Every finding on record at Midwestern Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers to meet the needs of each resident for 1 of 1 (Resident #1) that received Enteral Feedings.LVN A failed to administered Resident #1's Enteral feeding for two hours after his feeding bag of nutrition ran out on 12/22/25. This deficient practice placed Resident #1 at risk for dehydration and insufficient caloric intake.Findings Included:Record Review of Resident #1's Face Sheet dated 02/10/26 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] with the latest return date of 11/08/25. Resident #1 had a primary diagnosis of Parkinson's Disease (progressive neurological disorder that primarily affects movement) and additional diagnosis of moderate protein-calorie Malnutrition (an imbalance between the nutrients your body needs and the nutrients it gets), dysphagia (swallowing disorder), aphasia (absence of speech) and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). He received his nutrition by enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract via a feeding tube).Record review of Resident #1's Quarterly MDS assessment, dated 11/12/25 revealed a BIMS score of 99 (unable to complete interview). The resident was positive for tube feedings. Record review of Resident #1 Care Plan, initiated on 12/23/22, revealed Resident #1 required tube feeding related to dysphagia. Record Review of Resident #1's Physician Orders dated 02/10/26 revealed the order: Enteral Feed, every shift, related to moderate protein-calorie malnutrition. Tube Feeding Continuous: Formula Jevity 1.5 at 70 cc/hr with H20 flush at 50 cc/hr, for 22 hours to allow for ADL care. Record Review of the Medication Administration Record for December dated 12/22/23 revealed Resident #1 Enteral feeding was given on the night shift 6:00 pm - 6:00 am, time was not specified. Resident #1 received a one-time bolus order on 12/22/23 at 9:30 pm for Jevity 1.5. Give 240 ml via PEG-Tube one time only due to extended period without feeding.In an interview with the DON on 2/10/26 at 9:15 am, she said she reported and investigated the incident. She said Resident #1 had an order for enteral continuous feeding for 22 hours in a 24-hour period. On 12/22/25 at approximately 2:30 pm, CNA B noted that Resident's #1 feeding pump was beeping. His assigned nurse, LVN A, was on break at that time, so she went and told RN C. RN C reported to LVN A when she came back from her break at 3:30 pm. LVN A said she did not know about it until 5:30 pm, at dinner time, when CNA D told her. LVN A told LVN E at shift change at 6:00 pm, his feeding pump needed to be changed, and he said he would take care of it. Resident #1 failed to receive his enteral feeding for approximately 2 hours. The Medical Director was notified of the incident, and he ordered a one-time bolus feeding. The resident was assessed with no injury, nor did he display any reported effects from the incident. In an observation on 2/10/26 at 11:50 am, Resident #1 was sitting in the lobby area in a specialized wheelchair receiving enteral feeding. He was not interviewable. In an interview on 2/10/26 at 1:33 pm, the Medical Director said the facility contacted him regarding the incident, and he ordered a bolus one-time feeding. He said Resident #1 did not experience any negative outcomes and was not harmed.In an interview on 2/10/26 at 1:46 pm, Resident #1's Responsible Party said the facility contacted him concerning the incident. He said he came to the facility frequently and asked Resident #1 if he experienced any negative outcomes and Resident #1 shook his head no. In an interview on 2/10/26 at 2:30 pm, RN C said CNA B reported to her Resident #1's feeding pump was beeping. She said LVN A was on break at that time and told LVN A, at 3:30 pm, when she returned from her break, and LVN A acknowledged. In an interview on 2/10/26 at 2:40 pm, CNA D said she reported to LVN A, at dinner time at 5:30 pm, that Resident #1's feeding pump needed to be changed. She said LVN A acknowledged.In an interview on 2/10/26 at 2:54 pm, CNA B said she told RN C that Resident's #1's feeding pump was beeping while LVN A was on her break. She said RN C said she would tell LVN A when she returned. In an interview on 2/12/26 at 10:25 am, LVN A said she did not remember RN C telling her Resident #1's feeding pump was beeping. She stated during dinner time at 5:30 pm, CNA D reported to her Resident #1's feeding pump was beeping. While she was on her way to replace Resident #1's nutritional bag, another resident needed some assistance, and she did not get it done. At shift change at 6:00 pm, she told LVN E, and he said he would change it for Resident #1.In an interview on 2/10/26 at 3:30 pm, the DON said possible negative outcomes would be the resident would get dehydrated and not receive sufficient caloric intake. She expected physician orders to be followed. LVN E no longer works at the facility and was not available for interview. Record review of the facility';s policy Enteral Nutrition, dated as reviewed on 6/25/2025, revealed the following [in part]: Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered.Policy Interpretation and Implementation:. 9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 15 residents (Residents #13 and #56) reviewed for resident rights. The facility failed to ensure Resident #25 and Resident #53 were served lunch in the dining room in a dignified manner on 7/08/2025. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.During an observation and interview on 8/26/25 at 12:05 PM Resident #25 and Resident #53 [JM1] were not served lunch with the rest of their table. Resident #53 was sitting at table with 2 other residents and while they were served lunch and started eating Resident #53 waited until 12:18 PM, 13 minutes after the other 2 were served, while staff was serving other tables before being served. Resident #25 was sitting with 1 other resident while the other resident was served at 12:07 PM and started eating, Resident # waited until 12:25 PM, 18 minutes while other resident was served, while staff was serving other tables until he was served. During an interview with Resident #53 on 8/26/25 at 12:11 PM, Resident #53 [JM2] stated that he was hungry and guessed he would have to eat by himself if staff did not serve him soon. Resident #53 stated that sometimes he must wait to be served after his table partners have been served[JM3] . Resident #53 was served at 12:18 PM, 13 minutes after the other two residents were served at his table. During an interview with Resident #25 on 8/26/25 at 12:15 PM, Resident #25 stated he must be patient, and wait until they get around to serving him. Resident #25 stated that this doesn't happen often that the other resident gets served and you must wait while staff serve other tables before you get your food, but sometimes it does happen. Resident #25 stated he would like to eat with his table partners when she gets her food. During an interview on 8/26/25 at 12:55 PM, LVN B who was the charge nurse for dining stated that Residents #25 and #53 did not have special orders and should have been served with their table. LVN B stated that general the trays are placed in order of seating by dietary staff and are delivered one table at a time. LVN B stated she did not know why the residents were not served at the same time but will correct the problem. LVN B stated that it is a right and dignity issues and residents should not have to wait to be served while others are eating at their table. During an interview on 8/26/25 at 1:05 PM, DM stated that dietary tries to line up trays and serve out one table at a time but sometimes they do not know who will be eating in the dining room at each meal. The DM stated that dietary should pay more attention on who comes to the dining room and where they are seated so to be able to serve each resident at that table before moving on to the next table. The DM stated it is not right for one or two residents to sit while others eat, and they have to wait. Record review of a facility policy titled Quality of Life-Dignity dated October 2009 indicated, .each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .

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, by failing to ensure: 1. The food fryer was left in an unsanitary condition, food fryer had not been cleaned after use, food crumbs dried to fryer baskets and inside fryer walls. 2. Cart with clean bowls and plates stored on it was not clean, food particles observed. 3. Floor behind stove, fryer and oven not swiped, food particles and trash found on floor. These failures could place residents at risk for decline in nutritional health status and foodborne illness.On 8/26/25 at 8:54 AM during the observation of dietary kitchen, fryer not clean, has food scrapes on baskets and fryer. Cart with clean bowls and plates stored on it was not clean, food particles observed. The floor behind stove, fryer and oven not swiped, food particles and trash were found on floor. In an interview on 8/26/25 at 11:20 AM, the Dietary Manager stated that fryer and fryer baskets should have been cleaned after last use. The Dietary Manager stated that the clean dish cart should be cleaned before placing clean dishes on cart. Dietary Manager stated that the floors behind equipment should be swept and mopped daily. The Dietary Manager stated that there is a cleaning schedule that staff are to follow and stated that equipment should be cleaned and sanitized after each use to prevent food borne illness, and the kitchen should be cleaned daily, and no food scraps or particles should be left out as to not attract pests. [JM1] Record review of the facility's policy for Kitchen Sanitation, dated October 2022, revised June 2024, stated [in part]: Section 1. All utensils, counters, shelves and equipment shall be kept clean, Section 11B. 1. Fixed equipment will be routinely cleaned and maintained, 3. Food contact equipment will be cleaned and sanitized after every use.

Based on interviews and record reviews, the facility failed to implement and maintain an effective training program for 1 of 16 existing staff (LPN E) whose training records were reviewed for multiple training topics, including the following: The facility failed to ensure LPN E was trained in Communication; QAPI; Resident Rights; Infection Control; Dementia; Abuse Neglect and Exploitation; Behavioral Health; HIV; Restraint Reduction; Falls; and Compliance and Ethics.These failures could place residents at risk of receiving care from incompetent/untrained staff.The finding included: Record review of personnel files revealed: LPN E had a hire date of 1-13-2021 and did not receive initial and/or annual trainings or in-services. LPN E had no current training for:CommunicationResident Rights Infection ControlCompliance and EthicsAbuse Neglect ExploitationQAPIBehavioral HealthDementiaHIVRestraint ReductionPrevention of Falls. In an Interview on 8-28-25 at 3:33 PM the ADMN stated her intention for staff training to encompass all employees and to include all resident care areas. She verbalized understanding that employees should have education to provide appropriate care to residents. She stated the negative outcome to not having education up to date would be that staff may not be able to provide appropriate care. In an interview on 8-28-25 at 3:59 PM the HR Coordinator revealed LPN E had been employed as a PRN staff since 1/13/21 and she did not complete trainings in Communication, Resident Rights, Infection Control, Compliance and Ethics, Abuse Neglect and Exploitation, QAPI, Behavioral Health, HIV, Prevention of Falls, Restraint Reduction, Dementia. HR Coordinator is responsible for monitoring staff training. Failure to complete trainings could put residents at risk for negative outcome. In an interview on 8-28-2025 at 5:30 PM the HR Coordinator stated LPN E was a PRN staff nurse and her most current shift worked was 8-16-2025. Record Review of the facility policy provided by ADMN titled In-Service Training, All Staff dated 12/9/2024 and reviewed/revised 8/5/2025 revealed [in part]: Policy StatementAll staff are required to participate in initial orientation and annual in-service training.Policy Interpretation and Implementation #1 All staff are required to participate in regular in-service education.#2 For the purpose of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.#3 The primary objective of in-service training is to ensure that staff are able to interact in a manner that enhances the residents quality of life and quality of care and can demonstrate competency in the topic areas of training. #5 Training methods and teaching materials are appropriate to the expected roles of those attending.#6 Required training topics include the following: Effective Communication with resident sand family (direct care staff) Resident rights and responsibilities Preventing abuse neglect exploitation and misappropriation of resident property including:a. Activities that constitute abuse neglect exploitation or misappropriation of resident propertyb. Procedures for reporting incidences of abuse neglect exploitation or misappropriation of resident property; andc. Dementia management and resident abuse prevention. Elements and goals of the facility QAPI program. The infection and prevention control program standards, policies and procedures. Behavioral health; and The compliance and ethics program standards; policies and procedures.#7 Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment.#8 Completed training is documented by the staff development coordinator, or his or her designee and includes: The date and time of the training The topic of the training The method used for training A summary of the competency assessment; and The hours of training completed.

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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 residents (Resident #8) reviewed for care plans.1. Resident #8 did not have a care plan developed to address his need for one-on-one in-room individual activity pursuits.2. Resident #8's care plan was not revised and updated with a care plan to address his bedbound status. This failure placed the resident at risk for social isolation, decreased awareness of his surroundings, and decreased feelings of well-being.The findings included: Record review of Resident #8's admission Record, dated 8/28/2025, revealed a [AGE] year-old male initially admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), chronic kidney disease stage 3 (mild to moderate kidney damage, leading to a reduced ability to filter waste and excess fluid from the blood), hypertension (high blood pressure), hearing loss, nuclear cataracts bilaterally (clouding and hardening of the central part of the eye's lens), osteoporosis (a condition that weakens bones and increases the risk of fracture), fracture of neck of right femur (right hip fracture), low back pain, chronic pain syndrome, dysphagia (swallowing problem), atherosclerosis of left leg (hardening of arteries). Record review of the Activity Participation Note, dated 2/03/2025, revealed the AD documented the following: Resident prefers independent in own room activities. It is very important for resident to be able to watch TV and movies. It is very important for resident to go outside in the sunshine, but with a blanket. Resident enjoys hunting and fishing. Resident has no other activity concerns at this time.Review of Resident #8's Significant Change in Condition MDS Assessment, dated 6/28/2025, revealed a BIMS score of 1 out of 15 (severe cognitive impairment) and documented activity preferences as being very important for doing favorite activities, keeping up with the news, going outside for fresh air, and participating in religious services or practices. Review of Resident #8's comprehensive care plan, dated as initiated 12/03/2024 and revised 6/30/2025, revealed it did not include a care plan to address the resident's activity interests or need for in-room one-on-one activities. The care plan had been updated to include hospice care services, but did not address the resident's bedbound status. Observation on 8/26/2025 at 10:59 AM revealed Resident #8 was lying on his back in bed with his eyes closed. He was wearing eyeglasses. The room door was open to the hallway. Observation on 8/27/2025 at 8:10 AM revealed Resident #8 was lying in bed with the head of bed elevated. His eyes were closed. The room door was open to the hallway. During an interview and record review on 8/28/2025 at 10:37 AM, the Activity Director stated Resident #8 was assisted into his wheelchair by the CNAs. She stated Resident #8's family member visited about 1 time per week and took the resident outside. She stated Resident #8 liked to be outside. The AD stated Resident #8 did not like group activities or being around people. She reviewed his electronic health record and stated the last documented activity progress note was dated 2/03/2025. She stated she was supposed to document a progress note every 3 months, every time an MDS assessment was due, and she had not done that for Resident #8. The AD reviewed Resident #8's electronic health record and stated he had a quarterly MDS assessment and activity progress note due now. She reviewed his care plan and did not see a care plan for activities. The AD stated Resident #8 liked music and she had taken a tablet into his room and played u-tube live music videos for him. She stated the resident did not really like the tablet. The AD stated the resident used to like hunting and fishing. She stated she had not been able to find any TV programs with fishing or hunting, other than programs with people shooting deer. She stated maybe he would like to watch people shooting deer. In an interview on 8/28/2025 at 11:08 AM, the AD stated she did not document one-on-one activity programming for Resident #8. Observation on 8/28/2025 at 11:16 AM revealed Resident #8 was lying on his back in bed. The TV was on in the room, but volume was low. The resident was not wearing his eyeglasses, which were on the bedside nightstand. The room door was open to the hallway. In an interview on 8/28/2025 at 11:16 AM, C.N.A. A stated she had been employed in the facility since December 2024 and she worked from 6:00 AM to 6:00 PM on the hall were Resident #8's room was located. She stated Resident #8 used to get up in his wheelchair for all meals in the main dining room before he fell and broke his hip and stated he still went to the dining room after he broke his hip. C.N.A. A stated about 2 months ago Resident #8 started staying in bed. She stated Resident #8's daughter did not want him to get up because he was in too much pain. C.N.A. A stated the hospice aide gave Resident #8 a bed bath on Tuesday and Thursday and sometimes on Saturday. She stated Resident #8 did not ever get up [out of bed]. C.N.A. A stated she had not seen the AD go into Resident #8's room to visit him and had not seen anyone go into the resident's room to do an activity with him. She stated Resident #8 was visited by his family member who lived out of town and came to stay for a week or longer a couple times a month. She stated the family member stayed in Resident #8's house and visited him daily during her stays. C.N.A. A stated Resident #8 had other family members who visited and his military friends visited when they could get a ride [to the facility], and they were old too. She stated she turned on the TV, but left the volume at the level the daughter had it on during her last visit. During an interview and record review on 8/28/2025 at 12:09 PM, the MDS Coordinator stated she oversaw care plans and sometimes each department entered their own care plans and sometimes she did it. She reviewed Resident #8's electronic health record and stated his last care plan conference was held 7/10/2025 and was attended by the resident's responsible family member, MDS Coordinator, SW, Dietary Manager, treatment nurse, and hospice nurse. She stated the Activity Director was not there and she was usually doing activities when care plan meetings were held. The MDS Coordinator stated activities were discussed and resident's family member did not want Resident #8 to be transferred from the bed with a mechanical lift due to the risk for injury. She stated the family member did not want him transferred at all. The MDS Coordinator stated she had added a care plan for activities today after the AD came and talked with her about a care plan for activities and she added one. The MDS Coordinator stated Resident #8 did not like large groups of people. She stated Resident #8 did not like eating in the dining room, either, when he had been assisted into the wheelchair and was taken to the dining room. On 8/28/2025 at 12:26 PM, the MDS Coordinator reviewed Resident #8's progress notes and found activity notes dated 12/03/24, 2/03/25, 5/06/25, 6/28/25 and printed them for the surveyor. The notes documented the similar entry: Resident prefers independent in own room activities. It is very important for resident to be able to watch TV and movies. It is very important for resident to go outside in the sunshine, but with a blanket. Resident enjoys hunting and fishing. Resident has no other activity concerns at this time. The MDS Coordinator stated the notes were documented before the care plan conference was held with Resident #8's responsible family member on 7/10/25, when she had stated she did not want him transferred from the bed. Record review of the facility's Lifetime Wellness Policies and Procedures for One-On-One Program, dated 1/01/2023, revealed the following [in part]: PolicyOne-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents who prefer not to attend group programs and/or for identified short term rehab patients.ProcedureThe resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week. Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, dated as reviewed January 2023, revealed the following [in part]: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for 1 of 2 residents (Resident #8) reviewed for individual in-room one-on-one activity programming.1. Resident #8 was observed lying in his bed throughout the survey with no observed visitors or in-room activity programs offered to him from 8/26/25 to 8/28/25.2. Resident #8 did not have an individual in-room activities program developed to meet his interests. These failures placed the resident at risk for social isolation, decreased awareness of his surroundings, and decreased feelings of well-being.The findings included: Record review of Resident #8's admission Record, dated 8/28/2025, revealed a [AGE] year-old male initially admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), chronic kidney disease stage 3 (mild to moderate kidney damage, leading to a reduced ability to filter waste and excess fluid from the blood), hypertension (high blood pressure), hearing loss, nuclear cataracts bilaterally (clouding and hardening of the central part of the eye's lens), osteoporosis (a condition that weakens bones and increases the risk of fracture), fracture of neck of right femur (right hip fracture), low back pain, chronic pain syndrome, dysphagia (swallowing problem), atherosclerosis of left leg (hardening of arteries). Record review of the Activity Participation Note, dated 2/03/2025, revealed the AD documented the following: Resident prefers independent in own room activities. It is very important for resident to be able to watch TV and movies. It is very important for resident to go outside in the sunshine, but with a blanket. Resident enjoys hunting and fishing. Resident has no other activity concerns at this time.Review of Resident #8's Significant Change in Condition MDS Assessment, dated 6/28/2025, revealed a BIMS score of 1 out of 15 (severe cognitive impairment) and documented activity preferences as being very important for doing favorite activities, keeping up with the news, going outside for fresh air, and participating in religious services or practices. Observation on 8/26/2025 at 10:59 AM revealed Resident #8 was lying on his back in bed with his eyes closed. He was wearing eyeglasses. The room door was open to the hallway. Observation on 8/27/2025 at 8:10 AM revealed Resident #8 was lying in bed with the head of bed elevated. His eyes were closed. The room door was open to the hallway. During an interview and record review on 8/28/2025 at 10:37 AM, the Activity Director stated Resident #8 was assisted into his wheelchair by the CNAs. She stated Resident #8's family member visited about 1 time per week and took the resident outside. She stated Resident #8 liked to be outside. The AD stated Resident #8 did not like group activities or being around people. She reviewed his electronic health record and stated the last documented activity progress note was dated 2/03/2025. She stated she was supposed to document a progress note every 3 months, every time an MDS assessment was due, and she had not done that for Resident #8. The AD reviewed Resident #8's electronic health record and stated he had a quarterly MDS assessment and activity progress note due now. She reviewed his care plan and did not see a care plan for activities. The AD stated Resident #8 liked music and she had taken a tablet into his room and played u-tube live music videos for him. She stated the resident did not really like the tablet. The AD stated the resident used to like hunting and fishing. She stated she had not been able to find any TV programs with fishing or hunting, other than programs with people shooting deer. She stated maybe he would like to watch people shooting deer. In an interview on 8/28/2025 at 11:08 AM, the AD stated she had documented one-on-one activity programming records for 3 other residents but did not have any for Resident #8. She stated she did some in-room activities with the other 3 residents and sometimes they came to the group activities. Observation on 8/28/2025 at 11:16 AM revealed Resident #8 was lying on his back in bed. The TV was on in the room, but volume was low. The resident was not wearing his eyeglasses, which were on the bedside nightstand. The room door was open to the hallway. In an interview on 8/28/2025 at 11:16 AM, C.N.A. A stated she had been employed in the facility since December 2024 and she worked from 6:00 AM to 6:00 PM on the hall were Resident #8's room was located. She stated Resident #8 used to get up in his wheelchair for all meals in the main dining room before he fell and broke his hip and stated he still went to the dining room after he broke his hip. C.N.A. A stated about 2 months ago Resident #8 started staying in bed. She stated Resident #8's family did not want him to get up because he was in too much pain. C.N.A. A stated the hospice aide gave Resident #8 a bed bath on Tuesday and Thursday and sometimes on Saturday. She stated Resident #8 did not ever get up [out of bed]. C.N.A. A stated she had not seen the AD go into Resident #8's room to visit him and had not seen anyone go into the resident's room to do an activity with him. She stated Resident #8 was visited by his family member who lived out of town and came to stay for a week or longer a couple times a month. She stated the family member stayed in Resident #8's house and visited him daily during her stays. C.N.A. A stated Resident #8 had other family members who visited and his military friends visited when they could get a ride [to the facility], and they were old too. She stated she turned on the TV, but left the volume at the level the family member had it on during her last visit. During an interview and record review on 8/28/2025 at 12:09 PM, the MDS Coordinator stated she oversaw care plans and sometimes each department entered their own care plans and sometimes she did it. She reviewed Resident #8's electronic health record and stated his last care plan conference was held 7/10/2025 and was attended by the resident's responsible family member, MDS Coordinator, SW, Dietary Manager, treatment nurse, and hospice nurse. She stated the Activity Director was not there and she was usually doing activities when care plan meetings were held. The MDS Coordinator stated activities were discussed and resident's family member did not want Resident #8 to be transferred from the bed with a mechanical lift due to the risk for injury. She stated the daughter did not want him transferred at all. The MDS Coordinator stated she had added a care plan for activities today after the AD came and talked with her about a care plan for activities and she added one. The MDS Coordinator stated Resident #8 did not like large groups of people. She stated Resident #8 did not like eating in the dining room, either, when he had been assisted into the wheelchair and was taken to the dining room. On 8/28/2025 at 12:26 PM, the MDS Coordinator reviewed Resident #8's progress notes and found activity notes dated 12/03/24, 2/03/25, 5/06/25, 6/28/25 and printed them for the surveyor. The notes documented the similar entry: Resident prefers independent in own room activities. It is very important for resident to be able to watch TV and movies. It is very important for resident to go outside in the sunshine, but with a blanket. Resident enjoys hunting and fishing. Resident has no other activity concerns at this time. The MDS Coordinator stated the notes were documented before the care plan conference was held with Resident #8's daughter on 7/10/25, when she had stated she did not want her father transferred from the bed. Record review of the facility's Lifetime Wellness Policies and Procedures for One-On-One Program, dated 1/01/2023, revealed the following [in part]: PolicyOne-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents who prefer not to attend group programs and/or for identified short term rehab patients.ProcedureActivity staff may utilize the One-on-One Tracking form to maintain an up to date list of residents identified for one-on-one programming each month.When visits are completed the date of intervention is noted and the appropriate documentation is completed in the wellness activity participation documentation on PCC.The following interventions for one-on-one programs may include but are not limited to:Health and Wellness EducationWellness on Wheels VisitMaintenance Exercise MusicAromatherapyMusic and MemorySensory StimulationCognitive Stimulation Social VisitSpiritual WellnessThe resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week.The activity/wellness staff are responsible for documenting each one-to-one session according to the facility documentation process and should include:DateDurationIntervention(s)Response(s)If a one-on-one intervention is offered but the resident refuses, it must also be documented with reason for refusal.

Based on observation, interview, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 residents (Resident #34) reviewed for pressure injuries. The facility failed to ensure Resident #34's wheelchair had a pressure reduction cushion on 8/28/2025. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.Record review of Resident #34 's Face Sheet revealed Resident #34 was a -year-old male admitted on with diagnoses of hypertension (high blood-pressure), hemiplegia and hemiparesis (loss of strength or paralysis), cerebral infarction (stroke), muscle wasting (muscle loss). Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed Resident #34 has a BIMS score of 00 (severe cognitive impairment), Section M in Resident #34's MDS revealed that Resident #34 was at risk for developing pressure ulcers/injuries, skin and ulcer/injury treatments, pressure reducing device for wheelchair. Record review of Resident #34 's comprehensive care plan dated 08/07/2025 revealed Resident #34 had the potential to develop a pressure ulcer/injury due to frequent urinary and/or bowel incontinence, immobility, poor nutrition, risk score of 11 (high risk) on Braden risk Assessment (tool used to assess a patient's risk of developing pressure ulcers), sheering/friction. Record review of Resident #34's consolidated orders dated 4/30/25, stated 'Pressure redistribution cushion to wheelchair'. During an observation on 8/26/25 at 12:05 PM, Resident #34 in dining room for lunch, Resident #34 sitting in wheelchair, no cushion on seat. During an interview on 8/28/25 at 8:40 AM, Resident #34 stated he did not have a cushion in wheelchair but thought he would like to have one, stating it would make wheelchair more comfortable. An interview on 8/28/25 at 9:00 AM, RN C, the charge nurse for Hall C and Resident #34. She stated that wheelchair cushion is on the resident's order but did not know if Resident #34 has one for his wheelchair, RN stated that CNA could answer that. RN C stated that if resident has been assessed as high risk for skin issues, having a pressure reducing cushion would help reduce risk of injury. An interview on 8/26/25 at 10:15 AM, CNA D stated that she did not know that resident [NAME][JM1] had an order for wheelchair cushion, CNA D stated she has never placed a cushion on residents' wheelchair. CNA D stated that resident only gets out of bed and uses wheelchair during meals, resident goes to dining room, and resident goes to church services on Thursdays. During an interview on 8/28/2025 at 11:00 AM the DON said the CNAs assisting the residents should be ensuring pressure reduction cushions were present in the resident's wheelchair when they were up[JM2] . She said all direct care staff were trained on hire and annually and she would ensure each resident at risk had a cushion in place. She said that the resident's risk for pressure ulcers was determined through assessments and if the resident was at risk, then there should be a pressure reduction cushion present to prevent skin breakdown. During an interview on 8/28/2025 at 11:30 AM the Administrator said the nursing staff were responsible for ensuring residents that were at risk for skin breakdown had the appropriate pressure reduction cushion in their wheelchair. She said staff were trained on the use of pressure reduction techniques and devices and expected the procedure was followed to prevent pressure injuries. Record review of a facility policy titled Skin Management: Prevention and Treatment of Wounds dated 12/01/2021 indicated [in part]: .the purpose of this procedure is to prevent skin breakdown. 2. Prevention: residents at risk for developing pressure injuries will have pressure reduction cushion devices in their wheelchair .

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, for 1 (Resident #1) of 16 residents reviewed. As a result of the failure to implement the facility policy, the resident was not free from abuse, staff did not report the abuse, residents were not protected from further abuse, and the facility administration was unaware of the verbal abuse and police intervention on 05/04/2025 between LVN B and Resident #1 until surveyor intervention on 05/18/2025 This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. While the immediacy was removed on 6/06/25 at 1:02 pm, the facility remained out of compliance at scope of pattern and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place the residents at risk of not being free of abuse. Findings included: Record review of the facility's Abuse Prohibition Policy dated 5/17/2024, revealed Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse.Verbal Abuse is defined as the use of, oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 4/30/25. Her diagnoses included: Autistic Disorder (neurodevelopmental disorder with difficulties in social interaction and social communication), Fetal Alcohol Syndrome (life-long physical, cognitive, and behavioral issues), long-term drug therapy, epilepsy (seizure disorder), tachycardia (rapid heart rate). Resident discharged from the facility on 05/05/2025. Record review of police report dated 5/4/25 at 6:59pm revealed When [Police officer] arrived, [Police officer] made contact with the reporting party, [LVN A], she stated they received a new patient [Resident #1] approximately 2 days ago. [LVN A] stated [Resident #1] was a psych patient who had been having a hard time adjusting to the facility. [LVN A] requested that [Police officer] speak with [Resident #1] to see if she met criteria to be assessed by [LIDDA] for a psych evaluation. [Police officer] made contact with [Resident #1] at the nurse's station, [Resident #1] was very upset at the time and was refusing to speak with [Police officer]. While [Police officer] was speaking to [Resident #1] in an attempt to build a rapport [LVN B] began walking towards the nurse's station. When [LVN B] approached the area, she began making statements like, Y'all need to take her ass somewhere. and Her [family member] needs to come get her! [LVN B] was very agitated and extremely rude. [Police officer] began asking [LVN B] for more background information on [Resident #1] because she did not speak to me. [LVN B] stated She is trying her crap. after she stated this [Resident #1] yelled at [LVN B] to shut up. [LVN B] stated, You don't scare me none, you might your [family member] but not me. I began explaining to [LVN B] our criteria and that I would not just be able to take her. [LVN B] began talking and said, Well then she needs to go to her room because she is one on one. [Resident #1] then yelled, I don't have to if I don't fucking want to! [LVN B] then turned to [Resident #1] pointed at her and yelled very angrily Go to your room! and then held her middle finger up towards [Resident #1]. That was when [Resident #1] stated I can punch you! and [LVN B] turned to [Resident #1] and waved her fingers as if inviting her over and stated, Come on! [Resident #1] stood aggressively and began walking towards [LVN B]. An aide and I stood between the two to keep things from escalating. [LVN B] stated She needs to go to jail mam! she then stated, Her [family member] dropped her here because she can't take care of her. another nurse stated neither of [Resident #1's] [family members] was answering the phone and [LVN B's] response was They don't want to have anything to do with her. [Resident #1] responded Shut up! and [LVN B] replied, Just telling the truth honey. This upset [Resident #1] to the point where she wanted to hurt [LVN B]. An aide and I continued following [Resident #1] and trying to keep her calm and away from [LVN B]. I was finally able to get [Resident #1] to separate and have a seat in the living area of the facility .[Police officer] contacted crisis line to see if she could be assessed by [LIDDA] .[LIDDA] came to the facility for the assessment and put in a referral to [Behavioral health hospital] and was denied due to [Resident #1's] IQ. LIDDA attempted an emergency detention order to the state hospital, and they refused the order. Officers remained until [Resident #1] was in bed and no longer a threat to the staff. Observation of body cam footage from police officer dated 5/4/25 from 7:12pm-7:19pm revealed the Police officer entered the building of the facility and went to the nurse's station and asked for the nurse that called and was directed down the hall to LVN A at her med cart. LVN A stated Resident #1 is a psych patient and need to see about an evaluation. LVN A pointed towards the nurse's station and stated the Police Officer could ask and aide where Resident #1 is. The Police officer walked to the nurse's station and CNA E showed Police officer who Resdient #1 was. Resident #1 was sitting in chair against the wall at the nurse's station quiet and looking around shaking her left leg and 1:1 aide (CNA E) was three chairs down from resident. Three residents sitting in chairs next to resident. Police officer attempted to speak to Resident #1, and she would not speak to the police officer. Resident #1 stated shut up to someone behind the police officer not seen on camera. Police officer turned around and LVN B wheeled her cart to the nurse's station and stated to the police officer, She's trying her crap & she needs to go to jail and Resident #1 stated shut up, shut up. LVN B stated, Don't scare me none, might your [family member] but not me. The police officer attempted to explain to LVN B that she can't just take her, and Resident #1 is not speaking to her. LVN B stated, she needs to go to her room, she's 1:1 and looks towards Resident #1. Resident #1 said, I don't have to if I don't fucking want to. LVN B stated, you need to go to your room loudly towards Resident #1 (Resident #1 not in camera view). LVN B flips Resident #1 off and states, I can do it too and Resident #1 stated, I can punch you and LVN B stated, come on and waved her fingers gesturing towards her to come, you punch me you're going to jail as Resident #1 is seen getting up and walking towards LVN B. Police officer says uh-uh and CNA D puts herself between LVN B and Resident #1. LVN B no longer in camera view. Resident #1 stated I don't care and Police officer tells her to go sit down. LVN B stated, she needs to go to jail ma'am, her [family member] left her here because she can't take care of her. They don't want to have anything to do with her. Resident #1 stated shut up and appeared to be tearing up. LVN B said, just telling the truth honey. CNA D stated, let's go for a walk, want to go for a walk with me and Resident #1 states, No, I want to punch that bitch. CNA D and Police officer said no, we are not doing that, and we have to respect our elders. CNA D stated again, want to go for a walk and LVN B (no longer in camera view) stated she's not to be out of her room for one thing. Resident #1 stated, yes I can and LVN B stated, she's on 1:1. CNA D encouraged Resident #1 to practice breathing. Resident #1 looks at her watch and a sound from watch played and Police officer stated, that's you [family member] right there. Resident #1 stated, I don't care. Police officer said, you don't want to talk to your [family member]? Resident #1 pulled a pen out of her left shorts pocket and stated, I wanna stab that bitch and CNA D stated, let's go on a walk, let's remove ourselves from the situation and we don't have to be ugly let's remove and go on a walk and calm down. We don't need to do the extra stuff. Resident #1 started walking towards the entrance of the nurse's station and CNA D walked with her and LVN C is seen at a med cart on the computer. Police and CNA D walk with Resident #1. CNA D put herself in the entry and police asked if she wanted to go walk with CNA D and Resident #1 said No and police said, we are not going over there with her and touched Resident #1's arm. Resident #1 shook police officer off and said move. The police officer said, back up, you're not going over there. Resident #1 tried to walk around CNA D and CNA D said [Resident #1], I'm not letting you in there, we can go for a walk, we can remove ourselves but that is not happening and Resident #1 stopped and stood still. Someone unknown stated, she's not supposed to be out here and Resident #1 stated yes I can. CNA D stated Let's go for a walk. LVN A is heard explaining Resident #1's actions to someone. The police officer asked Resident #1 if she wants to go outside, and she said no. CNA D stated I need you to back up, you are in my bubble and Resident #1 stepped back. CNA D thanked her. Someone from the nurse's station attempted to give Resident #1 the phone and CNA D stated your [family member] wants to talk to you. Resident #1 hung up the phone. The police officer stated How can we help you if you won't talk to anybody. We are here to help you. CNA D asked Resident #1 if she wants to go get a soda and Resident #1 shook her head no. LVN A asked CNA D she hung up? and CNA D said, oh yeah she hung up the phone. Resident #1 starts walking away. End video. In an interview on 5/18/25 at 10:45 am with the Police Officer, she stated she went out to the facility for a call for a welfare check on Resident #1 by LVN A. Resident #1 was very upset, and the Police officer got her to calm down. The Police officer stated that LVN B told the Police Officer she needed to take her [Resident #1] ass to jail. Resident #1 was right there so she heard LVN B. LVN B stated Resident #1's [family member] needed to come get her and Resident #1 needed to be in her room on 1:1. The Police officer stated Resident #1 stated she did not have to be in her room and LVN B flipped off Resident #1 and Resident #1 flipped off LVN B and then LVN B stated that's why nobody wants you. That's why she (family member) dropped you off to Resident #1. The police officer stated that Resident #1 said she was going to hit LVN B and LVN B said, do it. The Police officer said she got in between them and there were lots of staff around and nobody removed LVN B. The Police Officer stated it was not against the law, there was no immediate threat for Resident #1, and she had another nurse, and the police de-escalate the situation, so it was not enough to take LVN B in. LVN A was the nurse that called 911 to come check on Resident #1. In an interview on 5/18/25 at 1:30pm with DON, the DON stated she had never been told about the incident with LVN B by anyone until right then. Resident #1 was trying to hurt herself while she was at the facility and was there for 5 days, and was never without staff supervision. The DON stated she was never told about LVN B acting that way and would report it now and start an investigation now. She would have reported it at the time had she been made aware. The DON stated the Administrator, at the time, was no longer there. The DON stated he was the abuse coordinator and DON was the backup abuse coordinator at that time. In an interview on 5/18/25 at 5:50pm with LVN A, she stated she spoke with the police and witnessed Resident #1 trying to get at LVN B, but she did not know what initiated it. LVN A stated the aides prevented Resident #1 from getting LVN B so Resident #1 started throwing things down the hall. LVN A stated Resident #1 did calm down, went back to her room with her 1:1 staff, and went to sleep. LVN A stated she called Guardian A, and she was out of town, so LVN A tried to call Guardian B and he did not answer, so she called 911. LVN A stated she called because Resident #1 had grabbed an ink pen and started carving her arm and the police were right there. LVN A stated she told Resident #1 to stop, and she did. LVN A stated there was no injury. LVN A stated she did not see LVN B flip off Resident #1 or curse at her or tell her she was not wanted anywhere. In an interview on 5/18/25 at 6:48pm with CNA D, she stated that on 5/4/25, Resident #1 was frustrated and agitated, was trying to get out of the facility, and was on 1:1. CNA D stated the police had been called and LVN B said to Resident #1, you are here because your [family member] can't deal with you and you need to go to jail. Resident #1 said shut up, bitch and flipped off LVN B. LVN B flipped off Resident #1 and said, I can do it too. Resident #1 called LVN B a bitch and LVN B said, you need to go to jail and need to go to a mental hospital to Resident #1. CNA D stated Resident #1 said, shut up bitch, I'm gonna punch you and LVN B said, come on and punch me and I want you to punch me and CNA D stated she got up and tried to redirect Resident #1 and LVN B kept talking trash to Resident #1. CNA D stated she thought other nurses would have reported. CNA D stated she had been trained on abuse and neglect and she should have reported to the DON immediately because the DON was the Abuse coordinator and failure to report would not happen again. In an interview on 5/18/25 at 7:05pm with CNA C, she stated LVN B was agitating Resident #1 and told Resident #1 she needed to go to jail, and her [family member] dropped her off because nobody wanted her. CNA C stated Resident #1 got upset and said, shut up bitch and flipped off LVN B and LVN B kept going and flipped her off back. CNA C stated she could not believe this was happening right in front of the cops. CNA C stated Resident #1 went after LVN B and the aides intervened, and the cops didn't do anything. CNA C stated she thought the police would do something and take care of it. CNA C stated she came into work the next day to report it to the DON, but she was not there and then CNA C was off for a couple of days and time just went by. CNA C stated she did not report the incident because she thought others would and she should have reported it herself immediately. CNA C stated she had been trained on abuse and neglect and she should report to the DON, the abuse coordinator. CNA C stated she feels she can report to the DON and has in the past. In an interview on 5/19/25 at 12:24pm with Guardian A, she stated she did not want this writer to speak to Resident #1 as there were no current effects, but Guardian A did not want to upset Resident #1 and cause behaviors. Guardian A stated Resident #1 did tell her after discharge from the facility that a nurse flipped her off and told her they wanted her to go to jail. Resident #1 told Guardian A that the police saw the nurse do it. In an interview on 5/19/25 at 12:56pm with the ADON, she stated that all staff had been trained on abuse and neglect. The ADON stated all staff had been trained on what abuse would look like and who to report to. The ADON stated that they should report to the DON, abuse coordinator. The ADON stated she was not aware and had not heard anything about LVN B being abusive. The ADON stated what she had been told was that Resident #1 was throwing computers and laptops and swinging at nurses. The ADON stated she was told that by LVN A and LVN B. The ADON stated she spoke with the DON about it and the DON told the ADON she had went and checked on Resident #1 the next morning and she was fine and did not report anything. The ADON stated Guardian B requested Resident #1 be sent to the state hospital. The ADON stated LVN B would be terminated, and CNA C and CNA D were placed on final warning for not reporting it. In an interview on 5/19/25 at 4:54pm with LVN B, she stated Resident #1 was trying to get at patients and knocking things off the nurse's station and was psycho and 300 pounds. LVN B stated [Resident #1] was supposed to be on 1:1 in her room for suicide watch and coming to the front agitating other patients. LVN B stated, Resident #1 was [AGE] years old acting like a smart ass and would not mind staff. LVN B stated she was passing medications, parked her cart, and Resident #1 threw her the finger and LVN B did the same thing back. LVN B stated that Resident #1 needed to be in a mental institution and the facility was not appropriate, and staff were just babysitting. LVN B stated she told Resident #1 to go to her room and Resident #1 flipped her off and LVN B could not handle disrespectful children. LVN B stated she did flip off Resident #1 but did not say anything. LVN B stated it was a reaction because Resident #1 was pushing buttons. LVN B then stated she did tell the police they needed to take Resident #1 because she would not calm down. In a follow up interview on 5/20/25 at 12:48pm with the DON, she stated all staff had been trained on abuse and neglect a bunch of times. The DON stated she had her number posted and was the abuse coordinator. The DON stated at the time of the incident with LVN B, the abuse coordinator was the administrator, and the DON was back up abuse coordinator. The DON stated she had never heard of, and no one reported abuse from LVN B to Resident #1. The DON stated she had started 1:1 training with each staff member to prevent this in the future. The DON stated staff failed to report and she had retrained, counseled, and wrote up the staff that failed to report. The DON stated LVN B was suspended as soon as this writer informed DON about allegation, and LVN B was now terminated. LVN B worked approximately 10 shifts between 05/04/2025 and 05/18/2025. In an interview on 6/3/25 at 3:35pm with LVN C, she stated she was on another hall, and walked up to the nurse's station. LVN C stated she saw Resident #1 yelling at LVN B and LVN B was yelling back at her. LVN C stated she was attending to the other residents and LVN B was talking to Resident #1 about how she hated taking care of residents like her and stuff like that, something to that affect. LVN C stated LVN B did say Resident #1 needed to go to jail. LVN B said Resident #1's [family member] dropped her at the facility because she couldn't handle her. LVN C stated she did not see LVN B flip off Resident #1. LVN C stated, it was verbal abuse. LVN C stated she was going to report to the DON, but LVN A, the night nurse, was on the phone with her at that time, right after the incident, and she said, yes I'm talking to her right now. So, LVN C stated she didn't and thought LVN A reported it. LVN C stated LVN A said she was on the phone with the DON after the incident, but she did not know what she reported. LVN C stated she was covering the shift and was late to her shift because she got called in and never worked the night shift before. LVN C stated she said to LVN A, you got this, you are reporting it and LVN A said yes, she was talking to the DON right then. LVN C stated she went back to passing meds. In a follow up interview on 6/3/25 at 4:11pm with the DON, she stated LVN A did call her that night at 7:24pm and said Resident #1 was having behaviors, throwing things at the nurse's station, and grabbing pens and the cops were there. The DON advised LVN A to call the [family member] because the cops would not take Resident #1 but maybe they would calm her. The DON said LVN A never told her about LVN B, and LVN B was never even mentioned, and she wasn't even the patients nurse, so the DON did not think to ask anything about that. The DON stated she went to see Resident #1 the next morning and checked on her first thing that morning and Resident #1 never told the DON that happened either. In an interview on 6/4/25 at 8:40am with CNA E, she stated she was Resident #1's 1:1 on the evening of the incident and it was her first time working with Resident #1. Resident #1 was throwing everything, books, and pens off the nurse's station. Resident #1 would be yelling, and she called CNA E a bitch for following her and she said she didn't need a 1:1. CNA E stated other residents did see, maybe 2 or 3 residents at the nurse's station. They were staring at Resident #1, and one lady said we (staff) needed to call the cops. CNA E stated she did not see Resident #1 try to hurt herself. CNA E stated Resident #1 went outside because she did not want to be there at the facility. CNA E stated there were CNAs, residents, and nurses around during the incident. CNA E stated Resident #1 was calling LVN B a bitch and flipped her off. She stated LVN B flipped her off back, Resident #1 tried to hit LVN B, and another aide got in between them. CNA E stated she had moved back so she did not see everything. She stated the cops calmed Resident #1 down. