in resident groups in the facility. B- Staff, visitors, or other guests may attend resident group or family group meetings on at the respective group's invitation. Record review of policy titled, revised 12/13/16, revealed objectives were to help residents organize to represent their own best interest, contribute to the management of the facility, and to enhance the residents' sense of self-worth and effectiveness. Procedures were the residents will develop a self-administered residents' council with its own officers, agenda, and regular meeting times. Staff, visitors, or other guest may attend resident council meetings only at the respective group's invitation. The facility will provide a designated staff person who is approved by the resident council who is responsible for providing assistance and responding to written requests that result from group meetings. The facility will consider the views of the resident council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.

Based on observation, interview and record review, the facility failed to report an alleged violation of abuse or neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or neglect or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 2 (Resident #1 and Resident #6) of 6 residents reviewed for abuse/neglect. 1. The facility failed to report that Resident #1 had a laceration to the lower left leg which required 9 stitches. 2. The facility failed to report that Resident #1 was verbally abused by Activity Director. 3. The facility failed to report bruises to Resident #6's upper right arm, origin of injury could not be determined. This failure could place residents at risk of in a delay in care, continuous abuse or neglect, physical or psychosocial harm, including death. Findings include: Record review of Resident #1's medical record revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had the following diagnosis of major depressive disorder, recurrent, unspecified, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction, difficulty in walking, not elsewhere classified, unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent an 87-yeaar-old female who was admitted to the facility on [DATE]. Resident #1 does have touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/2023 At 11:02am with Resident #1 revealed that Resident #1 received a laceration on her lower left leg that required 9 stitches. Resident #1 stated CNA C did not move a bar that Resident #1 hit her leg on. Resident #1 stated that the laceration would not stop bleeding and that stiches were placed. Resident #1 also mentioned that the AD was verbally abusive towards her during a conversation regarding the monthly donation of pizza to the facility. The AD however did not appreciate the verbal assistance from Resident #1 and started hollering at Resident #1,. sShe stated that she let AD know that she was just offering help and nothing more. Record review of Resident #1's face sheet revealed that Resident #1 was an [AGE] year-old female. Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses of major depressive disorder, cerebral infarction, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, paralysis on one side of the body following a stroke, difficulty in walking, and unsteadiness on feet. Record review of Resident #1's MDS assessment revealed that resident is independent with touch assist with bathing. Resident #1 had a BIMs of 15 with no cognitive impairment. Record review of Resident #1's care plan revealed that Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 enjoys participating in exercises and reading daily chronicle. Resident #1 likes listening to music, bingo, cards, games, parties/socials, attending religious services, watching T.V./movies, watching football, and shopping. Resident #1 love spending time with grandkids and family when they come to visit. An interview on 12/15/2023 at 11:43am with CNA D revealed that Resident #1 was trying to get up and turned towards the side of the chair in the transport van by the time CNA D was getting to the back of the transport van. CNA D stated that Resident #1 did not move her feet so that she could turn around completely to sit down in the wheelchair, and that she (CNA D) had to move the wheelchair or Resident #1 would have fallen. CNA D stated that a surgery center placed the stitches in Resident #1's leg. CNA D stated that she reported the injury to her ADON. An interview on 12/15/23 at 2:01pm with BOM revealed that she heard arguing between a resident and the AD's voice kept getting louder and louder. BOM stated that she went to go and get her abuse coordinator who is the ADM of the building. BOM stated that the ADM went down to the activity room, BOM stated that it got quiet and cannot recall what was being said when voices were raised. An interview on 12/15/23 at 6:14 PM with ADM revealed BOM reported an incident of AD yelling in the activity room. ADM stated by the time she reached the room, there was no yelling, and the residents were reading, and that there was no need to make a report . In an interview on 12/16/23 at 9:10am, ADM stated a staff member or a family member who reported abuse would be no different. State Surveyor asked ADM if BOM felt it was bad enough to report it to ADM, why was it not investigated. ADM stated she went to the room and there was no sign of abuse or distress and BOM was a concerned employee. ADM stated that reportable incidents would be abuse, neglect, and exploitation as well as falls with injury and injury of unknown origin. ADM stated a negative outcome of not reporting abuse or neglect is the facility will run into trouble with state and many more abuses will occur . Record review of skin assessment dated [DATE], of Resident #6 revealed 2-3 x 3 bruising