Every finding on record at Mesquite Post Acute Care

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 2 of 5 (Resident #1 and Resident #2) residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC online portal for Resident #1 and Resident #2 within 20 business days after the IDT meeting held for Resident #1 on 04/30/2026 and Resident #2 on 04/09/2026.This failure could place residents who were PASRR positive at risk of not receiving PASRR services, which may enhance quality of life, and could lead to a decline in health. Findings included: Resident #1Record review of Resident #1's face sheet dated 07/30/2026 revealed a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included the following: other cerebral palsy (CP) (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), cognitive communication deficit, degenerative disease of the nervous system (progressive nervous system dysfunction), muscle weakness, and unspecified lack of coordination. Record review of Resident #1's annual MDS assessment, dated 03/20/2026 , revealed in Section C - Cognitive Patterns, Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Record review of the current care plan for Resident #1, undated, revealed the following focus areas: (Resident #1) is at risk for impaired cognitive function or impaired thought processes r/t CEREBRAL PALSY (Resident #1) has ADL Self Care Performance Deficit r/t CP Record review of Resident #1's PCSP dated 04/30/2026 revealed the initial IDT meeting was held on 04/30/2026. Attendees included the LIDDA Habilitation Coordinator, the Social Worker, MDS nurse, Director of Rehabilitation, and Resident #1. The following NFSS were identified and confirmed: B. Customized Manual Wheelchair, C. Durable Medical Equipment (Positioning Wedge), D. Specialized Assessment Occupational Therapy (OT), E. Specialized Assessment Physical Therapy (PT), F. Specialized Assessment Speech Therapy (ST), G. Specialized Occupational Therapy (OT), H. Specialized Physical Therapy (PT), and I. Specialized Speech Therapy (ST). The NFSS also identified a need for Day Habilitation Services and Habitation Coordination Services. Record review of facility's LTC Online Portal communication for Resident #1 as of 07/30/2026 indicated the NSFF for Resident #1 was submitted on 07/09/2026 at 05:04 PM. Resident #2Record review of Resident #2's face sheet dated 07/30/2026 revealed a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included the following: other cerebral palsy (CP) (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), cognitive communication deficit, reduced mobility, lack of coordination, paraplegia (form of paralysis), and difficulty walking. Record review of Resident #2's annual MDS assessment, dated 03/20/2026 , revealed in Section C - Cognitive Patterns, Resident #2 had a BIMS score of 14, which indicated slight cognitive impairment. Record review of the current care plan for Resident #2, undated, revealed the following focus areas: (Resident #2) has a diagnosis of Cerebral Palsy (Resident #2) has an ADL Self Care Performance Deficit r/t diagnosis of Cerebral Palsy, muscle weakness. Record review of Resident #2's PCSP dated 04/09/2026 revealed the quarterly IDT meeting was held on 04/09/2026. Attendees included the PASRR Habilitation Coordinator, the Social Worker, Director of Rehabilitation, MDS nurse, the Dietary Manager, and Resident #2. The following NFSS were identified and confirmed: B. Customized Manual Wheelchair, C. Durable Medical Equipment (unspecified), D. Specialized Assessment Occupational Therapy (OT), E. Specialized Assessment Physical Therapy (PT), F. Specialized Assessment Speech Therapy (ST), G. Specialized Occupational Therapy (OT), H. Specialized Physical Therapy (PT), and I. Specialized Speech Therapy (ST). The NFSS also identified a need for Habitation Coordination Services. Record review of facility's LTC Online Portal communication for Resident #2 as of 07/30/2026 indicated the NSFF for Resident #2 was submitted on 07/10/2026 at 07:42 AM. During an observation and attempted interview on 07/30/2026 at 4:20 PM Resident #1 was observed in his room, sitting in his wheelchair. An attempted interview was conducted and Resident #1 was unable to answer any questions in reference to his IDT meeting. Resident #1 was able to indicate that his wheelchair was currently working, but it was older and he did not know how long he had it. An observation of the wheelchair indicated the arms of the chair had signs of aging and wear with cracks in the plastic covering around the arms of the chair. During an attempted interview on 07/30/2026 at 11:15 AM, 1:30 PM, 3:15 PM. And 4:30 PM, Resident #2 was unavailable for interview. During an interview on 07/30/2026 at 2:30 PM the MDS nurse stated she was new to the position and was not the acting MDS nurse when the referenced IDT meetings were held for Resident #1 or Resident #2. The MDS nurse stated she started as MDS nurse in the middle of June, but she was in training for the first couple of weeks. The MDS nurse stated she had not completed an NFSS since she has been the MDS nurse, and she was not familiar of the process or timeframes. The MDS nurse stated she did review the NFSS in the LTC portal for Resident #1 and Resident #2 on this date, 07/30/2026, and the NFSS for Resident #1 and Resident #2 were not submitted within 20 business days from the IDT meetings. The MDS nurse stated she did not know why the NFSS was not submitted timely. The MDS nurse stated she did not know if there was a system in place to ensure the NFSS was completed timely, as the position was new to her. The MDS nurse stated she did not know who was responsible for submitting and monitoring the NFSS, but she stated she would follow up to find out. The MDS nurse stated she had received training on PASRR, but she planned to do additional training to re-educate herself on the process. The MDS nurse stated if a NFSS was not submitted timely it could cause a delay in services for a resident. The MDS nurse stated she did verify that Resident #1's and Resident #2's NFSS had since been submitted. During an interview on 07/30/2026 at 3:00 PM the DOR stated she was promoted to DOR the previous week. The DOR stated she had never completed an NFSS form, and she was not familiar with the process. The DOR stated she was not the facility's DOR when Resident #1 and Resident #2 had their IDT meetings in April 2026. During an interview on 07/30/2026 at 3:20 PM the ADM stated the facility had a new MDS nurse and a new DOR. The ADM stated she was not aware Resident #1's and Resident #2's NFSS were submitted late. The ADM stated the DOR was responsible for submitting the NFSS and the MDS nurse was responsible for monitoring the NFSS after submission to ensure it was accepted. The ADM stated the NFSS for Resident #1 and Resident #2 may have been delayed due to the change in staffing for the MDS nurse and DOR. The ADM stated it was her expectation that all residents' NFSS were submitted timely. The ADM stated they would work on obtaining a system to monitor this more closely and ensure the MDS nurse and DOR were educated on the process. The ADM stated if a resident's NFSS was not submitted timely it could cause a delay in PASRR services for the resident. Record review of the facility's policy titled, Resident Assessment: PASRR , undated, reflected the following: POLICY:It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. PURPOSE:This facility shall not admit on or after January 1, 1989, any new residents with:Mental illness ad defined in paragraph (m)(2)(i), 42 CFR 483.20 of the SOM unless the State mental health authority has determined , based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation. Mental retardation, as defined in paragraph (m)(2)(ii), 42 CFR 483.20 of the SOM unless the State mental retardation or developmental disability authority has determined prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation. PROCEDURES:A PASRR shall be completed on every resident upon admission. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 3 of 3 medication carts (Hall 200 Nurse Medication Cart, Hall 200 Medication Aide Cart, and Hall 300 Medication Aide Cart) reviewed for medication storage. The facility failed to ensure the Hall 200 Nurse Medication Cart was secured when unattended. The facility failed to ensure the Hall 200 Medication Aide Cart did not contain loose pills. 3. The facility failed to ensure the Hall 300 Medication Aide Cart was secured when unattended and did not contain loose pills. These failures could place residents at risk of not receiving prescribed medications as ordered, having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.1. During an observation and interview on 05/19/26 at 11:44 AM the Hall 200 Nurse Medication Cart was observed in hallway 200 with the lock popped out without a staff member present. Two maintenance staff were observed approximately 5 feet away from the medication cart working on a door in the hallway. LVN D came out of a resident room and approached the medication cart as the surveyor stood next to it. LVN D stated she was the charge nurse and was assigned to the Hall 200 Nurse Medication Cart. The surveyor pulled on all the drawers and all the drawers opened. The drawer that contained the narcotic medications opened however the lock box was secure. Various pill blister packs and bottles of medications and medical supplies such as syringes were observed in the drawers of the medication cart that opened. LVN D stated she was in the process of passing out medications to residents and she had been dealing with a resident that was confused and wanted pain medications, and she tried to help the resident figure it out. LVN D stated the policy for medication carts was that they were supposed to be locked when left unattended. She stated she was unaware she had not locked the medication cart and should have locked the cart. She stated she was responsible for all medications on that cart, and she was responsible for ensuring the cart was locked when unattended. LVN D stated there was no system she was aware of to ensure medication carts were locked. She stated she had been in-serviced and trained in medication administration and to ensure the carts were locked. She stated a potential negative outcome was that someone could have taken the insulin, or someone could have taken pills in the cart and crushed them up and then used the syringes to shoot the meds into their body, or someone could have used the syringes as a weapon. 2. During an observation and interview on 05/20/26 at 9:35 AM, the Hall 200 Medication Aide Cart was observed with LVN A. Six loose pills were found in the drawers of the medication cart. LVN A placed the pills in a dispensing cup and gave them to the DON for identification. The DON identified the medication as Sertraline 100 mg (2 tablets), Atorvastatin 20 mg (2 tablets), Potassium Chloride 10 mEq (1 tablet), and Cyclobenzaprine 10 mg (1 tablet). The DON took the identified medications to be destroyed. LVN A stated the medication cart should not contain loose pills. She stated she was responsible for the cart while she was on duty and had possession of the keys to the cart. LVN A stated she tried to check the cart at least weekly for loose or expired medications. She stated she had been too busy to check the cart that morning because she was trying to help the new medication aide pass medications. She stated she had been trained on proper medication storage in her nursing education. LVN A stated the medication carts were audited by the pharmacy consultant and checked randomly by nursing administration for secure storage and cleanliness. She stated a potential negative outcome for loose medication on the cart was that a resident could miss a dose of medication. 3. During an observation and interview on 05/20/26 at 10:06 AM, the Hall 300 Medication Aide Cart was observed in hallway 300 with the lock popped out unattended and without a staff member present. A resident was observed propelling herself in a wheelchair near the unlocked medication cart. The surveyor was able to access all drawers on the medication cart. The controlled medications drawer was able to be accessed however the lock box was secure. Blister packs of medication, liquid medication and OTC medications were observed on the cart that was opened. MA B was observed coming out of a resident room and approaching the medication cart as the surveyor stood next to it. MA B stated she was responsible for the Hall 300 Nurse Medication Aide Cart. MA B stated she was a new MA and also newly hired at the facility. She stated she had been oriented to the medication cart during her training with a facility staff member and stated the medication cart should be locked at all times when she was not supervising the cart. MA B stated a potential negative outcome for leaving the cart unlocked and unattended was that a resident could access the cart and take medication that could cause them harm. During an observation and interview on 05/20/26 at 10:18 AM, the Hall 300 Medication Aide Cart was observed with MA B. Nine loose pills were found in the drawers of the medication cart. MA B placed the pills in a dispensing cup and gave them to the ADON for identification. The ADON identified the medication as Metoprolol 25mg (2 tablets), Atorvastatin 20 mg (1 tablet), Tizanidine 2 mg (2 tablets), Carvedilol 25 mg (1 tablet), Pantoprazole 40 mg (1 tablet), Gabapentin 100 mg (1tablet), and Levetiracetam 750 mg (1 tablet). The ADON took the identified medications to be destroyed. MA B stated she was responsible for the Hall 300 Medication Cart. She stated the medication cart should not contain loose medications. MA B stated she typically checked the cart for loose or expired medications in the morning when she came on duty but did not have a chance to check it before beginning medication pass. She stated she had been trained in her MA training to keep medications securely stored. She stated she had also been trained on proper medication cart storage during her facility orientation. MA B stated a potential negative outcome for loose medication on the cart was missed medication doses or medication shortages. During an interview on 05/21/26 at 11:30 AM, the DON stated the policy was that medication carts should be locked anytime staff stepped away from them. She stated she was aware yesterday that staff left medication carts unlocked while unattended. She stated one of the staff was new and was in the process of learning. The DON stated she did rounds and stood by medication carts to prompt staff and ensure they remembered to lock them. She stated she had also educated staff on how important it was to ensure they were locked. The DON stated all new staff were trained for a minimum of 3 days in medication administration. She stated the first day the new staff shadowed nursing staff to observe and learn the routine. On the second day, they helped take vitals and passed medications. She stated that on the third day, the new staff completed the medication administration process and was shadowed by a staff for training purposes. She stated they answered any additional questions and determined if the staff member was ready or if more training was needed. The DON stated staff were also in-serviced on medication administration periodically by herself or the ADON. The DON stated the staff that passed the medications was responsible for ensuring the medication cart was locked but it was also everyone's responsibility to ensure medication carts were locked. The DON stated she expected staff to lock medication carts when unattended. She stated a potential negative outcome was that medications could be removed by an unauthorized person or a resident could be harmed by obtaining medications from the unlocked medication cart. During an interview on 05/21/26 at 12:02 PM, the ADM stated she was not aware there were loose medications on the medication carts. She stated the staff member who was assigned to the medication cart was responsible for assuring medication was stored securely. The ADM stated the system for monitoring proper storage of medications was cart checks conducted by nursing administration and monthly audits conducted by the pharmacy consultant. She stated her expectation of staff for storage of medications was that medications were securely stored for each resident. The ADM stated a potential negative outcome for loose medications on the cart was that a resident could miss a dose or receive a medication that was not theirs. During a follow-up interview on 05/21/26 at 12:58 PM, the DON stated she was not aware there were loose medications on the medication carts. She stated medications should be stored securely at all times. The DON stated the staff member who was assigned to the medication cart was responsible for assuring medications were stored securely by checking the cart for loose medications. She stated staff were trained to check the medication carts regularly for loose or expired medications and cleanliness. She stated carts were monitored by random audits conducted by nursing administration and by the pharmacy consultant during monthly onsite visits. The DON stated a potential negative outcome for loose pills on the medication carts was drug diversions and residents missing doses of ordered medications. During a follow-up interview on 05/21/26 at 1:10 PM, the ADM stated all medication carts must be locked when unattended. The ADM stated she was not aware staff left medication carts unlocked when unattended. She stated the system in place to ensure unattended medication carts were locked was that nursing leadership did rounds and spot-checked medication carts to ensure they were locked. The ADM stated Nursing leadership (the DON and the ADON) in-serviced staff to ensure medication carts were locked when unattended. The ADM stated she expected staff to lock medication carts when unattended. The ADM stated a potential negative outcome was that anyone, including residents, could get in there and take something that may not have been safe for them. Record review of the facility-provided policy titled, Policy/Procedure - Nursing Clinical, revised 05/2007, reflected: Section: Care and Treatment Subject: Medication Access and Storage Policy: It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedures: 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers.2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on interview and record review the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 7 of 23 confidential residents reviewed . The facility failed to provide sufficient staffing to prevent long wait times to answer call lights. This failure could place residents at risk of injury, pain, hospitalization, skin breakdown, poor self-worth, and a diminished quality of life.Findings include: During a confidential interview at an undisclosed date and time with a confidential resident in their room, they stated it often took 30 to 45 minutes for staff to answer their call light. They stated they were in the process of recovering from an injury and needed assistance from staff getting out of bed and into their wheelchair to do other things such as getting dressed or to use the restroom. They stated it was frustrating and they felt the wait was far too long. They stated it happened during all shifts. They stated they had complained to staff about the wait time. During a confidential interview at an undisclosed date and time with a confidential resident in their room, they stated it often took around 30 minutes for staff to answer their call light. They stated they felt it was too long, especially if they had an emergency. They stated it happened during all shifts. During a confidential interview at an undisclosed date and time with a confidential resident in their room, they stated it often took around 45 minutes for staff to answer their call light. They stated they felt it was too long, especially if they had an emergency. They stated sometimes they would get up and walk to the nurses' station to find a nurse and get the assistance they needed because they waited over 30 minutes. They stated it happened during all shifts. They stated they felt something needed to be done about it. During a confidential interview at an undisclosed date and time with a confidential resident in their room, they stated they often waited 45 minutes to 1 hour for staff to answer their call light. They stated the CNAs pass by their room and said they had to wait until a staff member could get to them. They stated they felt it was too long to wait as they needed help getting out of bed and dressing. They stated they had complained to staff about it but felt nothing had changed. They stated there had not been a regularly scheduled aide in their hall for 3 or 4 months. During a confidential interview at an undisclosed date and time with the resident council , four confidential residents stated they often waited 30 to 45 minutes for staff to respond to call lights. A confidential resident stated they were afraid their roommate would get out of bed and fall due to the excessive call light response time. A second confidential resident stated staff told them to be patient when they complained about call light response times. A third confidential resident stated a staff member who was covering the other side of their hall responded to her call light and said they would tell the nurse that covered their side of the hall that they needed assistance rather than that staff member just helping them. The third confidential resident also stated they had to walk to the nurses' station for help because their call light had been on for 45 minutes without response, and they felt sick and wanted to go to the hospital. Confidential Residents stated there had been ongoing complaints about call light response. Confidential Residents stated the call light issues caused them to feel like poop, irritated, aggravated, and unhappy. The Confidential Residents stated they felt the facility was often short-staffed. Record review of Resident Council Meeting notes, dated 11/13/25, revealed in part: Open Floor for Resident's Concerns: Nursing Concerns: call lights. Record review of Resident Council Meeting notes, dated 12/30/25, revealed in part: Open Floor for Resident's Concerns: Nursing Concerns: answering lights in a timely manner. Record review of Resident Council Meeting notes, dated 1/7/26, revealed in part: Open Floor for Resident's Concerns: Nursing Concerns: call lights timely. Record review of Resident Council Meeting notes, dated 2/13/26, revealed in part: Close remarks: night CNA answering call lights. Record review of Resident Council Meeting notes, dated 4/13/26, revealed in part: Nursing Department information: not answering the call light; they are turning off call lights and leaving and not addressing issues. During an interview on 05/19/26 at 11:44 AM LVN D stated she was the charge nurse for Hall 200. She stated she needed more staff as she had no nursing assistants to help her with nursing duties. LVN D stated the other 2 halls had two aides assigned. LVN D stated it was not possible for her to document residents' vital results in the EMAR as she took them because she was busy answering call lights, changing briefs, linens, answering the phone, and had no help. She stated in the mornings she had to check food trays before they were passed to residents. LVN D stated this all prevented her from being able to answer call lights timely. LVN D stated residents had complained to her about waiting a long time for their call light to be answered. LVN D stated she tried to answer call lights timely for residents that could not wait. She stated staff from other halls finished all duties on their halls before they came to help her. LVN D stated she was not aware of a system the facility had to ensure call lights were answered timely. She stated she was trained to answer call lights as soon as they went off. LVN D stated she was responsible for ensuring call lights were answered timely. LVN D stated a potential negative outcome was that a resident's blood pressure could bottom out while waiting for their call light to be answered. During an interview on 5/20/26 at 2:30 PM, CNA E stated she was the only CNA on Hall 200, and it was hard for her to answer call lights timely. CNA E stated there was a staff that floated to all three halls to help but they were not always available to help. She stated sometimes, it took her a while to take care of the residents before she could get to another call light that was going off. She stated it could take her up to 20 minutes to respond to a call light when she was showering another resident. CNA E stated she felt 20 minutes was too long for residents to wait. CNA E stated residents had complained to her that it took too long for staff to answer their call lights and she told management, but she was told this was the easiest hall and that this hall did not need more than one CNA assigned to it. She stated she did everything for residents in her hall and sometimes she forgot to get back to the residents. She stated she was trained that call lights were supposed to be answered as soon as they went on, and she was told to leave the call lights on until she got to them so they would not be forgotten. CNA E stated she was trained that everyone was responsible to answer call lights timely, but that was not always the case. She stated a potential negative outcome was that a resident could fall or not be breathing, residents may not be able to get help to go to the restroom or not be changed timely and they could get a yeast infection, urinary tract infection (a bacterial infection in the kidneys, bladder, ureters, and urethra), or something else that was harmful to them. During an interview on 5/21/26 at 11:30 AM, the DON stated there was no policy for staffing or call light response. The DON stated she was aware there were ongoing complaints about call light response times in the monthly Resident Council meetings and she had addressed it and in-serviced staff on call lights. She stated she was aware that most complaints were regarding the night shift. The DON stated call lights should have been answered as quickly as possible, but it could vary based on residents' needs. The DON stated staff were trained to fix problems at the time they walk in the room, if possible. The DON stated 30 minutes to wait for a call light to be answered was not timely. The DON stated 10 minutes to wait for a call light to be answered was about the time limit of where she would be concerned. The DON stated everyone in the building could answer call lights of which included but not limited to all nursing staff, dietary, and housekeeping were all responsible for answering call lights. She stated non-nursing staff could at least ask residents what they needed and find someone if they could not resolve the issue themselves. The DON stated she expected all staff to respond to call lights. The DON stated sometimes they scheduled and assigned aides to cover one and a half halls, or they had one aide in each hall and an aide that floated to help all the halls. The DON stated a potential negative outcome was skin breakdown for residents that needed to be changed and falls because residents could try to do it themselves and then fall. During an interview on 5/21/26 at 1:10 PM, the ADM stated there was no written policy on call light response. The ADM stated she was aware that in general there had been complaints of call light responses, but it was a while back. The ADM stated there had not been complaints recently that she was aware of. The ADM stated she was not aware concerns of call lights were discussed in resident council meetings monthly. The ADM stated she wanted staff to respond to call lights as soon as possible. The ADM stated she was not aware residents were waiting 30 minutes to 1 hour for call lights to be answered. The ADM stated she felt 30 minutes was too long to wait for a call light response. The ADM stated nursing leadership completed spot checks in the facility to ensure call lights were answered timely. The ADM stated that expectation was that anyone could answer the call lights, and that all staff should be helping answer call lights. The ADM stated nursing leadership had all staff meetings where they discussed answering call lights. The ADM stated she expected anyone who saw a call light activated to answer it. The ADM stated a potential negative outcome was it could affect the safety of the residents if they needed something urgently and could not get help timely.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 15.38% based on 4 out of 26 opportunities, which involved 4 of 5 Residents (Residents #12, # 20, #24 and #31) reviewed for medication administration. 1. LVN A failed to give Resident #20's dose of the medication Escitalopram at the ordered time, due to not having the medication available, resulting in a late dose. 2. LVN A failed to give Resident #31's doses of the medications Oxybutynin and Hydrochlorothiazide at the ordered time, due to not having the medication available, resulting in a late dose of each medication. 3. LVN A failed to give Resident #12's dose of the medication Citalopram at the ordered time, due to not having the medication available, resulting in a late dose. 4. LVN A failed to verify the dosage of the medication Clozapine prior to administering the medication to Resident #24, resulting in Resident #24 being underdosed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.1. Record review of Resident #20's face sheet dated 05/21/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: frontotemporal neurocognitive disorder (a progressive, irreversible brain disease), major depressive disorder (a mood disorder causing feelings of sadness and loss of interest in activities), and hypertension (high blood pressure). Record review of Resident #20's physician orders dated 05/21/26 reflected an order for Escitalopram Oxalate Oral Tablet 20 mg. Give 1 tablet my mouth one time a day related to Major Depressive Disorder with a start date of 04/29/26. Record review of Resident #20's MAR, dated 5/1/2026-5/31/2026, reflected the medication Escitalopram Oxalate Oral Tablet 20 mg was to be administered at 0600 (6:00 AM). During a medication administration observation and interview on 05/21/26 at 8:34 AM, for Resident #20, LVN A was unable to give the medication Escitalopram Oxalate Oral Tablet 20 mg due to the medication being unavailable on the medication cart or in the emergency kit in the medication storage room. LVN A stated the medication should be available for dispensing and had been ordered but must not have been delivered yet by the pharmacy. LVN A wrote the medication down and stated she would check with the pharmacy once she completed her medication pass. 2. Record review of Resident #31's face sheet dated 05/21/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: multiple sclerosis (a chronic autoimmune disease of the central nervous system), dementia (a progressive decline in mental abilities), and hypertension (high blood pressure). Record review of Resident #31's physician orders dated 05/21/26 reflected an order for Hydrochlorothiazide oral tablet 25 mg. Give 1 tablet by mouth one time a day for fluid related to hypertension with a start date of 04/20/26. Further review reflected an order for Oxybutynin Chloride oral tablet 5 mg. Give 1 tablet one time a day for bladder spasm with a start date of 04/20/26. Record review of Resident #31's MAR, dated 5/1/2026-5/31/2026, reflected the medications Hydrochlorothiazide oral tablet 25 mg and Oxybutynin Chloride oral tablet 5 mg were to be administered at 0600 (6:00 AM). During a medication administration observation and interview on 05/21/26 at 9:10 AM, LVN A was unable to give Resident #31 the medications Hydrochlorothiazide oral tablet 25 mg and Oxybutynin Chloride oral tablet 5 mg due to the medications being unavailable on the medication cart or in the emergency kit in the medication storage room. LVN A stated the medications should be available for dispensing and added the medications to her list to check on following medication pass. 3. Record review of Resident #12's face sheet dated 05/21/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease (a progressive, irreversible brain disorder), dementia (a progressive decline in mental abilities), and Type II Diabetes Mellitus (a chronic metabolic disease characterized by high blood sugar). Record review of Resident #12's physician orders dated 05/21/26 reflected an order for Citalopram Hydrobromide oral tablet 10 mg. Give 2 tablets by mouth one time a day for depression with a start date of 04/16/26. Record review of Resident #12's MAR, dated 5/1/2026-5/31/2026, reflected the medication Citalopram Hydrobromide Oral Tablet 10 mg. Give 2 tablets to equal 20 mg was to be administered at 0600 (6:00 AM). During a medication administration observation and interview on 05/21/26 at 9:19 AM, LVN A was unable to give Resident #12 the medication Citalopram Hydrobromide 10 mg (2 tablets to equal 20 mg) due to the medication being unavailable on the medication cart or in the emergency kit in the medication storage room. LVN A stated the medication should be available for dispensing and added the medication to her list to check on following medication pass. 4. Record review of Resident #24's face sheet dated 05/21/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: paranoid schizophrenia (a complex mental health condition), Type II Diabetes Mellitus (a chronic metabolic disease characterized by high blood sugar), major depressive disorder (a mood disorder causing feelings of sadness and loss of interest in activities). Record review of Resident #24's physician orders dated 05/21/26 reflected an order for Clozapine oral tablet 100 mg. Give 1 tablet by mouth two times a day related to paranoid schizophrenia. Give 100 mg with a start date of 03/17/26. During a medication administration observation on 05/21/26 at 9:29 AM, LVN A was observed dispensing one half tablet of 100 mg of Clozapine to Resident #24. The total dosage administered at this time was 50 mg of Clozapine. During an interview on 05/21/26 at 11:34 AM, LVN A stated it was the responsibility of the MAs to order and replenish the medications on the medication carts. She stated the MAs did routine inventory of the medication carts and faxed orders to the dispensing pharmacy. She stated the LVNs would receive a list from the MAs of medications that had been ordered but had not been delivered and the LVNs would then follow up on those medications with the pharmacy. LVN A stated the facility had recently hired new MAs who were not as familiar with the ordering process or which medications needed to be ordered as a priority before running out. LVN A stated she had been trying to assist the new MAs with the ordering process but some of the medications were not ordered in time to replenish the cart before running out of the medication. LVN A stated the facility utilized a liberalized medication pass meaning there was a window for medications to be given without being considered late. She stated the window for the morning medication pass was until 10:00 AM and there was a one-hour grace period meaning the medications could be given as late as 11:00 AM, unless the order stated a specific time for administration. LVN A stated she had ordered the medications that were not available for Residents #20, #31 and #12 after she completed her morning medication pass, but the medication would not be delivered in time to be given during the administration window. She stated any medication that was not administered during the administration window was considered late. LVN A stated late medications required calling the provider to notify of a late medication and verify the provider wanted staff to administer the medication late. She stated a late medication administration also had to be documented in the nursing progress note and passed on in report to the oncoming shift. LVN A stated a potential negative outcome for missed or late doses of medication due to the medication not being available in the facility would be residents could have increased behaviors, increased or uncontrolled pain, or uncontrolled blood pressure. LVN A stated she gave the wrong dose of Clozapine to Resident #24 after verifying with the surveyor that the blister pack of medication contained pills that were cut in half. She stated she read the order wrong and should have dispensed 2 (half tablets) of Clozapine to Resident #24 in order to give the full dose of Clozapine 100 mg as ordered. LVN A stated she had only given 50 mg of Clozapine by administering 1 (half tablet) of medication. She stated she had been trained to verify the order, then check the medication dosage prior to giving the medication in order to ensure accuracy. LVN A stated a potential negative outcome for failure to administer medications as ordered was the resident would be underdosed and could have side effects from not receiving the right amount of medication. During an interview on 05/21/26 at 12:02 PM, the ADM stated she was not aware medications had not been ordered timely, resulting in residents' having medications administered late. She stated she did not know why medications had not been ordered timely, but it was an opportunity to find out why. The ADM stated all nurses were trained on accurate medication administration through in-servicing and competency checks with nursing administration and the pharmacy consultant. She stated the DON was responsible for assuring medications were available and were administered accurately. She stated her expectation of staff was to have medications available in the facility and to follow orders accurately for medication administration. During an interview on 05/21/26 at 12:58 PM, the DON stated all nurses and MAs were trained on accurate medication administration. She stated she was responsible for ensuring medications were available and administered accurately. The DON stated staff were trained on accurate medication administration and monitored through skills checks conducted annually by a DON from another facility, and by competency checks conducted by the regional nurse or pharmacy consultant. She stated she was not aware medications were not being ordered timely, but she felt it was due to having new MA's in the facility and the communication system was not worked out yet. The DON stated her expectation of staff was to have medications available and to administer medications accurately by following physician's orders. She stated a potential negative outcome for inaccurate medication administration was it could kill somebody or injure a resident by giving the wrong dosage or omitting a medication. Record review of the facility-provided policy titled Medication Administration General Guidelines, dated 2007 reflected: PolicyMedications are administered as prescribed in accordance with the manufacturers' specifications. ProceduresMedication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 9. Verify medication is correct three (3) times before administering the medication. a. When pulling the medication package from the med cart b. When dose is prepared c. When dose is administered .

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 2 (Breakfast) meal reviewed for food and nutrition services. The facility failed to provide food that was palatable for the breakfast meal on 05/20/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 3 of 8 residents voiced concerns related to food palatability. One resident stated the food was cold and lacked flavor. One resident stated the food was lousy and not good. One resident stated the food was not good, lacked seasoning and the tortillas were served raw. During the resident council meeting on 05/20/26 at 10:00 AM, one resident stated that the oatmeal served in the morning was hard and under cooked. Observation on 05/20/26 at 7:42 AM the test trays arrived and were sampled by one surveyor at 7:43 AM with the following results: Regular TextureScrambled eggs - okaySausage - cold/lukewarmBacon - okayFrench Toast Sticks - okayOatmeal - dry/thick, some pieces were hard Mechanical Soft TextureSausage and gravy - lukewarm PureeEggs - okaySausage with gravy - cold/lukewarm, soup like consistencyCream of Wheat - cold/lukewarm During an interview on 05/20/26 at 7:58 AM, the ADM stated she thought the oatmeal was thick and stated the consistency for the puree sausage and gravy was not correct. During an interview on 05/21/26 at 11:00 AM, the DM stated she has not been the dietary manager for long at the facility and she tries to attend the resident council meetings to see what the residents were saying about the food. The DM stated she has tasted the food before it was served but she does not taste it regularly. The DM stated the residents have complained to her before about the oatmeal and the cream of wheat being too thick. The DM stated she thinks it was because the oatmeal sits for a little bit after being prepared and before serving. The DM stated she thought the oatmeal would thicken during that time. The DM stated she would love to add butter, salt, pepper and other seasonings to the food but she has had complaints before about her food being overly seasoned. The DM stated it was hard to please everyone at the facility. The DM stated a potential negative outcome to the residents was they may not eat or get fed if they did not like how it tasted. During an interview on 05/21/26 at 12:46 PM, the ADM stated she expected the food to taste acceptable and pleasing to the residents. The ADM stated she has not tasted the food with the DM being in place. The ADM stated the DM was trained on palatability of the food. The ADM stated a potential negative outcome to the residents was weight loss. Record review of the facility document titled Resident Council Notes, dated 04/13/26 revealed the following: Soups are cold and sometimes bland. Record review of the facility policy titled, General Food Preparation and Handling, undated, reflected the following: Policy: Food items will be prepared to conserved maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances.

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 dietary services. The facility failed to ensure foods were properly stored in the refrigerator, freezer and pantry.The facility failed to ensure the oven doors, refrigerator handles and microwave were properly cleaned. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 05/19/26 beginning at 9:40 AM the following items were observed:- 5 Dirty refrigerator handles. A dry hard/sticky substance was on inside of handles.- 1 block of a white hard food with no label and no date, wrapped in a plastic wrap in the refrigerator.- 1 small circular block of unknown white/grey food. No label and no date on plastic wrap in the refrigerator.- 1 box/bag of bacon with no date and not properly sealed in the refrigerator. The edges of the bacon appeared hard.- 1 bag of white shredded cheese not properly sealed in the refrigerator, dated 5/11/26 and use by 5/13/26.- 5 blocks of yellow cheese, dated 5/18/26 and no other label in the refrigerator.- 1 bag of French fries in the freezer not properly sealed and undated. - 2 Dirty oven handles. The handles had grease spots and were oily to the touch. - 1 box of spaghetti noodles not properly sealed and undated in the pantry.- 1 bag of cornflakes not properly sealed and undated in the pantry. - 1 gallon soy sauce on top shelf in the pantry with no lid, not properly sealed and no date on the bottle. - 1 Dirty microwave handle and inside top of the microwave. Dry food was noted on the handle and on the inside top of the microwave. During an interview on 05/19/26 at 9:58 AM, the DM stated she did not know why some of the foods were not stored properly in the kitchen. The DM stated she did not know why the refrigerator or oven handles were dirty and stated probably from cooking breakfast. The DM stated she did not know why the microwave handles or inside top was dirty. During a return visit to the kitchen on 05/20/26 at 10:40 AM, 1 box of quick cream of wheat, dated 05/12/26, was not properly sealed on a shelf in the kitchen by the refrigerators. During an interview on 05/21/26 at 11:00 AM, the DM stated all of the food stored in the kitchen should be labeled with an open and use by date and should be fully sealed. The DM stated the kitchen staff were trained on food storage and cleanliness, so she did not know why food items in the refrigerator, freezer and pantry were not labeled or sealed properly. The DM stated the evening shift handled more of the clean duties for the kitchen. The DM stated she did not know why the evening shift from 05/18/26 did not clean the kitchen properly. The DM stated the morning shift staff were responsible for sealing and labeling the food properly. The DM stated she did not know when the kitchen staff was last trained on storing and labeling the food and kitchen cleanliness. The DM stated a potential negative outcome to the residents was they could get sick. During an interview on 05/21/26 at 12:46 PM, the ADM stated she expected the food to be labeled and stored properly in the kitchen. The ADM stated the food should be properly sealed so no air could get in when it was stored. The ADM stated the kitchen staff were trained to follow a regular cleaning and deep cleaning schedule due to cleanliness and sanitation being a priority in the kitchen. The ADM stated she did not know why food was not stored properly or some of the kitchen equipment was not cleaned. The ADM stated a potential negative outcome for the residents was a potential for spoiled food if it was not stored properly and they could get sick. Record review of the facility policy titled, General Food Preparation and Handling, undated, reflected the following: Policy: Food items will be prepared to conserved maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances.Procedure:1. The kitchen will be kept neat and orderly.a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. 2. Food Storagea. Foods will be received, checked and stored properly.

Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals (breakfast and lunch) observed for puree texture. The facility failed to provide pureed food in proper form for the breakfast and lunch meals observed on 05/20/26. This failure could place residents at risk of decreased food intake, choking and aspiration. The findings included: During an observation on 05/20/26 at 7:40 AM, the DM prepared puree eggs, cream of wheat and puree's sausage with gravy and provided a sample tray to the surveyor. The surveyor tasted the puree sausage with gravy, and it had small chunks of meat and was in a soup like form, meaning the sausage and gravy did not hold any shape. During an interview on 05/20/26 at 7:58 AM, the ADM stated she agreed that the sausage and gravy was not the correct consistency for the puree form. During an observation on 05/20/26 at 12:00 PM, the DM prepared puree chicken, mashed potatoes, bread and mixed vegetables and provided a sample tray to the surveyors. The surveyors tasted the puree mixed vegetables, and it had small chunks in it and was in a soup like form, meaning the mixed vegetables did not hold any shape. During an interview on 05/20/26 at 12:10 PM, the ADM stated she agreed that the mixed vegetables were not the correct consistency for the puree form. During an interview on 05/21/26 at 11:00 AM the DM stated she had been trained on puree form and to mix it good so there are no chunks of food. The DM stated the puree food should be a smooth consistency and be able to hold form. The DM stated she had a hard time getting the sausage and gravy and the mixed vegetables to hold form. The DM stated a potential negative outcome to the residents was they could choke on it. During an interview on 05/21/26 at 12:46 PM the ADM stated she expected the puree foods to be a safe and proper consistency every times it was sent out to the residents. The ADM stated the puree food should be smooth and be able to hold form. The ADM stated the DM had been trained on food consistency, but it was unknown when. The ADM stated she did not know why the puree foods were sent out when not in proper form. The ADM stated a potential negative outcome to the residents was a choking hazard. Record review of the facility's policy and procedure titled, Texture and consistency-Modified Diets, undated, reflected the following: Policy: Texture and consistency-modified diets will be individualized with modifications made by the speech-language pathologist and physician in conjunction with the registered dietician nutritionist or designee and director of food and nutrition services.Procedure: .5. The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 17 Residents (Resident #54) and 1 of 2 Shower rooms (Shower Room A) reviewed. The facility failed to store Resident #54's portable oxygen tank properly when not in use. The facility failed to ensure Lemon disinfectant spray bottle was not stored properly in Shower Room A. These failures could place residents at risk for poisoning or chemical burns and avoidable injuries related to improperly storing a portable oxygen tank. The findings included: Record review of Resident #54's face sheet, dated 05/21/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Wernicke's encephalopathy (brain damage) reduced mobility and chronic obstructive pulmonary disease (lung disease). Record review of Resident #54's quarterly MDS assessment, dated 03/26/26, revealed a BIMS score of 03, indicating Resident #54's cognition was severely impaired. Record review of Resident #54's order summary report, dated 05/21/26, revealed an order: Oxygen 2-4 LPM via nasal cannula to keep SpO2 greater than 90% as needed related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE with a start date of 08/07/25. During an initial tour observation on 05/19/26 at 10:35 AM in Resident #54's room revealed 1 portable oxygen tank free-standing and sitting up on a long dresser. Attempted interview on 05/19/26 at 10:37 AM with Resident #54 revealed he was not interview-able. During an observation on 05/20/26 at 7:39 AM in Resident #54's room revealed 1 portable oxygen tank free-standing and sitting up on a long dresser. Clothes were observed scattered on the long dresser around the portable oxygen tank. During an interview on 05/20/26 at 8:01 AM, LVN C stated she did not know why the portable oxygen tank was on the dresser in Resident #54's room. LVN C stated the portable oxygen tanks were supposed to be stored in the oxygen storage room with the racks. LVN C stated a potential negative outcome to the residents was that the portable oxygen tank could have gone through the wall if it fell over and it was full. During an observation on 05/20/26 at 1:10 PM of Shower Room A, 1 spray bottle labeled Lemon Disinfectant with a warning label Keep out of reach of children was stored hanging on the rail by the toilet. A small amount of liquid with bubbles was noted in the bottom of the spray bottle. During an interview on 05/20/26 at 1:13 PM, the DON stated she did not know why the Lemon Disinfectant spray was being stored in the shower room. The DON stated a potential negative outcome to the residents was that it could cause injury to the residents if it got on them or if ingested. During an interview on 05/21/26 at 12:26 PM, the DON stated if a portable oxygen tank was not in use, it should be stored in the oxygen room. The DON stated the staff were trained to never store the portable oxygen tanks free standing. The DON stated she did not know why the portable oxygen tank was being stored on the dresser in Resident #54's room. The DON stated a potential negative outcome to the residents was it could become like a missile if it fell over. During an interview on 05/21/26 at 12:46 PM, the ADM stated the portable oxygen tanks should always be stored in a cart, or a bag on the back of their wheelchair if they were in use. The ADM stated if a portable oxygen tank was not in use, it should be stored in the oxygen room with the holders. The ADM stated the staff were trained on proper storage of portable oxygen tanks and she did not know why this tank was stored improperly. The ADM stated a potential negative outcome to the residents was it could explode if it was knocked over. The ADM stated she expected the cleaning chemicals to be stored locked in carts or cleaning closets when not in use. The ADM stated she did not know why the cleaning spray was being stored in Shower Room A. The ADM stated a potential negative outcome to the residents was it could be harmful if they got ahold of it and possibly ingested or got the spray in their eyes. Record review of the facility's policy and procedure titled, Oxygen Storage, with a revised date of 07/18, reflected the following: Policy: It is the policy of this facility to ensure oxygen and all other gases are stored according to gas storage regulations. Procedure: All oxygen cylinders shall be stored in a locked, outside area.Cylinders will be physically supported, either in a stand, or rack, or chained to or strapped to the wall. Record review of the facility's policy and procedure titled, Safety Management. Subject: Hazardous Chemicals, undated, reflected the following: .Procedure:.8. Chemicals must be properly stored, labeled, maintained and handled according to manufacturer's guidelines.

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 3 of 19 residents (Residents #2, #4 and #26) reviewed for infection control. 1. CNA E failed to wear proper PPE (gown) when providing direct resident care for Resident #2 who was on EBP on 5/20/26. 2. CNA E failed to wear proper PPE (gown) when providing direct resident care between Residents #2 and #4 when Resident #2 was on EBP on 5/20/26. 3. CNA F failed to wear proper PPE (gown and gloves) when providing direct resident care for Resident #26 who was on EBP on 5/20/26. These failures could place residents at risk for the spread of infection and cross contamination.Findings included: 1. Record review of Resident #2's face sheet, dated 5/20/26, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: pressure ulcer of sacral region(base of spine), stage 4 (tissue loss where the skin, subcutaneous fat, and muscle are destroyed, leaving bone, tendon, or fascia exposed (connective tissue)), acute kidney failure (rapid decline in kidney function), urinary tract infections (bacterial infections in the kidneys, bladder, ureters, and urethra), ileostomy status (surgical procedure that creates a new way for digestive waste to leave the body by diverting it from the large intestine), pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere (three distinct but related species of bacteria), resistance to carbapenem (ability to resist treatment with carbapenem antibiotics), acquired absence of right foot, and acquired absence of left leg below knee. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition was intact. Section - H - Bladder and Bowel revealed the resident had an ostomy (opening in the abdomen to allow waste or urine to exit the body). Section - M - Skin Conditions revealed the resident had a stage 4 pressure ulcer. Record review of Resident #2's undated care plan revealed: focus: The resident had a surgical wound to L BKA (left below the knee amputation), date initiated 2/17/25. Interventions: Use Enhanced Barrier Precautions, date initiated: 2/17/26. The resident had a Stage 4 pressure ulcer to the coccyx (final bone at the base of the spine), date initiated: 8/6/25, revision on: 12/31/25. Interventions: Use Enhanced Barrier Precautions, date initiated: 4/15/25. Record review of Resident #2's current Physician's Orders, dated 5/20/26, revealed an order with a start date of 5/5/25 for LLL (lower left leg) (surgical wound) - cleanse with NS (normal saline), pat dry with 4x4 gauze, apply collagen, cover with non-adherent dressing qod (every other day) and prn (as needed) one time a day every other day related to acquired absence of left leg below knee. There was also an order dated 5/19/26 which revealed that the resident had a central venous catheter to R (right) upper chest monitor site q (every) shift for bleeding, pain, redness, tenderness, swelling, & dislodgement. Document ( - ) Absent or ( + ) if present. Notify MD (medical director) & dialysis center every shift related to end stage renal disease. Additionally, there was an order dated 1/27/26 for colostomy care every shift related to ileostomy status, need for assistance with personal care. Further review revealed an order dated 3/31/26 for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: dialysis port, wounds, and ostomy, colostomy every shift. Record review of Resident #4's face sheet, dated 5/20/26, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included: muscle wasting atrophy, not elsewhere classified, unspecified site (loss of muscle tissue), schizoaffective disorder, depressive type (mental health condition), systemic lupus erythematosus, unspecified (autoimmune disease), and personal history of transient ischemic attack and cerebral infarction without residual deficits (previous mini-stroke and localized stroke). Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #4's current Physician's Orders, dated 5/20/26, revealed there were no orders for Enhanced Barrier precautions. During an observation on 5/20/26 at 9:10 AM, CNA E was observed inside Residents #2 and #4's bedroom. CNA E assisted Resident #2 with dressing and then transferred Resident #2 from the bed to wheelchair. CNA E handed Resident #2 their belongings such as water cup, money, and grabber, etcetera. Then Resident #2 left the room. Then CNA E fixed Resident #2's bed and then she fixed Resident #4's bed. CNA E was not wearing a gown when she assisted Resident #2 with dressing, transferring, and handing her belongings, and when she fixed both beds in the room. Enhanced Barrier Precaution signage was posted on the outside of Resident #2 and #4's bedroom door. During an interview on 5/20/26 at 2:30 PM, CNA E stated she was trained on EBP and was supposed to wear PPE which included a gown, gloves, possibly shoe and hair covers depending on the situation for residents who were on EBP. She stated she must wear PPE when she touched the residents and provided care, or when she touched anything, the residents had contact with. She stated she was to remove the PPE before she exited the resident's room and disposed of the items in the biohazard bin. CNA E stated she also must wash or sanitize her hands before she entered, during care, and after she exited the resident's room. CNA E stated she did not believe she had to wear PPE if she went into the room just to talk to the residents who were on EBP. CNA E stated she was supposed to wear PPE when she touched residents' linens and changed their briefs when they were on EBP. CNA E stated she recalled she went into Residents #2 and #4's room and did not wear any PPE besides gloves when she helped Resident #2 get dressed and transferred to her wheelchair. CNA E stated she believed she was supposed to wear PPE when she fixed Resident #2's bed and helped her get ready and transferred her. CNA E stated she also fixed Resident #2 and #4's beds when she was in there. CNA E stated she did not wear any PPE besides gloves when she fixed Residents #2 and #4's linens and bedding today. CNA E stated she sanitized before she entered the room and after she exited the room and in between when she fixed their beds. CNA E stated she also changed gloves when she fixed their beds. CNA E stated she did not know where the gowns were as they were normally outside the resident rooms in the hallway in a container. CNA E stated she recalled there being a container filled with PPE in the hallway outside their door, but she had been off for the past two days, and this was her first day back to work. CNA E stated she knew there were some in the linen closet, but she was not thinking at the time when she helped the residents. She stated she was not aware she forgot to wear PPE when she provided direct care to Residents #2 and #4 prior to this interview. She stated the system that was in place to ensure she remembered to wear PPE for residents who were on EBP was the container filled with PPE that was placed outside their doors. CNA E stated she was trained on EBP and infection control through training videos she watched during onboarding when she was hired. She stated she was responsible for wearing PPE when she went into rooms and provided direct care for residents who were on EBP. She stated a potential negative outcome was that germs could be transferred on her body and clothing and then she could transfer that to other residents and it could keep spreading and someone could get sick. 2. Record review of Resident #26's face sheet, dated 5/20/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included: anoxic brain damage, not elsewhere classified, (brain damage due to loss of oxygen), major depressive disorder, recurrent severe without psychotic features (mental illness), muscle wasting atrophy, not elsewhere classified, unspecified site (loss of muscle tissue), chronic obstructive pulmonary disease, unspecified (lung disease that block airflow and made it hard to breathe), personal history of urinary tract infections (history of bacterial infections in the kidneys, bladder, ureters, and urethra), colostomy status (surgically created opening in the abdomen that connects the colon to the outside of the body that allows waste to bypass the rectum and collect in an external pouch), and acquired absence of right leg below knee. Record review of Resident #26's quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition was intact. Section - H - Bladder and Bowel revealed the resident had in indwelling catheter and ostomy. Section - M - Skin Conditions revealed the resident had a stage 3 pressure ulcer. Record review of Resident #26's undated care plan revealed: focus: The resident had an indwelling foley catheter, 18FR (French) 30cc, for diagnosis of neuromuscular dysfunction of the bladder, obstructive and reflux uropathy (disruption of the signals required to store and empty urine) , date initiated 2/15/25, revision on: 3/17/2025. Interventions: Use Enhanced Barrier Precautions, date initiated: 2/15/25. The resident had a Stage 3 pressure wound to the coccyx; resident prefers to perform her own wound care and is followed by wound provider outside of facility. Continuing education provided on infection control, date initiated: 2/17/25, revision on: 9/30/25. Interventions: Use Enhanced Barrier Precautions, date initiated: 3/17/25. Record review of Resident #26's current Physician's Orders, dated 5/20/26, revealed an order with a start date of 3/17/25 for a catheter type: 18 FR (French) #30ML - to closed urinary drainage system - diagnosis for use: Neuromuscular dysfunction of the bladder (disruption of the signals required to store and empty urine) . The was also an order dated 3/31/26 for colostomy care every shift related to colostomy status. Additionally, the was an order with a start date of 3/23/26 for Wound Care-(Right ischium (lower and back part of the hip bone)) (stage 3): Cleanse wound with WC/NS (wound care/normal saline), pat dry with gauze, apply MD compounded topical (medication compounded by a medical doctor) (APG+) (Alkyl Polyglucoside), cover with silicone Super absorbent dressing as needed for Right Ischium Wound. Further review revealed an order dated 3/17/25 for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: wounds, indwelling catheter and colostomy every shift for catheter and wounds. During an observation and interview on 5/20/26 at 2:51 PM, CNA F was observed inside Resident #26's room combing Resident#26's hair while Resident #26 sat in their wheelchair. CNA F was not wearing a gown or gloves during this observation. Enhanced Barrier Precaution signage was posted on the outside of Resident #26's bedroom door. CNA F stepped into the hallway to speak with the surveyor. CNA F stated she was a floater and worked in all three halls. CNA F stated she was trained that she was supposed to wear gowns, gloves, and masks when she entered resident's room to provide patient care, touch their belongings, and touch anything else that may have had contact with resident's fluids for residents that had an infection and were on EBP. CNA F stated she was combing Resident #26's hair and was about to put two braids in her hair. CNA F stated she was not aware Resident #26 was on EBP which was why she had not worn any PPE during this encounter. She stated she could now see the EBP signage posted on the outside of Resident #26's door and stated she should have worn PPE when she combed the resident's hair. She stated she was in-serviced during morning report by nursing staff to ensure she was aware of which residents were on EBP, and there was usually a bin outside the room in the hallway filled with PPE but there was not one outside Resident #26's room today. She stated the last time she worked was Sunday (5/17/26) and she believed it could have changed since then because she noticed today the PPE was moved to a container that hung on the back of the resident's doors. She stated she was not in-serviced about that change when she came on shift today. CNA F stated she was last trained on EBP about a month ago during her onboarding training. She stated the charge nurse was responsible for ensuring staff remembered to wear PPE, however she was responsible for herself to wear PPE. CNA F stated a potential negative outcome was that she could catch AIDS (acquired immunodeficiency syndrome) or she could transfer an infection such as AIDS, syphilis, or any infection the resident had to others and they could get sick. During an interview on 5/21/26 at 11:30 AM, the DON stated the policy for EBP was that staff were to implement EBP with residents who were on EBP when they had contact with anything going in or outside of their bodies and when they were providing care. The DON stated staff were expected to wear gowns and gloves when they had close contact with those residents. The DON stated she expected staff to follow the EBP that was listed on the signage on resident's doors. The DON stated this included perineal care and handling their linens. The DON stated she had just learned that EBP required them to wear PPE when they changed linens. She stated they determined it was still close proximity with resident's belongings since the residents touched those things. The DON stated combing the resident's hair was considered direct contact with the patient and staff was to practice EBP during that task as well. The DON stated staff were to wash hands or use hand sanitizer before they entered, after they exited, and in-between tasks with the resident such as if they changed the resident. The DON stated staff should wear gloves when handling resident's cups to get them water if they were on EBP. She stated she had an infection control bulletin board, in-serviced staff, and there were signs on doors so that it did not get overlooked. The DON stated staff were expected to follow the EBP policy even when they were rushed to get tasks done. The DON stated PPE was hung on the inside of the residents' doors for staff to utilize. The DON stated they used to have PPE placed outside of the doors, but they felt there would have been too many PPE carts in the hallway, so they moved them to be hung on the inside of the doors. The DON stated they initially hung the PPE on the front of the resident room doors, but they felt it was not efficient and changed to hanging on the back of the doors. The DON stated there was a supply room filled with PPE and an additional supply center staff could get PPE from. The DON stated Resident #2 was on EBP for significant wounds and because they had a port for dialysis. The DON stated Resident #26 was on EBP for wounds and a catheter. The DON stated a potential negative outcome of not following EBP and infection control policy was that infection could be spread and could cause residents to get sick because they were at risk due to their health issues. During an interview on 5/21/26 at 1:10 PM, the ADM stated the policy for EBP was that staff were to wear the appropriate gown and gloves when they provided care to a resident that was on EBP. The ADM stated staff were also to complete hand hygiene before they entered and after they exited those rooms. She stated she was not aware staff did not wear PPE when they provided care for residents on EBP. The ADM stated the system to monitor this was ongoing in-services provided to staff on the EBP protocol, the signage, and spot checks completed by the nursing leadership as a team. The ADM stated she and nursing leadership were responsible for ensuring EBP were followed. The ADM stated Residents #2 and #26 were both on EBP. The ADM reviewed the EBP signage and stated EBP were required when staff changed linens and touched their personal items. The ADM stated a potential negative outcome of staff not following infection control and EBP policies was that there was an opportunity for infection control issues and cross contamination. Record review of the facility's undated sign posted outside Residents #2 and #26's doors, titled, Enhanced Barrier Precautions, revealed: EVERYONE MUST: Clean their hands, including before entering and when leaving the rooms. PROVIDERS AND STAFF MUST ALSO:Wear gloves and a gown for the following High-Contact Resident Care Activities .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toiletingDevice care use: central line, urinary catheter, feeding tube, tracheostomy.Wound care: any skin opening requiring a dressing.Do not wear the same gown and gloves for the care of more than one person. Record review of the facility-provided policy titled, IPCP (Interprofessional Collaborative Practice) Standard and Transmission-Based Precautions- 483.80 Infection Control, revision dated April 2025, revealed in part: Policy:It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In Long Term Care (LTC), it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protects the resident and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being. Where possible, the goal is to isolate the organism, not the resident. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Procedure:3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (multidrug-resistant organism) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).a. PPE: The use of gown and gloves for high-contact resident care activities is indicated when Contact Precautions do not otherwise apply, for nursing home residents with:i. Wounds and/or indwelling medical devices regardless of known MDRO infection or colonization.- Wounds include, but are not limited to chronic wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.- Generally, shorter-lasting wounds, such as skin tears or skin breaks covered by an adhesive bandage are not included.- Indwelling medical devices include, but are not limited to central lines,peripherally inserted central catheter (PICC) lines, urinary catheters, feeding tubes, and tracheostomies.- Peripheral intravenous lines (not PICC lines) or lines used for hypodermoclysis (subcutaneous hydration/nutrition) are not included.c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:i. Dressingii. Bathing/showeringiii. Transferringiv. Providing hygienev. Changing linensvi. Changing briefs or assisting with toiletingvii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheter, feeding tube, tracheostomy/ventilator.

Based on observation, interview, and record review the facility failed to respect the resident's right to personal privacy and confidentiality of his or her medical records on 1 of 2 medication carts (Hall 200 Nurse Medication Cart) reviewed for privacy in that: 1. LVN D left the computer screen unlocked with a resident's medication information visible on the Hall 200 Nurse Medication Cart when she left the medication cart unattended. 2. LVN D left a list of residents' vitals exposed on top of the Hall 200 Nurse Medication Cart. These failures could place residents at risk of having medical information or care instructions exposed to others and misuse of personal/medical information.The findings included: During an observation and interview on 05/19/26 at 11:44 AM the Hall 200 Nurse Medication Cart was observed in Hallway 200 with an unlocked computer screen. The computer screen displayed a resident's EMAR. There was also a list of residents and their vital results on a sheet of paper in a clipboard lying faced-up on top of the medication cart. Two maintenance staff were observed approximately 5 feet away from the medication cart working on a door in the hallway. LVN D came out of a resident's room and approached the medication cart as the surveyor stood next to it. LVN D stated she was the charge nurse and was assigned to the Hall 200 Nurse Medication Cart. LVN D stated she was in the process of passing out medications and taking vitals and she had been dealing with a resident that was confused and wanted pain medications, and she tried to help the resident figure it out. LVN D stated the policy was that computer screens were supposed to be locked, and residents' personal information was supposed to be covered when left unattended. She stated she was supposed to lock the computer and flip over the list of vitals when she stepped away from them. She stated this was a HIPAA violation. She stated she was unaware she had left the computer screen unlocked and left residents' vital results exposed and was trained not to do so. She stated she was responsible for ensuring residents' privacy was respected. LVN D stated staff usually completed spot checks to ensure computer screens were locked and residents' personal information was kept private. She stated she had been in-serviced and trained in medication administration and to ensure the carts were locked and they maintained privacy. She stated a potential negative outcome was that someone could get a resident's private information and use it against them or it could cause residents' embarrassment. During an observation and interview on 05/19/26 at 1:20 PM it was revealed that the Hall 200 Nurse Medication Cart had a list of residents and their vital results on a sheet of paper in a clipboard lying faced-up on top of the medication cart with no staff present. During an interview on 5/21/26 at 11:30 AM, the DON stated the policy was that residents' health and care information was only shared with who was approved such as providers, the inter-disciplinary team, and relevant staff. The DON stated computer screens should have been locked, and all documents should have been locked up in the medication cart so that passersby did not see it anytime staff stepped away from them. She stated she was aware yesterday that staff left the computer screen unlocked and vitals exposed on top of the medication cart while unattended. The DON stated she did rounds and stood by medication carts to prompt staff and ensure they remembered to lock the screen and ensure privacy was maintained. She stated she had also educated staff on how important it was to ensure medication carts were locked up and privacy was maintained. The DON stated all new staff were trained for a minimum of 3 days in medication administration. She stated the first day the new staff shadowed nursing staff to observe and learn the routine and HIPAA requirements. On the second day, they helped take vitals and passed medications. She stated that on the third day, the new staff completed the medication administration process and was shadowed by a staff for training purposes. She stated they answered any additional questions and determined if the staff member was ready or if more training was needed. The DON stated staff were also in-serviced on medication administration periodically by herself or the ADON. The DON stated the staff that passed the medications were responsible for ensuring privacy was maintained but it was also everyone's responsibility to ensure privacy was maintained. The DON stated she expected staff to maintain privacy when carts were unattended. She stated a potential negative outcome was that someone not approved could get their information and their dignity and rights would be violated. During an interview on 5/21/26 at 1:10 PM, the ADM stated all screens should have been shut down and all paperwork should have been covered for privacy when staff walked away from the medication carts. The ADM stated she was not aware screens were unlocked and paperwork with residents' personal information was exposed on medication carts while unattended. The ADM stated nursing leadership did spot checks to ensure staff locked screens and had not exposed residents' records. The ADM stated the DON and the ADON in-serviced staff on privacy and medication cart privacy. The ADM stated herself and the leadership team were responsible for ensuring privacy was maintained. She stated she expected staff to lock screens and cover paperwork anytime they walked away from the carts, so others did not see it. The ADM stated a potential negative outcome was that there would be a breach of confidentiality and breach of HIPAA, and people could get residents' personal information. Record review of the facility policy, Resident Rights, amended July 13, 2017, revealed the following in part: As a resident of this nursing facility, you have the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. Privacy and Confidentiality. You have the right to personal privacy and confidentiality of your personal and medical records. You have the right to: -secure and confidential personal and medical records.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611 met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care. Findings include: During an interview with the ADM during entrance conference on 05/19/26 at 9:08 AM it was revealed the facility would need the Texas Health and Human Services Form 3762 Room Size Waiver for Facilities for several rooms at the facility. The ADM stated the rooms were in the part of the facility that was not in use and awaiting renovations, but the rooms were still listed on their bed classification form. Record review of Texas Health and Human Services Form 3740 (Bed Classifications (Numbers and Location) dated 05/20/26 documented that room [ROOM NUMBER] was listed as a Title 18/19 bed classification semi-private rooms for two residents. rooms [ROOM NUMBER] were listed as Title 18 rooms. During an interview on 05/21/26 at 10:56 AM, the ADM stated the facility did not have a policy for the room size waiver. The ADM stated the facility followed state regulations for the room sizes. During an observation on 05/21/26 at 11:50 AM with the Maintenance Aide, room [ROOM NUMBER] was measured to be 141.81 Sq. Ft. The room was not occupied. During an observation on 05/21/26 at 11:53 AM with the Maintenance Aide, room [ROOM NUMBER] was measured at 155.04 Sq. Ft. The room was not occupied. During an observation on 05/21/26 at 11:55 AM with the Maintenance Aide, room [ROOM NUMBER] was measured at 151.59 Sq. Ft. The room was not occupied. During an observation on 05/21/26 at 11:58 AM with the Maintenance Aide, room [ROOM NUMBER] was measured at 155.1 Sq. Ft. The room was not occupied. During an interview on 05/21/26 at 12:46 PM with the ADM regarding the square footage for Rooms 407, 602, 604 and 611. When asked if she wanted to continue with the room size waiver she stated, Yes. The ADM stated Rooms 407, 602, 604, and 611 were still listed on their bed classification form. The ADM stated the facility did not have plans to open up the rooms in the near future and stated the long-term goals were to renovate and make sure all of the rooms were up to date. The ADM stated a potential negative outcome to the residents was not enough space to move around.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #1's care plan regarding aggressive and physical behaviors toward one other resident that occurred on 09/03/25.The facility failed to update or add interventions to Resident #2's care plan regarding aggressive and physical behaviors toward one other resident that occurred on 09/06/25.The facility failed to update or add interventions to Resident #3's care plan regarding aggressive and physical behaviors toward other resident that occurred on 09/07/25.These failures could result in residents not receiving the care that they need to prevent further incidents of aggression.Findings Included: Resident #1Record review of Resident #1's face sheet, dated 09/24/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit (difficulty communicating), dementia (memory loss), and intermittent explosive disorder (mental disorder characterized by sudden intense outburst of anger). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section A indicated the assessment was his first assessment. *Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired.*Section E did not reveal any coded behaviors that included behaviors directed towards others.*Section V revealed that Resident #1 triggered for CAA #9 Behavioral Symptoms and should have been care planned.Record review of Resident #1's Change of Condition Evaluation, dated 09/03/25 revealed:The change of condition identified was behavioral symptoms (agitation, psychosis).Findings: Resident redirected with no continued behaviors.Skin Status Evaluation: No change of condition reported.Vitals Signs were evaluated.Provider Notification and Feedback: clinician notified on 09/03/25 at 5:00 PM, and recommendation of the clinician was to monitor.Resident Representative Notified on 09/03/25 at 5:00 PM. Record review of Resident #1's progress notes, dated 06/23/25-09/24/25, revealed:*09/3/25 at 5:54 PM LVN A documented Resident (unidentified in the progress note) yelled out and it was witnessed that Resident #1 hit another resident. The DON, resident representative and the doctor were notified. Further review of Resident #1's progress notes did not reveal any further incidents of aggression after 09/03/25. Record review of the facility's incident and accident report, dated 09/24/25 revealed:Resident #1 had an incident of resident-to-resident aggression that occurred on 09/03/25. Record review of Resident #1's Q15 minute rounds documentation indicated that he was on 15 minute checks from 09/03/25-09/06/25. Record review of Resident #1's care plan, dated 9/2/25 revealed the following:*Resident #1 had a focus behavior that addressed his risk for wandering and elopement (initiated 09/04/25).*Resident #1's care plan dated 09/2/25 did not address the incident of aggression from 09/03/25 by way of goals and interventions. During an interview on 09/24/25 at 6:57 PM, Resident #1 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 09/03/25. Resident #2Record review of Resident #2's face sheet, dated 09/24/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (memory loss), anxiety (increased worry) and major depressive disorder (mood disorder characterized by persistent feelings of sadness). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired.*Section E did not reveal any coded behaviors.*Section V revealed that Resident #2 did not trigger for CAA #9 Behavioral Symptoms.Record review of Resident #2's Change of Condition Evaluation, dated 09/06/25 revealed:The change of condition identified was other (resident to resident- hit another resident).Findings: No changes noted and the incident had not occurred before.Skin Status Evaluation: No change of condition reported.Vitals Signs were evaluated.Provider Notification and Feedback: clinician notified on 09/06/25 at 11:45 PM, and recommendation of the clinician was to monitor.Resident Representative Notified on 09/06/25 at 11:45 PM. Record review of Resident #2's progress notes, dated 06/23/25-09/24/25, revealed:*09/7/25 at 3:11 AM the ADON documented Resident #2 hit another resident that was watching TV in the dining room. Resident #2 hit another resident twice on the back of the neck and upper back. Both of the residents were separated. Further review of Resident #2's progress notes did not reveal any further incidents of aggression after 09/06/25. Record review of the facility's incident and accident report, dated 09/24/25 revealed:Resident #2 had an incident of resident-to-resident aggression that occurred on 09/06/25. Record review of Resident #2's Q15 minute rounds documentation indicated that he was on 15 minute checks from 09/06/25-09/09/25. Review of Resident #2's care plan, dated 2/5/25 revealed the following:*Resident #2 had a focus with the category behavioral symptoms for having a history of verbal and physical behaviors (initiated 2/11/25; revision 2/11/25). The goal was for Resident #2 to have fewer episodes. Interventions included managing Resident #2's medications as ordered.*Resident #2 care plan did not address the incident of aggression from 09/06/25 by way of goals and interventions. During an interview on 09/24/25 at 6:18 PM, Resident #2 was unable to participate in an interview as he did not answer any questions related to the incident that occurred on 09/06/25. Resident #3Record review of Resident #3's face sheet, dated 09/24/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by sudden intense outburst of anger), cognitive communication deficit (difficulty communicating), anxiety (increased worry), dementia (memory loss), and major depressive disorder (mood disorder characterized by persistent feelings of sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed the following: *Section V revealed that Resident #3 did not trigger for CAA #9 Behavioral Symptoms. Record review of Resident #3's Quarterly Minimum Data Set, dated [DATE], revealed the following: *Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired.*Section E did not reveal any coded behaviors. Record review of Resident #3's physician orders, dated 09/24/25, revealed the following:*Resident #3 was ordered Valium 2MG for intermittent explosive disorder (Revision Date: 09/16/25 Supply last order date: open).*Resident #3 was ordered Clonazepam 1MG for anxiety, and psychotic disturbance (Revision Date: 09/15/25 end date: 9/9/25).*Resident #3 was ordered Clonazepam .5MG for increased anxiety (Revision Date: 09/09/25; Supply last order date: 9/7/25).*Resident #3 was ordered Clonazepam 1MG for increased behaviors (Revision Date: 09/07/25 Supply last order date: open).Record review of Resident #3's Change of Condition Evaluation, dated 09/07/25 revealed:The change of condition identified was other (resident to resident- hit another resident).Findings: Since the change of condition the conditions have gotten better. Resident #3 was hard of hearing and written communication was noted to help. Resident #3 was placed on 1:1 with medication adjustments. Resident #3 had difficulty hearing others.Skin Status Evaluation: No change of condition reported.Vitals Signs were evaluated.Provider Notification and Feedback: clinician notified on 09/07/25 at 5:00 PM, and recommendation of the clinician was to monitor Q15 and monitor new medication (medication not listed).Resident Representative Notified on 09/07/25 at 5:00 PM. Record review of Resident #3's progress notes, dated 06/23/25-09/24/25, revealed:*09/07/25 at 5:00 PM the LVN B documented Resident #3 was outside with other residents when a female resident became upset with Resident #3 for continually touching her book. It was observed that when the female resident blocked him from touching her book Resident #3 hit her on the shoulder. There were no injuries. The residents were separated and assessed. Resident #3 was extremely hard of hearing, so communication was completed with written instruction to stay away from female residents. Resident #3 voiced understanding. Record review of the facility's incident and accident report, dated 09/24/25 revealed:Resident #3 had an incident of resident-to-resident aggression that occurred on 09/07/25. Record review of Resident #3's Q15 minute rounds documentation indicated that he was on 15 minute checks from 09/07/25-09/09/25. Resident #3's care plan, dated 2/5/25 revealed the following:*Resident #3 had a focus with the category behavioral symptoms for displaying physical behaviors. (initiated 2/11/25; revised 7/01/25) The goal was for Resident #3 to have fewer episodes of the behavior. Interventions included ensuring Resident #3 was removed from the situation, approach in a calm manner, medications adjustments by the provider, and praise any indication of progress/improvement in behavior.*Resident #3's care plan did not address the incident of aggression from 09/07/25 by way of goals and interventions. During an interview on 09/25/25 at 10:40 AM, Resident #3 stated he did not want to talk about his incidents of aggression but that he tried to get along with his peers. He stated he had a hard time hearing and never requested a hearing aid. He stated he had some changes to his medication, but he felt that his medication was working. He stated he had not had any additional incidents of aggression since 09/07/25 and had no intention of causing trouble. During an interview on 9/24/25 at 11:14 AM CNA G stated he had been trained on resident altercation processes after incidents regarding Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. He reported that the incidents of aggression were isolated and had not happened before the dates of the incidents and since the incident of aggression dates. He reported he had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. He reported all resident behaviors were manageable. During an interview on 9/24/25 at 12:14 PM the DON stated if the residents made physical contact with one another then staff should separate the residents and start monitoring Q15. She stated there were times where the residents were placed on 1:1 supervision She stated in all three incidents of aggression involving Resident #1 on 09/03/25, Resident #2 on 09/06/25 and Resident #3 on 09/07/25 the staff separated the residents from the other resident or residents involved, implemented Q15 monitoring, assessed all residents involved (no negative findings), notified the resident representatives and doctors. The DON stated all incidents of aggression involving Resident #1, Resident #2, and Resident #3 were isolated events and had not happened before the dates of the incident and had not occurred after the dates of the incident. During an interview on 9/24/25 at 1:33 PM CNA C stated she was present when Resident #3 had his incident of aggression on 09/07/25 and he hit two other residents. CNA C stated it was around 4:15 PM and she was preparing for the resident's smoke break. She stated Resident #3 was irritating another resident and when the other resident redirect Resident #3 he responded by hitting her. CNA C stated she immediately stepped in and separated the residents. She stated she called for help and LVN D came, but before LVN B came another resident was speaking up and Resident #3 hit her. She stated LVN B came immediately when she called him. She stated other residents were outside and they were talking to Resident #3 and it did not make the situation better. She stated it happened very fast but there were no injuries. She stated there was no indication that Resident #3 was upset. She stated Resident #3 appeared to be his normal self. She stated she felt that Resident #3 and his behaviors were manageable but on 09/07/25 the other residents were talking to him. She had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. She reported that the incidents of aggression were isolated and had not happened before the dates of the incidents and since the incident of aggression date. She reported she had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. She reported all resident behaviors were manageable. During an interview on 9/24/25 at 3:31 PM the ADON stated she and her staff had been trained that when there was a resident-to-resident altercation they were to separate the residents and then report the incident to management. The ADON stated she was made aware of all three incidents of aggression involving Resident #1 on 09/03/25, Resident #2 on 09/06/25 and Resident #3 on 09/07/25. She stated it was reported to her when the incident occurred on 09/06/25 staff separated the residents, assessed the residents (no negative findings) and notified the doctor and the resident representatives. She stated because of each incident all staff were reeducated and trained on the ANE policy and resident altercations. The staff conducted monitoring Q15 to ensure further incidents did not occur. The ADON stated the resident-to-resident altercations were handled appropriately because the staff responded immediately by separating the residents and reporting.During an interview on 9/24/25 at 3:49 PM LVN D stated he was present for when Resident #3 had his incident of aggression. He stated he could not remember if he heard a commotion or if CNA C called him, but he went to assist, and CNA C had already separated the residents to include Resident #3. He stated Resident #3 placed his hands on another resident's book and when the other resident redirected his hands off her book he hit her. LVN D stated during the same incident another resident was walking by, and Resident #3 hit the other resident. LVN D stated the incident of aggression had never happened before with Resident #3 and the other residents involved. He stated the other residents involved do not have a history of behaviors. He stated he assessed all residents involved and there were no negative findings. LVN D stated Resident #3 was placed on monitoring Q15. He stated there were no further incidents. He had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. He reported that the incidents of aggression were isolated and had not happened before the date of the incidents and since the incident of aggression date. He reported he had been trained to separate the residents that were involved in a resident-to-resident altercation, protect the residents, implement monitoring for residents involved and report the incident to management immediately. He reported all resident behaviors were manageable and he did not report any concerns with managing resident behaviors. During an interview on 9/24/25 at 4:20 PM LVN E stated she was present when Resident #2 had his incident of aggression on 09/06/25. She stated she was seated at the nurse's station and heard skin contact like a slapping noise. She stated she and CNA K immediately separated Resident #2 from the other resident. She stated she assessed both residents and there were no negative findings. She stated Resident #2 had never had an incident of aggression with other residents and this was isolated. She stated Resident #2 could get aggressive but not towards residents. She stated Resident #2 would be aggressive during resident care. She stated for example he would grab the doors, chairs and items around when staff attempt to lay him down. She had been trained on the facility's ANE policy and resident altercation process after Resident #1, Resident #2, and Resident #3 that occurred on 09/03/25, 09/06/25, and 09/07/25. She reported that the incidents of aggression were isolated and had not happened before the date of the incidents and since the incident of aggression date. During an interview on 9/24/25 at 5:21 PM CNA F stated she did observe/ hear the indent of aggression involving Resident #2 on 09/06/25 but heard a loud slapping noise. She stated she went and assisted the nurse (LVN E) with the residents. She stated she was at the nurse's station completing documentation when the incident happened. She stated they intervened immediately and monitored the residents for the remainder of the shift. She stated there were no further incidents. She stated Resident #2 did not ever have any incidents of aggression and this was abnormal for him. She stated LVN C assessed them and there were no negative findings.During an interview on 9/24/25 at 6:20 PM the MDS Coordinator stated the incident of aggression that occurred on 09/03/25 was discussed in the morning meeting and should have been revised. She stated the incident of aggression involving Resident #2 also would have been discussed in the morning meeting because it occurred on 09/06/25. She stated Resident #2's aggression was normal behavior for him. She stated the incident of aggression that occurred on 09/07/25 involving Resident #3 also would have been discussed in the morning meeting. She stated Resident #3 had some medication changes and since the change had experienced an increased in behavior. She stated none of the incidents of aggression that occurred involving Resident #1, Resident #2 and Resident #3 had been reflected in their care plans. She stated the care plan was a way that staff could see what was needed to care for the residents. She stated the care plan was updated by the nursing staff, the SW, activities, dietary, therapy and her. She stated they go over the care plan in daily meetings by reviewing incidents under risk management. She stated they also go over incidents weekly in the Standards of Care Meeting (SOCs). She stated if there was an incident she would open the system up so that the correct discipline can make changes. She stated if she was not present at work then the DON or ADON can also perform the revisions. She stated the care plan was used by all staff. She stated the clinical staff such as the aides can view the care plan contents in the care plan in the POCs located in the EMR. The MDS Coordinator stated she was familiar with the care plan policy. She stated if a CAA was triggered in the MDS then it should be care planned unless otherwise indicated. She stated all behaviors should be care planned. She stated Resident #1 triggered for behavior, but it was the behavior for wandering/elopement. She stated Resident #1 after his incident of aggression should have had his care planned updated/ revised for the behavior (aggression). The MDS Coordinator stated the potential negative outcome for not care planning the incidents of aggression was that additional incidents could occur. She stated the CNAs, and the nurse knew to separate the residents and implement monitoring Q15 even if the incident was not care planned because it was a part of the facility process to sperate the residents and start monitoring. She stated she was unsure if the staff would know specific goals for the residents without the care plan being revised. She stated the system to monitor the creation, implementation and revision of care plans was when there was an incident that occurred, they reviewed daily in the risk management portion of their daily meeting. She stated they also reviewed any incidents in their weekly meeting. She stated once the incidents were discussed she would open the area up in the care plan and the respective role/discipline would complete the care plan. She stated the overall goal was to keep the residents safe from harm. The MDS Coordinator stated that the DON and ADON would have been the disciplines responsible for the revisions. The MDS Coordinator stated outside of the daily risk management or morning meetings, and at the weekly SOC meeting she was unsure if there were any additional processes to help monitor the creation, implementation and revision of care plans. The MDS Coordinator stated she expected the care plans for the residents to be revised after she opened up it up in the EMR and when there was incident involving the residents. She stated she would at least allow for two weeks if there was an incident for the care plan to be revised. She stated although the policy addressed the standard times for when the care plan should be revised (48 hours after admission, 7 days after admission, 21 days after admission, quarterly and annually), the care plan should be revised after there was a resident-to-resident altercation. The MDS Coordinator stated she was responsible for care plan revisions, and she was not available then the respective department would be responsible. She stated she was not unavailable for any of the days in which the incidents of aggression occurred involving Resident #1, Resident #2, and Resident #3. She stated the reason the care plan revisions were not completed was because she did not remember going over the incidents as thoroughly as they normally do. She stated she was unsure why they did not go over the incidents of aggression as thoroughly as they normally do. During an interview on 9/25/25 at 8:59 AM ADON stated a care plan was a plan in which stated how they were going to take care of the residents in the facility. She stated they have to keep the care plan updated for all of the care that they are providing for the residents. She stated all the staff used the care plan. She stated the nurses and aides needed to know how they were going to care for the residents. She stated all staff had access to the care plan. She stated regarding behaviors the care plan showed how staff were going to treat them and how they would assist with the behavior. She stated the information from the care plan was communicated from the DON and her verbally to staff. She stated all information in the care plan can be viewed by the aides in the EMR under the POCs. She stated the purpose of updating the care plan was that it would be reflected in the POCs and that way the aides would know how to handle resident behaviors. She stated the revision could play a part in reducing resident behaviors and preventing them from happening again. The ADON stated she was familiar with the care plan policy. She stated she had never revised a care plan immediately after an incident but that the care plan should be revised if there was an incident of aggression. The ADON stated the potential negative outcome for not revising care plans was that the resident behavior would not get better and the negative behavior would continue. She stated she was unaware that the revisions on all three incidents of aggression had not been completed. She stated the facility's system to create, implement, monitor and revise resident care plans was the revisions were conducted in the daily meetings and the weekly SOC meetings. She stated revisions would also be conducted during the monthly care plan meetings that occurred on a quarterly basis. She stated she had been trained on care plan revisions. She explained the company that was over the facility was very proactive about care plans and the system to implement and revise. She stated that care plans should be revised as incidents were happening and if there were changes with the residents. She stated the MDS Coordinator was responsible for revisions and that she normally completed the revisions for the resident care plan. The ADON stated she did not have a reason why the care plan revisions were not made. She stated she remembered discussing the incidents of aggression in their morning meetings. During an interview on 9/25/25 at 9:30 AM the ADM stated the care plan was the plan of care for the residents. She stated the care plan laid out care for the residents. She stated all the staff in all disciplines could refer to the care plan as it was a tool to use. She stated residents that had behaviors were reflected in the MDS and it would trigger the CAAs to be reflected in the care plan. The ADM stated care planning behaviors helped mitigate the behaviors for the best outcome of the behavior. The ADM stated all staff used the care plan. The ADM stated the aides could access the care plan contents through the POCs, but all other disciplines can view the care plan in its entirety. The ADM stated she was familiar with the care plan. She stated their facility policy did not spell out the expectation regarding care revisions. She stated the policy had a minimum requirement to update the care plan on a quarterly basis. She stated the facility process to monitor care plan revisions was during the daily meetings they (the IDT) discuss risk management and the incidents in their entirety. She stated if there was an altercation they would discuss in their morning meeting because this would essentially be a self-report. She stated when they discussed the incident it was the opportunity to ensure that the progress notes were done, care plan was revised, and interventions implemented. She stated quarterly revisions were the minimum expectation according to the facility policy. She stated ideally and her expectation was for the care plan was revised at the time of risk management discussion daily. She stated standard interventions would be what the facility staff did. She stated the staff separated the residents and implemented monitoring Q15. She stated interventions were implemented and discussed but were not updated in the care plan. She stated that for the residents involved in the incidents of aggression they (the IDT) discussed environmental factors, medication changes, and psychiatric supervision. The ADM stated the incidents of aggression were isolated and not ongoing for all three residents (Resident #1, Resident #2, and Resident #3). The ADM stated the potential negative outcome for not revising resident care plans after a resident-to-resident altercations was the staff may not know how to respond or intervene with said resident because the care plan was used as a tool. She stated she was unaware that the revisions had not been made. She stated the system to monitor a resident care plan was the daily meetings where they discussed risk management, weekly SOC meetings, quarterly and annual resident care plan meetings. The ADM stated they were taking the missed revisions for Resident #1, Resident #2 and Resident #3 as an opportunity to grow. She stated she and her staff had been trained on care plan and care plan revisions. She stated the new corporate took over in February 2025 and they received training from February 2025 by the new management company. She stated the best practice would be that the care plan was revised as part of the follow-up to resident incidents involved. She stated to follow policy then the care plan would be updated quarterly. She stated the IDT was responsible for revising the care plan. She stated regarding behaviors the SW would have been responsible. The ADM stated the reason the SW did not complete the care plans revisions could have been because she was new and prior to coming to the facility she had not completed the care plans. The ADM stated the MDS Coordinator was the keeper of the entire care plan and should have notified the SW. During an interview on 9/25/25 at 10:03 AM the DON stated the care plan was a guide that contained the plan of care for each resident. The DON stated the care plan contained the needs and the way to care for each resident. The DON stated the care plan specified the needs of each resident. The DON stated all staff have access to the care plan to use depending on their discipline. The DON said when they identify a behavior, they care planned the incident so that staff know how to approach the situation. She stated depending on the role that would determine how they (the staff) were able to view the information from the care plan. She stated once the information was placed in the care plan then the appropriate portions would be tasked out to the clinical staff such as the aides. The DON stated even if the care plan was not revised, she felt that the facility's education system was strong enough to educate the staff on facility expectations. The DON stated she felt the staff were aware of the residents' personal interventions. The DON stated she was familiar with the facility care plan policy. She stated although they discussed incidents involving residents daily in risk management the care plan revisions for Resident #1, Resident #2, and Resident #3 fell through the cracks. The DON stated additionally they monitored care plan revisions through weekly SOC meetings that occur weekly (Wednesday) at 1:00 PM. She stated the potential negative outcome for not revising care plan meetings was the staff may be unaware of incidents that happened or interventions that were needed. The DON stated staff could miss resident care needs. The DON stated she was unaware that the care plan revisions for all three incidents of aggression had not been completed. She stated the system to monitor care plan revisions was that all residents were updated quarterly and annually. She stated she had been trained about a couple of weeks ago and again on 09/25/25. She stated she had been trained by her corporate management team that all incidents should be addressed by the IDT. She stated all disciplines were involved but that the SW would address chronic issues and the clinical team would address acute issues. She stated the MDS coordinator was responsible for care plan revisions and that they all review anything that fell under their discipline. The DON stated she did not have an excusable reason why the care plan revisions were not completed.During an interview on 9/25/25 at 10:21 AM the SW stated a care plan was a plan of care for each resident. She stated it told staff what the plan of care was for each resident so that staff could provide appropriate care for each resident. The SW stated behaviors should be care planned and revised so that all staff were aware of resident behaviors. She stated care planning behaviors would help create interventions to help address resident behavior. She stated care planning and revising resident behaviors would also assist with making necessary referrals that the residents may need. The SW stated leadership, the facility aides, nurses and the entire IDT used the care plan to provide care for the residents. The SW stated the clinical staff also received verbal instruction from the nurses about the residents' interventions and goals. The SW stated she was familiar with the facility's care plan policy. She stated the revised the care plan on a quarterly basis per the facility policy. The SW stated this did not mean they would not look at the care plan before the quarter or annual because ideally, they should revise the care plan anytime an event or incident occurred. The SW stated the potential negative outcome of not revising the care plan was that the resident may not receive appropriate care and what they need to address the situation identified. She stated she was unaware care plan revisions had not been completed. She stated she remember discussing the incidents of aggression involving Resident #1, Resident #2, and Resident #3 in morning meeting, b

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances for 12 of 20 confidential residents. The facility failed to ensure 12 of 20 confidential residents were provided, through postings in prominent locations; the grievance procedures, were provided access to the Grievance form, information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. These failures could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 03/26/2025 at 3:00pm, 12 of 20 confidential residents, revealed they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. Residents stated Grievance forms had previously been available in the Social Worker's office; however, the Social Work position was now vacant. The residents did not know they had the right to receive a written decision once their grievance was resolved. Twelve Residents attended the meeting, the 12 Residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 3/27/2025 at 11:17am; the facility did not include instructions regarding the Grievance procedures with any of the prominent postings. Grievance forms were placed in manila folder on a bulletin board to the right of the nurses' station, the folder was not reachable to Residents in wheelchairs. There was a wire basket on the wall outside of the Social Worker's office, however, the basket was not labeled and was not covered or secure. Interview with the ADM on 3/27/2025 at 11:05am; the ADM stated she was the Grievance Officer for the facility. The ADM stated she was responsible for the review of Grievances and assigned them to department heads during morning meeting. The ADM stated the Grievance form was kept at the Social Worker and all offices would have a Grievance form. ADM stated there is a folder on a bulletin board next to the Nurses' Station with Grievance forms. The ADM stated there was a wire basket outside of the Social Worker's office that could be for completed Grievances. The ADM stated the basket was not labeled, it does not have a cover, and it is not secured. The ADM stated the folder, and the basket are not a successful system if the Residents are unaware of the availability of the form or where the Grievance form can be submitted. The ADM stated she was unaware the Grievance process was not being discussed in Resident Council. The ADM agreed the Grievance process cannot be successful if Residents are not educated on the process. The ADM stated the facility has 72 hours to resolve Grievances once they were submitted. The ADM stated she assigned the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance; the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. Record Review of the Grievance Policy last updated in 2023, revealed the following: Policy Statement: The facility will establish a grievance process that allows the residents a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have. Procedure: 1. The facility will make available information on how to file a grievance available to residents, family, and staff. a. Residents or their representative have the right to file a grievance orally , in writing, and/or anonymously. b. Contact information of the facility grievance office to include name, business, and email address, phone number, and reasonable expected time frame for completing review of the grievance. c. Contact information of independent entities with whom grievances may be filed, which include the state agency, Quality Improvement Organization, State Survey Agency, Ombudsman, or protection/advocacy agencies. d. The right to obtain a written decision regarding their grievance. 2. The Administrator or designed will assign the responsibility of investigating the grievance. 3. General concerns may be voiced at Resident and/or Family Council meetings. 4. The Administrator or designee evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. 5. The Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the Administrator; and as required by State Law. 6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance. 7. If during the investigation abuse, neglect, misappropriation and/or injuries of unknown source are identified, the facility will refer to the Abuse Policy. a. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and b. Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievances for period of no less than 3 years from the issuance of the grievance decision.

Based on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage areas and 1 of 2 medication carts (Med Cart A) reviewed for medication storage. 1. The facility failed to keep a record of a receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure expired medications were not kept in Med Cart A. These failures could place residents at risk of not receiving the therapeutic benefit of medications, loss of prescribed medications and drug diversion. The findings included: 1. During an observation and interview with the DON on 3/26/25 at 11:17 AM, the following unlogged medications were observed in the controlled medications storage area waiting to be disposed of: -Morphine 100/5 -- 29.5 mls -Temazepam 30 mg - 28 capsules -Clonazepam 1 mg - 9 tablets -Alprazolam 0.2 mg - 7 tablets -Tramadol HCl 50 mg - 29 tablets -Lorazepam 1 mg - 75 tablets -Tramadol HCl 50 mg - 29 tablets -Alprazolam 0.5 mg - 46 tablets -Morphine 20mg/ml - 16 mls -Lorazepam 1 mg - 9 tablets -Lorazepam 2mg/ml - 19 mls -Hydroco/APAP 5-325 mg - 36 tablets -Ativan 2mg/ml - 16 mls -Morphine 500/5 - 27.5 mls -Lorazepam Intensol 2mg/ml - 29 mls -Tramadol HCl 50 mg - 42 tablets -Morphine Sulfate 100 mg/5 ml - 29.5 mls -Tramadol HCl 50 mg - 46 tablets -Lorazepam 2 mg/ ml - 2.25 mls -Temazepam 15 mg - 7 tablets -Lorazepam 2 mg/ ml - 80 mls -Temazepam 15 mg - 3 capsules -Tramadol HCl 50 mg - 15 tablets - Alprazolam 0.25 mg - 20 tablets -Tramadol HCl 50 mg - 44 tablets -Lorazepam 1 mg - 37 tablets During the observation of the unlogged medications, the DON stated her process for reconciliation and storage of controlled medications that needed to be disposed of was as follows: The DON and the nurse that brought her the medications would review the narcotic sheet indicating how much medication was left, then the DON and nurse would each sign the narcotic sheet. The narcotic sheet was placed with the medication, and the medication and narcotic sheet were placed in the locked cabinet until the medication destruction was completed with the pharmacist. The DON stated she was unaware that the stored medications needed to be logged upon receipt, prior to their destruction with the pharmacist. The DON stated she would log the medications and put in a request for the pharmacy consultant to visit the facility to conduct a medication destruction. During an interview on 3/26/25 at 11:25 AM, the Clinical Resource Nurse stated controlled medications that were being stored for destruction should be logged. She stated best practice was to log discontinued controlled medications upon receipt, then properly store the medications for destruction with the pharmacist. During a follow-up interview on 3/27/25 at 9:47 AM, the DON stated she was responsible for logging discontinued medications that were being stored for destruction. She stated the reason the controlled medications had not been logged was because she was overwhelmed on which tasks to prioritize after the facility's recent change of ownership and being recently hired to her position. She stated she was not aware that she needed to log the controlled medications in addition to reconciling and signing the narcotic sheets and securely storing the medications. She stated the pharmacy consultant had briefly visited the building on the same day the survey team entered for the recertification survey. The DON stated the pharmacy consultant would return to complete her visit and conduct medication destruction following the survey. She stated the policy of the facility was for the DON to log discontinued controlled medications upon receipt, prior to destruction with the pharmacist. The DON stated a potential negative outcome for failure to accurately inventory discontinued controlled medications prior to disposal would be that the medications could go missing and be unaccounted for. During an interview on 3/27/25 at 11:30 AM, the ADM stated she was not aware that discontinued controlled medications were not logged. She stated it was the responsibility of the DON to keep an inventory of discontinued controlled medications that were being stored for destruction. She stated her expectation of staff for logging discontinued controlled medications was to follow the facility's policy. The ADM stated a potential negative outcome for failure to accurately log discontinued controlled medications being stored for disposal would be missing medications. During a phone interview on 3/27/25 at 2:02 PM, the Clinical Consultant Pharmacist stated she was the pharmacist assigned to the facility and would be responsible for medication destruction during her visits. She stated discontinued controlled medications should be reconciled upon receipt then logged and stored for destruction, in order to maintain an accurate inventory while awaiting disposal. She stated her expectation upon entering the facility for drug destruction was that all controlled medications were logged. She stated her process for reconciliation of controlled medications prior to destruction was to check the DON's medication log against the count on the narcotic sheet and then against the actual quantity of the medication being stored. 2. During an observation of Medication Cart A with CMA C on 3/26/2024 at 10:13 AM, a bottle labeled Vitamin B-12 (an essential water-soluble vitamin that plays a crucial role in various bodily functions) 1,000 mcg Dietary Supplements, had an open date of 9-1-24 and an expiration date of 2/25, was found on the top drawer of the cart. During an interview with the DON on 3/26/2025 at 5:22 pm, she stated the DON, ADON and nurses were responsible for checking the medications carts for expired medications. She stated medication cart audits are done as well and the pharmacy consultants come out monthly and conducts cart checks as well. She stated the last audit was 3/25/2025 when the pharmacy consultant came out. She stated the potential negative outcome of expired medication being in the carts could be a negative reaction to the medication if used. She stated the nurses should be checking their carts daily. She stated the last training for the medications carts was in February 2025. During an interview with CMA C on 3/27/2025 at 9:54AM, she stated she had been trained on checking the carts but does not remember the last training they had. She stated they were told by the ADON's and DON to check the carts weekly and daily. She stated the potential negative outcome of having expired medication is the med cart is not having the same therapeutic effect needed if the expired medication is used. She stated she had the cart check recently and must have missed the expired bottle of medication. Record review of the facility's policy titled Discontinued Medications, from the Pharmacy Policy and Procedure Manual 2007, revised 01/24 revealed: Policy When medications are discontinued by prescriber order, a resident is transferred or discharged and does not take medication with him/her, or in the event of a resident's death, the medications are marked as discontinued and destroyed or returned the issuing pharmacy, if applicable per state regulations. Procedures . 2. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose and separate from active orders until destroyed or picked up by pharmacy staff. Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual(s) storing the medication, the strength of the medication and the date of disposition. . Record review of the facility's policy titled Disposal of Medications, from the Pharmacy Policy and Procedure Manual 2007, revised 01/24 revealed: Policy . 2. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations. . 4. Prior to return, disposal, movement to separate storage area for medications awaiting destruction or discharge to home with resident, medications should be documented on a disposition including the following information: a. Date of disposition b. Nurse's or other responsible person's initials or signature verifying the information c. Resident's name d. Name, strength, and form of medication e. Prescriber (Rx) number f. Quantity . Record review of the facility's policy titled Medication Access and Storage last revised 5/2007 revealed: .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists .

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 dietary services, in that: The facility failed to seal foods stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 03/25/25 at 09:58 AM during initial observation of the kitchen: Observed the following in the refrigerator: -[NAME] Slaw in plastic bag not sealed. -Lunch meat in plastic bag not sealed. During a follow up visit on 03/16/7 at 02:10 pm the following was observed: -Sliced cheese in plastic bag not sealed. During an interview on 03/26/25 at 02:15M with DM, she stated all food in the refrigerator should be sealed. She stated all staff were responsible for sealing food place in the refrigerator. She stated all staff have had proper training. She stated the potential negative outcome of not sealing food in refrigerator could affect the quality of the food. During an interview on 03/27/25 at 10:08 AM with the ADM, she stated all food placed in the refrigerator should be covered or sealed. She stated the DM was responsible for monitoring the refrigerator along with all dietary staff. She stated all staff had been trained. She stated the potential negative outcome could be food spoiling or cross contamination of food. Record review of the facility's undated policy, titled Food Storage, reflected the following: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner . 8. The dietary manager, or his/her designee will check refrigerators and freezers at least daily. Record review of the facility policy, titled Food, Sanitary Condition for, undated reflected the following: Procedures: 1. The facility will store, prepare, distribute, and serve food under sanitary conditions .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 20 residents (Resident #254 and Resident #5) reviewed for infection control. 1. LVN A failed to sanitize his hands between glove changes during wound care for Resident # 5. 2. CNA B failed to wear proper PPE when providing direct care for Resident #254 who was on Enhanced Barrier Precautions. These failures could place residents at risk for spread of infection and cross contamination. Findings included: 1. Record review of Resident #5's face sheet dated 03/26/25 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: psychotic disturbance (a collection of symptoms that affect the mind), major depressive disorder (mood disorder), atherosclerotic heart disease (the buildup of substances in the artery walls), hypertension (high blood pressure), and cognitive communication deficit (communication difficulty caused by cognitive impairment). Record review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 09, indicating the resident's cognition was moderately impaired. Record review of Resident #5's comprehensive care plan dated 02/12/25 revealed a focus area of: Resident has actual impairment to skin integrity on left foot 2nd toe and an intervention of: Monitor/document location, size and treatment of skin injury. Record review of Resident #5's current physician's orders revealed an order with a start date of 03/19/25 for wound care: Cleanse wound on second toe on left foot and apply dressing daily. During an observation on 03/26/25 at 9:40 AM of wound care for Resident #5, LVN A washed his hands, put on PPE, removed the dressing to Resident #5's left foot, and performed wound care according to physician's orders. LVN A changed gloves and applied a new dressing to Resident #5's left foot. LVN A removed his PPE and washed his hands. LVN A did not sanitize his hands between the glove change during wound care. During an interview on 03/26/25 at 4:05 PM, LVN B stated he did not sanitize his hands between glove changes during wound care for Resident #5. He stated he did not know why he skipped the step of sanitizing his hands. He stated, I even had a bottle of sanitizer in my cart and forgot to use it. LVN B stated hands should be sanitized before the wound care procedure, when gloves are changed, and after the procedure. He stated he was trained on proper hand hygiene through in-services conducted by nursing administration. LVN B stated a potential negative outcome of failure to perform hand hygiene between glove changes was cross-contamination and infection. 2. Record review of Resident #254's face sheet dated 03/26/25 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: cerebral palsy (congenital disorder of movement due to abnormal brain development), contracture of muscle (tightening of muscle that restricts normal movement), and cognitive communication deficit (communication difficulty caused by cognitive impairment). Record review of Resident #254's admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident's cognition was intact. Section M-Skin Conditions, revealed the resident had a stage 3 pressure ulcer and received treatment for pressure ulcer/injury care. Record review of Resident #254's comprehensive care plan dated 02/16/25 revealed the following wound care intervention: Use Enhanced Barrier Precautions. Record review of Resident #254's current physician's orders revealed an order with a start date of 03/26/25 to cleanse open areas to coccyx with wound cleanser and apply ointment daily. Further review revealed an order with a start date of 03/17/25 for Enhanced Barrier Precautions: PPE required for high resident contact care activities- every shift for wound care. Record review of sign on Resident #254's door revealed: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: . Changing Briefs or assisting with toileting During an observation on 03/26/25 at 10:06 AM of incontinent care for Resident #254, CNA B washed her hands, put on gloves, and performed incontinent care for the resident. Following the procedure, CNA B washed her hands and exited the room. Signage on Resident #254's door stated, Enhanced Barrier Precautions and a storage container with PPE was observed outside the resident's door. CNA B did not put on a gown prior to performing incontinent care for Resident #254. During an interview on 03/26/25 at 4:02 PM, CNA B stated she did not put on a gown prior to performing incontinent care for Resident #254. CNA B stated EBP required a staff member who was doing direct care to gown and glove up for the protection of the resident. She stated she should have put a gown on before performing incontinent care for Resident #254 because the resident had a wound. CNA B stated she made a mistake by not putting on a gown and she realized it after she had already started incontinent care. She stated she was trained on EBP approximately monthly through in-services conducted by the DON. CNA B stated a potential negative outcome for failure to wear PPE during direct care of a resident on EBP would be the spread of infection between residents. During an interview on 03/26/25 at 5:37 PM, the DON stated she was not aware staff were not performing hand hygiene between glove changes and were not utilizing PPE while performing direct care on residents on EBP. She stated hand hygiene should be performed before wound care, each time gloves were changed and following the wound care procedure. She stated any resident with non-intact skin or an invasive line, such as a urinary catheter, should be on EBP. The DON stated staff were trained on proper hand hygiene and on EBP through in-services, computer-based training and competency checks conducted by nursing administration. She stated a potential negative outcome for failure to follow hand hygiene protocol during wound care and failure to utilize proper PPE during direct care of a resident on EBP, would be cross-contamination and the spread of infection, including drug-resistant organisms. During an interview on 03/27/25 at 11:30 AM, the ADM stated she was not aware staff were not performing hand hygiene between glove changes and were not utilizing PPE while performing direct care on residents on EBP. She stated it was the DON's responsibility to assure staff were trained on proper hand hygiene and EBP. She stated her expectation of staff regarding hand hygiene and EBP was that staff follow policies at all times. The ADM stated a potential negative outcome for failure to observe proper hand hygiene and failure to follow EBP protocol would be infection and cross-contamination between residents. Record review of the facility's document titled, In-service Training Report and dated 03/11/25 with a subject of Hand Hygiene was conducted by the DON and signed by LVN A and seventeen other staff members. Record review of the facility's document titled, In-service Training Report and dated 03/11/25 with a subject of Infection Control was conducted by the DON and signed by CNA B and forty-four other staff members. Record review of the facility's policy titled, Hand Hygiene, revised 12/23 revealed: Policy It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. . Procedure 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . k. After handling used dressings, contaminated equipment, etc.; . m. after removing gloves Record review of the facility policy titled, Standard and Transmission-Based Precautions, revised 03/24 revealed: Policy It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Procedure 3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-resident. . a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices . -Wounds include, but are not limited to chronic wounds, pressure injuries . c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: . vi. Changing briefs or assisting with toileting .

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 20 residents (Residents #38) reviewed for advanced directives, in that: Residents #38's OOH-DNR form was missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Record review of Resident #38's face sheet, dated 03/27/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease (progressive disorder that causes narrowing or blocking of the blood vessels outside the heart), diabetes (high blood sugar), schizoaffective disorder (mental illness), and dementia (cognitive loss). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #38's physician order summary dated 03/27/25 revealed the following order: Code Status: DNR dated 08/28/24. Record review of Resident #38's care plan, dated 02/12/25, revealed care plan for DNR. Record review of Resident #38's Out of Hospital Do Not Resuscitate form dated 08/02/224 revealed no witness names or signature, or notary signature. Under the section, All persons who have signed above must sign below, revealed no witness or notary signature and no resident signature. During an interview on 03/27/25 at 09:59 AM with the DON, she stated the social worker was responsible for completing the OOH DNR form. She stated they did not have a social worker. She verified Resident #38's DNR did not have a witness or notary signature, and the signatures at the bottom of form was also not there. She stated an OOH DNR was not valid unless the form was completely filled out. She stated she had not been trained on how to complete an OOH DNR. She stated she was not aware the OOH DNR was incomplete. She stated they have not had time to do a complete audit of all DNR's since taking the building over on 02/01/25. She stated the potential negative outcome could be not having the proper documentation during an emergency or during a code. During an interview on 03/27/25 at 10:08 AM with the ADM, she stated the social worker and nursing staff were responsible for completing OOH DNRs. She stated they do not have a social worker. She stated the DON was responsible for validating the OOH DNR was complete. She stated she was not aware of any incomplete OOH DNR forms. She stated an OOH DNR was not valid if not completely filled out. She stated the potential negative outcome could be during an emergency they would not follow residents wishes if there was no appropriate documentation. Record review of the Out of Hospital Do Not Resuscitated (OOH-DNR) order Instructions for issuing an OOH-DNR order dated revised October 12, 2023, revealed the following: In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611, met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care. Findings include: Record review of the CASPER 3 (facility assessment report) during preparation for survey revealed a waiver for room size requirements had been done yearly by the facility. Record review of Room Size Wavier for Facilities dated 02/15/24, during preparation for survey, revealed a wavier for rooms #s 407, 602, 604, and 611. Record review of Texas Health and Human Services Form 3740 (Bed Classifications (Numbers and Location) dated 03/25/25 documented that rooms #'s 407 were listed as a Title 18/19 bed classification semi-private rooms for two residents. rooms [ROOM NUMBER] were listed as a Title 19 bed classification semi-private rooms for two residents. During an interview on 03/25/25 at 10:23 AM with the ADM regarding the square footage for room #'s 407, 602, 604 and 611. When asked if she wanted to continue the room wavier for the room size waiver, she stated, Yes, I want to continue the room waiver. The ADM stated room #'s 407, 602, 604, and 611 had a waiver in the past. She stated, the rooms are not being used at this time but will be used once they complete renovation and open the unit back up. During an observation on 03/25/25 from 1:00 PM to 1:30 PM, of the following rooms - 407,602, 604 and 611 revealed the rooms was not occupied. No policy was provided by the ADM. She stated they followed the regulation of life safety related to room size.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when the SW witnessed CNA A slap Resident #1 on the arm. An Immediate Jeopardy (IJ) situation was determined to have existed on 07/15/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to beginning of the survey. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Record review of Resident #1's face sheet, dated 08/15/24, revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility on 07/19/24. Resident #1 was admitted with the following diagnoses: autistic disorder (a condition that affects brain development), symptomatic epilepsy (uncontrollable movements), and bipolar disorder (mood disorder). Record review of Resident #1's Quarterly MDS dated [DATE], documented that Resident #1's cognitive skills for decision making were modified dependence - some difficulty in new situations only. According to the MDS, Resident #1 had physical behaviors directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1-3 days out of the 7 day week, Verbal behaviors directed towards others (e.g., threatening others, screaming at others, cursing at others) 1-3 days out of the 7 days week, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1-3 days out of the 7 day week. Record review of Resident #1s Care Plan undated, revealed Resident #1 had a focus area: I have the potential for episodes of adverse behaviors: Verbally aggressive: cursing, racial slurs, yelling/screaming and physically aggression: r/t explosive disorder. Date Initiated 12/04/23, Goal: I will remain injury free r/t adverse behaviors through next review date. Date Initiated: 12/04/23, Interventions: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression, Monitor for early warning signs of behavior - approach in calm manner, call by name, remove from unwanted stimuli to a safe environment. Date Initiated: 12/04/23. Record review of Resident #1's Progress notes dated 07/15/24 at 3:40 pm Type: Social Services Progress note: This writer observed CNA slap resident on arm. This writer notified administrator immediately. During an interview on 08/16/24 at 9:02 AM, the SW was asked about the incident regarding Resident #1 that happened on 07/15/24. The SW stated she was standing at the nurses station, which is also near the DON office. The SW stated CNA A was also standing at the nurses station at this time. The SW stated Resident #1 then came up to the nurses station and spit at CNA A. The SW stated she then saw CNA A swing her arm and slapped Resident #1's arm. The SW stated she immediately intervened and told CNA A that she could not do that, she could not slap the residents. The SW stated the CNA A replied to her, I'm sorry, I didn't mean to. It was just a reaction. The SW stated she then removed Resident #1 from CNA A and went straight to the DON's office because the ADM and DON were both in there at that time. The SW stated she told the ADM what happened and the ADM went out to speak to CNA A at that time. The SW stated the DON started doing a head to toe assessment on Resident #1. The SW stated she did not see CNA A on the floor anymore that shift and did not see her at the facility since this incident. The SW stated the facility received abuse training every 2 weeks, on pay days. The SW was able to verbalize the different forms of abuse and stated the ADM was the abuse coordinator at the facility. The SW stated an in-service was done by the DON or ADM the same day as the incident. During a phone interview on 08/16/24 at 9:12 AM, CNA A was asked about the incident between her and Resident #1 on 07/15/24. CNA A stated she was standing at the nurses station talking to the SW about another resident on 07/15/24, when she saw Resident #1 was going up to the nurses station. CNA A stated he went to the nurses station and spit at her. CNA A stated she raised her hand and slapped at his arm. CNA A stated, I didn't mean to. It was just a knee jerk reaction. CNA A stated the SW then told her she could not hit residents and told her to sit down at the nurses station. CNA A stated the SW then took Resident #1 with her to the DON's office and told the ADM what happened. CNA A stated she was immediately suspended by the ADM and then the ADM called her a few days later to let her know she could not go back to work at the facility. CNA A stated she received abuse training every two weeks, on pay days. CNA A stated she knows she is not allowed to slap residents. CNA A stated, I'm sorry. I did wrong. During a phone interview on 08/16/24 at 9:22 AM, Family member A stated the facility notified him of an incident between Resident #1 and CNA A. Family member A stated he was told CNA A hit Resident #1 on the arm after Resident #1 spit on her. Family member A stated he was told CNA A was terminated and that the facility was going to report the incident to the Health and Human Services Commissions to be investigated. During an interview on 08/16/24 at 9:34 AM, the DON stated he did not witness the incident between Resident #1 and CNA A on 07/15/24. The DON stated he was talking to the ADM in his office, which is near the nurses station, when the SW came in and told them she saw CNA A hit Resident #1. The DON stated the ADM suspended CNA A right away and he did an assessment on Resident #1, where no injuries were noted. The DON stated there were no other residents around the nurses station at this time. The DON stated Resident #1 was asked if he was ok, and he was calm. The DON stated he provided abuse training every two weeks on pay days, and remembers going over the in-service with CNA A on the previous pay day, 07/10/24, but was unsure if she signed the in-service document. The DON stated he expects staff to not take behaviors personally and to step away when getting frustrated with a resident. The DON stated an in-service was performed with staff regarding abuse and behaviors on 07/15/24. The DON stated CNA A was not allowed to return to work at the facility after this incident. Attempted phone interview on 08/16/24 at 12:01 PM with Resident #1 via group home House Manager phone number. This was the only phone number provided for the group home Resident #1 currently resides at. No answer. Left a voice message to call surveyor back with call back number provided. During an interview on 08/16/24 at 1:47 PM, the ADM stated she expects the facility to be abuse free and for staff to respect all residents and care for them in the best way possible, meeting every need. The ADM was asked about the incident between CNA A and Resident #1 on 07/15/24. The ADM stated she was talking with the DON in his office. The ADM stated the SW came in and advised them that Resident #1 had been removed from CNA A because CNA A slapped Resident #1. The ADM stated she immediately went out to speak with CNA A and tell her she was going to be suspended due to abuse allegations. The ADM stated she talked with the SW and called CNA A to terminate her employment at the facility. The ADM stated CNA A told her it was just a reaction. The ADM stated CNA A had worked at the facility for many years and had received many abuse trainings. The ADM stated it was her job to keep residents at the facility safe from abuse, so abuse in-services happened every pay day, which is every 2 weeks. The ADM stated safe surveys were done with other residents and a head-to-toe assessment was performed on Resident #1, which showed no injuries. The ADM stated an abuse in-service was started immediately following this incident. Record review of facility Inservice Form, dated 04/10/24, revealed: Subject: Abuse, Neglect and Use of Restraints 1. Remove resident or residents from the abuse situation immediately. 2. Report abuse allegation immediately to Administrator and or Charge Nurse if you do not report the abuse or alleged abuse, you are allowing this to happen and will be help responsible as well. 3. If you are not sure report it anyway to the ADM [phone number] CNA A's printed name and signature was observed on the in-service form. Record review of facility Inservice Form, dated 05/24/24, revealed: Subject: Abuse and Neglect You must notify the Administrator immediately if you: See abuse Hear abuse Suspect abuse Three types of abuse are: Physical Verbal Misappropriation CNA A's printed name and signature was observed on the in-service form. Record review of facility Inservice Attendance Record form, dated 06/25/24 revealed: Subject: .Abuse and Neglect CNA A's printed name and signature was observed on the in-service form. Record review of facility In-service Training Report form, dated 07/10/24, revealed: Topic: .Abuse/Neglect Contents or summary of training session: .Staff will not for any reason harm or treat any patient with the intent to harm. Patient will be treated with respect and dignity. Record review of facility In-Service Training Report form, dated 07/15/24, revealed: Topic: Abuse/Neglect Contents or summary of training session: No staff will use any type of physical force to cause injury or impairment, such as hitting, slapping, pinching, kicking, or force feeding. Staff shall not use nonverbal actions or words to cause distress or pain to residents, such as yelling, cursing, unwanted advances, yelling, neglect, sexual assault or emotional distress. Record review of facility Disciplinary Action Form, dated 07/15/24, revealed CNA A had suspected resident abuse. The nature of the offense was alleged physical abuse towards resident Action taken: Suspension, with suspension start date on 07/15/24. Record review of facility Separation Notice Form, dated 07/18/24, revealed CNA A received a separation notice due to Resident Abuse, signed and dated by CNA A on 07/18/24. Record review of facility policy titled, Abuse Prevention Program, with a revised date of 12/16, revealed the following: Policy Statement: Our residents have the rights to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . The ADM was notified on 08/16/24 at 1:45 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 07/15/24. The facility implement the following interventions: CNA A was immediately removed from the residents and placed on suspension. CNA A was terminated while on suspension and not allowed to return to the facility. The facility performed a head to toe assessment on Resident #1 and MD and family were notified of the incident. The facility began in-services regarding abuse with staff on 07/15/24.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #1 and #2) reviewed for infection control. 1. LVN A failed to change her gloves during wound care for Resident #1 after cleaning each wound. 2. LVN A failed to use proper handwashing technique for a minimum of 20 seconds during wound care for Resident #2. These failures could place residents at risk for infection and cross contamination. Findings included: Resident #1 Record Review of Resident #1's face sheet revealed a [AGE] year-old male with an admitted [DATE]. Residents #1 had a history of peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), dementia, type 2 diabetes, metabolic encephalopathy (problem with the brain cause by chemical imbalance in the blood), hypertension (high blood pressure), and muscle weakness. Record review of Resident #1's MDS Section C- Cognitive Patterns dated 10/23/2023 revealed a BIMS summary score of 04 which indicated resident had severely impaired cognition. MDS Section M- Skin Condition revealed Resident #1 had a risk for pressure ulcer/injury. Record review of physician orders for Resident #1 revealed the following wound care orders: - Wound care order initiated 4/9/2024 for the left hip: Clean with wound cleanser or NS . Pat dry with gauze. Pack with silver alginate rope, apply border gauze dressing daily, and as needed as needed for wound care. - Wound care order initiated on 3/06/2024 for the left ischium: Cleanse with Wound Cleanser or NS, pat dry with 4x4 gauze, pack with gauze saturated Dakin's solution 1/2 strength, cover with border gauze. - Wound care order initiated on 4/09/2024 for the chest: Clean with wound cleanser and pat dry with gauze. Apply Bactroban, cover with border quake dressing daily and as needed. Resident #2 Record review of Resident #2's face sheet revealed an [AGE] year-old female with an admitted [DATE]. Resident #2 had a history of Alzheimer's (brain disorder that slowly destroys memory), hyperlipidemia (elevated level of lipids), major depressive disorder, muscle weakness, and age-related physical debility. Record review of Resident #2' MDS Section C- Cognitive Patterns dated 2/26/2024 revealed no BIMS score which indicated resident is rarely/never understood. Section M- Skin conditions revealed resident was at risk for developing ulcers/injuries. ' Record review of resident #2's physician orders revealed a wound care order for the coccyx with a start date of 4/9/2024: cleanse area with wound cleanser, pat dry with gauze, apply calcium alginate and hydrocolloid dressing every other day, and prn as needed for wound care. During a wound care observation on 4/18/2024 at 11:00 AM, LVN A did not change her gloves and wash her hands after cleaning a wound on Resident #1's chest. LVN A applied a new wound dressing with contaminated gloves. During a wound care observation on 4/18/2024 at 11:10 AM LVN A did not change her gloves and wash her hands after cleaning a wound to Resident #1's left hip. LVN A applied a new wound dressing with contaminated gloves. During a wound care observation on 4/18/2024 at 11:14 AM LVN A did not change her gloves and wash her hands after cleaning Residents #1's left ischium (lower and back part of the hip bone) wound. LVN A applied a new wound dressing with contaminated gloves. During a wound care observation for Resident #2 on 4/18/24 at 2:23 PM LVN A was observed dispensing soap to the fingertips of her right hand, placing the dispensed soap under running water, and rubbing the fingertips of both hands together before rinsing. LVN A utilized approximately less than 10 seconds to wash her hands. LVN A donned clean gloves and removed a dirty dressing to Resident #2's coccyx. LVN A removed her soiled gloves and washed her hands in the sink for 12 seconds, dispensing soap to her fingertips, and washing only the fingertips of her hands. LVN A donned on clean gloves, applied a new dressing to the wound, removed her contaminated gloves, and washed her hands in the sink for 8 seconds, applying soap to her fingertips and washing only the fingertips of her hands. During an interview with LVN A on 04/18/2024 at 2:27PM, she stated she had been trained on handwashing many times. She stated handwashing should occur for a minimum of 20 seconds. She stated risk of not handwashing, or changing gloves can lead to a risk of infection for the resident. She stated the DON and the ADON do in-services on handwashing. She stated she was nervous and does not do wound care as she was PRN. During an interview with the DON on 4/18/2024 at 4:35 PM, he stated staff should perform handwashing before wound care begins, after removing soiled dressing, after cleaning the wound, and after applying a new dressing. He stated nurses should be changing gloves after removing a soiled dressing, and after cleaning the wound during wound care. The DON stated handwashing should occur for a minimum of 20 seconds. He stated there should be enough soap to cover both hands and create a lather. He stated the negative consequences for improper handwashing and glove changes could be infection risk spreading from one resident to another and spreading infection to the staff. He stated he does the training for handwashing yearly but will implement in-services twice a month. He stated the last handwashing in-service was 2/14/2024. The DON stated he conducts random observations throughout the facility and utilizes facility cameras to monitor for handwashing compliance. He stated he was not aware of staff not following facility policy for handwashing. During an interview with ADM on 4/18/2024 at 5:03 PM, she stated staff should wash their hands before wound care, after wound care, or any time between glove changes. She stated nurses should change gloves during wound care after cleaning the wound. She stated handwashing should occur for 20 seconds with enough soap to wash both hands entirely and between each finger, after rinsing, utilizing paper towels to dry their hands, and to turn off the faucet. She stated the negative consequence of improper handwashing is spreading infection. The ADM stated the DON was responsible for training on handwashing. She stated she began an in-service 4/18/2024 and the last one was 2/14/2024. She stated the DON was the infection preventionist and he monitors for compliance. She stated she believed staff was following handwashing policy and utilizing their nursing knowledge. She stated LVN A had been trained on infection control upon hire on 3/18/2024 and this was her 3rd shift at the facility. Record review of Handwashing Policy revised December 2009 revealed . Policy interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. .5. Employees must wash their hands for at least 15 seconds using antimicrobial soap and water under the following conditions: 7 .K. Before and after changing a dressing .R. After handling soiled or used linens, dressings . Procedure Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Record review of Infection control Guidelines for All nursing procedures revised August 2012 revealed . General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin and/or mucous membranes. 3. Employees must wash their hands for 10- 15 seconds using antimicrobial soap and water. 4.Alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations. .e. Before moving from a contaminated body site to a clean body site during resident care. Record review of Internet CDC Handwashing Guidelines titled Hand Hygiene in the Healthcare Setting last revised January 1, 2018, revealed: The CDC Guideline for Hand Hygiene in Healthcare Settings recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. . Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse for 4 of 6 residents (Resident #1, Resident #2, Resident #3, and Resident #5), reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A was witnessed by CNA B, by using force to hold down combative residents (Resident #1, and Resident #5). The facility failed to ensure a safe environment free from abuse for Resident #2 and Resident #3 when Resident stated that CNA A physically and verbally abused her. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. While the IJ was removed on 09/11/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with diagnoses which included: Parkinson's Disease (disorder of the central nervous system that affects movements, often including tremors), neurocognitive disorder with Lewy bodies (a disease associated with abnormal deposits of a protein called alpha synuclein in the brain), dementia, muscle weakness, restlessness and agitation, schizoaffective disorders, intellectual disabilities. Record review of Resident #1's Significant Change in Status MDS dated [DATE] documented that Resident #1's BIMS was a 10/15, meaning moderately impaired cognition. According to the MDS, Resident #1 is listed to not having any change in mental status listed for disorganized thinking, for altered level of consciousness behavior is present and fluctuates. Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually , verbal behavioral symptoms directed toward others such as, threatening others, screaming at others, cursing at others, other behavioral symptoms not directed towards others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #1 was not listed as showing behaviors for refusing care. Resident #1 needs supervision with bed mobility such as moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture such supervision would include: oversight, encouragement, or cueing. Resident #1 needs supervision for transfers and is listed as total dependent with a two person assist. Resident #1 is listed as not being steady and only able to stabilize with staff assistance during transitions and walking, this includes moving from seated to standing position, walking, surface to surface transfers. Resident #1 uses a wheelchair. Record review of Resident #1s Care Plan dated 08/01/2023 revealed Resident #1 had episodes of adverse behaviors of being physically aggressive; hitting, pinching, kicking, staff and resistive to care. Interventions: administer meds per order (updated 09/07/2023), anticipate behaviors and redirect when in close proximity to others that might invoke aggression (updated 09/07/2023), assess for pain (updated 09/07/2023), ensure family and MD aware of behaviors and or any increase in behaviors noted (updated on 09/07/2023), maintain calm environment (updated 09/07/2023), medication regimen review quarterly and PRN after any resident to resident behavior event (updated on 09/07/2023), monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli to a safe environment (updated on 09/07/2023), behaviors include hitting, being resistive to care, refusing food (updated 09/07/2023). Record review of Resident #1s Care Plan dated 07/24/2023 and a revision date of 09/07/2023 indicated Resident #1 had a potential for injury with a history of falls and is at risk for further falls with safety interventions. Interventions: administer meds as ordered, monitor labs, report abnormalities to MD, avoid use of restraints, bed in low position at all times, educated on noncompliance with safety interventions and explain possible risks/outcomes due to noncompliance issues, enlist family input regarding fall history and possible factors to help decrease; falls, ensure staff is aware of safety needs of the resident, fall mat at bedside at all times, keep personal items and frequently used items within reach. Record Review of Resident 1's Physician Order, dated 06/20/2023, revealed: Donepezil HCI oral tablet 5 mg for confusion. Resident 1's Physician Order dated 06/20/2023 Olanzapine oral tablet 5 mg for behaviors related to other schizoaffective disorders. Record Review of Resident #1's Progress notes dated 09/07/2023 at 5:40 pm and indicated incident date as of 08/30/2023, signed by RN revealed: Resident sister came to the nurse's station and asked CN if she knew why her brother had a black eye. CN immediately went to assess. Upon entering resident room CN noted right eye swollen shut with a small cut present to mid eyebrow with scanty amount of dry blood. [NAME] peri-orbital ecchymosis also noted. CN proceeded to perform a general assessment right eyebrow cleaned with NS. Resident #2: Record Review of Resident #2's face sheet documented she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmitted [DATE]. Resident #2 was admitted with diagnoses which included: dementia, anxiety, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), schizoaffective disorder, major depressive disorder, type 2 diabetes, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), bipolar disorder, high blood pressure, and acid reflux. Record review of Resident #2's Admission MDS dated [DATE] documented that Resident #2's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #2 has no difficulty in normal conversation, social interaction, or watching tv. Resident #1 is listed to not showing a change in mental status, disorganized thinking, or altered level of consciousness. Resident #2 did not exhibit behaviors such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #2 did not exhibit the behaviors of rejecting care. Resident #2 uses a wheelchair and has no upper and lower body extremity impairment. Resident #2 shows to need supervision for transfers such as bed mobility and transfers meaning oversight, encouragement, or cueing. Resident #2 is listed as not being steady when walking, surface to surface transfers and needs supervision but is able to stabilize without assistance. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had cognitive impairment with diagnosis of intellectual disability with impaired ability to make decision and is at risk for impaired communication and impaired safety awareness. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had a diagnosis of major depressive disorder and bipolar and is at risk for fluctuations in mood, little interest, or pleasure in doing things, and decreased socialization. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had episodes of anxiety and is at risk for fluctuation in moods, currently taking buspirone. Record review of Resident #2s Care Plan date revised 08/01/2023 revealed Resident #2 had episodes of adverse behaviors of being verbally and physically aggressive; hitting, pinching, kicking, staff and resistive to care. Record Review of Resident #2s Physician Orders dated 07/14/2023, revealed: Wellbutrin XL Oral tablet Extended Release 24-hour 300 mg, give 1 tablet by mouth one time a day for depression. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: dementia, acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), schizoaffective disorder, major depressive disorder, muscle weakness, tremor, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperthyroidism (is the production of too much thyroxine hormone), anxiety, drug induced dyskinesia (an involuntary movement disorder), insomnia, high blood pressure, pain in joint, overactive bladder. Record review of Resident #3's Admission MDS dated [DATE] documented that Resident #3's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #3 has moderate difficulty-speaker and must increase volume and speak distinctly. Resident #3 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #3 did not exhibit behaviors of rejecting care. Resident #3 uses a wheelchair and has no upper and lower body extremity impairment. Resident #3 shows a need of extensive assistance with resident involvement and staff to provide weight-bearing support for bed mobility, walking in room, and locomotion on unit, needing two people assist and resident highly involved in activity. Resident #3 is listed as not steady and only able to stabilize with staff assistance. Resident #3 is listed as not capable of increased independence. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had episodes of anxiety and at risk for fluctuation in moods. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had a diagnosis of major depression/schizoaffective disorder and am at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization. Record review of Resident #3s Care Plan date revised 08/15/2023 revealed Resident #3 had impaired understanding and reasoning for expressing information needs: ability is limited to making concrete requests. Resident #4: Record Review of Resident #4's face sheet documented she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: type 2 diabetes, cardiac arrhythmias, muscle weakness, abnormalities of gait, gout, anemia, bipolar disorder, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in your blood), manic episode, rheumatoid arthritis, acid reflux, enlarged prostate, pseudobulbar affect (pathological laughing and crying), polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body. Record review of Resident #4's Annual MDS dated [DATE] documented that Resident #4's BIMS was a 15/15, meaning intact cognition. Resident #4 is not listed as showing a change in mental status for disorganized thinking and altered level of consciousness and disorganized thinking. Resident #4 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #4 is listed for significantly disrupt care or living environment, meaning would disrupt care of living environment. Resident #4 is listed as showing rejection of care for 1-3 days. Resident #4 is shows total dependence for bed mobility and transfers with wheelchair, standing position, and locomotion on the unit with setup only. Resident #4 uses a wheelchair and has impairment with lower extremities but no impairment for upper extremities. Resident #4 is listed as steady, but able to stabilize without staff assistance for walking and transfers between bed and wheelchair. Resident #4 is listed as not being capable of increased independence. Record review of Resident #4s Care Plan date revised 05/03/2023 revealed Resident #4 had a mood problem with disease process of bipolar disorder and manic episode. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 had cognitive impairment: memory problems: diagnosis of bipolar disorder and pseudobulbar affect (pathological laughing and crying), impaired mobility to make decisions and is at risk for impairment safety awareness. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 is at risk for adverse consequences with receiving psychotropic medications Klonopin, and multiple med use due to nine or more medications. Record review of Resident #4s Care Plan date revised 08/14/2023 revealed Resident #4 had episodes of adverse behaviors. Inappropriate behavior. Resident with multiple urinals and multiple water pitchers in room at bedside. Resident adamant regarding removal of pitcher and urinal removal. Does not want pitchers and urinal to be removed. Resident with verbal outburst with nursing staff. Record review of Resident #4s Care Plan date revised 08/04/2023 revealed Resident #4 had problematic demeanor in which resident acts out characterized by ineffective coping, verbal/physical, aggression related to anger. Resident #5: Record Review of Resident #5's face sheet documented she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 was admitted with diagnoses which included: Alzheimer's Disease, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), overactive bladder, iron deficiency, major depression, macular degeneration (an eye disease that causes vision loss), high blood pressure, pain in unspecified joint, muscle weakness, reduced mobility. Record review of Resident #5's Quarterly MDS dated [DATE] documented that Resident #5's BIMS was a 99, meaning the resident interview was not successful. Resident #5 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #5 usually understands-misses some part-intent of message but comprehends most conversation. Resident #5 has the ability to recall memory after 5 minutes and 5 could recall long past. Resident #5 is moderately impaired-decisions poor, cues/supervision required for decision making. Resident #5 does show the behavior is present and fluctuates for inattention, disorganized thinking or incoherent. Resident #5 does not show altered level of consciousness. Resident #5 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #5 did exhibit the behavior of rejecting care for 1-3 days. Resident #5 shows the need for extensive assistance with one person assist for bed mobility and transfers but is listed as limited assistance with one person assist for locomotion on the unit. Resident #5 uses a wheelchair and shows no upper or lower extremity impairment. Resident #5 is listed as steady, but able to stabilize without staff assistance for walking and surface to surface transfers. Record review of Resident #5s Care Plan date revised 03/03/2023 revealed Resident #5 had a cognitive impairment, memory problems short/long term diagnosis of dementia and impaired safety awareness. Record review of Resident #5s Care Plan date revised 08/03/2023 revealed Resident #5 had a diagnosis of depression/mood disorder and is at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization, currently receiving Remeron. During an interview on 09/06/2023 at 3:09 pm, DON stated that for Resident #1 that she heard about the black eye the morning of 08/30/2023. DON stated that she thought it was a fall because Resident #1 has a history of falls. DON stated that resident #1 wasn't found on the floor or anything, he was found in bed. DON stated that they did not report because it was an unwitnessed fall. When asked if that is considered an injury of unknown origin, DON shook her head and stated, your right it is considered injury of unknown origin. When asked why it was not reported, DON stated they were thinking that it was just a fall. DON stated, your right we should have reported and didn't. DON stated that she was not in the facility at the time of the incident. DON stated that she is just helping out in the facility for a while. DON stated that the ADON had more details about the incident because it was reported to her, and she was not at work today. During an interview on 09/06/2023 at 4:15 pm, Administrator stated that with Resident #1 she believed that he had a fall. Administrator stated that Resident #1 had a history of falls. Administrator stated that Resident #1 was found in bed and was not found on the floor. Administrator stated that she did not report the black eye for Resident #1 because she did not know about it. Administrator stated that she did not report when she had found out because she thought it was an unwitnessed fall. Administrator stated she guessed she should have reported and will go ahead and do that since she believed it to be an unwitnessed fall. Administrator stated she was not told it was a fall, Resident #1 just had a history of it. Administrator stated that she heard about Resident's black eye after the meeting the morning of 08/30/2023 by DON. During an interview on 09/07/2023 at 3:25 pm, CNA B stated that she had witnessed abuse recently. CNA B stated that she did report to the ADON that she had witnessed CNA A being rough with residents while providing care. CNA B stated that while working with CNA A she witnessed CNA A hold Resident #1 down by holding his arms down with CNA A body weight and the residents would fight C CNA B stated that she witnessed CNA A being aggressive when he would hold the residents down. CNA B stated that CNA A would hold down the resident's that would fight him. CNA B stated that she witnessed the resident would try and get up from CNA A holding them down and CNA A would not let them up. CNA B stated that Resident #1 is not the only resident that she witnessed CNA A holding down when they don't want to be held down. CNA B stated that she also witnessed CNA A being rough and holding down Resident #5 and Resident #6. CNA B stated that the resident would fight CNA A to get him off them. CNA B stated that when she reported the abuse to the ADON she was told to provide a statement, but she had forgotten to write a statement because she was tired. CNA B stated that she reported to the ADON after a meeting that staff had that was due to Resident #1 coming up with an unexplained black eye on CNA A's shift. CNA B stated that she did not intervene to stop CNA A because she was scared of CNA A, but she did report to the ADON. Interview with on 09/07/2023 at 4:26 pm, CNA C reported that she heard CNA A verbally abusing Resident #2 approximately 3 weeks ago. CNA C stated that CNA A was calling Resident #2 names and telling her to shut up and called her stupid and ugly. CNA C stated that she reported the incident to the ADON. CNA C stated that she could tell it bothered Resident #2 because she looked upset. CNA C stated that CNA A showed no interest in wanting to be there most of the time. CNA C stated that CNA A would get mad if he had to answer the call lights. During an interview on 09/07/2023 at 5:00 pm, RN stated that she has always known CNA A to have a bad attitude towards the residents and others. RN stated that she has heard by other staff members that CNA A would be rough with resident's by grabbing and yanking on their arms. RN stated that she did not report what she had heard to anyone because she did not see it. RN stated that she had worked the night shift on 08/30/2023 and then next morning she was made aware by a family member that Resident #1 had a black eye. RN stated on this shift CNA A was working. RN stated that while she was assessing Resident #1 that Resident #4 had stated to RN that CNA A needed to be watched because when CNA A comes into change Resident #1, Resident #4 would hear a lot of rustling around and that Resident #1 acts scared around CNA A. RN stated that she was the nurse on shift working that night and she was not aware of any falls for Resident #1. RN stated that he was found in bed with a black eye. RN stated she did not remember seeing the black eye any time before that day. During an Interview on 09/07/2023 at 5:17 pm, Resident #2 stated that she had a problem with CNA A because he was mean. Resident #2 stated she thinks it was because he does not like her. Resident #2 stated that CNA A told her that she complains too much. Resident #2 stated that a couple of weeks ago that she had a bag of trash in her hand, and she was walking with her walker toward the door and CNA A was walking towards her and got in front of her. Resident #2 stated that CNA A told her, You better not put that trash in the hall. Resident #2 stated that she told CNA A that she was going to go throw it away. Resident #2 stated that CNA A grabbed the bag of trash out of her hand aggressively and then threw it back at her. Resident #2 stated CNA A called her stupid when he threw the trash at her. Resident #2 stated that on other occasions CNA A would tell her to shut up and stop pressing on the call light so much and he would hold her arms down roughly when he said it. Resident #2 stated that CNA A had called her stupid before. Resident #2 stated that she had told the ADON and Administrator and was told by both of them that it would be taken care of, but CNA A was still mean to her. Resident #2 stated she was scared of CNA A, and she didn't like having to rely on him for help. During an Interview on 09/07/2023 at 5:33 pm, Resident #3 stated that she had a few staff members that she didn't care too much for because they were rude, but one staff member would call her names and hold her down when she didn't want care. Resident #3 stated that CNA A would tell her that she was the one in the bed needing help when she would use the call lights to get help. Resident #3 stated that CNA A had said Shut up stupid bitch. Resident #3 stated that she did get tired of the name calling so she started lashing out at CNA A verbally back at him. Resident #3 stated he made her upset and felt bad. Resident #3 stated that she had dealt with abuse in her younger days, so she knows what abuse is and CNA A was abusive. Resident #3 stated that people are there to get help not to be treated like animals. Resident #3 stated that she reported to the nursing staff about the incidents, but nothing ever changed. Resident #3 stated that CNA A continued to treat her like that. During an interview 09/07/2023 at 6:00 pm, CNA A stated that he had not witnessed any form of abuse or neglect. CNA A stated that he had been trained in abuse and neglect by in-services and these trainings occur approximately every three to four months. CNA A stated that the 5 types of abuse are: physical, emotional, sexual, verbal, and financial. CNA A stated that he is unsure why people would say that he is abusive when he's not. CNA A stated that he cannot control what other people say. CNA A stated that would handle difficult behaviors by redirecting and coming back to try to work with resident again after cooling off period. CNA A stated that he never held anyone down unless they were hitting him, and he just held them into place until they stopped hitting and then would let them go. CNA A stated that he did not feel that this is a restraint. CNA A stated that he has never been physically or verbally abusive. CNA A stated that he does not work a designated hall, that all staff just work all halls, and they help each other out. CNA A stated that he did work nights for a while but did not like it so he moved to days. During an interview 09/08/2023 at 10:59 am, ADON stated that Resident #1 did not have a fall. ADON stated that they believed that Resident #1 had a fall at the time because he had a history of falls. ADON stated she was unsure if investigation was completed. ADON stated that she had been told by other staff members before that CNA A would hold down combative residents. ADON stated that she was told by some of the staff that CNA A would cross the resident's arms across their chest and then he would hold down the resident. ADON stated that she did not report this to the abuse coordinator (Administrator) because at that point it is just hearsay. ADON stated that she would report if the staff completed a written statement. ADON stated, I don't think that he was hurting the resident. ADON stated how else are you supposed to keep from getting hit by a resident? ADON stated she was unsure of what the policy stated about dealing with combative residents. ADON stated she would deal with combative behaviors by redirecting, walking away for a little bit if the resident was still combative, or get some help from another staff to see if the resident would respond differently to another staff. When asked if policy indicated that Resident could be held down, ADON stated, No, I don't think it says that. When asked ADON if it is considered a restraint to hold a resident down, ADON responded, Yeah, I guess it is. During an Interview 09/08/2023 at 11:19 am, Resident #4 stated that he did not witness his roommate Resident #1 being held down, but he could hear a lot of rustling around when CNA A would provide care. Resident #4 stated that he knew it was CNA A because he knows his voice. Resident #4 stated that he would hear a lot of banging, hitting the wall, and the resident groaning like he was hurting, and you could tell he was being hurt. Resident #4 stated that during the day when he was up and about that when CNA A would come around then Resident #1 would show fear by trying to move away from CNA A and just the fear in his eyes. Resident #4 stated you can see fear in someone. Resident #4 stated that CNA A was not the friendliest person and would get agitated easily. Resident #4 stated he would hear CNA A say stay still in a stern voice and hear all the rustling around. Resident #4 stated he was behind the curtain and could not easily get up to check what was going on. Resident #4 stated that he did tell the RN about this situation and to watch out for CNA A. During an interview 09/08/2023 at 4:28 pm. Administrator stated that she had heard from other staff members of CNA A holding down residents, but she thought that it was because the other staff didn't like CNA A. Administrator stated that she had not witnessed CNA A hold down residents. Administrator stated that Resident #3 did tell her that CNA A was calling her names. Administrator stated that Resident #3 would say things to CNA A like, You probably have a small penis. Administrator stated that she did not get any other reports from any other residents. Administrator stated that if you can't hold the residents, then how are you supposed to control when they are fighting you? Administrator stated she is not sure what the policy says, and she will have to read it to see what it says. Administrator stated that she has heard complaints from Resident #3 about CNA A, but she believes that she does not like him. Record Review of the facility provided policy revised on 12/2016, labeled, Abuse Prevention Program, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abusee prevention, the administration will: 1. Protect our residents by anyone including but not necessarily limited to: facility staff, other resident's, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid out facility in preventing abuse, neglect, or mistreatment of our residents. 5. Implement measures to address factors that may lead to abusive situations, for example: B). Instruct staff regarding appropriate ways to address interpretive conflicts. Record Review of the facility provided policy revised on 07/2017, labeled, Abuse and Neglect-Clinical Protocol, revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include A). Injury assessment, B). pain assessment, C) Current behavior, D). Patient's age and sex, E). All current medications, F). Other platelet inhibitors, G). Vital Signs, H). Behavior over the last 24 hours, I). History of any tendency towards bruising, J). All active diagnosis, K). Any recent labs. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the physician, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Record Review of CNA A Work Schedule for the dates following: 08/29/2023-09/06/2023, revealed: 08/29/2023: In Day: 05:56 pm, out lunch: 00:01 am, In-Lunch: 01:02 am, Out Day: 06:25 am: (11:46) 09/01/2023 [TRUNCATED]

Based on Interview and Record Review the facility failed to thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment, while the investigation is in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State Law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Residents affected by allegations of abuse were 4 out of 6 residents reviewed for abuse and neglect. (Resident #1, Resident #2, Resident #3 and Resident #5). The facility failed to investigate and report allegations of abuse for Resident #1, Resident #2, and Resident #3 and Resident #5. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. While the IJ was removed on 09/11/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings Include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with diagnoses which included: Parkinson's Disease (disorder of the central nervous system that affects movements, often including tremors), neurocognitive disorder with Lewy bodies (a disease associated with abnormal deposits of a protein called alpha synuclein in the brain), dementia, muscle weakness, restlessness and agitation, schizoaffective disorders, intellectual disabilities. Record review of Resident #1's Significant Change in Status MDS dated [DATE] documented that Resident #1's BIMS was a 10/15, meaning moderately impaired cognition. According to the MDS, Resident #1 is listed to not having any change in mental status listed for disorganized thinking, for altered level of consciousness behavior is present and fluctuates. Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually , verbal behavioral symptoms directed toward others such as, threatening others, screaming at others, cursing at others, other behavioral symptoms not directed towards others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #1 was not listed as showing behaviors for refusing care. Resident #1 needs supervision with bed mobility such as moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture such supervision would include: oversight, encouragement, or cueing. Resident #1 needs supervision for transfers and is listed as total dependent with a two person assist. Resident #1 is listed as not being steady and only able to stabilize with staff assistance during transitions and walking, this includes moving from seated to standing position, walking, surface to surface transfers. Resident #1 uses a wheelchair. Record review of Resident #1s Care Plan dated 08/01/2023 revealed Resident #1 had episodes of adverse behaviors of being physically aggressive; hitting, pinching, kicking, staff and resistive to care. Interventions: administer meds per order (updated 09/07/2023), anticipate behaviors and redirect when in close proximity to others that might invoke aggression (updated 09/07/2023), assess for pain (updated 09/07/2023), ensure family and MD aware of behaviors and or any increase in behaviors noted (updated on 09/07/2023), maintain calm environment (updated 09/07/2023), medication regimen review quarterly and PRN after any resident to resident behavior event (updated on 09/07/2023), monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli to a safe environment (updated on 09/07/2023), behaviors include hitting, being resistive to care, refusing food (updated 09/07/2023). Record review of Resident #1s Care Plan dated 07/24/2023 and a revision date of 09/07/2023 indicated Resident #1 had a potential for injury with a history of falls and is at risk for further falls with safety interventions. Interventions: administer meds as ordered, monitor labs, report abnormalities to MD, avoid use of restraints, bed in low position at all times, educated on noncompliance with safety interventions and explain possible risks/outcomes due to noncompliance issues, enlist family input regarding fall history and possible factors to help decrease; falls, ensure staff is aware of safety needs of the resident, fall mat at bedside at all times, keep personal items and frequently used items within reach. Record Review of Resident 1's Physician Order, dated 06/20/2023, revealed: Donepezil HCI oral tablet 5 mg for confusion. Resident 1's Physician Order dated 06/20/2023 Olanzapine oral tablet 5 mg for behaviors related to other schizoaffective disorders. Record Review of Resident #1's Progress notes dated 09/07/2023 at 5:40 pm and indicated incident date as of 08/30/2023, signed by RN revealed: Resident sister came to the nurse's station and asked CN if she knew why her brother had a black eye. CN immediately went to assess. Upon entering resident room CN noted right eye swollen shut with a small cut present to mid eyebrow with scanty amount of dry blood. [NAME] peri-orbital ecchymosis also noted. CN proceeded to perform a general assessment right eyebrow cleaned with NS. Resident #2: Record Review of Resident #2's face sheet documented she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmitted [DATE]. Resident #2 was admitted with diagnoses which included: dementia, anxiety, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), schizoaffective disorder, major depressive disorder, type 2 diabetes, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), bipolar disorder, high blood pressure, and acid reflux. Record review of Resident #2's Admission MDS dated [DATE] documented that Resident #2's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #2 has no difficulty in normal conversation, social interaction, or watching tv. Resident #1 is listed to not showing a change in mental status, disorganized thinking, or altered level of consciousness. Resident #2 did not exhibit behaviors such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #2 did not exhibit the behaviors of rejecting care. Resident #2 uses a wheelchair and has no upper and lower body extremity impairment. Resident #2 shows to need supervision for transfers such as bed mobility and transfers meaning oversight, encouragement, or cueing. Resident #2 is listed as not being steady when walking, surface to surface transfers and needs supervision but is able to stabilize without assistance. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had cognitive impairment with diagnosis of intellectual disability with impaired ability to make decision and is at risk for impaired communication and impaired safety awareness. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had a diagnosis of major depressive disorder and bipolar and is at risk for fluctuations in mood, little interest, or pleasure in doing things, and decreased socialization. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had episodes of anxiety and is at risk for fluctuation in moods, currently taking buspirone. Record review of Resident #2s Care Plan date revised 08/01/2023 revealed Resident #2 had episodes of adverse behaviors of being verbally and physically aggressive; hitting, pinching, kicking, staff and resistive to care. Record Review of Resident #2s Physician Orders dated 07/14/2023, revealed: Wellbutrin XL Oral tablet Extended Release 24-hour 300 mg, give 1 tablet by mouth one time a day for depression. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: dementia, acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), schizoaffective disorder, major depressive disorder, muscle weakness, tremor, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperthyroidism (is the production of too much thyroxine hormone), anxiety, drug induced dyskinesia (an involuntary movement disorder), insomnia, high blood pressure, pain in joint, overactive bladder. Record review of Resident #3's Admission MDS dated [DATE] documented that Resident #3's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #3 has moderate difficulty-speaker and must increase volume and speak distinctly. Resident #3 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #3 did not exhibit behaviors of rejecting care. Resident #3 uses a wheelchair and has no upper and lower body extremity impairment. Resident #3 shows a need of extensive assistance with resident involvement and staff to provide weight-bearing support for bed mobility, walking in room, and locomotion on unit, needing two people assist and resident highly involved in activity. Resident #3 is listed as not steady and only able to stabilize with staff assistance. Resident #3 is listed as not capable of increased independence. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had episodes of anxiety and at risk for fluctuation in moods. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had a diagnosis of major depression/schizoaffective disorder and am at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization. Record review of Resident #3s Care Plan date revised 08/15/2023 revealed Resident #3 had impaired understanding and reasoning for expressing information needs: ability is limited to making concrete requests. Resident #4: Record Review of Resident #4's face sheet documented she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: type 2 diabetes, cardiac arrhythmias, muscle weakness, abnormalities of gait, gout, anemia, bipolar disorder, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in your blood), manic episode, rheumatoid arthritis, acid reflux, enlarged prostate, pseudobulbar affect (pathological laughing and crying), polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body. Record review of Resident #4's Annual MDS dated [DATE] documented that Resident #4's BIMS was a 15/15, meaning intact cognition. Resident #4 is not listed as showing a change in mental status for disorganized thinking and altered level of consciousness and disorganized thinking. Resident #4 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #4 is listed for significantly disrupt care or living environment, meaning would disrupt care of living environment. Resident #4 is listed as showing rejection of care for 1-3 days. Resident #4 is shows total dependence for bed mobility and transfers with wheelchair, standing position, and locomotion on the unit with setup only. Resident #4 uses a wheelchair and has impairment with lower extremities but no impairment for upper extremities. Resident #4 is listed as steady, but able to stabilize without staff assistance for walking and transfers between bed and wheelchair. Resident #4 is listed as not being capable of increased independence. Record review of Resident #4s Care Plan date revised 05/03/2023 revealed Resident #4 had a mood problem with disease process of bipolar disorder and manic episode. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 had cognitive impairment: memory problems: diagnosis of bipolar disorder and pseudobulbar affect (pathological laughing and crying), impaired mobility to make decisions and is at risk for impairment safety awareness. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 is at risk for adverse consequences with receiving psychotropic medications Klonopin, and multiple med use due to nine or more medications. Record review of Resident #4s Care Plan date revised 08/14/2023 revealed Resident #4 had episodes of adverse behaviors. Inappropriate behavior. Resident with multiple urinals and multiple water pitchers in room at bedside. Resident adamant regarding removal of pitcher and urinal removal. Does not want pitchers and urinal to be removed. Resident with verbal outburst with nursing staff. Record review of Resident #4s Care Plan date revised 08/04/2023 revealed Resident #4 had problematic demeanor in which resident acts out characterized by ineffective coping, verbal/physical, aggression related to anger. Resident #5: Record Review of Resident #5's face sheet documented she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 was admitted with diagnoses which included: Alzheimer's Disease, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), overactive bladder, iron deficiency, major depression, macular degeneration (an eye disease that causes vision loss), high blood pressure, pain in unspecified joint, muscle weakness, reduced mobility. Record review of Resident #5's Quarterly MDS dated [DATE] documented that Resident #5's BIMS was a 99, meaning the resident interview was not successful. Resident #5 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #5 usually understands-misses some part-intent of message but comprehends most conversation. Resident #5 has the ability to recall memory after 5 minutes and 5 could recall long past. Resident #5 is moderately impaired-decisions poor, cues/supervision required for decision making. Resident #5 does show the behavior is present and fluctuates for inattention, disorganized thinking or incoherent. Resident #5 does not show altered level of consciousness. Resident #5 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #5 did exhibit the behavior of rejecting care for 1-3 days. Resident #5 shows the need for extensive assistance with one person assist for bed mobility and transfers but is listed as limited assistance with one person assist for locomotion on the unit. Resident #5 uses a wheelchair and shows no upper or lower extremity impairment. Resident #5 is listed as steady, but able to stabilize without staff assistance for walking and surface to surface transfers. Record review of Resident #5s Care Plan date revised 03/03/2023 revealed Resident #5 had a cognitive impairment, memory problems short/long term diagnosis of dementia and impaired safety awareness. Record review of Resident #5s Care Plan date revised 08/03/2023 revealed Resident #5 had a diagnosis of depression/mood disorder and is at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization, currently receiving Remeron. During an interview on 09/06/2023 at 3:09 pm, DON stated that for Resident #1 that she heard about the black eye the morning of 08/30/2023. DON stated that she thought it was a fall because Resident #1 has a history of falls. DON stated that resident #1 wasn't found on the floor or anything, he was found in bed. DON stated that they did not report because it was an unwitnessed fall. When asked if that is considered an injury of unknown origin, DON shook her head and stated, your right it is considered injury of unknown origin. When asked why it was not reported, DON stated they were thinking that it was just a fall. DON stated, your right we should have reported and didn't. DON stated that she was not in the facility at the time of the incident. DON stated that she is just helping out in the facility for a while. DON stated that the ADON had more details about the incident because it was reported to her, and she was not at work today. During an interview on 09/06/2023 at 4:15 pm, Administrator stated that with Resident #1 she believed that he had a fall. Administrator stated that Resident #1 had a history of falls. Administrator stated that Resident #1 was found in bed and was not found on the floor. Administrator stated that she did not report the black eye for Resident #1 because she did not know about it. Administrator stated that she did not report when she had found out because she thought it was an unwitnessed fall. Administrator stated she guessed she should have reported and will go ahead and do that since she believed it to be an unwitnessed fall. Administrator stated she was not told it was a fall, Resident #1 just had a history of it. Administrator stated that she heard about Resident's black eye after the meeting the morning of 08/30/2023 by DON. During an interview on 09/07/2023 at 3:25 pm, CNA B stated that she had witnessed abuse recently. CNA B stated that she did report to the ADON that she had witnessed CNA A being rough with residents while providing care. CNA B stated that while working with CNA A she witnessed CNA A hold Resident #1 down by holding his arms down with CNA A body weight and the residents would fight C CNA B stated that she witnessed CNA A being aggressive when he would hold the residents down. CNA B stated that CNA A would hold down the resident's that would fight him. CNA B stated that she witnessed the resident would try and get up from CNA A holding them down and CNA A would not let them up. CNA B stated that Resident #1 is not the only resident that she witnessed CNA A holding down when they don't want to be held down. CNA B stated that she also witnessed CNA A being rough and holding down Resident #5 and Resident #6. CNA B stated that the resident would fight CNA A to get him off them. CNA B stated that when she reported the abuse to the ADON she was told to provide a statement, but she had forgotten to write a statement because she was tired. CNA B stated that she reported to the ADON after a meeting that staff had that was due to Resident #1 coming up with an unexplained black eye on CNA A's shift. CNA B stated that she did not intervene to stop CNA A because she was scared of CNA A, but she did report to the ADON. Interview with on 09/07/2023 at 4:26 pm, CNA C reported that she heard CNA A verbally abusing Resident #2 approximately 3 weeks ago. CNA C stated that CNA A was calling Resident #2 names and telling her to shut up and called her stupid and ugly. CNA C stated that she reported the incident to the ADON. CNA C stated that she could tell it bothered Resident #2 because she looked upset. CNA C stated that CNA A showed no interest in wanting to be there most of the time. CNA C stated that CNA A would get mad if he had to answer the call lights. During an interview on 09/07/2023 at 5:00 pm, RN stated that she has always known CNA A to have a bad attitude towards the residents and others. RN stated that she has heard by other staff members that CNA A would be rough with resident's by grabbing and yanking on their arms. RN stated that she did not report what she had heard to anyone because she did not see it. RN stated that she had worked the night shift on 08/30/2023 and then next morning she was made aware by a family member that Resident #1 had a black eye. RN stated on this shift CNA A was working. RN stated that while she was assessing Resident #1 that Resident #4 had stated to RN that CNA A needed to be watched because when CNA A comes into change Resident #1, Resident #4 would hear a lot of rustling around and that Resident #1 acts scared around CNA A. RN stated that she was the nurse on shift working that night and she was not aware of any falls for Resident #1. RN stated that he was found in bed with a black eye. RN stated she did not remember seeing the black eye any time before that day. During an Interview on 09/07/2023 at 5:17 pm, Resident #2 stated that she had a problem with CNA A because he was mean. Resident #2 stated she thinks it was because he does not like her. Resident #2 stated that CNA A told her that she complains too much. Resident #2 stated that a couple of weeks ago that she had a bag of trash in her hand, and she was walking with her walker toward the door and CNA A was walking towards her and got in front of her. Resident #2 stated that CNA A told her, You better not put that trash in the hall. Resident #2 stated that she told CNA A that she was going to go throw it away. Resident #2 stated that CNA A grabbed the bag of trash out of her hand aggressively and then threw it back at her. Resident #2 stated CNA A called her stupid when he threw the trash at her. Resident #2 stated that on other occasions CNA A would tell her to shut up and stop pressing on the call light so much and he would hold her arms down roughly when he said it. Resident #2 stated that CNA A had called her stupid before. Resident #2 stated that she had told the ADON and Administrator and was told by both of them that it would be taken care of, but CNA A was still mean to her. Resident #2 stated she was scared of CNA A, and she didn't like having to rely on him for help. During an Interview on 09/07/2023 at 5:33 pm, Resident #3 stated that she had a few staff members that she didn't care too much for because they were rude, but one staff member would call her names and hold her down when she didn't want care. Resident #3 stated that CNA A would tell her that she was the one in the bed needing help when she would use the call lights to get help. Resident #3 stated that CNA A had said Shut up stupid bitch. Resident #3 stated that she did get tired of the name calling so she started lashing out at CNA A verbally back at him. Resident #3 stated he made her upset and felt bad. Resident #3 stated that she had dealt with abuse in her younger days, so she knows what abuse is and CNA A was abusive. Resident #3 stated that people are there to get help not to be treated like animals. Resident #3 stated that she reported to the nursing staff about the incidents, but nothing ever changed. Resident #3 stated that CNA A continued to treat her like that. During an interview 09/07/2023 at 6:00 pm, CNA A stated that he had not witnessed any form of abuse or neglect. CNA A stated that he had been trained in abuse and neglect by in-services and these trainings occur approximately every three to four months. CNA A stated that the 5 types of abuse are: physical, emotional, sexual, verbal, and financial. CNA A stated that he is unsure why people would say that he is abusive when he's not. CNA A stated that he cannot control what other people say. CNA A stated that would handle difficult behaviors by redirecting and coming back to try to work with resident again after cooling off period. CNA A stated that he never held anyone down unless they were hitting him, and he just held them into place until they stopped hitting and then would let them go. CNA A stated that he did not feel that this is a restraint. CNA A stated that he has never been physically or verbally abusive. CNA A stated that he does not work a designated hall, that all staff just work all halls, and they help each other out. CNA A stated that he did work nights for a while but did not like it so he moved to days. During an interview 09/08/2023 at 10:59 am, ADON stated that Resident #1 did not have a fall. ADON stated that they believed that Resident #1 had a fall at the time because he had a history of falls. ADON stated she was unsure if investigation was completed. ADON stated that she had been told by other staff members before that CNA A would hold down combative residents. ADON stated that she was told by some of the staff that CNA A would cross the resident's arms across their chest and then he would hold down the resident. ADON stated that she did not report this to the abuse coordinator (Administrator) because at that point it is just hearsay. ADON stated that she would report if the staff completed a written statement. ADON stated, I don't think that he was hurting the resident. ADON stated how else are you supposed to keep from getting hit by a resident? ADON stated she was unsure of what the policy stated about dealing with combative residents. ADON stated she would deal with combative behaviors by redirecting, walking away for a little bit if the resident was still combative, or get some help from another staff to see if the resident would respond differently to another staff. When asked if policy indicated that Resident could be held down, ADON stated, No, I don't think it says that. When asked ADON if it is considered a restraint to hold a resident down, ADON responded, Yeah, I guess it is. During an Interview 09/08/2023 at 11:19 am, Resident #4 stated that he did not witness his roommate Resident #1 being held down, but he could hear a lot of rustling around when CNA A would provide care. Resident #4 stated that he knew it was CNA A because he knows his voice. Resident #4 stated that he would hear a lot of banging, hitting the wall, and the resident groaning like he was hurting, and you could tell he was being hurt. Resident #4 stated that during the day when he was up and about that when CNA A would come around then Resident #1 would show fear by trying to move away from CNA A and just the fear in his eyes. Resident #4 stated you can see fear in someone. Resident #4 stated that CNA A was not the friendliest person and would get agitated easily. Resident #4 stated he would hear CNA A say stay still in a stern voice and hear all the rustling around. Resident #4 stated he was behind the curtain and could not easily get up to check what was going on. Resident #4 stated that he did tell the RN about this situation and to watch out for CNA A. During an interview 09/08/2023 at 4:28 pm. Administrator stated that she had heard from other staff members of CNA A holding down residents, but she thought that it was because the other staff didn't like CNA A. Administrator stated that she had not witnessed CNA A hold down residents. Administrator stated that Resident #3 did tell her that CNA A was calling her names. Administrator stated that Resident #3 would say things to CNA A like, You probably have a small penis. Administrator stated that she did not get any other reports from any other residents. Administrator stated that if you can't hold the residents, then how are you supposed to control when they are fighting you? Administrator stated she is not sure what the policy says, and she will have to read it to see what it says. Administrator stated that she has heard complaints from Resident #3 about CNA A, but she believes that she does not like him. Record Review of the facility provided policy revised on 12/2016, labeled, Abuse Prevention Program, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abusee prevention, the administration will: 1. Protect our residents by anyone including but not necessarily limited to: facility staff, other resident's, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid out facility in preventing abuse, neglect, or mistreatment of our residents. 5. Implement measures to address factors that may lead to abusive situations, for example: B). Instruct staff regarding appropriate ways to address interpretive conflicts. Record Review of the facility provided policy revised on 07/2017, labeled, Abuse and Neglect-Clinical Protocol, revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include A). Injury assessment, B). pain assessment, C) Current behavior, D). Patient's age and sex, E). All current medications, F). Other platelet inhibitors, G). Vital Signs, H). Behavior over the last 24 hours, I). History of any tendency towards bruising, J). All active diagnosis, K). Any recent labs. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the physician, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regu[TRUNCATED]

Based on Interview and Record Review the facility failed to ensure that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are required to treat the resident's medical symptoms. The facility failed to ensure that Resident #1, Resident #2, Resident #3, and Resident #5 was free from the use of restraints when CNA A was witnessed restraining residents by holding them down by crossing their arms across their chest and holding them down. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. While the IJ was removed on 09/11/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings Include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with diagnoses which included: Parkinson's Disease (disorder of the central nervous system that affects movements, often including tremors), neurocognitive disorder with Lewy bodies (a disease associated with abnormal deposits of a protein called alpha synuclein in the brain), dementia, muscle weakness, restlessness and agitation, schizoaffective disorders, intellectual disabilities. Record review of Resident #1's Significant Change in Status MDS dated [DATE] documented that Resident #1's BIMS was a 10/15, meaning moderately impaired cognition. According to the MDS, Resident #1 is listed to not having any change in mental status listed for disorganized thinking, for altered level of consciousness behavior is present and fluctuates. Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually , verbal behavioral symptoms directed toward others such as, threatening others, screaming at others, cursing at others, other behavioral symptoms not directed towards others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #1 was not listed as showing behaviors for refusing care. Resident #1 needs supervision with bed mobility such as moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture such supervision would include: oversight, encouragement, or cueing. Resident #1 needs supervision for transfers and is listed as total dependent with a two person assist. Resident #1 is listed as not being steady and only able to stabilize with staff assistance during transitions and walking, this includes moving from seated to standing position, walking, surface to surface transfers. Resident #1 uses a wheelchair. Record review of Resident #1s Care Plan dated 08/01/2023 revealed Resident #1 had episodes of adverse behaviors of being physically aggressive; hitting, pinching, kicking, staff and resistive to care. Interventions: administer meds per order (updated 09/07/2023), anticipate behaviors and redirect when in close proximity to others that might invoke aggression (updated 09/07/2023), assess for pain (updated 09/07/2023), ensure family and MD aware of behaviors and or any increase in behaviors noted (updated on 09/07/2023), maintain calm environment (updated 09/07/2023), medication regimen review quarterly and PRN after any resident to resident behavior event (updated on 09/07/2023), monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli to a safe environment (updated on 09/07/2023), behaviors include hitting, being resistive to care, refusing food (updated 09/07/2023). Record review of Resident #1s Care Plan dated 07/24/2023 and a revision date of 09/07/2023 indicated Resident #1 had a potential for injury with a history of falls and is at risk for further falls with safety interventions. Interventions: administer meds as ordered, monitor labs, report abnormalities to MD, avoid use of restraints, bed in low position at all times, educated on noncompliance with safety interventions and explain possible risks/outcomes due to noncompliance issues, enlist family input regarding fall history and possible factors to help decrease; falls, ensure staff is aware of safety needs of the resident, fall mat at bedside at all times, keep personal items and frequently used items within reach. Record Review of Resident 1's Physician Order, dated 06/20/2023, revealed: Donepezil HCI oral tablet 5 mg for confusion. Resident 1's Physician Order dated 06/20/2023 Olanzapine oral tablet 5 mg for behaviors related to other schizoaffective disorders. Record Review of Resident #1's Progress notes dated 09/07/2023 at 5:40 pm and indicated incident date as of 08/30/2023, signed by RN revealed: Resident sister came to the nurse's station and asked CN if she knew why her brother had a black eye. CN immediately went to assess. Upon entering resident room CN noted right eye swollen shut with a small cut present to mid eyebrow with scanty amount of dry blood. [NAME] peri-orbital ecchymosis also noted. CN proceeded to perform a general assessment right eyebrow cleaned with NS. Resident #2: Record Review of Resident #2's face sheet documented she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmitted [DATE]. Resident #2 was admitted with diagnoses which included: dementia, anxiety, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), schizoaffective disorder, major depressive disorder, type 2 diabetes, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), bipolar disorder, high blood pressure, and acid reflux. Record review of Resident #2's Admission MDS dated [DATE] documented that Resident #2's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #2 has no difficulty in normal conversation, social interaction, or watching tv. Resident #1 is listed to not showing a change in mental status, disorganized thinking, or altered level of consciousness. Resident #2 did not exhibit behaviors such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #2 did not exhibit the behaviors of rejecting care. Resident #2 uses a wheelchair and has no upper and lower body extremity impairment. Resident #2 shows to need supervision for transfers such as bed mobility and transfers meaning oversight, encouragement, or cueing. Resident #2 is listed as not being steady when walking, surface to surface transfers and needs supervision but is able to stabilize without assistance. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had cognitive impairment with diagnosis of intellectual disability with impaired ability to make decision and is at risk for impaired communication and impaired safety awareness. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had a diagnosis of major depressive disorder and bipolar and is at risk for fluctuations in mood, little interest, or pleasure in doing things, and decreased socialization. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had episodes of anxiety and is at risk for fluctuation in moods, currently taking buspirone. Record review of Resident #2s Care Plan date revised 08/01/2023 revealed Resident #2 had episodes of adverse behaviors of being verbally and physically aggressive; hitting, pinching, kicking, staff and resistive to care. Record Review of Resident #2s Physician Orders dated 07/14/2023, revealed: Wellbutrin XL Oral tablet Extended Release 24-hour 300 mg, give 1 tablet by mouth one time a day for depression. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: dementia, acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), schizoaffective disorder, major depressive disorder, muscle weakness, tremor, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperthyroidism (is the production of too much thyroxine hormone), anxiety, drug induced dyskinesia (an involuntary movement disorder), insomnia, high blood pressure, pain in joint, overactive bladder. Record review of Resident #3's Admission MDS dated [DATE] documented that Resident #3's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #3 has moderate difficulty-speaker and must increase volume and speak distinctly. Resident #3 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #3 did not exhibit behaviors of rejecting care. Resident #3 uses a wheelchair and has no upper and lower body extremity impairment. Resident #3 shows a need of extensive assistance with resident involvement and staff to provide weight-bearing support for bed mobility, walking in room, and locomotion on unit, needing two people assist and resident highly involved in activity. Resident #3 is listed as not steady and only able to stabilize with staff assistance. Resident #3 is listed as not capable of increased independence. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had episodes of anxiety and at risk for fluctuation in moods. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had a diagnosis of major depression/schizoaffective disorder and am at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization. Record review of Resident #3s Care Plan date revised 08/15/2023 revealed Resident #3 had impaired understanding and reasoning for expressing information needs: ability is limited to making concrete requests. Resident #4: Record Review of Resident #4's face sheet documented she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: type 2 diabetes, cardiac arrhythmias, muscle weakness, abnormalities of gait, gout, anemia, bipolar disorder, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in your blood), manic episode, rheumatoid arthritis, acid reflux, enlarged prostate, pseudobulbar affect (pathological laughing and crying), polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body. Record review of Resident #4's Annual MDS dated [DATE] documented that Resident #4's BIMS was a 15/15, meaning intact cognition. Resident #4 is not listed as showing a change in mental status for disorganized thinking and altered level of consciousness and disorganized thinking. Resident #4 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #4 is listed for significantly disrupt care or living environment, meaning would disrupt care of living environment. Resident #4 is listed as showing rejection of care for 1-3 days. Resident #4 is shows total dependence for bed mobility and transfers with wheelchair, standing position, and locomotion on the unit with setup only. Resident #4 uses a wheelchair and has impairment with lower extremities but no impairment for upper extremities. Resident #4 is listed as steady, but able to stabilize without staff assistance for walking and transfers between bed and wheelchair. Resident #4 is listed as not being capable of increased independence. Record review of Resident #4s Care Plan date revised 05/03/2023 revealed Resident #4 had a mood problem with disease process of bipolar disorder and manic episode. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 had cognitive impairment: memory problems: diagnosis of bipolar disorder and pseudobulbar affect (pathological laughing and crying), impaired mobility to make decisions and is at risk for impairment safety awareness. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 is at risk for adverse consequences with receiving psychotropic medications Klonopin, and multiple med use due to nine or more medications. Record review of Resident #4s Care Plan date revised 08/14/2023 revealed Resident #4 had episodes of adverse behaviors. Inappropriate behavior. Resident with multiple urinals and multiple water pitchers in room at bedside. Resident adamant regarding removal of pitcher and urinal removal. Does not want pitchers and urinal to be removed. Resident with verbal outburst with nursing staff. Record review of Resident #4s Care Plan date revised 08/04/2023 revealed Resident #4 had problematic demeanor in which resident acts out characterized by ineffective coping, verbal/physical, aggression related to anger. Resident #5: Record Review of Resident #5's face sheet documented she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 was admitted with diagnoses which included: Alzheimer's Disease, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), overactive bladder, iron deficiency, major depression, macular degeneration (an eye disease that causes vision loss), high blood pressure, pain in unspecified joint, muscle weakness, reduced mobility. Record review of Resident #5's Quarterly MDS dated [DATE] documented that Resident #5's BIMS was a 99, meaning the resident interview was not successful. Resident #5 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #5 usually understands-misses some part-intent of message but comprehends most conversation. Resident #5 has the ability to recall memory after 5 minutes and 5 could recall long past. Resident #5 is moderately impaired-decisions poor, cues/supervision required for decision making. Resident #5 does show the behavior is present and fluctuates for inattention, disorganized thinking or incoherent. Resident #5 does not show altered level of consciousness. Resident #5 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #5 did exhibit the behavior of rejecting care for 1-3 days. Resident #5 shows the need for extensive assistance with one person assist for bed mobility and transfers but is listed as limited assistance with one person assist for locomotion on the unit. Resident #5 uses a wheelchair and shows no upper or lower extremity impairment. Resident #5 is listed as steady, but able to stabilize without staff assistance for walking and surface to surface transfers. Record review of Resident #5s Care Plan date revised 03/03/2023 revealed Resident #5 had a cognitive impairment, memory problems short/long term diagnosis of dementia and impaired safety awareness. Record review of Resident #5s Care Plan date revised 08/03/2023 revealed Resident #5 had a diagnosis of depression/mood disorder and is at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization, currently receiving Remeron. During an interview on 09/06/2023 at 3:09 pm, DON stated that for Resident #1 that she heard about the black eye the morning of 08/30/2023. DON stated that she thought it was a fall because Resident #1 has a history of falls. DON stated that resident #1 wasn't found on the floor or anything, he was found in bed. DON stated that they did not report because it was an unwitnessed fall. When asked if that is considered an injury of unknown origin, DON shook her head and stated, your right it is considered injury of unknown origin. When asked why it was not reported, DON stated they were thinking that it was just a fall. DON stated, your right we should have reported and didn't. DON stated that she was not in the facility at the time of the incident. DON stated that she is just helping out in the facility for a while. DON stated that the ADON had more details about the incident because it was reported to her, and she was not at work today. During an interview on 09/06/2023 at 4:15 pm, Administrator stated that with Resident #1 she believed that he had a fall. Administrator stated that Resident #1 had a history of falls. Administrator stated that Resident #1 was found in bed and was not found on the floor. Administrator stated that she did not report the black eye for Resident #1 because she did not know about it. Administrator stated that she did not report when she had found out because she thought it was an unwitnessed fall. Administrator stated she guessed she should have reported and will go ahead and do that since she believed it to be an unwitnessed fall. Administrator stated she was not told it was a fall, Resident #1 just had a history of it. Administrator stated that she heard about Resident's black eye after the meeting the morning of 08/30/2023 by DON. During an interview on 09/07/2023 at 3:25 pm, CNA B stated that she had witnessed abuse recently. CNA B stated that she did report to the ADON that she had witnessed CNA A being rough with residents while providing care. CNA B stated that while working with CNA A she witnessed CNA A hold Resident #1 down by holding his arms down with CNA A body weight and the residents would fight C CNA B stated that she witnessed CNA A being aggressive when he would hold the residents down. CNA B stated that CNA A would hold down the resident's that would fight him. CNA B stated that she witnessed the resident would try and get up from CNA A holding them down and CNA A would not let them up. CNA B stated that Resident #1 is not the only resident that she witnessed CNA A holding down when they don't want to be held down. CNA B stated that she also witnessed CNA A being rough and holding down Resident #5 and Resident #6. CNA B stated that the resident would fight CNA A to get him off them. CNA B stated that when she reported the abuse to the ADON she was told to provide a statement, but she had forgotten to write a statement because she was tired. CNA B stated that she reported to the ADON after a meeting that staff had that was due to Resident #1 coming up with an unexplained black eye on CNA A's shift. CNA B stated that she did not intervene to stop CNA A because she was scared of CNA A, but she did report to the ADON. During an interview on 09/07/2023 at 5:00 pm, RN stated that she has always known CNA A to have a bad attitude towards the residents and others. RN stated that she has heard by other staff members that CNA A would be rough with resident's by grabbing and yanking on their arms. RN stated that she did not report what she had heard to anyone because she did not see it. RN stated that she had worked the night shift on 08/30/2023 and then next morning she was made aware by a family member that Resident #1 had a black eye. RN stated on this shift CNA A was working. RN stated that while she was assessing Resident #1 that Resident #4 had stated to RN that CNA A needed to be watched because when CNA A comes into change Resident #1, Resident #4 would hear a lot of rustling around and that Resident #1 acts scared around CNA A. RN stated that she was the nurse on shift working that night and she was not aware of any falls for Resident #1. RN stated that he was found in bed with a black eye. RN stated she did not remember seeing the black eye any time before that day. During an Interview on 09/07/2023 at 5:17 pm, Resident #2 stated that she had a problem with CNA A because he was mean. Resident #2 stated she thinks it was because he does not like her. Resident #2 stated that CNA A told her that she complains too much. Resident #2 stated that a couple of weeks ago that she had a bag of trash in her hand, and she was walking with her walker toward the door and CNA A was walking towards her and got in front of her. Resident #2 stated that CNA A told her, You better not put that trash in the hall. Resident #2 stated that she told CNA A that she was going to go throw it away. Resident #2 stated that CNA A grabbed the bag of trash out of her hand aggressively and then threw it back at her. Resident #2 stated CNA A called her stupid when he threw the trash at her. Resident #2 stated that on other occasions CNA A would tell her to shut up and stop pressing on the call light so much and he would hold her arms down roughly when he said it. Resident #2 stated that CNA A had called her stupid before. Resident #2 stated that she had told the ADON and Administrator and was told by both of them that it would be taken care of, but CNA A was still mean to her. Resident #2 stated she was scared of CNA A, and she didn't like having to rely on him for help. During an Interview on 09/07/2023 at 5:33 pm, Resident #3 stated that she had a few staff members that she didn't care too much for because they were rude, but one staff member would call her names and hold her down when she didn't want care. Resident #3 stated that CNA A would tell her that she was the one in the bed needing help when she would use the call lights to get help. Resident #3 stated that CNA A had said Shut up stupid bitch. Resident #3 stated that she did get tired of the name calling so she started lashing out at CNA A verbally back at him. Resident #3 stated he made her upset and felt bad. Resident #3 stated that she had dealt with abuse in her younger days, so she knows what abuse is and CNA A was abusive. Resident #3 stated that people are there to get help not to be treated like animals. Resident #3 stated that she reported to the nursing staff about the incidents, but nothing ever changed. Resident #3 stated that CNA A continued to treat her like that. During an interview 09/07/2023 at 6:00 pm, CNA A stated that he had not witnessed any form of abuse or neglect. CNA A stated that he had been trained in abuse and neglect by in-services and these trainings occur approximately every three to four months. CNA A stated that the 5 types of abuse are: physical, emotional, sexual, verbal, and financial. CNA A stated that he is unsure why people would say that he is abusive when he's not. CNA A stated that he cannot control what other people say. CNA A stated that would handle difficult behaviors by redirecting and coming back to try to work with resident again after cooling off period. CNA A stated that he never held anyone down unless they were hitting him, and he just held them into place until they stopped hitting and then would let them go. CNA A stated that he did not feel that this is a restraint. CNA A stated that he has never been physically or verbally abusive. CNA A stated that he does not work a designated hall, that all staff just work all halls, and they help each other out. CNA A stated that he did work nights for a while but did not like it so he moved to days. During an interview 09/08/2023 at 10:59 am, ADON stated that Resident #1 did not have a fall. ADON stated that they believed that Resident #1 had a fall at the time because he had a history of falls. ADON stated she was unsure if investigation was completed. ADON stated that she had been told by other staff members before that CNA A would hold down combative residents. ADON stated that she was told by some of the staff that CNA A would cross the resident's arms across their chest and then he would hold down the resident. ADON stated that she did not report this to the abuse coordinator (Administrator) because at that point it is just hearsay. ADON stated that she would report if the staff completed a written statement. ADON stated, I don't think that he was hurting the resident. ADON stated how else are you supposed to keep from getting hit by a resident? ADON stated she was unsure of what the policy stated about dealing with combative residents. ADON stated she would deal with combative behaviors by redirecting, walking away for a little bit if the resident was still combative, or get some help from another staff to see if the resident would respond differently to another staff. When asked if policy indicated that Resident could be held down, ADON stated, No, I don't think it says that. When asked ADON if it is considered a restraint to hold a resident down, ADON responded, Yeah, I guess it is. During an Interview 09/08/2023 at 11:19 am, Resident #4 stated that he did not witness his roommate Resident #1 being held down, but he could hear a lot of rustling around when CNA A would provide care. Resident #4 stated that he knew it was CNA A because he knows his voice. Resident #4 stated that he would hear a lot of banging, hitting the wall, and the resident groaning like he was hurting, and you could tell he was being hurt. Resident #4 stated that during the day when he was up and about that when CNA A would come around then Resident #1 would show fear by trying to move away from CNA A and just the fear in his eyes. Resident #4 stated you can see fear in someone. Resident #4 stated that CNA A was not the friendliest person and would get agitated easily. Resident #4 stated he would hear CNA A say stay still in a stern voice and hear all the rustling around. Resident #4 stated he was behind the curtain and could not easily get up to check what was going on. Resident #4 stated that he did tell the RN about this situation and to watch out for CNA A. During an interview 09/08/2023 at 4:28 pm. Administrator stated that she had heard from other staff members of CNA A holding down residents, but she thought that it was because the other staff didn't like CNA A. Administrator stated that she had not witnessed CNA A hold down residents. Administrator stated that Resident #3 did tell her that CNA A was calling her names. Administrator stated that Resident #3 would say things to CNA A like, You probably have a small penis. Administrator stated that she did not get any other reports from any other residents. Administrator stated that if you can't hold the residents, then how are you supposed to control when they are fighting you? Administrator stated she is not sure what the policy says, and she will have to read it to see what it says. Administrator stated that she has heard complaints from Resident #3 about CNA A, but she believes that she does not like him. Record Review of the facility provided policy revised on 12/2016, labeled, Abuse Prevention Program, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abusee prevention, the administration will: 1. Protect our residents by anyone including but not necessarily limited to: facility staff, other resident's, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid out facility in preventing abuse, neglect, or mistreatment of our residents. 5. Implement measures to address factors that may lead to abusive situations, for example: B). Instruct staff regarding appropriate ways to address interpretive conflicts. Record Review of the facility provided policy revised on 07/2017, labeled, Abuse and Neglect-Clinical Protocol, revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include A). Injury assessment, B). pain assessment, C) Current behavior, D). Patient's age and sex, E). All current medications, F). Other platelet inhibitors, G). Vital Signs, H). Behavior over the last 24 hours, I). History of any tendency towards bruising, J). All active diagnosis, K). Any recent labs. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the physician, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Record Review of CNA A Work Schedule for the dates following: 08/29/2023-09/06/2023, revealed: 08/29/2023: In Day: 05:56 pm, out lunch: 00:01 am, In-Lunch: 01:02 am, Out Day: 06:25 am: (11:46) 09/01/2023 In Day: 06:03 pm, Out Lunch: 01:34 am, In Lunch: 01:48 AM, Out Day: 06:22AM: (11:32) 09/02/2023: Overtime 1 X 5 Premium: (5:34) 09/02/2023: In Day: 06:10 PM, Out Lunch: 00:02 AM, In Lunch: 1:08 AM, Out Day: 06:42 AM (11.44) 09/03/2023: In Day: 06:13 PM, Out Lunch: 00:36 AM, In Lunch: 01:48 AM, Out Day: 06:31 AM (11.10) 09/06/2023: In Day: 06:09 PM, Out Lunch: 02:11 AM, In Lunch: 03:12 AM, Out Day: 06:25 AM (11.25) 09/07/2023: In Day: 06:03 PM, Out Lunch: 00:10 AM, In Lunch: 01:11 AM, Out Day: 06:41 AM (11.62) Record Review of the original reported statement by RN of incident dated 08/30/2023 stated: A[TRUNCATED]

Based on Interview and Record Review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility failed to ensure that Resident #1, Resident #2, Resident #3, and Resident #5 was free from abuse when CNA A was witnessed holding residents by holding them down by crossing their arms across their chest and holding them down. The facility failed to implement polikcies by not reporting, investigating allegations of abuse. The facility failed to implement policies by allowing CNA A to continue working with residents with allegations of abuse. (Resident #2 and Resident #3) An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. While the IJ was removed on 09/11/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with diagnoses which included: Parkinson's Disease (disorder of the central nervous system that affects movements, often including tremors), neurocognitive disorder with Lewy bodies (a disease associated with abnormal deposits of a protein called alpha synuclein in the brain), dementia, muscle weakness, restlessness and agitation, schizoaffective disorders, intellectual disabilities. Record review of Resident #1's Significant Change in Status MDS dated [DATE] documented that Resident #1's BIMS was a 10/15, meaning moderately impaired cognition. According to the MDS, Resident #1 is listed to not having any change in mental status listed for disorganized thinking, for altered level of consciousness behavior is present and fluctuates. Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually , verbal behavioral symptoms directed toward others such as, threatening others, screaming at others, cursing at others, other behavioral symptoms not directed towards others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #1 was not listed as showing behaviors for refusing care. Resident #1 needs supervision with bed mobility such as moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture such supervision would include: oversight, encouragement, or cueing. Resident #1 needs supervision for transfers and is listed as total dependent with a two person assist. Resident #1 is listed as not being steady and only able to stabilize with staff assistance during transitions and walking, this includes moving from seated to standing position, walking, surface to surface transfers. Resident #1 uses a wheelchair. Record review of Resident #1s Care Plan dated 08/01/2023 revealed Resident #1 had episodes of adverse behaviors of being physically aggressive; hitting, pinching, kicking, staff and resistive to care. Interventions: administer meds per order (updated 09/07/2023), anticipate behaviors and redirect when in close proximity to others that might invoke aggression (updated 09/07/2023), assess for pain (updated 09/07/2023), ensure family and MD aware of behaviors and or any increase in behaviors noted (updated on 09/07/2023), maintain calm environment (updated 09/07/2023), medication regimen review quarterly and PRN after any resident to resident behavior event (updated on 09/07/2023), monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli to a safe environment (updated on 09/07/2023), behaviors include hitting, being resistive to care, refusing food (updated 09/07/2023). Record review of Resident #1s Care Plan dated 07/24/2023 and a revision date of 09/07/2023 indicated Resident #1 had a potential for injury with a history of falls and is at risk for further falls with safety interventions. Interventions: administer meds as ordered, monitor labs, report abnormalities to MD, avoid use of restraints, bed in low position at all times, educated on noncompliance with safety interventions and explain possible risks/outcomes due to noncompliance issues, enlist family input regarding fall history and possible factors to help decrease; falls, ensure staff is aware of safety needs of the resident, fall mat at bedside at all times, keep personal items and frequently used items within reach. Record Review of Resident 1's Physician Order, dated 06/20/2023, revealed: Donepezil HCI oral tablet 5 mg for confusion. Resident 1's Physician Order dated 06/20/2023 Olanzapine oral tablet 5 mg for behaviors related to other schizoaffective disorders. Record Review of Resident #1's Progress notes dated 09/07/2023 at 5:40 pm and indicated incident date as of 08/30/2023, signed by RN revealed: Resident sister came to the nurse's station and asked CN if she knew why her brother had a black eye. CN immediately went to assess. Upon entering resident room CN noted right eye swollen shut with a small cut present to mid eyebrow with scanty amount of dry blood. [NAME] peri-orbital ecchymosis also noted. CN proceeded to perform a general assessment right eyebrow cleaned with NS. Resident #2: Record Review of Resident #2's face sheet documented she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmitted [DATE]. Resident #2 was admitted with diagnoses which included: dementia, anxiety, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), schizoaffective disorder, major depressive disorder, type 2 diabetes, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), bipolar disorder, high blood pressure, and acid reflux. Record review of Resident #2's Admission MDS dated [DATE] documented that Resident #2's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #2 has no difficulty in normal conversation, social interaction, or watching tv. Resident #1 is listed to not showing a change in mental status, disorganized thinking, or altered level of consciousness. Resident #2 did not exhibit behaviors such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #2 did not exhibit the behaviors of rejecting care. Resident #2 uses a wheelchair and has no upper and lower body extremity impairment. Resident #2 shows to need supervision for transfers such as bed mobility and transfers meaning oversight, encouragement, or cueing. Resident #2 is listed as not being steady when walking, surface to surface transfers and needs supervision but is able to stabilize without assistance. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had cognitive impairment with diagnosis of intellectual disability with impaired ability to make decision and is at risk for impaired communication and impaired safety awareness. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had a diagnosis of major depressive disorder and bipolar and is at risk for fluctuations in mood, little interest, or pleasure in doing things, and decreased socialization. Record review of Resident #2s Care Plan date revised 03/30/2023 revealed Resident #2 had episodes of anxiety and is at risk for fluctuation in moods, currently taking buspirone. Record review of Resident #2s Care Plan date revised 08/01/2023 revealed Resident #2 had episodes of adverse behaviors of being verbally and physically aggressive; hitting, pinching, kicking, staff and resistive to care. Record Review of Resident #2s Physician Orders dated 07/14/2023, revealed: Wellbutrin XL Oral tablet Extended Release 24-hour 300 mg, give 1 tablet by mouth one time a day for depression. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: dementia, acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), schizoaffective disorder, major depressive disorder, muscle weakness, tremor, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperthyroidism (is the production of too much thyroxine hormone), anxiety, drug induced dyskinesia (an involuntary movement disorder), insomnia, high blood pressure, pain in joint, overactive bladder. Record review of Resident #3's Admission MDS dated [DATE] documented that Resident #3's BIMS was a 15/15, meaning intact cognition. According to the MDS, Resident #3 has moderate difficulty-speaker and must increase volume and speak distinctly. Resident #3 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #3 did not exhibit behaviors of rejecting care. Resident #3 uses a wheelchair and has no upper and lower body extremity impairment. Resident #3 shows a need of extensive assistance with resident involvement and staff to provide weight-bearing support for bed mobility, walking in room, and locomotion on unit, needing two people assist and resident highly involved in activity. Resident #3 is listed as not steady and only able to stabilize with staff assistance. Resident #3 is listed as not capable of increased independence. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had episodes of anxiety and at risk for fluctuation in moods. Record review of Resident #3s Care Plan date revised 07/08/2023 revealed Resident #3 had a diagnosis of major depression/schizoaffective disorder and am at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization. Record review of Resident #3s Care Plan date revised 08/15/2023 revealed Resident #3 had impaired understanding and reasoning for expressing information needs: ability is limited to making concrete requests. Resident #4: Record Review of Resident #4's face sheet documented she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: type 2 diabetes, cardiac arrhythmias, muscle weakness, abnormalities of gait, gout, anemia, bipolar disorder, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in your blood), manic episode, rheumatoid arthritis, acid reflux, enlarged prostate, pseudobulbar affect (pathological laughing and crying), polyneuropathy the simultaneous malfunction of many peripheral nerves throughout the body. Record review of Resident #4's Annual MDS dated [DATE] documented that Resident #4's BIMS was a 15/15, meaning intact cognition. Resident #4 is not listed as showing a change in mental status for disorganized thinking and altered level of consciousness and disorganized thinking. Resident #4 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #4 is listed for significantly disrupt care or living environment, meaning would disrupt care of living environment. Resident #4 is listed as showing rejection of care for 1-3 days. Resident #4 is shows total dependence for bed mobility and transfers with wheelchair, standing position, and locomotion on the unit with setup only. Resident #4 uses a wheelchair and has impairment with lower extremities but no impairment for upper extremities. Resident #4 is listed as steady, but able to stabilize without staff assistance for walking and transfers between bed and wheelchair. Resident #4 is listed as not being capable of increased independence. Record review of Resident #4s Care Plan date revised 05/03/2023 revealed Resident #4 had a mood problem with disease process of bipolar disorder and manic episode. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 had cognitive impairment: memory problems: diagnosis of bipolar disorder and pseudobulbar affect (pathological laughing and crying), impaired mobility to make decisions and is at risk for impairment safety awareness. Record review of Resident #4s Care Plan date revised 08/03/2023 revealed Resident #4 is at risk for adverse consequences with receiving psychotropic medications Klonopin, and multiple med use due to nine or more medications. Record review of Resident #4s Care Plan date revised 08/14/2023 revealed Resident #4 had episodes of adverse behaviors. Inappropriate behavior. Resident with multiple urinals and multiple water pitchers in room at bedside. Resident adamant regarding removal of pitcher and urinal removal. Does not want pitchers and urinal to be removed. Resident with verbal outburst with nursing staff. Record review of Resident #4s Care Plan date revised 08/04/2023 revealed Resident #4 had problematic demeanor in which resident acts out characterized by ineffective coping, verbal/physical, aggression related to anger. Resident #5: Record Review of Resident #5's face sheet documented she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 was admitted with diagnoses which included: Alzheimer's Disease, hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), overactive bladder, iron deficiency, major depression, macular degeneration (an eye disease that causes vision loss), high blood pressure, pain in unspecified joint, muscle weakness, reduced mobility. Record review of Resident #5's Quarterly MDS dated [DATE] documented that Resident #5's BIMS was a 99, meaning the resident interview was not successful. Resident #5 has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #5 usually understands-misses some part-intent of message but comprehends most conversation. Resident #5 has the ability to recall memory after 5 minutes and 5 could recall long past. Resident #5 is moderately impaired-decisions poor, cues/supervision required for decision making. Resident #5 does show the behavior is present and fluctuates for inattention, disorganized thinking or incoherent. Resident #5 does not show altered level of consciousness. Resident #5 did not exhibit behaviors for physical behavioral symptom directed towards others such as hitting, scratching, pushing, kicking, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds. Resident #5 did exhibit the behavior of rejecting care for 1-3 days. Resident #5 shows the need for extensive assistance with one person assist for bed mobility and transfers but is listed as limited assistance with one person assist for locomotion on the unit. Resident #5 uses a wheelchair and shows no upper or lower extremity impairment. Resident #5 is listed as steady, but able to stabilize without staff assistance for walking and surface to surface transfers. Record review of Resident #5s Care Plan date revised 03/03/2023 revealed Resident #5 had a cognitive impairment, memory problems short/long term diagnosis of dementia and impaired safety awareness. Record review of Resident #5s Care Plan date revised 08/03/2023 revealed Resident #5 had a diagnosis of depression/mood disorder and is at risk for fluctuation in moods, little interest, or pleasure in doing things and decreased socialization, currently receiving Remeron. During an interview on 09/06/2023 at 3:09 pm, DON stated that for Resident #1 that she heard about the black eye the morning of 08/30/2023. DON stated that she thought it was a fall because Resident #1 has a history of falls. DON stated that resident #1 wasn't found on the floor or anything, he was found in bed. DON stated that they did not report because it was an unwitnessed fall. When asked if that is considered an injury of unknown origin, DON shook her head and stated, your right it is considered injury of unknown origin. When asked why it was not reported, DON stated they were thinking that it was just a fall. DON stated, your right we should have reported and didn't. DON stated that she was not in the facility at the time of the incident. DON stated that she is just helping out in the facility for a while. DON stated that the ADON had more details about the incident because it was reported to her, and she was not at work today. During an interview on 09/06/2023 at 4:15 pm, Administrator stated that with Resident #1 she believed that he had a fall. Administrator stated that Resident #1 had a history of falls. Administrator stated that Resident #1 was found in bed and was not found on the floor. Administrator stated that she did not report the black eye for Resident #1 because she did not know about it. Administrator stated that she did not report when she had found out because she thought it was an unwitnessed fall. Administrator stated she guessed she should have reported and will go ahead and do that since she believed it to be an unwitnessed fall. Administrator stated she was not told it was a fall, Resident #1 just had a history of it. Administrator stated that she heard about Resident's black eye after the meeting the morning of 08/30/2023 by DON. During an interview on 09/07/2023 at 3:25 pm, CNA B stated that she had witnessed abuse recently. CNA B stated that she did report to the ADON that she had witnessed CNA A being rough with residents while providing care. CNA B stated that while working with CNA A she witnessed CNA A hold Resident #1 down by holding his arms down with CNA A body weight and the residents would fight C CNA B stated that she witnessed CNA A being aggressive when he would hold the residents down. CNA B stated that CNA A would hold down the resident's that would fight him. CNA B stated that she witnessed the resident would try and get up from CNA A holding them down and CNA A would not let them up. CNA B stated that Resident #1 is not the only resident that she witnessed CNA A holding down when they don't want to be held down. CNA B stated that she also witnessed CNA A being rough and holding down Resident #5 and Resident #6. CNA B stated that the resident would fight CNA A to get him off them. CNA B stated that when she reported the abuse to the ADON she was told to provide a statement, but she had forgotten to write a statement because she was tired. CNA B stated that she reported to the ADON after a meeting that staff had that was due to Resident #1 coming up with an unexplained black eye on CNA A's shift. CNA B stated that she did not intervene to stop CNA A because she was scared of CNA A, but she did report to the ADON. Interview with on 09/07/2023 at 4:26 pm, CNA C reported that she heard CNA A verbally abusing Resident #2 approximately 3 weeks ago. CNA C stated that CNA A was calling Resident #2 names and telling her to shut up and called her stupid and ugly. CNA C stated that she reported the incident to the ADON. CNA C stated that she could tell it bothered Resident #2 because she looked upset. CNA C stated that CNA A showed no interest in wanting to be there most of the time. CNA C stated that CNA A would get mad if he had to answer the call lights. During an interview on 09/07/2023 at 5:00 pm, RN stated that she has always known CNA A to have a bad attitude towards the residents and others. RN stated that she has heard by other staff members that CNA A would be rough with resident's by grabbing and yanking on their arms. RN stated that she did not report what she had heard to anyone because she did not see it. RN stated that she had worked the night shift on 08/30/2023 and then next morning she was made aware by a family member that Resident #1 had a black eye. RN stated on this shift CNA A was working. RN stated that while she was assessing Resident #1 that Resident #4 had stated to RN that CNA A needed to be watched because when CNA A comes into change Resident #1, Resident #4 would hear a lot of rustling around and that Resident #1 acts scared around CNA A. RN stated that she was the nurse on shift working that night and she was not aware of any falls for Resident #1. RN stated that he was found in bed with a black eye. RN stated she did not remember seeing the black eye any time before that day. During an Interview on 09/07/2023 at 5:17 pm, Resident #2 stated that she had a problem with CNA A because he was mean. Resident #2 stated she thinks it was because he does not like her. Resident #2 stated that CNA A told her that she complains too much. Resident #2 stated that a couple of weeks ago that she had a bag of trash in her hand, and she was walking with her walker toward the door and CNA A was walking towards her and got in front of her. Resident #2 stated that CNA A told her, You better not put that trash in the hall. Resident #2 stated that she told CNA A that she was going to go throw it away. Resident #2 stated that CNA A grabbed the bag of trash out of her hand aggressively and then threw it back at her. Resident #2 stated CNA A called her stupid when he threw the trash at her. Resident #2 stated that on other occasions CNA A would tell her to shut up and stop pressing on the call light so much and he would hold her arms down roughly when he said it. Resident #2 stated that CNA A had called her stupid before. Resident #2 stated that she had told the ADON and Administrator and was told by both of them that it would be taken care of, but CNA A was still mean to her. Resident #2 stated she was scared of CNA A, and she didn't like having to rely on him for help. During an Interview on 09/07/2023 at 5:33 pm, Resident #3 stated that she had a few staff members that she didn't care too much for because they were rude, but one staff member would call her names and hold her down when she didn't want care. Resident #3 stated that CNA A would tell her that she was the one in the bed needing help when she would use the call lights to get help. Resident #3 stated that CNA A had said Shut up stupid bitch. Resident #3 stated that she did get tired of the name calling so she started lashing out at CNA A verbally back at him. Resident #3 stated he made her upset and felt bad. Resident #3 stated that she had dealt with abuse in her younger days, so she knows what abuse is and CNA A was abusive. Resident #3 stated that people are there to get help not to be treated like animals. Resident #3 stated that she reported to the nursing staff about the incidents, but nothing ever changed. Resident #3 stated that CNA A continued to treat her like that. During an interview 09/07/2023 at 6:00 pm, CNA A stated that he had not witnessed any form of abuse or neglect. CNA A stated that he had been trained in abuse and neglect by in-services and these trainings occur approximately every three to four months. CNA A stated that the 5 types of abuse are: physical, emotional, sexual, verbal, and financial. CNA A stated that he is unsure why people would say that he is abusive when he's not. CNA A stated that he cannot control what other people say. CNA A stated that would handle difficult behaviors by redirecting and coming back to try to work with resident again after cooling off period. CNA A stated that he never held anyone down unless they were hitting him, and he just held them into place until they stopped hitting and then would let them go. CNA A stated that he did not feel that this is a restraint. CNA A stated that he has never been physically or verbally abusive. CNA A stated that he does not work a designated hall, that all staff just work all halls, and they help each other out. CNA A stated that he did work nights for a while but did not like it so he moved to days. During an interview 09/08/2023 at 10:59 am, ADON stated that Resident #1 did not have a fall. ADON stated that they believed that Resident #1 had a fall at the time because he had a history of falls. ADON stated she was unsure if investigation was completed. ADON stated that she had been told by other staff members before that CNA A would hold down combative residents. ADON stated that she was told by some of the staff that CNA A would cross the resident's arms across their chest and then he would hold down the resident. ADON stated that she did not report this to the abuse coordinator (Administrator) because at that point it is just hearsay. ADON stated that she would report if the staff completed a written statement. ADON stated, I don't think that he was hurting the resident. ADON stated how else are you supposed to keep from getting hit by a resident? ADON stated she was unsure of what the policy stated about dealing with combative residents. ADON stated she would deal with combative behaviors by redirecting, walking away for a little bit if the resident was still combative, or get some help from another staff to see if the resident would respond differently to another staff. When asked if policy indicated that Resident could be held down, ADON stated, No, I don't think it says that. When asked ADON if it is considered a restraint to hold a resident down, ADON responded, Yeah, I guess it is. During an Interview 09/08/2023 at 11:19 am, Resident #4 stated that he did not witness his roommate Resident #1 being held down, but he could hear a lot of rustling around when CNA A would provide care. Resident #4 stated that he knew it was CNA A because he knows his voice. Resident #4 stated that he would hear a lot of banging, hitting the wall, and the resident groaning like he was hurting, and you could tell he was being hurt. Resident #4 stated that during the day when he was up and about that when CNA A would come around then Resident #1 would show fear by trying to move away from CNA A and just the fear in his eyes. Resident #4 stated you can see fear in someone. Resident #4 stated that CNA A was not the friendliest person and would get agitated easily. Resident #4 stated he would hear CNA A say stay still in a stern voice and hear all the rustling around. Resident #4 stated he was behind the curtain and could not easily get up to check what was going on. Resident #4 stated that he did tell the RN about this situation and to watch out for CNA A. During an interview 09/08/2023 at 4:28 pm. Administrator stated that she had heard from other staff members of CNA A holding down residents, but she thought that it was because the other staff didn't like CNA A. Administrator stated that she had not witnessed CNA A hold down residents. Administrator stated that Resident #3 did tell her that CNA A was calling her names. Administrator stated that Resident #3 would say things to CNA A like, You probably have a small penis. Administrator stated that she did not get any other reports from any other residents. Administrator stated that if you can't hold the residents, then how are you supposed to control when they are fighting you? Administrator stated she is not sure what the policy says, and she will have to read it to see what it says. Administrator stated that she has heard complaints from Resident #3 about CNA A, but she believes that she does not like him. Record Review of the facility provided policy revised on 12/2016, labeled, Abuse Prevention Program, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abusee prevention, the administration will: 1. Protect our residents by anyone including but not necessarily limited to: facility staff, other resident's, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid out facility in preventing abuse, neglect, or mistreatment of our residents. 5. Implement measures to address factors that may lead to abusive situations, for example: B). Instruct staff regarding appropriate ways to address interpretive conflicts. Record Review of the facility provided policy revised on 07/2017, labeled, Abuse and Neglect-Clinical Protocol, revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include A). Injury assessment, B). pain assessment, C) Current behavior, D). Patient's age and sex, E). All current medications, F). Other platelet inhibitors, G). Vital Signs, H). Behavior over the last 24 hours, I). History of any tendency towards bruising, J). All active diagnosis, K). Any recent labs. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. 2. The management and staff, with the support of the physician, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Record Review of CNA A Work Schedule for the dates following: [TRUNCATED]

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 residents (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and #11) of 15 residents observed for infection control, in that: Facility's Licensed Vocational Nurse (LVN), Certified Medication Aide (CMA), Certified Nurses' Aides (CNAs), nurse aide (NA), and dietary aide failed to follow donning and doffing procedures for wearing personal protective equipment (PPE), when caring for residents presumptive of COVID-1. These residents were presumptive of having COVID-19 due to being either exposed to a roommate who tested positive for COVID-19 or had signs and symptoms of possible COVID-19 or had returned to facility from a hospital visit; PPE was not available to staff before moving a resident presumptive with COVID-19, who had an elevated temperature, from a nonquarantine room to a quarantine room; and staff failed to wear PPE before entering facility and going to nurses' station near hallways where residents resided. An Immediate Jeopardy (IJ) situation was identified on 10/22/20. While the IJ was removed on 10/23/20, the facility remained out of compliance at a severity of no actual harm, but more than minimal harm that was not Immediate Jeopardy at a scope of pattern, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. These failures could place residents at risk for being exposed to COVID-19, health complications, and death. Findings include: Record Review of R#1's face sheet indicated she was an [AGE] year-old female, who was admitted to facility 04/28/20. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#1 had been in quarantine room [ROOM NUMBER] due to her roommate testing positive for COVID-19 before 10/21/20. On 10/21/20, R#1 received her test results revealing she was positive for COVID-19. Review of his Minimum Data Set (MDS) 09/02/20 indicated R#1 scored an 11, indicating she was moderately impaired. In addition, this MDS indicated R#1 required extensive assistance with two-person assist for bed mobility, transfer, and toilet use; she required extensive assistance with one person assist for dressing and personal hygiene; she required supervision with set up help only for eating and locomotion on and off the unit, and walking did not occur. Record Review of R#2's face sheet indicated he was a [AGE] year-old male, who was admitted to facility on 09/28/18. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R# 2 had been in quarantine room [ROOM NUMBER] due to an elevated temperature before 10/21/20. On 10/21/20, R#2 received his test results revealing he was positive for COVID-19. Review of his Minimum Data Set (MDS) 07/10/20 indicated R#2 scored a 15 revealing he was cognitively intact. In addition, this MDS indicated R#2 required supervision with set up help only for bed mobility, transfer, walking, locomotion, dressing, eating, toilet use and personal hygiene. Record Review of R#3's face sheet indicated she was a [AGE] year-old female, who was admitted to facility on 01/18/19. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#3 who had been in room [ROOM NUMBER] due to her roommate testing positive for COVID-19. On 10/21/20 R#3 received her testing result revealing she was positive for COVID-19. Review of his Minimum Data Set (MDS) 09/23/20 indicated R#3 scored a 15 revealing she was cognitively intact. In addition, this MDS indicated R#3 required supervision with set up help only for bed mobility, transfer, walking, locomotion, dressing, eating, toilet use and personal hygiene. Record Review of R#4's face sheet indicated she was a [AGE] year-old female, who was admitted to facility 08/09/19. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#4 who had been in room [ROOM NUMBER] due to her roommate testing positive for COVID-19. On 10/21/20 R# 4 received her testing result revealing she was positive for COVID-19. Review of his Minimum Data Set (MDS) 08/25/20 indicated R#4 scored a 3, indicating she was severely impaired. In addition, this MDS indicated R#4 required extensive assistance with two-person assist for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene; she required supervision with set up help only for eating, and walking did not occur. Record Review of R#5's face sheet indicated she was a [AGE] year-old female, who was admitted to facility on 03/31/20. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#5 who had been in room [ROOM NUMBER]B due to her roommate testing positive for COVID-19. On 10/21/20 R#5 received her testing result revealing she was positive for COVID-19. Review of his Minimum Data Set (MDS) 07/10/20 indicated R#5 scored a 15 revealing she was cognitively intact. In addition, this MDS indicated R#5 required supervision with set up help only for bed mobility, transfer, walking, locomotion, dressing, eating, toilet use and personal hygiene. Record Review of R#7's face sheet indicated he was a [AGE] year-old male, who was admitted to facility 09/05/18. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log 10/21/20 indicated R#7 was in room [ROOM NUMBER] B until 10/21/20, when he was moved to 201A after receiving COVID-19 test results revealing he was positive. Review of his Minimum Data Set MDS) 09/21/20 indicated R#7 scored a 99, indicating he was unable to complete interview. In addition, this MDS indicated R#7 required extensive assistance with two-person assist for bed mobility, transfer, dressing, toilet use; he required extensive assistance with one person assist for locomotion on and off the unit, and eating, and walking did not occur. Record Review of R#8's face sheet indicated he was a [AGE] year-old male, who was admitted to facility on 05/04/19. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log 10/21/20 indicated R#8 was in room [ROOM NUMBER]A until 10/21/20, when he was moved to 201B after receiving COVID-19 test results revealing he was positive. Review of his Minimum Data Set (MDS) 07/20/20 indicated R#8 scored a 7 revealing he was severely impaired. In addition, this MDS indicated R#8 required supervision with set up help only for bed mobility, transfer, walking, eating, and toilet use, he required supervision with one-person physical assist for dressing, and limited assistance with one-person assist personal hygiene. Record Review of R#9's face sheet indicated he was a [AGE] year-old male, who was admitted to facility 06/24/20. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log 10/21/20 indicated R#9 was in room [ROOM NUMBER]B until 10/21/20, when he was moved to 204B after receiving COVID-19 test results revealing he was positive. Review of his Minimum Data Set (MDS) 10/02/20 indicated R#9 scored a 00, indicating he was unable to complete interview. In addition, this MDS indicated R#9 required supervision with set up help only for bed mobility, transfer, walking, locomotion, dressing, and toilet use, and he required limited assistance with one-person physical assist for eating and personal hygiene. Record Review of R#10's face sheet indicated she was a [AGE] year-old female, who was admitted to facility 09/01/17. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#10 was in room [ROOM NUMBER]B until 10/21/20, when she was moved to 205 after receiving COVID-19 test results revealing she was positive. Review of his Minimum Data Set (MDS) 09/22/20 indicated R#10 scored a 10, indicating she was moderately impaired. In addition, this MDS indicated R#10 required extensive assistance with one-person assist for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene; she required supervision with set up help only for eating, and walking did not occur. Record Review of R#11's face sheet indicated she was an [AGE] year-old female, who was admitted to facility on 09/19/19. This report includes his [DIAGNOSES REDACTED]. Review of facility's Tracking Log dated 10/21/20 indicated R#11 was in room [ROOM NUMBER]A until 10/21/20, when she was moved to 208A after receiving COVID-19 test results revealing she was positive. Review of his Minimum Data Set (MDS) 08/12/20 indicated R#11 scored a 5 revealing she was severely impaired. In addition, this MDS indicated R#11 required supervision with set up help only for bed mobility, transfer, walking, locomotion, dressing, eating, toilet use and personal hygiene. Observation and review of facility's floor plan on10/21/20 at 4:30 pm of the facility's layout indicated there were six halls. The North side of the building had three halls, hall 100 had nonquarantine rooms with 14 residents, hall 200 had quarantine rooms with 6 residents, and hall 300 had nonquarantine rooms with 14 residents. The South side of the building had three halls, hall 400 was nonquarantine with 15 residents, hall 500 was nonquarantine with 11 residents, and hall 500/600 (rooms 511 to 611) had 16 residents who were COVID-19 positive. The North side area was separated from the South side by a foyer with two sets of double doors. In addition, PPE was stored in a building that housed most of the facility's administrative offices and was separated from the facility's building with residents. This foyer was the area used by the screener to screen staff for presumptive COVID-19 before going past double doors to residents' rooms. Observation on 10/21/20 at 5 pm revealed there 6 residents in the quarantine rooms, R#1 was in room [ROOM NUMBER], R#2 was in room [ROOM NUMBER], R#3 was in room [ROOM NUMBER], R#4 was in room [ROOM NUMBER], R#5 was in room [ROOM NUMBER] and R#6 was in room [ROOM NUMBER]. However, Tracking Log dated 10/21/20 was provided by DON on 10/22/22 at approximately 8 am confirming the residents listed above received their test results revealing they were positive for COVID-19. R#6 was in a quarantine room due to returning to facility from a hospital visit and was not positive for COVID-19. This report included the following residents who were added to the list after receiving test results revealing they were positive for COVID-19. Afterwards, they were moved to quarantine the rooms as follows; R#7 in room [ROOM NUMBER]A, R#8 in room [ROOM NUMBER]B, R#9 in room [ROOM NUMBER]B, R#10 in room [ROOM NUMBER]A, R#11 in room [ROOM NUMBER]A. Observation on 10/21/20 at 5:15 pm indicated Dietary Aide-A, who was wearing a plastic gown and N95 face mask, pulled a large barrel to hall 200 and entered R#1, R#2, R#3, R#4, and R#5's quarantine rooms then exited with their meal trays, which he disposed into the barrel. Afterwards, Dietary Aide-A pulled the barrel into hall 300 and entered nonquarantine rooms, while wearing the same gown and N95 face mask he wore in hall 200, and exited with residents' meal trays, which he disposed into the barrel. During an interview on 10/21/20 at 5:21 pm Dietary Aide-A indicated he was provided a gown and face mask; however, he was not asked to don or doff before or entering a quarantine room to pick up a meal tray or before going into a nonquarantine room. During an interview with Food Service Supervisor indicated dietary aides are issued a face a mask and gown at the start of their shift and was not sure why Dietary Aide-A on 10/21/20 did not don or doff before removing residents' trays from their quarantine room and nonquarantine rooms. Observation on 10/21/20 at 5:30 pm indicated Certified Nurse Aides-A and B entered R#2's quarantine room in hall 200 to provided care, a few minutes later they exited R#2's room and entered R#1's quarantine room in hall 200 to provide care, while wearing the same face mask and gown. Afterwards, CNA-B entered R#8s nonquarantine room in hall 100 to provide care while wearing the same PPE worn when caring for R#2 and R#1. Observation on 10/21/20 at 6:05 pm CNAs-B and C took a mechanical lift into R#6s quarantine room in hall 200 to transfer R#6 to her bed. Afterwards, CNA-C entered R#205B's quarantine room in hall 200 to provide care to R#1. During an interview on 10/21/20 at 6:20 pm CNA-C confirmed he assisted CNA-B with transferring R#6 (quarantine) to her bed and change her brief and clothes. Afterwards, he changed his gloves and gown before entering R#1's room (quarantine) to assist her with toileting. Approximately two minutes later CNA-C exited R#1's room and confirmed he did not wash his hands after assisting R#6 and before applying his gown and gloves to assist R#1. During an interview on 10/21/20 at 5:38 pm with CNA-B indicated she uses the same PPE provided to her when she enters the facility at 6 am until she leaves at 6 pm. During this shift CNA-B cares for residents in quarantine rooms in hall 200 and in nonquarantine rooms in halls 100 and 300. CNA-B indicated she had not been instructed to don or doff her PPE between resident in the quarantine rooms, or when she goes from quarantine to nonquarantine rooms to care of residents. During an interview on 10/21/20 at 5:35 pm indicated Certified Medication Aide-A (CMA-A) indicated she has been provide a face mask at the start of her shift; however, she has not been instructed to don and/or doff when entering and exiting resident's room who are presumptive for COVID-19. In addition, CMA-A indicated she wears the same mask from quarantine room to quarantine room and then continues wears to the same mask when entering nonquarantine rooms. Observation on 10/21/20 at 6:32 pm indicated Certified Medication Aide-A (CMA-A) administered medications to R#3 (quarantine room) by placing the cup of pill and cup of water to her mouth; she administered medication to R#4, who was in a quarantine room in hall 200, by placing the cup of pill and cup of water to her mouth; she administered medications to R#5, who was in a quarantine room in hall 200, administered medications to R# 8, who was in a nonquarantine room in hall, 100, and administered medications to R#9, who was in a nonquarantine room in hall 100. During this medication pass CMA-A wore the same face mask, gown, and face shield between R#3, R#4, R#5, R#8, and R#9. During an interview on 10/21/20 at 5:42 pm with CNA-A indicated she uses the same PPE that is provided to her when she enters the facility to work her shift from 6 am to 6 pm. CNA-A indicated during her shift she cares for residents in quarantine rooms in hall 200 and in nonquarantine rooms in halls 100 and 300. CNA-A indicated she had not been instructed to change her PPE between residents in the quarantine rooms, or when going from quarantine rooms to nonquarantine rooms to care for residents. Observation on 10/21/20 at 6:25 pm revealed R#3 and R#4, who were in quarantine rooms in hall 200, were coughing. LVN-A entered R#3's quarantine room in hall 200 and took her temperature. Afterwards, LVN-A entered R#4's quarantine room in hall 200 to assess her without donning or doffing her PPE (face mask and gown) that she wore in R#3's room. During an interview on 10/21/20 at 6:45 pm with LVN-A indicated on 10/19/20 at approximately 8 PM, she discovered R#14 had and elevated temperature over 100 Fahrenheit. LVN-A recalled, R#14's room was in the same hallway as R#16's room, who was sent to the hospital because of low oxygen levels and a change of condition. LVN-A contacted a hospital staff, who confirmed R#16 was positive for COVID-19, that's when LVN-A informed ADON, who indicated she would follow-up with the hospital. LVN-A, who was only wearing a surgical mask indicated she needed full PPE to care for Resident #16, who was presumptive for COVID. LVN-A indicated she had no extra PPE at her work station nor did she have the key to the storage where the PPE was stored, she contacted LVN-B in hall 600 (COVID positive residents) to obtain PPE. LVN-A indicated she as well as her CNAs were wearing a surgical mask, and did not have an N95 face mask, gowns, or face shields, but LVN-B gave her two N95 face masks and two gowns but no face shields. LVN-A applied an N95 mask and gown and gave one of the two CNAs the other N95 face mask and gown, but did not have a third set to provide CNA-E. LVN. LVN-A indicated ADON called and directed her to move R#14 from hall 100 (nonquarantine room) to hall 200 (quarantine room) and LVN-A and two CNAs including CNA-E, who only had a surgical mask, but no gown or face shield, moved R14 to a quarantine room. LVN-A and two CNAs, including CNA-E for the rest of the shift continued to care for residents in hall 200 (quarantine rooms) and halls 100 and 300 (nonquarantine rooms) while wearing the same PPE (N95 mask and gown, and surgical mask for CNA-E). The rest of the night LVN-A closely monitored resident's vitals when she discovered R#4 and R#15 had elevated temperatures. LVN-A indicated prior to 10/20/20 all staff working hall 100, 200, and 300 were provided with a surgical mask, and staff were not directed to change PPE from quarantine room to quarantine room or from quarantine rooms to nonquarantine rooms (100 and 300). LVN-A indicated the lack of PPE led to the screener, who screens staff for COVID signs, approached the North nurses' station on 10/21/20 before 6 am, because she could not locate a face mask. The North side is where the presumptive COVID and non COVID residents reside. LVN-A directed the screener to go to the South nurses' station, because she was unable to provide her with PPE due to not having any extra PPE at the nurses' station and not having a key to the PPE inventory. During an interview on 10/21/20 at 4:57 pm with CNA-E indicated on 10/19/20 at approximately 9:15 pm she was directed by LVN-A to assist with transferring R#14 from a nonquarantine room in hall 100 to a quarantine room in hall 200, because he had an elevated temperature and was in close contact with R#16, who had tested positive for COVID-19. CNA-E indicated LVN-A made an effort to locate PPE, because they were all wearing surgical face mask; however, LVN-A located two N95 mask and gowns. CNA-E indicated LVN-A and a CNA used the N95 face mask and gowns; however, she used her surgical mask and did not have a gown, face shield, hair cover, or shoe covers, while transferring R#14 to a quarantine room. During an interview on 10/21/20 at 5:20 am with CNA-D indicated she worked on 10/16/20, 10/17/20 and 10/18/20 in halls 100, 200, and 300. CNA-D indicated hall 200 was the quarantine hall with potential COVID residents (R#6, R#13, R#14, and R#16, who passed away on 10/17/20). While working these days, CNA-D indicated she wore a surgical mask and was not provided an N95 face mask or a gown; however, the night of 10/21/20 she was offered a kit that included an N95 face mask, face shield, gown, hair cover, and shoe covers. CNA-D indicated prior to 10/21/20 she wore the same PPE throughout her shift because she was not directed or provided PPE for donning or doffing before entering or exiting residents quarantine rooms or before going from quarantine rooms to nonquarantine rooms. During an interview on 10/22/20 at 10:00 am with LVN-C indicated since being employed she had not received an in-service specific to the use of PPE needed to care for residents in the quarantine rooms before going into the nonquarantine rooms. LVN-B indicated she was offered a face mask but was not offered a gown, or face shield when caring for residents in the quarantine rooms. During an interview on 10/22/20 at 4:21 pm NA-A indicated prior to 10/21/20 she was not informed or in-serviced that when you go from quarantine room to quarantine rooms she should use PPE and remove it when exiting the room. In addition, NA-A was not informed that she should remove her PPE from quarantine room to quarantine room, and from quarantine rooms to nonquarantine rooms. NA-A indicated prior to 10/21/20 she wore her surgical mask throughout her shift (6 am to 6 pm) from quarantine rooms to nonquarantine rooms. During an interview on 10/22/20 at 3:57 pm with Central Supply Staff (CSS-A) indicated she is responsible for ordering and distributing PPE as needed to residents and staff. Prior to 10/21/20, she distributed a kit with PPE (N95 face mask for staff and surgical mask for residents) to the staff in hall 100, 200, 300 and 500; however, hall 200 was provided with one package-10 gowns per shift (6 am to 6 pm and 6 pm to 6 am) and boxes of gloves. CSS-A indicated on 10/21/20 the kit provided to nurses, CNAs, CMA, housekeepers, laundry staff, and dietary staff includes an N95 mask, gowns, hair cover, shoe covers, and a face shield. CSS-A indicated Administrator, DON, ADON have a key to the office, where the PPE is stored and locked. On 10/19/20 CSS-A recalled receiving a call from ADON requesting PPE needed to move R#14 and she informed her the PPE was stored in the office. CSS-A indicated there was not a short supply of PPE and could order more as needed. During an interview on 10/23/20 at 12:34 pm with Nurse Practitioner-A indicated if residents were presumptive positive and they failed to use PPE per policy that's not good. And not changing PPE has potential to spread COVID-19 to other residents who do not have it. Especially when staff care for resident in the warm/quarantine rooms and go to the cold/nonquarantine rooms to care for residents, this virus will spread to the residents who do not have it. During an interview on 10/23/20 at 12:20 pm with Nurse Practitioner-B (NP-B) indicated she works at the hospital, where patients are placed in the warm/quarantine rooms there because they have a high chance of having COVID-19. These residents' who are presumptive for COVID-19, put everybody at risk for contracting it, that's why you assume they are positive, best practice is to don and doff PPE to protect others. (NP-B) indicated education is important in treating these residents because at the hospital they are dying. In addition, the use of PPE is important to prevent COVID-19 or any other virus from spreading from person to person, which can also be carried on their shoes. If a staff enters a warm/quarantine room they should don as they enter and doff as they exit before entering the next quarantine room. If the staff go from warm/quarantine room to cold/nonquarantine room they should doff PPE, failure to do so is not is not acceptable. During an interview on 10/23/20 at 3:15 pm Nurse Practitioner-C indicated residents in quarantine should be treated as if they had COVID to prevent from spreading it; therefore, staff who cared for residents in the quarantine rooms, who are presumptive for COVID-19 due to being exposed to someone with COVID, should have changed PPE before going to a non COVID room. This also applies to everyone in the community who are required to quarantine when they are exposed to someone with COVID-19, this helps to prevent spreading [MEDICAL CONDITION]. During an interview on 10/23/20 at 2:43 pm Nurse Practitioner-D indicated if a resident is suspected of having COVID, it in unacceptable for staff to go from room to room unless they know all residents are COVID positive, but when they don't know they should don or doff PPE before and after entering to care for resident who were a potential for having COVID-19. Observation on10/21/20 at 5:17 pm revealed there were storage carts as follows: the cart between rooms [ROOM NUMBERS] contained 8 white gowns and 1 bag of 18-Ultra Briefs; the cart between rooms [ROOM NUMBERS] contained10 white gowns and 2 boxes of gloves; the cart between rooms [ROOM NUMBERS] contained 3 boxes of gloves, a trash bag, and 1 plastic blue gown, and the cart between rooms [ROOM NUMBERS] contained a box of gloves 2 plastic gowns. The PPE in these carts were not used by the nurse, CMA, CNAs, and dietary aide prior to entering quarantine rooms for residents (R#1, R#2, R#3, R#4, and R#5). Observation on 10/21/20 at 6:15 pm revealed DON placed bags of gowns on the medication cart at the nurses' station located at the entrance to halls 100, 200, and 300. During an interview on 10/21/20 at 5:55 pm Director of Nurses (DON) indicated the facility did not have a shortage of PPE, and currently had approximately 1000 items of PPE for staff to use. Nurses, CNAs, and CMAs upon entering the facility are issues a kit that includes a gown, hair cover, N95 mask, shoe coverings are optional, and face shield if you work with residents who are COVID-19 positive. If these staff are working with residents in quarantine or nonquarantine rooms, they are issued face mask and gowns. DON confirmed there were 37 residents in halls 100, 200, and 300. Six of thirty-seven residents were in quarantine due to having a roommate who had tested positive for COVID-19 or had signs and symptoms of possible COVID-19. (R#1, R#2, R#3, R#4, and R#5). In addition, there was one resident (R#6) in the quarantine hall due to returning from a hospital visit. On 10/22/20 DON indicated residents (R#1, R#2, R#3, R#4 and R#5) who were in quarantine rooms in hall 200 had received their testing results indicating they were positive for COVID-19. In addition, residents (R#7, R#8, R#9, R#10 and R#11), who were in the nonquarantine rooms in halls 100 and 300 received their testing results on 10/21/20 indicating they were positive for COVID-19 and were moved to quarantine rooms in hall 200. DON indicated all the residents, who were COVID-19 positive were moved to halls 100, 200, and 300, and the North side of the building was designed as the COVID unit. The residents who were not positive were moved to the South side of the building and facility no longer has a warm/quarantine unit. Facilities policies and procedures revealed the following: General Infection Control Practices: Isolation-Categories of Transmission-Based Precautions revised October 2018, are initiated when a resident develops signs and symptoms of a transmissible infection: arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed status. Policy for Possible Pandemic Respiratory Infections (undated) indicated COVID-19 and other respiratory infections are known to spread from person-to-person. Caring for residents with presumptive or confirmed infections required personal protective equipment (PPE: gloves, gowns, face mask, and face shields if eye contamination is possible). These PPE is donned if there will be any contact with potentially infectious material, afterwards remove PPE and place in biohazard bag. Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures revised July 2020 and based on current CDC recommendations for infection prevention practices for COVID-19. This policy indicated the facility would follow recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. This policy indicated while in the building, personnel are required to strictly adhere to established infection prevention control policies, including: hand hygiene; respiratory hygiene; appropriate use of PPE; transmission-based precautions where indicated: universal source control (using facemasks or cloth coverings as indicated); surveillance and reporting of respiratory infections; etc. This policy indicated to address asymptomatic and pre-symptomatic transmission, universal source control is required. Anyone entering the facility is required to wear a cloth face covering. Staff are required to wear face coverings upon entering the facility and prior to leaving the building. Contact precaution may be implemented for resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff will wear gloves when entering the room and gloves will be removed and hygiene performed before leaving the room. Staff will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing talking, or by the performance of procedures such as suctioning. Staff will wear mask when entering the room. Gloves, gown and goggles should be worn if there is a risk of spraying respiratory secretions. Airborne Precautions are indicated when an individual is infected with a pathogen that is very small and can be transmitted long distances through the air. Any individuals who enter the room of a resident placed on airborne infections disease shall be masked and transported to a facility with an air borne infection isolation room. The Infection Control for all Nursing Procedures, revised August 2012 included the following: Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including facility protocols for isolation (standard and transmission based) precautions; the location of all personal protective gear; the location of medical waste containers, etc. The general guidelines indicated standard precautions will be used in the care of all residents in all situations regardless of confirmed presence of infectious diseases. And transmission-base precautions will be used whenever more stringent that standard precautions are needed to prevent the spread of infections. Personal Protective Equipment (PPE) indicated staff wear facemasks all the times while in the facility; staff will wear eye protection during any resident-care encounters or procedures; far a resident with known or suspected CVOID-19 staff will wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. If there is moderate to substantial COVDI-19 transmission in the community staff wear all recommended PPE (i.e. gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit. The Coronavirus Disease (COVID-19)-managing Supplies and Resources dated July 2020 indicated the Infection Preventionist appoints an Infection Prevention and Control Supply Coordinator who is responsible for monitoring the current supply and anticipated needs for: Personal protective equipment (gloves, gowns, eyewear, facemasks). These supplies are stationed throughout the facility to facilitate access and ease of use, for example PPE in all resident care areas and nursing stations. The Infection Control for all Nursing Procedures, revised 08/2012 included the following: Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including facility protocols for isolation (standard and transmission based) precautions; the location of all personal protective gear; the location of medical waste containers, etc. The general guidelines indicated standard precautions will be used i

Based on interviews and record review, it was determined the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 residents (Resident #3) reviewed for Quality of Care. - LVN A accused Resident #3 of abuse, called the police and had him arrested instead of calling his physician and getting an order for [REDACTED]. The facility's failure to notify staff who were identified in Resident #3's Care Plan instead of calling the police and a failure to change the Care Plan to update behaviors and new interventions placed all 85 residents at risk of being provided improper medical treatment or interventions. The evidence is as follows: Review of Resident #3's clinical record documented the following: -Resident #3 admitted to the facility on [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -Current Care Plan: have episodes of verbally, physically and inappropriate behavior. Staff are to: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression, Assess for pain, Ensure family/MD/aware of behaviors and/ or any increase in behaviors noted, Ensure staff is aware of residents behaviors and successful interventions, Maintain a calm environment, Monitor for early warning signs of behavior- approach in calm manner, call by name, remove from unwanted stimuli to a safe environment, Redirect behaviors as resident displays them, and Refer to Social Services as needed -A quarterly MDS resident assessment, dated 6/13/18, documented the resident sometimes understood others and was sometimes understood, resident scored 8 of 15 on a mini-mental exam, independent with transfers, ambulation, locomotion, limited assistance by one staff for dressing and bathing, continent, open lesion on foot, 71 inches tall and 224 pounds. -Nurse's Note, dated 9/13/18 at 5:49 a.m., documented the following: at about 3:35 a.m., resident came out of his room and stated, Hey, nurse asked him what he needed. He pointed to his left foot. His wound was covered but he could have used a sock on. (sig) Nurse asked resident to go to his room and lay down and nurse would fix his bandage. Resident refused. He walked around the dining area for a few minutes but was agitated. At 3:45 a.m., nurse put the medication cart in the opening at the nurse's station to prevent him from coming behind the nurse's desk. He then came back to the nurse's station and nurse asked him what he needed. He pointed to his left foot. Nurse again asked resident to go to his room and elevate his foot, that she would be there to dress his foot. Resident refused, became verbally abusive and picked up Narcotic notebook and went through motions of throwing book at nurse and CNA but did not let go. he did this multiple times. Nurse held up computer key board to prevent him from hitting her and he hit the keyboard with the narcotic notebook. Nurse redirected resident to go to his room and lie down so she could fix the dressing to his left foot. he continued to refuse care and started pushing medication cart in at nurse and CNA, nurse called north side and asked for the male nurse to come over to the south side STAT. When he came he asked resident if he could help him but resident refused and was verbally abusive. At 3:59 a.m., nurse called 911. nurse continued to redirect resident. He continued to be verbally abusive and pushing medication cart at nurse and CNA. At 4:16 a.m. nurse called NP but phone just rang, no option to leave voice mail. Resident continued pushing medication cart into CNA and nurse. Officers arrived and resident was noncompliant to their requests. Officers asked resident to sit down and he sat in chair but continued to be agitated. At approximately 4:30 a.m., officers were able to escort him to the police vehicle. During an interview on 9/14/18 at 2:00 p.m., Resident #3's family member stated LVN A had Resident #3 arrested and thrown in jail because of behaviors instead of getting him the medical help that he so desperately needed. During an interview on 9/14/18 at 3:02 p.m., the Health Services Administrator at the local jail, stated since Resident #3 was arrested, he has been extremly confused, tearful, upset and does not know where he is at. During an interview on 9/17/18 at 1:31 p.m., LVN A stated they say Resident #3 has Alzheimer's but she was just not too sure of that. LVN A stated a couple of weeks ago, Resident #3 started coming after her and hitting her with a folded up shirt. LVN A stated she called the police that time but the police did not take him to jail. LVN A stated a couple of days ago, Resident #3 was very agitated and approached her while pointing to his foot. LVN A stated she asked Resident #3 to go and lay down on his bed so she could look at his foot. LVN A stated Resident #3 kept coming in and out of his room and the next thing she knew, Resident #3 was at the nurse's station. LVN A stated she told Resident #3 to go back to his room and lay down and he picked up a pink narcotic book and acted like he was going to hit her so she was on the phone and called the police and told them to come over. LVN A stated when the police got to the facility, they got Resident #3 to sit down and she said to the police, she wanted to press charges because she did not know what else to do. LVN A stated she told the police she wanted Resident # 3 out of the facility because he was agitated and aggressive. LVN A stated she had never had training to deal with an aggressive resident ever. LVN A stated she had been a victim of domestic violence before and there was something about Resident #3 that scared her. LVN A stated she did not have training to deal with ugly people like Resident #3. LVN A stated she felt she was stuck taking care of Resident #3. During an interview on 9/18/18 at 8:25 a.m., SW stated when a resident has behaviors, staff are to call the Administrator, not the police. During an interview on 9/18/18 at 10:38 a.m., ADON B stated the protocol with a resident with behaviors was to report to the ADON and she would report to the DON and they would talk about the behaviors. ADON B stated if it triggers an incident then the behaviors would be reviewed on a daily basis. ADON B stated she had called 911 for an uncontrollable behavior. ADON B stated the police would come out and help them to stabilize the resident so the resident could be sent out to the hospital but she would never have a resident arrested. ADON B stated if a resident was having a severe behavior, she would call the doctor to get an emergency medication for that resident. During an interview on 8/18/18 at 10:52 a.m., the Administrator stated they did not have a protocol to follow when a resident has a catastrophic behavior. During an interview on 9/19/18 at 9: 30 a.m., Resident #3's NP stated they have an answering service during the day and after 5:00 p.m., the physician takes calls until 9:00 p.m. NP stated she was not sure what to do since she just found out that morning that Resident #3 was in jail. NP stated that was not right at all, the nurse should have called her to get an emergency medication. NP said calling the police should be the last resort and the police should help only to help staff give a shot of an emergency medication. Review of the Facility Roster (CMS Form 802), received on 9/17/18, documented a census of 85 residents.

Based on interviews and record review, it was determined the facility failed to ensure that staff who provided direct services to residents had the appropriate competencies and skills sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 9 residents (Resident #3) whose care was reviewed in that: LVN A stated she had never had training to deal with an aggressive resident ever. LVN A stated she did not have training to deal with ugly people like Resident #3. LVN A called the police and pressed charges against Resident #3 instead of following his care plan for behaviors. The actions taken to incarcerate Resident #3 resulted in the resident being extremely confused, tearful, very upset and did not know where he was at. This deficient practice could affect 85 residents at the facility by not being cared for by properly trained staff. The evidence is as follows: Review of Resident #3's clinical record documented the following: -Resident #3 admitted to the facility on [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -Current Care Plan: have episodes of verbally, physically and inappropriate behavior. Staff are to: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression, Assess for pain, Ensure family/MD/aware of behaviors and/ or any increase in behaviors noted, Ensure staff is aware of residents behaviors and successful interventions, Maintain a calm environment, Monitor for early warning signs of behavior- approach in calm manner, call by name, remove from unwanted stimuli to a safe environment, Redirect behaviors as resident displays them, and Refer to Social Services as needed. -A quarterly MDS resident assessment, dated 6/13/18, documented the resident sometimes understood others and was sometimes understood, resident scored 8 of 15 on a mini-mental exam, independent with transfers, ambulation, locomotion, limited assistance by one staff for dressing and bathing, continent, open lesion on foot, 71 inches tall and 224 pounds. -Nurse's Note, dated 9/13/18 at 5:49 a.m., documented the following: at about 3:35 a.m., resident came out of his room and stated, Hey, nurse asked him what he needed. He pointed to his left foot. His wound was covered but he could have used a sock on. (sic) Nurse asked resident to go to his room and lay down and nurse would fix his bandage. Resident refused. He walked around the dining area for a few minutes but was agitated. At 3:45 a.m., nurse put the medication cart in the opening at the nurse's station to prevent him from coming behind the nurse's desk. He then came back to the nurse's station and nurse asked him what he needed. He pointed to his left foot. Nurse again asked resident to go to his room and elevate his foot, that she would be there to dress his foot. Resident refused, became verbally abusive and picked up Narcotic notebook and went through motions of throwing book at nurse and CNA but did not let go. he did this multiple times. Nurse held up computer key board to prevent him from hitting her and he hit the keyboard with the narcotic notebook. Nurse redirected resident to go to his room and lie down so she could fix the dressing to his left foot. he continued to refuse care and started pushing medication cart in at nurse and CNA, nurse called north side and asked for the male nurse to come over to the south side STAT. When he came he asked resident if he could help him but resident refused and was verbally abusive. At 3:59 a.m., nurse called 911. nurse continued to redirect resident. He continued to be verbally abusive and pushing medication cart at nurse and CNA. At 4:16 a.m. nurse called NP but phone just rang, no option to leave voice mail. Resident continued pushing medication cart into CNA and nurse. Officers arrived and resident was noncompliant to their requests. Officers asked resident to sit down and he sat in chair but continued to be agitated. At approximately 4:30 a.m., officers were able to escort him to the police vehicle. During an interview on 9/14/18 at 3:02 p.m., the Health Services Administrator at the local jail, stated since Resident #3 was arrested, he has been extremly confused, tearful, upset and does not know where he is at. During an interview on 9/17/18 at 1:31 p.m., LVN A stated they say Resident #3 has Alzheimer's but she was just not too sure of that. LVN A stated a couple of weeks ago, Resident #3 started coming after her and hitting her with a folded up shirt. LVN A stated she called the police that time but the police did not take him to jail. LVN A stated a couple of days ago, Resident #3 was very agitated and approached her while pointing to his foot. LVN A stated she asked Resident #3 to go and lay down on his bed so she could look at his foot. LVN A stated Resident #3 kept coming in and out of his room and the next thing she knew, Resident #3 was at the nurse's station. LVN A stated she told Resident #3 to go back to his room and lay down and he picked up a pink narcotic book and acted like he was going to her so she was on the phone and called the police and told them to come over. LVN A stated when the police got to the facility, they got Resident #3 to sit down and she said to the police, she wanted to press charges because she did not know what else to do. LVN A stated she told the police she wanted Resident # 3 out of the facility because he was agitated and aggressive. LVN A stated she had never had training to deal with an aggressive resident ever. LVN A stated she had been in domestic violence and there was something about Resident #3 that scared her. LVN A stated she did not have training to deal with ugly people like Resident #3. LVN A stated she felt she was stuck taking care of Resident #3. During an interview on 9/18/18 at 8:25 a.m., SW stated when a resident has behaviors, staff are to call the Administrator, not the police. During an interview on 9/18/18 at 10:38 a.m., ADON B stated the protocol with a resident with behaviors was to report to the ADON and she would report to the DON and they would talk about the behaviors. ADON B stated if it triggers an incident then the behaviors would be reviewed on a daily basis. ADON B stated she had called 911 for an uncontrollable behavior. ADON B stated the police would come out and help them to stabilize the resident so the resident could be sent out to the hospital but she would never have a resident arrested. ADON B stated if a resident was having a severe behavior, she would call the doctor to get an emergency medication for that resident. During an interview on 8/18/18 at 10:52 a.m., the Administrator stated they did not have a protocol to follow when a resident has a catastrophic behavior. Review of an in-service for staff, Coping with Behaviors with Dementia, documented the following: Strategies to reduce combativeness Evaluate the resident and the situation *what is the resident trying to communicate through the behavior? *What was happening prior to the episode? Has this occurred before? Under the same circumstances? *Are there loud noises in the resident's environment? *Is the resident's environment chaotic or busy? *Have their physical needs been met (hunger, pain, thirst, toileting, and body temperature (cold/hot), sleep pattern disruption? *Have new medications been introduced? *How has location and situation contributed to the behavior. Wandering *Redirect pacing into productive activity or something purposeful if possible. *reassure the resident *Does the resident wander at a specific time of day? Anticipate interventions for that time frame each day. Sleep Problem Management *Address nighttime restlessness. *attempt to improve sleep hygiene. Reduce noise and light, play soothing music. *Keep a consistent sleep schedule. *use night lights *Limit caffeine Situations *Environmental adjustments: modify the environment whenever possible to reduce agitation. *Extrinsic factors: loud/distracting noises: minimize when possible, relocate resident even if temporary. *Is the resident territorial (chair, television) Prevention/De-escalation: *Maintain your composure: be aware of your emotions, tone and body language *Approach: respond calmly and express support, use positive and friendly facial expressions. *Always approach the resident from the front, not the back. *Active listening: Engage the resident to determine need when possible. *Effective verbal responding: Are you reflecting or paraphrasing to clarify understanding. Use a gentle, relaxed tone. *Stance: Are you at eye level? Are your arms crossed on your chest? keep arms at sides. Be sure to be at a safe distance if potential for combative behavior exists. Review of the Facility Roster (CMS Form 802), received on 9/17/18, documented a census of 85 residents.

Based on interview, and record review, the facility failed to implement adequate supervision to prevent an identified hazard by not following the resident's comprehensive person centered care plan that prevented injury to a resident. The facility failed to implement/provide adequate supervision according to resident 1 of 6, resident #1's care plan, by leaving resident #1 alone in her wheel chair in her room, resulting in an unwitnessed fall with a fracture to her zygomatic arch (cheekbone). This failure affected 1 resident, Resident #1 and had the potential to affect the other 32 residents with history of falls, by placing them at risk for injury, and not addressing their highest practical physical, mental and psycho-social well-being. Findings included: Resident # 1: Record review of Resident # 1's face sheet revealed a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident # 1 progress notes reflected the following: Resident #1 had a fall on 1/21/18, and 1/24/18 requiring the facility to implement changes to the resident's care plan. The intervention to decrease/prevent falls was documented on the care plan as, Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to common area to be monitored. Date initiated 1/23/18. Documented in the nurses notes on 2/1/18 Resident #1 was found in her room alone on the floor laying in blood and vomit, and the wheelchair was tipped forward with her legs on the footrest of the wheelchair. Dietary staff found Resident #1 on the floor in her room alone and called out for help. The fall on 2/1/18 resulted in a Non-displaced hairline fracture to left zygomatic arch. Record review of Resident # 1's Annual Minimum Data Set ((MDS) dated [DATE] documented: Section C. Brief Interview for Mental Status (BIMS). C0500. BIMS Summary Score; Resident # 1 scored a 3 out of a possible 15. This score indicated significant cognitive impairment. Section V-V0200 Care Area Assessment (CAA) Summary indicated -11.Falls was triggered as a care area of concern. Section J- Health Conditions; J1900: Any falls since Admission/Entry or reentry or prior assessment? This was coded as Yes. A- no injury Record review of Resident #1's comprehensive care plans revealed the following: Focus: Resident #1 at risk for falls related to: decrease cognition and mobility, history of falls, psych medication and cognitive impairment related to dementia. I believe I am capable of performing ADLs, ambulating, transfer without assist, and forget to ask for assistance. Resident #1 had recent fall attempting to transfer herself to bed. Date initiated 11/16/15. Goal: I will not sustain injury related to falls by next review date. Date initiated 11/16/15. Interventions: 1. Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to the common area to be monitored. Date initiated 1/23/18 with the revision date of 2/23/18 . 3. Falling Star program. Date initiated 12/19/17. 4. Monitor me for falls and injuries, report injuries to physician and treat as ordered. Date initiated 11/16/15 with the revision date of 10/29/17. 5. Offer assist with ADLs, transferring, ambulating as necessary. Date initiated 11/16/15. Record review of Resident #1's progress notes reflected the following: 2/1/18 at 9 PM: notified MD about found on floor. Laying on left lateral side. Small laceration to left forehead near left eye. Skin tear left forearm which started on 2/1/18. This is signed by LVN #1. Record review of physician orders [REDACTED]. 1. X-ray to left hip due to fall-STAT, neuro checks. Send to ER for evaluation and treatment if family requests. Dated 2/1/18 at 8 PM. 2. Send to CMC ER for evaluation treatment status [REDACTED]. Dated 2/1/18 at 10:15 PM. Record review of ER report revealed the following: Exam on 2/2/18 showed; Head: on exam: left frontal forehead ecchymosis. Head CT performed and revealed the following: 1. Non-displaced hairline fracture to the left zygomatic arch (cheekbone). Minimally displaced comminuted (break or splinter of the bone into more than two fragments) fracture to the posterior lateral left maxillary sinus wall. Minimally displaced comminuted fracture to the lateral wall of the left orbit. Sutures versus minimally displaced hairline fractures of both nasal bones. Record review of incident report revealed the following information: Date of incident: 2/1/18 at 8:00 PM. Incident location: Resident's room Incident description: Resident found lying on her left lateral side on floor by CNA. Immediate action taken: Resident assessed for injuries. Has small laceration to left forehead near left eye. Bleeding. Small skin tear to left forearm near antecubital area. Blood pressure elevated. Transferred to bed with aide of CNA x2 and charge nurse. Notified nurse practitioner, neural checks initiated. New order for x-ray to left hip. Stated that the family wanted to send out for evaluation then to send out. Notified family. Family okay with resident being evaluated at the facility. Will continue to monitor. Injuries observed the time of incident: 1. Laceration to face. 2. Skin tear to left antecubital area. Level of pain: 5 Level of consciousness: Alert Mobility: Wheelchair-bound Injuries report post incident: No injuries observed post incident. Predisposing physiological factors: 1. Confused 2. Incontinent 3. Impaired memory This progress note was completed by LVN# 1 Record review of Post Fall Review dated 2/2/18 revealed the following: Description of fall: Found on left lateral side, lying on floor, blood around head. Laceration found to left side of four head, near left eye. Unwitnessed fall. Location of fall: 2. Where did the fall occur? Resident's room Location of resident prior to fall 3. Where was the resident prior to the fall? Wheelchair Activity at time of fall: 4. What was the resident doing during prior to the fall? Sitting 5. What type of assistance was resident receiving at time of fall? Alone and unattended Cognition: 6. Describe the resident's cognition prior to fall Alert, disoriented at times, but can follow simple instructions 7. Is this the resident's usual mental status? Yes 8. Describe resident's psychological status prior to fall confused 8a. Is this the resident's usual psychological status? Yes Conditions that may contribute: 10. Does the resident have any of the following conditions that may contribute to the fall? b. History of falls f. Cognitive deficits 12. Can resident demonstrate use of call light in room? b. No . Interview on 3/20/18 at 4:50 PM with MDS coordinator confirmed Resident #1 suffered a facial fracture from the fall that occurred on 2/1/18. She stated Resident #1 had an unwitnessed fall in the dining room on 1/21/18. MDS coordinator stated she updated the care plan on 1/23/18 to include either placing the resident in bed after meals or keeping her in common areas for monitoring if she did not want to go to bed. Interview on 3/21/18 at 11:01 AM with MDS coordinator confirmed Resident #1 was found by Dietary Aide #2. MDS coordinator stated she conducted the post fall review assessment to find the underlying cause. She stated she updated the care plan and updated the Cardex which is available for CNA's to review for changes in resident care. MDS coordinator stated staff did not follow the care plan update which she put into place on 1/23/18 (Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to the common area to be monitored.) Record review of witness statement dated 2/2/18 by CNA #1 revealed the following: I, CNA #1 took Resident #1 to lay down in her room. Resident refused so I left to tend to another resident. I heard someone yelling, came out of the other resident's room and the girls in dietary said you need to quit playing this woman is on the floor. I then proceeded to the room to tend to the resident and called the nurse. Record review of witness statement dated 2/1/18 by Dietary Aide #2 revealed the following: As I was going down the hall to leave I passed Resident #1's room. Saw her on the floor face first. I dropped what I had in my hands and yelled I need a nurse down the hall and no one was around when I went into the room. Her blood was thick. CNA #1 came around. He went to get the nurse. Record review of witness statement dated 2/1/18 by Dietary Aide #1 revealed the following: As I was walking to clock out I witnessed Resident #1 lying on the floor with blood everywhere and throw up. CNA #1 was coming off the 600 hallway and Resident #1 was screaming for help. She was in her wheelchair it wasn't locked because she was on the floor. Interview on 3/21/18 at 11:15 AM with CNA #1 revealed he was in the room with another resident when he heard Dietary Aide #2 yell that someone was on the floor. He stated he went to the room and saw Resident #1 on the floor with her wheelchair tipped towards her but not on top of her. CNA #1 stated her legs were still on the foot rest. He stated he saw blood and vomit on the floor. CNA #1 stated he moved the wheelchair and asked Dietary Aide #2 to stay with the resident while he got the nurse. He stated he and CNA #2 cleaned up the mess after they assisted resident #1 to bed. CNA #1 stated whenever changes are made in resident care he hears it by word-of-mouth from other CNA's or by the nurses. CNA #1 confirmed he was unaware resident #1 was not to be left in her room unattended. He stated no one had told him there was a change in care for Resident #1 until after the fact of the fall on 2/1/18. CNA #1 confirmed he has access to the Cardex but he only looks at those for new residents. Interview on 3/21/18 at 1:52 PM with Dietary Aide #1 revealed she was walking down the hall to clock out and heard someone saying help me. Dietary Aide #1 stated they looked in Resident #1's room and saw her on the floor and the wheelchair was leaned over her but not on top of her. She stated Dietary Aide #2 went into the room and asked Resident #1 if she was okay. She stated Dietary Aide #2 started screaming for help. CNA #1 came out of another residence room and I told him to go help for Resident #1. Dietary Aide #1 stated Resident #1 was in her room not in the hallway. Interview on 3/21/18 at 2:10 PM with Dietary Aide #2 revealed she and Dietary Aide #1 passed Resident #1's room as they were clocking out. She stated she saw a Resident #1 on the floor with the wheelchair tipped over and she yelled for help. She stated CNA #1 came from around the corner from another room. Dietary Aide #2 stated CNA #1 said oh man she fell , she fell again. Dietary Aide #2 told CNA #1 to go get help. She confirmed she stayed with the resident while CNA #1 left to get the nurse. She stated the next day she was informed that Resident #1 had a fracture. Dietary Aide #2 confirmed resident was found in her room facing towards the bed like someone had just pushed the wheelchair in the room and left. Record review of in-service training report dated 2/2/18 revealed the following: Topic: Resident #1 Contents or summary of training session: Ensure resident is place to bed after meals. If resident refuses to go she is to be kept in the common area. Conducted by name, title, and qualification: MDS coordinator Record review of a second in-service training report dated 2/2/18 revealed the following: Topic: Resident #1 Contents or summary of training session: Please monitor Resident #1 closely for the next 72 hours related to death of husband and recent fall. Conducted by name, title, and qualification: Previous DON (who was employeed at facility during this incident) Record review of policy and procedure titled using the care plan dated 2001 with the revision date of (MONTH) 2006 revealed the following: Record reviewed facility's policy titled Falls and Fall Risk, Managing revised date (MONTH) 2007. Policy statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falls. Policy interpretation and implementation: Monitoring Subsequent Falls and Fall Risk 1.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. 2. If interventions have been successful in preventing falling, staff will continue the intervention or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. ~ Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 3/20/18 confirmed a census of 83.

Based on interview, and record review, the facility failed to implement for each resident a comprehensive person centered care plan for 1 of 6 residents in order to maintain the resident's highest practical physical, mental and psycho-social well-being. The facility did not ensure Resident #1's care plan for supervision was implemented, leaving resident alone in her wheel chair in her room, and resulted in an unwitnessed fall with a fracture to her zygomatic arch (cheekbone). This failure affected 1 resident, Resident #1 and had the potential to affect the other 32 residents with history of falls, by placing them at risk for injury, and not addressing their highest practical physical, mental and psycho-social well-being. Findings included: Resident # 1: Record review of Resident # 1's face sheet revealed a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident # 1 progress notes reflected the following: Resident #1 had a fall on 1/21/18, and 1/24/18 requiring the facility to implement changes to the resident's care plan. The intervention to decrease/prevent falls was documented on the care plan as, Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to common area to be monitored. Date initiated 1/23/18. Documented in the nurses notes on 2/1/18 Resident #1 was found in her room alone on the floor laying in blood and vomit, and the wheelchair was tipped forward with her legs on the footrest of the wheelchair. Dietary staff found Resident #1 on the floor in her room alone and called out for help. The fall on 2/1/18 resulted in a Non-displaced hairline fracture to left zygomatic arch. Record review of Resident # 1's Annual Minimum Data Set ((MDS) dated [DATE] documented: Section C. Brief Interview for Mental Status (BIMS). C0500. BIMS Summary Score; Resident # 1 scored a 3 out of a possible 15. This score indicated significant cognitive impairment. Section V-V0200 Care Area Assessment (CAA) Summary indicated -11.Falls was triggered as a care area of concern. Section J- Health Conditions; J1900: Any falls since Admission/Entry or reentry or prior assessment? This was coded as Yes. A- no injury Record review of Resident #1's comprehensive care plans revealed the following: Focus: Resident #1 at risk for falls related to: decrease cognition and mobility, history of falls, psych medication and cognitive impairment related to dementia. I believe I am capable of performing ADLs, ambulating, transfer without assist, and forget to ask for assistance. Resident #1 had recent fall attempting to transfer herself to bed. Date initiated 11/16/15. Goal: I will not sustain injury related to falls by next review date. Date initiated 11/16/15. Interventions: 1. Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to the common area to be monitored. Date initiated 1/23/18 with the revision date of 2/23/18 . 3. Falling Star program. Date initiated 12/19/17. 4. Monitor me for falls and injuries, report injuries to physician and treat as ordered. Date initiated 11/16/15 with the revision date of 10/29/17. 5. Offer assist with ADLs, transferring, ambulating as necessary. Date initiated 11/16/15. Record review of Resident #1's progress notes reflected the following: 2/1/18 at 9 PM: notified MD about found on floor. Laying on left lateral side. Small laceration to left forehead near left eye. Skin tear left forearm which started on 2/1/18. This is signed by LVN #1. Record review of physician orders [REDACTED]. 1. X-ray to left hip due to fall-STAT, neuro checks. Send to ER for evaluation and treatment if family requests. Dated 2/1/18 at 8 PM. 2. Send to CMC ER for evaluation treatment status [REDACTED]. Dated 2/1/18 at 10:15 PM. Record review of ER report revealed the following: Exam on 2/2/18 showed; Head: on exam: left frontal forehead ecchymosis. Head CT performed and revealed the following: 1. Non-displaced hairline fracture to the left zygomatic arch (cheekbone). Minimally displaced comminuted (break or splinter of the bone into more than two fragments) fracture to the posterior lateral left maxillary sinus wall. Minimally displaced comminuted fracture to the lateral wall of the left orbit. Sutures versus minimally displaced hairline fractures of both nasal bones. Record review of incident report revealed the following information: Date of incident: 2/1/18 at 8:00 PM. Incident location: Resident's room Incident description: Resident found lying on her left lateral side on floor by CNA. Immediate action taken: Resident assessed for injuries. Has small laceration to left forehead near left eye. Bleeding. Small skin tear to left forearm near antecubital area. Blood pressure elevated. Transferred to bed with aide of CNA x2 and charge nurse. Notified nurse practitioner, neural checks initiated. New order for x-ray to left hip. Stated that the family wanted to send out for evaluation then to send out. Notified family. Family okay with resident being evaluated at the facility. Will continue to monitor. Injuries observed the time of incident: 1. Laceration to face. 2. Skin tear to left antecubital area. Level of pain: 5 Level of consciousness: Alert Mobility: Wheelchair-bound Injuries report post incident: No injuries observed post incident. Predisposing physiological factors: 1. Confused 2. Incontinent 3. Impaired memory This progress note was completed by LVN# 1 Record review of Post Fall Review dated 2/2/18 revealed the following: Description of fall: Found on left lateral side, lying on floor, blood around head. Laceration found to left side of four head, near left eye. Unwitnessed fall. Location of fall: 2. Where did the fall occur? Resident's room Location of resident prior to fall 3. Where was the resident prior to the fall? Wheelchair Activity at time of fall: 4. What was the resident doing during prior to the fall? Sitting 5. What type of assistance was resident receiving at time of fall? Alone and unattended Cognition: 6. Describe the resident's cognition prior to fall Alert, disoriented at times, but can follow simple instructions 7. Is this the resident's usual mental status? Yes 8. Describe resident's psychological status prior to fall confused 8a. Is this the resident's usual psychological status? Yes Conditions that may contribute: 10. Does the resident have any of the following conditions that may contribute to the fall? b. History of falls f. Cognitive deficits 12. Can resident demonstrate use of call light in room? b. No . Interview on 3/20/18 at 4:50 PM with MDS coordinator confirmed Resident #1 suffered a facial fracture from the fall that occurred on 2/1/18. She stated Resident #1 had an unwitnessed fall in the dining room on 1/21/18. MDS coordinator stated she updated the care plan on 1/23/18 to include either placing the resident in bed after meals or keeping her in common areas for monitoring if she did not want to go to bed. Interview on 3/21/18 at 11:01 AM with MDS coordinator confirmed Resident #1 was found by Dietary Aide #2. MDS coordinator stated she conducted the post fall review assessment to find the underlying cause. She stated she updated the care plan and updated the Cardex which is available for CNA's to review for changes in resident care. MDS coordinator stated staff did not follow the care plan update which she put into place on 1/23/18 (Ensure I am laid in bed after meals. Do not leave me in my wheelchair alone in my room. If I do not want to lay in bed please bring me back to the common area to be monitored.) Record review of witness statement dated 2/2/18 by CNA #1 revealed the following: I, CNA #1 took Resident #1 to lay down in her room. Resident refused so I left to tend to another resident. I heard someone yelling, came out of the other resident's room and the girls in dietary said you need to quit playing this woman is on the floor. I then proceeded to the room to tend to the resident and called the nurse. Record review of witness statement dated 2/1/18 by Dietary Aide #2 revealed the following: As I was going down the hall to leave I passed Resident #1's room. Saw her on the floor face first. I dropped what I had in my hands and yelled I need a nurse down the hall and no one was around when I went into the room. Her blood was thick. CNA #1 came around. He went to get the nurse. Record review of witness statement dated 2/1/18 by Dietary Aide #1 revealed the following: As I was walking to clock out I witnessed Resident #1 lying on the floor with blood everywhere and throw up. CNA #1 was coming off the 600 hallway and Resident #1 was screaming for help. She was in her wheelchair it wasn't locked because she was on the floor. Interview on 3/21/18 at 11:15 AM with CNA #1 revealed he was in the room with another resident when he heard Dietary Aide #2 yell that someone was on the floor. He stated he went to the room and saw Resident #1 on the floor with her wheelchair tipped towards her but not on top of her. CNA #1 stated her legs were still on the foot rest. He stated he saw blood and vomit on the floor. CNA #1 stated he moved the wheelchair and asked Dietary Aide #2 to stay with the resident while he got the nurse. He stated he and CNA #2 cleaned up the mess after they assisted resident #1 to bed. CNA #1 stated whenever changes are made in resident care he hears it by word-of-mouth from other CNA's or by the nurses. CNA #1 confirmed he was unaware resident #1 was not to be left in her room unattended. He stated no one had told him there was a change in care for Resident #1 until after the fact of the fall on 2/1/18. CNA #1 confirmed he has access to the Cardex but he only looks at those for new residents. Interview on 3/21/18 at 1:52 PM with Dietary Aide #1 revealed she was walking down the hall to clock out and heard someone saying help me. Dietary Aide #1 stated they looked in Resident #1's room and saw her on the floor and the wheelchair was leaned over her but not on top of her. She stated Dietary Aide #2 went into the room and asked Resident #1 if she was okay. She stated Dietary Aide #2 started screaming for help. CNA #1 came out of another residence room and I told him to go help for Resident #1. Dietary Aide #1 stated Resident #1 was in her room not in the hallway. Interview on 3/21/18 at 2:10 PM with Dietary Aide #2 revealed she and Dietary Aide #1 passed Resident #1's room as they were clocking out. She stated she saw a Resident #1 on the floor with the wheelchair tipped over and she yelled for help. She stated CNA #1 came from around the corner from another room. Dietary Aide #2 stated CNA #1 said oh man she fell , she fell again. Dietary Aide #2 told CNA #1 to go get help. She confirmed she stayed with the resident while CNA #1 left to get the nurse. She stated the next day she was informed that Resident #1 had a fracture. Dietary Aide #2 confirmed resident was found in her room facing towards the bed like someone had just pushed the wheelchair in the room and left. Record review of in-service training report dated 2/2/18 revealed the following: Topic: Resident #1 Contents or summary of training session: Ensure resident is place to bed after meals. If resident refuses to go she is to be kept in the common area. Conducted by name, title, and qualification: MDS coordinator Record review of a second in-service training report dated 2/2/18 revealed the following: Topic: Resident #1 Contents or summary of training session: Please monitor Resident #1 closely for the next 72 hours related to death of husband and recent fall. Conducted by name, title, and qualification: Previous DON (who was present during this incident) Record review of policy and procedure titled using the care plan dated 2001 with the revision date of (MONTH) 2006 revealed the following: Policy statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy interpretation and implementation: 1. Care plans are updated on PCC (system used by CNAs for documentation). 2. The nurse supervisor uses the care plan to complete the CNA's daily/weekly work assignment sheets and/or flow sheets. 3. CNA is responsible for reporting to the nurse supervisor any change of the resident's condition in care plan goals and objectives that have not been met or expected outcomes that have not been achieved. 4. Other facility staff noting a change in the resident's condition also report those changes to the nurse supervisor and/or the MDS assessment coordinator. 5. Changes in the residence condition was reported to the MDS assessment coordinator the review of the resident's assessment and care plans can be made. ~ Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 3/20/18 confirmed a census of 83.

Based on observation, interview and record review it was determined that the facility failed to ensure that a resident who entered the facility without a pressure sore does not develop a pressure sore for one Resident # 1 of 3 residents reviewed for pressure sores The facility failed to ensure a resident receives the necessary treatment and services to prevent new pressure ulcers from developing by continuing to allow the Resident when walking to wear poor fitting shoes for 6 months and 17 days that caused blister formation, which turned into a Stage 3 Pressure Ulcer. Once the blisters on both lateral heels were identified, the facility continued to allow the Resident to wear poor fitting shoes for another 30 days causing the blisters to open and deepen tissue damage with ultimately resulting in an infection necessitating antibiotic therapy and weekly outpatient physician treatment to debride the wound. Outpatient physician specialty care began 09/15/15 and currently continues. Per facility Nursing Policy and Procedure Skin-Preventative Guideline for Resident at Risk for Pressure Sores the facility failed to thoroughly perform the steps of recognition, problem and cause identification, prevention and management, or monitoring in accordance with recognized standards of practice for one Resident. This failure has the potential to affect 43 more residents being treated for [REDACTED]. Findings include: Resident # 1 was admitted to the facility on [DATE] with Brief Interview of Mental Status-1 (BIMS Score of 0-7 is listed as severe cognitive impairment). A BIMS-1 would indicate Resident # 1 is not be expected to communicate in a coherent manner nor follow directions thus needs to be protected. Resident # 1 also did not have any pressure sores at the time of admission as evident per record review of Minimum Data Set' s ((MDS) dated [DATE], 07/30/15 and Admission Nursing Assessment dated 06/30/15 at 1:45 p.m. - Skin Condition: [MEDICAL CONDITION] - LLE and Skin Inspection Report dated 07/02/15 Skin Status-Intact . Interview on 12/08/15 at 9:10 a.m. during initial tour, ADON #1 stated, Resident #1 has pressure ulcers that were blisters; she got them while in the hospital . Observation and interview on 12/09/15 at 10:25 a.m., Resident # 1 wound care provided by L.V.N. # 1 with assist of ADON #1. After dressings were removed, unusual location of heel ulcers noted to be lateral location on heel versus posterior heel as understood during initial tour when ADON # 1 stated the ulcers were hospital acquired. L.V.N. # 1 stated, Right heel is Stage 2 and Left heel is Stage 3. In response to whether resident slept with her toes pointed lateral medially while lying down or sleeping, L.V.N. #1 stated, No, the sores are from the open back shoes she wore. Resident # 1 walks on her heels that created the pressure sores. In response to question regarding length of time Resident # 1 was in the hospital, ADON #1 said, I ' m not sure . Interview on 12/09/15 at 4:00 p.m., ADON # 1 stated Resident # 1 was in Acute Care Hospital #1 on 06/16/15 and discharged on [DATE] . The following timeline was submitted by the ADON #1: 10/25/14 admitted to NF (initial admission)06/10/15 discharged to Rehab Hospital for behaviors (Resident # 1 ' s behaviors may have been this particular resident expression of pain from the developing ulcers. Resident # 1 Brief Interview of Mental Status score is 0 - 1)06/16/15 admitted to Acute Care Hospital #106/18/15 admitted to NF 06/19/15 admitted to Rehab Hospital again for behaviors06/30/15 admitted to NF Record Review revealed, Acute Care Hospital #1Patient Transfer Form dated 06/18/15 at 1400, Skin Condition-Intact . Record Review of NF Departmental Notes dated 07/26/15 revealed documented first entry of skin abnormality, resident ambulates independently, dry cracked heels noted documented by R.N. # 2 Record Review revealed, Skin Inspection assessment dated [DATE], Skin - Intact . Record Review revealed, Departmental Notes dated 08/08/15 at 03:28 a.m. 3 days before pressure sore documented identification, Resident in bed has been getting agitated when CNAs go into check her to see if she is wet but has not tried to get up no falls tonight will continue to monitor . Agitation observed the nurse may have been another sign of pain experienced by a resident with BIMS 0 -1(Score of 0-7 is listed as severe cognitive impairment). Record Review revealed, Departmental Notes dated 08/07/15 at 10:09 a.m. 4 days before pressure sore documented identification, Resident is currently in a wc d/t weakness noted to ble ' s; she does con to ambulate as well . Considering Resident # 1 BIMS 0 - 1 ' (Score of 0-7 is listed as severe cognitive impairment), the nurse ' s notation, weakness noted to ble ' s would have indicated a need for thorough assessment of bilateral lower extremities since this resident has limited ability to communicate pain. Record Review revealed, Departmental Notes dated 08/11/15 Resident with fluid filled blisters that are dark in color. Message left for FNP #1 and daughter. Record Review revealed, Care Plan dated 08/11/15: Pressure Sores, #1: Right Heel Stage II, #2: Left Heel Stage II. Reduce the risk of further skin breakdown. Nutritional assessments according to the RD recommendations. Nurse to examine skin daily for signs of redness, discoloration. Assess areas prone to breakdown. Care Plan Comments dated, 08/11/15 revealed, Resident walks frequently in plastic oversized shoes with no socks and appears to walk on back of heels. Family notified and asked to take shoes out of facility and bring new ones. Resident is very non-compliant with care / instructions. -ADON # 1. Record Review revealed 08/11/15 as Day 0 of Pressure Sore identification as revealed in the following chart documentations: - Physician/Prescriber Telephone Orders: dated 08/11/15 at 1400,- [MEDICATION NAME] Spray to bilat heels Q Shift until healed for Blisters; signed MD#1 / FNP#2 / ADON #1 - Care Plan Comments dated, 08/11/15 revealed, Family notified and asked to take shoes out of facility and bring new ones. ADON # 1. Record Review revealed on day 3 following wound identification that facility allows Resident # 1 to continue wearing shoes that caused the ulcers; physician progress notes [REDACTED]. Record Review revealed, first Registered Dietician note made 20 days after Pressure Sore identification, but does not make nutritional recommendations for wound healing. This suggests no evidence of intradepartmental communication regarding newly identified wound concerns to actively be addressed for wound healing. - Nutritional Progress Notes dated 08/31/15 reveal, Labs on 07/29/15 H/H 13.2/40.7 (WNL), TP 7.3, Alb 3.1, BUN 25, Creat 1.22, all WNL Record Review revealed, 21 days after Pressure Ulcer identification, Care Plan Comments dated, 09/01/15 Family brought clog like shoe, those were not effective .will attempt non-skid socks. -ADON # 1 Record Review revealed 28 days after Pressure Ulcer identification wounds are now open and facility continues to allow Resident # 1 to wear the poor fitting shoes that created the pressure ulcers. Progress Notes dated 09/07/15 reveals, Heel blisters now open scabbing; blisters con trauma from constant walking on heels of shoes. Record Review revealed on day 30, facility wound specialist documentation revealed, Wound Centrics dictated Consult note dated 09/10/15: CC/HPI: She walks around constantly. She has nonstageable wounds to her heels bilaterally which have been intact and dry; however, with all the walking she does have a slight opened area on her right heel. The patient is noncompliant with wound care .The patient has [MEDICAL CONDITION] to lower extremities 2-3+ pitted with limited circulation noted to the pedal pulses. We have requested for a Doppler to be done to determine the extent of circulation down. The patient did not verbalize understanding, was cussing in Spanish the entire time that we were trying to look at her lower extremities. ROS: CONSTITUTIONAL: Negative for fever, chills. EYES: Negative for redness, discharge. ENT: Negative for ear pain, nosebleeds, sore throat. RESPIRATORY: Negative for cough, shortness of breath. CARDIOLOGY: Negative for chest pain, palpitations. [MEDICATION NAME]: Negative for nausea, vomiting diarrhea. UROLORY: Negative for dysuria, hematuria. NEUROLOGY: Negative for [MEDICAL CONDITIONS]. PSYCHOLOGY: Negative for delusions or homicidal ideations. PE: General Appearance: Normal, NAD, pleasant. The patient is an elderly well-developed Hispanic female. HEENT: Skin: Normal, no rash. Extremities: She does have the 2 to 3+ [MEDICAL CONDITION] to lower extremities bilaterally. She does have decubitus on the heels bilaterally; the left heel is having an open area on the edges. AP: 1. Decubitus stage IV to heels bilaterally. We will paint with [MEDICATION NAME], apply calcium alginate to keep as dry as possible and over with a pad of dressing. 2. [MEDICAL CONDITION] with bilateral lower extremity [MEDICAL CONDITION] causing increased risk for the breakdown and continued wound. 3. Extreme [MEDICAL CONDITION]. I am ordering a Doppler with ABI to determine extent of poor circulation. Interview on 12/08/15 with L.V.N. # 1 said, Resident # 1 speaks Spanish but it is gibberish. Record Review revealed normal Doppler result dated 09/10/15 revealed no cardiovascular or physiological cause for pressure ulcer development. Doppler Study result stated by local cardiologist: Conclusion: 1. Unremarkable bilateral lower extremity arterial Doppler study. 2. Normal Velocity. 3. Normal Ankle brachial indices bilaterally. Record Review revealed on day 34 after pressure ulcer identification that the pressure ulcer has now further deteriorated into an infection , Physician/Prescriber Telephone Orders: dated 09/14/15, [MEDICATION NAME] 500 mg 1 tab PO x 7 days for Foul smell to wound; signed by MD#1 / FNP#1 / ADON #1 Record Review of wound measurements revealed Resident # 1 slow healing and ulcer enlargement, Wound Healing Progress Reports and documents from facility new computer system with new wound healing progress report document titled Skin Observation Tool - (Licensed Nurse) : 08/11/15 Day 00, Left Heel, no fluid filled blister, 9.00 x 4.00 08/18/15 Day 07, Left Heel, no fluid filled blister, 9.00 x 4.00 08/25/15 Day 14, Left Heel, no fluid filled blister, 9.00 x 4.00 09/01/15 Day 21, Left heel, Blister, Length-4.00, Width-7.0, Unstageable 09/08/15 Day 28, Left heel, Blister, Length-4.00, Width-7.0, Stage-N/A, scabbing old blister 09/15/15 Day 35, Left heel, Blister Length-5.5, Width-8.0, Stage-N/A, scabbing old blister 08/11/15 Day 00, Right Heel, no fluid filled blister, 6.00 x 5.00 08/18/15 Day 07, Right Heel, no fluid filled blister, 6.00 x 5.00 08/25/15 Day 14, Right Heel, no fluid filled blister, 5.00 x 4.00 09/01/15 Day 21, Right heel, Blister, Length-6.00, Width-6.0, Stage-Unstageable09/08/15 Day 28, Right heel, Blister, Length-6.00, Width-6.0, Unstageable, scabbing old blister 09/15/15 Day 35, Right heel, Blister Length-6.00, Width-6.00, Stage-Unstageable, scabbing old blister Record Review 35 days after pressure ulcer identified, local wound care center M.D. #2 Physician Note dated 09/15/15 at 1:00 p.m. revealed M.D. pre and post exam findings: -#1: Left Heel Lateral: -Size Pre: 3.00 x 5.00 x 0.70cm. -Size Post: 3.25 x 5.25 x 0.85 cm. -Exudate: Moderate, [DIAGNOSES REDACTED]: Moderate, [MEDICAL CONDITION]: Moderate. -% Slough: 30-60, % Devitalized: 30-60. -Procedure: Debridement - subcutaneous tissue. -#2: Right Heel: -Size Pre: 3.00 x 3.00 x 0.75cm. -Size Post: 3.25 x 3.25 x 0.85cm.-Exudate: Moderate, [DIAGNOSES REDACTED]: Moderate, [MEDICAL CONDITION]: Moderate. -% Slough: 30-60, % Devitalized: 30-60. -Procedure: Debridement - subcutaneous tissue. Record Review revealed 56 days after pressure sore wound was identified the Registered Dietician acknowledges pressure sore / wound healing concern dated 10/06/15 Nutritional Therapy Assessment: Nutrition [DIAGNOSES REDACTED]. Monitoring & evaluation follow for wound healing . Telephone Interview on 12/10/15 at 4:55 p.m. L.V.N # 1 stated, I called doctor to report blisters and he gave a [MEDICATION NAME] order. We called our wound care specialist FNP # 3, but the family wanted to send resident # 1 out for care. So appointment with Local Wound Doctor was made. We put resident ' s shoes that caused the pressure sores on the top shelf of her closet but her daughter would put them back on resident # 1 ' s feet; because resident # 1 kept saying ' where are my momma shoes? ' We explained to daughter that shoes were probably the reason resident # had blisters. But she kept putting the shoes on her mom. Then daughter would bring other similar type shoes that didn ' t fit until finally we were successful with treaded slipper socks. Record Review revealed Resident # 1 did not have the capability to follow instructions, did not have any pressure ulcers, [MEDICAL CONDITION] or venous and arterial related wounds or ulcers. Admission MDS, Resident Assessment and Care Screening dated 11/01/14 and 10/29/15 documented that Resident # 1 had severe cognitive impairment and 07/30/15 had moderately impaired cognitive skills for daily decision making. The following are facts pulled from MDSs to support previous finding. 11/01/14 MDS: C0500 BIMS - 1 (Score of 0-7 is listed as severe cognitive impairment), M0150 - 0, Resident is not at risk of developing Pressure Ulcer, M1040 - Z, No Other Ulcers, Wounds or Skin Problems present 07/30/15 C1000 Cognitive Skills for Daily Decision Making Code 2, Moderately impaired (decisions poor, cues/supervision required), M0150 - 1, Resident at risk of developing Pressure Ulcer, M1040 - Z, No Other Ulcers, Wounds or Skin Problems present 10/29/15 C0500 - BIMS - 0 (Score of 0-7 is listed as severe cognitive impairment), M0150 - 1, Resident at risk of developing Pressure Ulcer, M0300 - 2, Stage 2 pressure ulcers, Date of oldest Stage 2 pressure ulcer: 08-11-2015, M1030 - 0, Venous or Arterial Ulcers, M1040 - Z, No Other Ulcers, Wounds or Skin Problems present Record Review revealed, Nursing Policy and Procedure, Subject: Skin-Preventative Guideline for Resident at Risk for Pressure Sores, Effective Date: 01/2008, Revised Date: 03/2012, Applies to: Licensed Nurses. POLICY: It is the policy of this home that a resident who enters the home without a pressure ulcer will not develop pressure ulcers unless the resident ' s clinical condition demonstrated that they were unavailable. DEFINITIONS: Avoidable: The resident developed a pressure ulcer(s), or that an existing pressure ulcer deteriorated or failed to heal adequately and that the home failed to thoroughly perform the steps of recognition, problem and cause identification, prevention and management, or monitoring in accordance with recognized standards of practice.' RISK FACOTRS (Examples include, but are not limited to) 1. Cardiovascular conditions 2. Depression; [MEDICAL CONDITION]; 3. Decreased cognition or level of consciousness; 4. Local [MEDICAL CONDITION]; 5. Intense, or prolonged unrelieved pressure, 6. Shearing and friction associated with moving; 7. Lack of appropriate skin barriers; 8. Inadequate pressure reducing devices PRESSUSRE RELIEF: 1. Relieve the underlying cause of pressure, addressing pressure, shear, other physical friction, 2. Elevate [MEDICAL CONDITION] extremities. 3. Avoid shearing forces . 4. Avoid friction: a. Consider protective devices . b. Suggest the use of socks SUPPORTIVE MEASURE/NUTRITION 1. Promote a well-balanced diet 2. Obtain a dietary consultation 3. Assess the need for nutritional supplements 4. Assess the need for pain medications LOCAL MEASURE FOR AREAS PRONE TO THE DEVELOPMENT OF SKIN BREAKDOWN 1. Assess areas most prone to breakdown: a. Heels Record review of the facility Skin-Preventative Guideline for Resident at Risk for Pressure Sores, Resident # 1 qualifies for 8 of the 22 listed Risk Factors that increase a resident's susceptibility to develop or to not heal pressure ulcers. Further review of resident record reveals FNP staged the pressure ulcers as Stage 4 yet Nursing Service staged the pressure ulcers as Stage 3; the physician wound specialist only used measurements. 1 of 43 residents was receiving preventative skin care as documented on CMS-672 dated 12/08/15. Also documented on CMS-672 were 3 residents with Pressure Ulcers.