to upper inner arms. Record review of Resident #6's face sheet, dated 12/17/2023 revealed that Resident #6 is an [AGE] year-old female who was admitted to facility on 01/04/2021. Resident #6 has diagnoses of dementia, with agitation, difficulty swallowing, cognitive communication deficit, dysphagia, muscle wasting and atrophy, other reduced mobility, need for assistance with personal care, other lack of coordination, major depressive disorder, recurrent, moderate, bipolar disorder, current episode manic severe with psychotic features. Record Review of Resident #6's MDS assessment, dated 09/28/2023, revealed that Resident #6 has a BIMs of 02 indicating severe cognitive impairment and is totally dependent on staff for care. Record review of Resident #6's care plan, dated 10/04/2023, revealed that Resident #6 will receive daily skin assessments secondary to being on anticoagulant therapy. Observation on 12/17/2023 at 11:43am ADON wheeled Resident #6 to her room so that visualization of bruising could be seen. Visualization of 2 small bruises were visualized on Resident #6's right upper arm. Resident #6 could not verbalize where these bruises came from. DON was also present at time of visualization. Bruising appears to be 2 small circles well below where a vaccine would be administered. The bruising is not on the deltoid muscle of the arm. Bruising is in the healing stages of light green and faded purple. Interview on 12/17/2023 at 11:45am revealed during visualization of bruising DON stated that Resident #6 recently had a vaccine in that arm. Neither the DON nor ADON could say where the bruising came from. DON stated that education was given on sling use as Regional nurse and DON expressed the bruising could possibly come from the mechanical lift straps. ADON stated the bruising could have taken place from Resident #6's shirt rubbing on resident's arm. Neither DON or ADON could confirm or deny where bruising came from. Record review of Resident #6's skin assessment dated [DATE] did not reveal any bruising on Resident #6. Event nurses note, dated 12/17/23, documented 2 small bruises identified on resident's right upper arm. Record review of Resident #6's vaccine record does show that a vaccine was administered on 12/05/2023 to the Right Deltoid. Interview on 12/17/23 at 12:59 PM, ADM stated as soon as I hear about abuse, will report and suspend employee to do an investigation, complete investigation and report to the state. Interview on 12/17/2023 at 3:15pm with ADM was asked what a reportable injury would be, ADM stated that an injury of unknown origin and or an injury that caused harm to the resident. Interview on 12/17/2023 at 3:28pm with ADON, DON, and Regional RN were asked about bruises on Resident #6. Staff responded with an injury of unknown origin or an injury that caused harm to a resident as a reportable injury. Staff were asked how they could prove without a doubt, that the bruising on Resident #6 was from the mechanical lift sling straps, since the previous interviews were inconsistent, and a definitive answer could not be given. Staff stated that the facility would perform an investigation to determine where if the injury of unknown origin should be reported. Staff was unable to provide policy regarding this process. Staff stated bruising would be reported since a definitive origin of the injury could not be determined. It was acknowledged by staff that bruising would be reported to State agency. Staff stated the injury that Resident #1 received on the transport van was not reportable. Staff stated that the injury was addressed by the surgery center, making the injury non-reportable. Staff stated that an injury that caused harm to a resident would be reportable. ADM joined meeting at this time, and stated she was unaware of injury to Resident #1. Record review of facility provided policy titled Abuse/Neglect, revised date 03/29/2018 stated the following: .E. Reporting . .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of resident, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 07/10/2019. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. F. Investigation 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for the required reporting to HHSC per reporting guidelines found in Provider Letter 19-17.

Based on observation, interview, and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 3 (Resident #1, Resident #2, Resident #3) of 5 residents reviewed for dental care in that: Resident #1, Resident #2, and Resident #3 had various dental needs that had not been met per facility policy. This failure could place residents at risk of quality of life, nutritional decline, or infection. Findings included: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted to the facility initially on 1/4/21 and readmitted [DATE]. Her diagnoses included but were not limited to Heart Failure, dementia with behavioral disturbance, bipolar disorder, and borderline personality disorder. Resident #1 was currently on hospice services. Record review of Resident #1's MDS, dated [DATE], revealed a functional status of total dependence for personal hygiene. Functional status for eating was scored as extensive assistance. Resident #1's MDS indicated a BIMS of 02 which indicated severe cognitive impairment. Resident #1's MDS under Functional Abilities and Goals indicated an 01 indicating Resident #1 was dependent on oral hygiene care. Resident #1's MDS in Section L indicated choice Z which states none of the above were present. The options were broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, abnormal mouth tissue, obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort or difficulty with chewing, unable to examine, or none of the above were present. Record review of Resident #1's care plan, dated 10/4/2023, revealed a care plan goal of having dentures with an intervention of monitor for/record poor fitting/missing dental appliances. Additional intervention to coordinate arrangements for dental care, transportation as needed/ as ordered. Record review of Resident #1 orders, dated 9/28/23, revealed an order for a regular diet, pureed texture, nectar consistency. Resident #1 progress note, dated 8/3/23 by ADON, revealed that Resident #1 continues to remove dentures and states they were bothering her. During an interview on 10/17/23 at 3:52 PM, DON indicated that dental services were provided in May 2023, and they were declined by Resident #1. Prior to this date, it was indicated the social worker was helping. Resident #2 Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included but were not limited to unspecified dementia without behavioral disturbance, dental root caries, and need for assistance with personal care. Record review of Resident #2's orders, dated 11/3/2016, revealed an order for dental care PRN. Record review of Resident #2's care plan, dated 8/29/23, revealed a focus of Resident #2 has oral/dental health problems and missing teeth. Resident #2 is signed up to see in house dentist with an intervention stating to monitor/document and report to MD regarding oral/dental problems needing attention: teeth missing, loose, broken, eroded, or decayed. Record review of Resident #2's MDS, dated [DATE], revealed a BIMS of 05 which indicated severe cognitive impairment. Resident #2's MDS, Section L for oral/dental status indicated broken or loosely fitting full or partial denture and mouth or facial pain, discomfort, or difficulty with chewing. In an observation and interview on 10/17/23 at 2:49 PM, Resident #2 indicated that the dental issue was irritating. Resident #2 indicated she was unable to chew well but was able to eat foods she liked. Observation of Resident #2's teeth revealed severe tartar/plaque buildup with approximately 3 teeth missing from top row. In an interview on 10/17/23 at 2:24 PM, SW revealed that partial upper for Resident #2 has been worked on for about 3 years. SW indicated that this last May, the paperwork was sent for dental services and then the resident declined due to the time lapsed of services being provided. Resident #3 Resident #3 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included but not limited to Parkinson's Disease, reduced mobility, and need for assistance with personal care. Resident #3's care plan, dated 10/4/2023, revealed a focus of oral/dental health problems. Resident has broken, carious, and missing teeth with a focus of coordinate arrangements for dental care, transportation as needed/ordered. Record Review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 10 indicating moderate cognitive impairment. Resident #3's MDS, section L, indicated an oral/dental status of broken or loosely fitting full or partial denture and mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident #3's orders indicated may have dental consult PRN dated 6/20/23. An interview on 10/17/23 at 4:25 PM, Resident #3 indicated that they were still waiting for dentures and not having them bothers him very much. In an interview on 10/17/23 at 2:15 PM, DON stated that there was a flip-flop with dental company. DON indicated that when the dental company visits, they come with a list that has resident's names who were no longer residing at the facility. DON stated the SW who was employed before worked on the dental coordination but has not been employed for a couple of months. In an interview on 10/17/23 at 2:24 PM, SW stated she was employed at facility in 2017 and retired in August 2023. SW indicated that the dental company ceased contact with SW in December 2022 and contact was going to DON. SW stated she was sending referrals but was unable to obtain any information. SW indicated that dental needs of the residents were not being met. The SW indicated that all the residents had complaints about the dental company. SW stated there was a lack of communication. In an interview on 10/17/23 at 2:37 PM, MDS Nurse found a card on the social worker's old desk to MDM Dental. MDS Nurse also stated that there had been no new residents since the SW retired. DON stated she would oversee dental when asked who oversaw the services. Record review of CMS 802, dated 10/17/23, indicated that the last resident to be entered into facility was on 9/21/23. In an interview on 10/17/23 at 2:37 PM, DON indicated dental emails received by corporate office only. In an interview on 10/17/23 at 2:42 PM, DON stated the dental company had not been contacted. DON indicated a negative outcome would be tooth pain and alter how the resident eats. In an interview on 10/17/23 at 2:44 PM, MDS Nurse revealed a negative outcome would be an infection if resident's dental needs were not met. In an interview on 10/17/23 at 2:50 PM, DON provided number to an alternate dental company. On 10/17/23 at 3:37 PM, attempted to call dental companies provided with one being disconnected and one out of business. In an interview on 10/17/2023 at 3:57 PM, DON indicated third dental company and has been since January 2023. DON confirmed last visit by dental company prior was in May. DON stated that the visits have never been consistent. Record review of Dental Services, dated 2003, revealed that Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Implementation of the policy included: Oral health services are available to meet the resident's needs. 2. Routine and emergency dental services are provided to our residents through: o A contract agreement with a local dentist; o Referral to the resident's personal dentist; o Referral to community dentists; or o Referral to other health care organizations that provide dental services. 3. The Director of Nursing Services, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services. 4. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. The facility failed to store food at least 6 inches above the floor. This failure could place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 7/16/2023 at 10:30am revealed the following: 1. Observation of freezer 1 on 7/16/23 at 10:30 am revealed onion rings with no label or date. 2. Observation of freezer 1 on 7/16/ 23 at 10:30 am revealed tater tots with no label or date. 3. Observation of freezer I on 7/16/23 at 10:33 am revealed chicken with no label or date. 4. Observation of shelf 1 on 6/16/23 at 10:34 am revealed vegetable oil open on shelf with no date. 5. Observation of shelf 1 on 6/16 at 10:34 am revealed Cal do [NAME] Bouillon on shelf with no date. 6. Observation of refrigerator 1 on 7/6/23 at 10:35 am revealed cooked bacon and sausage in a plasticzip lock bag with no label or date. 7. Observation of refrigerator 1 on 7/16/23 at 1035 am revealed watermelon in plastic zip lock bag with no label or date. 8. Observation of refrigerator 1 on 6/16/23 at 10:35 am revealed open container of mustard in fridge with no date. 9. Observation of refrigerator 1 on 6/16/23 at 10: 37 am revealed unidentified white plastic container in fridge with no label or date. 10. Observation of pantry on 6/16/23 at 10:40 am revealed Items in pantry not stored six inches above the floor. An interview on 7/17/2023 at 1:30pm with Cook A, stated that all kitchen staff are responsible for safe food storage per their policy. Cook A stated that she would go to the policy to see what the policy stated concerning food storage. Cook A stated that the negative outcome for not practicing food storage would be contamination. An interview with Dietary Manager on 7/17/23 at 1:35 pm stated that kitchen staff are to follow facility policy for proper food storage. Dietary Manager stated that a negative outcome for Residents would be contamination. Record review of in-service dated 1/16/23 at 2: 30 PM, training contained proper labeling and storage. Record review of Dietary Services Policy & Procedure Manual, dated 2012, for storage area stated all stored items must be above the floor on surfaces which allow thorough cleaning. Record review of Food and Drug Administration Food Code, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor.

Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 (Resident #13 and Resident #18) of 12 residents reviewed for care plan timing. 1. Resident #13 had a comprehensive assessment completed on 05/10/23 and her most recent care plan was developed on 05/31/23. 2. Resident #18 had a comprehensive assessment completed on 06/18/23 and her most recent care plan was developed on 05/23/23. These failures could place residents at risk of not receiving appropriate levels of care for needs identified in the comprehensive assessment. Findings include: 1. Record review of Resident #13's face sheet, dated 07/16/23, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, frontal lobe and executive function deficit following cerebral infarction (impaired memory, problem solving, inhibition, and decision making due to stroke), protein calorie malnutrition, muscle wasting, cognitive communication deficit, unsteadiness on feet, need for assistance with personal care, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #13's Quarterly MDS completed on 05/10/23 revealed a BIMS of 3 out of 15 which indicated severely impaired cognition. Section G of the assessment indicated Resident #13 needed extensive assistance to total dependance on 1-2 staff members across all ADLs except for eating which required supervision by one staff member. Record review of Resident #13's care plan revealed a completion date of 05/31/23. 2. Record review of Resident #18's face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), acute and chronic respiratory failure with hypoxia (respiratory system fails in gas exchange function resulting in below-normal levels of oxygen in the blood, specifically in the arteries), muscle wasting and atrophy, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), history of falling, and cognitive communication disorder (impaired ability to use language and speech to exchange information, thoughts, or feelings). Record review of Resident #18's Quarterly MDS completed on 06/18/23 revealed a BIMS of 5 out of 15 which indicated severely impaired cognition. Section G of the assessment indicated Resident #18 needed extensive assistance by one to two staff members across all ADLs except eating which required supervision by one staff person. Record review of Resident #18's care plan revealed a completion date of 05/23/23 During an interview on 07/18/23 at 09:52 AM, ADON stated MDS RN is responsible for completing MDS assessments and care plans. She said she was not sure about the timing of a care plan related to an MDS assessment. When asked for a possible negative outcome of having a care plan that has not been updated according to the latest MDS assessment, she stated, That is like being neglectful, if there is something we missed that is very important it could even lead to hospitalization . An interview was attempted via telephone with MDS LVN on 07/18/23 at 10:28 AM. There was no answer and no return call. (She was out of the facility attending a training.) During an interview on 07/24/23 at 02:16 PM, MDS LVN stated the RNs of the facility are responsible for developing comprehensive care plans. She stated she takes the information from the MDS assessment and puts it into the care plan. MDS LVN stated she uses the facility's policy as well as the Resident Assessment Instrument for determining the time frame between MDS assessment and care plan development. She confirmed the facility's policy states a comprehensive care plan will be developed within 7 days of a comprehensive assessment. When asked for a possible negative outcome of a care plan not being updated within 7 days of the MDS assessment she said, Things being missed from the last MDS. Record review of undated facility policy titled; Comprehensive Care Planning revealed the following: .When developing the comprehensive care plan, facility staff will, at minimum, use the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services.A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment.The resident's care plan will be reviewed after each Admission, Quarterly, Annual, and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #130) of 12 residents reviewed for care planning. Resident #130's baseline care plan was inaccurate, in that it stated Resident #130 was taking antipsychotic medication and it did not state Resident #130 was taking antidepressant medication. This failure could place newly admitted residents at risk of having inaccurate or misleading baseline care plans. Findings include: Record review of Resident #130's face sheet, dated 07/17/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute cystitis without hematuria (infection of the urinary bladder without blood in the urine), infectious gastroenteritis and colitis (irritation and inflammation of stomach and intestines resulting in nausea and diarrhea), type 2 diabetes, dementia (a group of thinking and social symptoms that interferes with daily functioning), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #130's baseline care plan, dated 07/08/23, revealed a focus area of resident requires antipsychotic medications. The baseline care plan did not mention antidepressant medication. Record review of Resident #130's active physician's orders revealed an order for an antidepressant medication [Buspirone HCI] and no order for an antipsychotic medication. Record review of Resident #130's discontinued, struck out, and completed physician's orders revealed no antipsychotic medication. During an interview on 07/17/23 at 08:23 AM, Resident #130 stated she did not remember being on antipsychotic medications, she said, Psychotic, that sounds scary. During an interview on 07/17/23 at 09:47 AM, Resident #130's family member and secondary medical power of attorney stated Resident #130 lived with her before admission to the hospital for 10 days and from there admission to the facility. She said Resident #130 did not take antipsychotic medication. During an interview on 07/18/23 at 09:52 AM, the DON stated charge nurses are responsible for writing baseline care plans when a resident is admitted . During an interview on 07/18/23 at 09:53 AM, the ADON stated a possible negative outcome of having an inaccurate baseline care plan was, You could miss important medication or care that is not transcribed to the next shift. Record review of an undated facility policy titled; Base Line Care Plans revealed the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety . This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will . Include the minimum healthcare information necessary to properly care for a resident including, but not limited to . Physician orders . It will be based on the admission orders, information about the resident available from transferring provider, and discussion with the resident and resident representative, if applicable.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 (Resident #2) of 12 residents reviewed for respiratory care. The facility failed to ensure Resident #2 was provided O2 at 4 lpm continuously as ordered. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services. Findings include: Record review of Resident #2's face sheet dated, 07/17/23, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), type 2 diabetes (insufficient production of insulin, causing high blood sugar), hypertension (high blood pressure), and acute respiratory failure with hypoxia (respiratory system fails in gas exchange function resulting in below-normal levels of oxygen in the blood, specifically in the arteries). Record review of Resident #2's Quarterly MDS dated , 04/21/23, revealed a BIMS of 2 out of 15 which indicated severe cognitive impairment. Section O of the MDS revealed Resident #2 was receiving O2 therapy while a resident. Record review of Resident #2's care plan dated, 05/08/23, revealed an intervention for Resident #2's altered cardiovascular status was Give oxygen as ordered by the physician. The care plan further revealed an intervention for Resident #2's oxygen therapy was, Oxygen at 4 lpm per nasal canula. Record review of Resident #2's orders revealed an order, dated 04/06/23, for continuous O2 via nasal cannula at 4 lpm related to acute respiratory failure with hypoxia. An observation on 07/16/23 at 10:30 AM, revealed Resident #2 lying in a geri chair in her room asleep. She was receiving O2 via nasal cannula at 2 lpm. During an interview on 07/17/23 at 02:52 PM, Resident #2's family member revealed Resident #2 began receiving O2 on a continuous basis in 2020 after having COVID. An observation on 07/17/23 at 09:15 AM, revealed Resident #2 lying in a geri chair in her room asleep receiving O2 via nasal cannula at 2 lpm. An observation on 07/17/23 at 11:57 AM, revealed Resident #2 in a geri chair at a table in the dining room receiving O2 via nasal cannula at 2 lpm. An observation on 07/17/23 at 01:30 PM, revealed Resident #2 lying in bed asleep on her back covered with a blanket to underneath her chin receiving O2 via nasal cannula at 2 lpm. An observation on 07/18/23 at 09:15 AM, revealed Resident #2 asleep in a geri chair in her room receiving O2 via nasal cannula at 2 lpm. During an interview on 07/18/23 at 09:52 AM, ADON said charge nurses were responsible for setting the O2 concentration levels for residents. She stated they knew what level to set the O2 to because the orders were in the Electronic Health Record. ADON stated a possible negative outcome of not setting O2 concentration as high as ordered by the physician was, They could be confused. When asked why Resident #2 was not receiving O2 at the ordered concentration level, ADON said, I don't know. During an interview on 07/18/23 at 09:54 AM, DON stated a possible negative outcome of not setting O2 concentration as high as ordered by the physician was, Hypoxia. During an interview on 07/18/23 at 10:04 AM, CNA B stated the nurses were responsible for setting the O2 levels. During an interview on 07/18/23 at 10:07 AM, RN D stated the physician decided the concentration for O2. She said the nurses were responsible for setting the O2 levels. She stated she knew what level to set the O2 concentration to by reading the physician's order. RN D said a possible negative outcome of not setting the O2concentration as high as ordered by the physician was, They can suffer from low O2 levels, hypoxemia, confusion, restlessness, and the resident can become ill. Record review of facility policy dated 02/13/07 and titled, Oxygen Administration revealed the following: Oxygen therapy includes the administration of oxygen in liters/minute by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases.The amount of oxygen by percent of concentration of lpm, and the method of administration, is ordered by the physician. The administration, monitoring or responses, and safety precautions associated with it are performed by the nurse.Goals 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.Procedure 1. Become familiar with the type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered. Record review of facility policy dated 2015 and titled, Physician's Orders revealed the following: .Physician's monthly consolidated orders must be reviewed by a licensed nurse to assure they reflect all current orders.

Based on 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 1 (Resident #130) of 17 residents reviewed for infection control. Resident #130 was on transmission-based precautions for C. diff (an infection of the large intestine caused by bacteria, resulting in diarrhea and possible drop in blood pressure) and staff failed to use proper hand hygiene when they exited her room. This failure could place all residents of the facility at risk of contracting C. diff. an infectious disease. Findings include: Record review of Resident #130's face sheet, dated 07/17/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute cystitis without hematuria (infection of the urinary bladder without blood in the urine), infectious gastroenteritis and colitis (irritation and inflammation of stomach and intestines resulting in nausea and diarrhea), type 2 diabetes (insufficient production of insulin, causing high blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #130's baseline care plan, dated 07/08/23, revealed a focus area of resident has C. Difficile. The interventions listed for this focus area included, but were not limited to the following: Contact Isolation . Educate resident/family/staff regarding preventative measures to contain the infection. Record review of Resident #130's active physician's orders revealed an active order dated 07/08/23 that read Res. [Resident] to be placed on Contact precautions due to DX of C-DIFF. An observation on 07/16/23 at 10:07 AM, revealed yelling from behind the closed door of a room. The door had contact precaution signage and a cart with gloves, shoe covers, masks, and gowns next to the door in the hall. The signs on the door listed handwashing and hand sanitizing along with PPE necessary to enter the room. Resident #130 was inside the room lying on her back in bed with the head of the bed slightly elevated. She stated she had a bowel movement and needed someone to come clean her up. During an interview on 07/17/23 at 08:21 AM, Resident #130 stated staff wash their hands in her bathroom before they exit her room. An observation on 07/17/23 at 08:31 AM, revealed CNA B and CNA C donned PPE and entered Resident #130's room. An observation on 07/17/23 at 08:37 AM, revealed CNA B and CNA C exited Resident #130's room and used the ABHR hanging from the hall wall outside the room. During an interview on 07/17/23 at 08:37 AM, CNA C was asked if she washed her hands in the bathroom of Resident #130's room before exiting and using ABHR. CNA C hesitated and looked at CNA B. CNA B was asked the same question and she replied, Are we supposed to? During an interview on 07/18/23 at 09:52 AM, ADON stated the transmission-based precautions for C. diff were contact precautions. She said ABHR does not work on C. diff. She stated a possible negative outcome of not washing hands with soap and water after providing care to a resident with a diagnosis of C. diff was passing C. diff or getting it yourself. When asked how staff were trained on the precautions necessary for C. diff, ADON stated, We do an in-service. When asked how staff were to know Resident #130 had C. diff and what precautions were necessary, ADON stated, We did an in-service prior to her [Resident #130] coming and set up the signs [on Resident #130's door] and gave a report of what to expect. ADON said she was responsible for letting direct care staff know what a resident is on transmission-based precautions for. During an interview on 07/18/23 at 10:04 AM, CNA B stated caring for a resident with C. diff required PPE and washing hands with soap and water. She said ABHR did not work on C. diff. She stated a possible negative outcome of not washing her hands after caring for a resident with C. diff would be spreading it. She stated staff were trained via in-services on the computer regarding what precautions to use with C. diff. CNA B said direct care staff found out what precautions were necessary by reading the signs on the door of a resident who is placed on transmission-based precautions. She said the nurse was responsible for letting direct care staff know what a resident was on precautions for. During an interview on 07/18/23 at 10:07 AM, RN D said precautions for caring for a resident with a diagnosis of C. diff were glove and gown and you can use sanitizer going in [to the resident's room] but you must wash with soap and water and leave your gloves and gown in the room. She stated ABHR did not work on C. diff. She said a possible negative outcome of not washing hands with soap and water after providing care to a resident with a diagnosis of C. diff was you can give it to yourself or any of your residents. She said staff were trained via in-services and handouts. RN D stated, We have handouts at the desk and instructions on the door [of the resident's room]. She stated nurses were responsible for notifying staff of residents on transmission-based precautions. Record review of facility in-service dated 07/07/2023 and titled, Contact Precautions/Hand Hygiene revealed a sign-in sheet containing CNA B and CNA C's signatures. The in-service revealed the following: . You must use soap/water for the following: (alcohol based hand cleaner is not recommended) . After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile . If someone with C. diff (or caring for someone with C. diff) doesn't clean their hands with soap and water .they can spread the germs to people and things they touch. C. diff can also live on people's skin. People who touch infected person's skin can pick up the germs on their hands .Washing with soap and water is the best way to prevent the spread from person to person. When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or sometimes years on surfaces and in the soil. The germs become active again when these spores are swallowed and reach the intestines. Record review of facility policy dated 03/2023 and titled, Definitions revealed the following: .'Contact precautions' are measures that are 'intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment.' .'Hand washing' refers to washing hands with plain (i.e., nonantimicrobial) soap and water. Record review of facility policy dated 03/2023 and titled, Fundamentals of Infection Control Precautions revealed the following: . Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .Before and after assisting a resident with toileting (hand washing with soap and water); After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile (hand washing with soap and water); .

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free from accident hazards as was possible and that each resident received assistance devices to prevent accidents for 1 of 5 Residents (Resident #1), reviewed for accident hazards. CNA A failed to secure the seat belt around Resident #1 when transporting him in the facility's van to a doctor's appointment almost 86 miles away, causing the resident to fall out of his wheelchair when the driver slammed on the brakes to avoid hitting another car that cut her off in a construction zone. This failure resulted in Resident #1 being taken to the hospital where he was treated for an approximately 3 x 5-inch hematoma (blood filled-raised bruise) to his shoulder. It was determined a past non-compliance Immediate Jeopardy (IJ) existed from 10/20/2021 through 10/22/2021. This IJ was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey, 10/28/21. This failure could place residents at risk for accidents that lead to injuries such as bruising, skin tears, fractures, hematomas, and death. Findings include: Record review of Resident #1's face sheet, dated 10/28/2021, revealed that Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hypertensive [CONDITION(S)] with heart failure (heart problems because of high blood pressure), [CONDITION(S)] disease, [CONDITION(S)] (swelling caused by excess fluid), [CONDITION(S)] [CONDITION(S)] (arteries become narrowed and hardened), pain, and long term (current) use of anticoagulants (blood thinners). Record review of Resident #1's care plan, most recently revised on 10/28/21, revealed the following: The resident has had an actual fall. Resident has bruising to right neck and shoulder. Date Initiated: 10/21/2021 Revision on: 10/28/2021 Record review of Resident #1's MDS, dated [DATE], indicated that the resident had a BIMS score of 03 out of 15, indicating severe cognitive impairment. Section G of the MDS indicated that Resident #1 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, locomotion and personal hygiene. Record review of the facility's Provider Investigation Report, concerning the incident with Resident #1 on 10/20/21, signed and dated on 10/23/2021 by ADM documented the following in the Description of the Allegation section: Staff was driving resident to doctors [sic] appointment in [NAME]. She was going through a construction site when suddenly someone cut in front her causing her to hit the brakes abruptly. When the staff came to an abrupt stop the resident fell from his wheelchair onto the floor of the van. The Description of Injury section documented hematoma on the right side of neck/collar bone/shoulder area. The Investigation Summary section documented Admin was notified of incident and immediately suspended perpetrator. Resident was assessed by doctor at diagnostic clinic in [NAME] and advised for EMS to be called. EMS was called and resident was treated at (local hospital) emergency room . (Family Member) was notified and doctor was notified of incident. Staff was taken to sister facility in [NAME] to be drug tested . Drug test was negative. Staff gave statement that stated she was driving through construction when someone cut her off causing her to stop quickly. When she did this the resident fell out of his chair onto the floor. Staff also stated she did not place the seatbelt on resident, only the wheelchair was secured. Transport van was inspected 10/20/21 by the maintenance at sister facility before in use again. Transport van was inspected by maintenance at (the facility) and was inspected by a third-party company on 10/22/21. All inspections showed the van was functioning properly. Resident was released from ER [DATE] with a hematoma to the right shoulder/neck/collar bone area. Resident stated they were driving through [NAME] when someone cut off the driver and she came to a quick stop. Resident stated he flew out of his chair and was not wearing a seatbelt. Safe survey was completed, and no other residents stated there was abuse/neglect. In-service for abuse/neglect was given to staff. In-service was given to all van drivers on the use of wheelchair restraints and seatbelt safety during transport. Off-cycle QA was completed to initiate an action plan for the transportation system. An action plan was put into place where Admin, DON, ADON, or designee will check off all transported residents Monday through friday [sic] x4 weeks to ensure safety. The perpetrator was terminated. Record review of Google Maps revealed the distance between the town the facility was located in and the town where Resident #1 had a doctor's appointment was 86.9 miles. Record review of Resident #1's progress notes revealed a note dated 10/21/2021 at 12:39 PM stating: CNA notified DON that while on transport a called [sic] pulled out in front of her causing her to have to slam on her brakes. At this time resident was thrown from wheelchair. CNA stated she had forgot to buckle in resident with seat belt. Resident was seen by DR at his appointment and an ambulance called to have him transferred to (name of hospital) ER [sic]. During an interview on 10/28/2021 at 8:12 AM, DON reported CNA-A was driving Resident #1 to a doctor's appointment in another town that was approximately 87 miles away, thru a construction zone, when a car, that was speeding, cut in front of the van and CNA A, who was driving the van, slammed on her brakes causing Resident #1 to fall out of his wheelchair. DON said CNA A secured Resident #1's wheelchair in the van but failed to strap him into the wheelchair with the seat belt. DON said CNA A was terminated because she failed to secure Resident #1 in his wheelchair with the seat belt, the van was inspected, and the seat belts were found to be in working order, all staff were in-serviced on Abuse/Neglect, and transportation staff were re-trained on Transportation Safety. During an interview and observation on 10/28/2021 at 9:08 AM, Resident #1 said he was being taken to a doctor's appointment in the facility's van by CNA when another car sped around them and cut them off. He said CNA A slammed on her brakes and he fell out of his wheelchair. He said he was not wearing a seatbelt. He said the CNA A told him she thought she had put it on his but must have forgot. He said he hurt his shoulder and revealed his bruise. It was very large and dark in color, covering the entire top of his shoulder and up to his neck. When asked if he was scared, he said, I didn't have time to be scared. He said he went to the hospital to be treated and came back to the facility the same day. He said he still had pain and the facility gave him Tylenol that helped reduce his pain. An interview was attempted with CNA A at 10:12 AM on 10/28/21 by telephone but she did not answer. A message was left on her voicemail, but she did not return the call. Record review of CNA A's employee file revealed she was hired on 6/28/21. She was trained on the facility's Employee Auto Training Handbook on 9/6/21. She was terminated on 10/20/21. Record review of the facility's Vehicle Inspection Report, dated 10/22/2021 and signed by the Maintenance Supervisor and ADM, revealed the following: Seat Belts clean and in good working condition. Record review of the third-party inspection company's Service Order, dated 10/22/2021 revealed the following: 1.) Service call to customer's location. Notes: Wheelchair securement system assessment needed. 2.) Inspect wheelchair securement system for proper condition and operation. Advise on any failures or missing/damaged components. There were no parts or repairs documented as being needed. Record review of the facility's undated Employee Auto Training Handbook revealed the following in part: Rules 9. All safety devices, including seat belts/restraint devices/wheelchair tie downs, will be used by anyone operating or riding in a vehicle. Record review of in-services revealed an in-service on 10/21/21 for all transportation staff on Transportation Safety to include use of seatbelts and safety straps. In-serviced all staff across different shifts and disciplines on Abuse/Neglect. During an interview on 10/28/2021 at 9:41 am and on 10/28/2021 at 9:55 am, LVN B and LVN C respectively, confirmed they were in-serviced on transportation safety and the use of seatbelts for everyone riding in their van. Record review of the QAPI meeting notes revealed they met on 10/22/21 and implemented a monitoring schedule for the ADM, DON, ADON or designee to check each Resident that is going to be transported in the van for safety belts and securing them appropriately for 4 weeks. They created a logbook to document their observations. They also had the van inspected by an outside agency to confirm it was in working order.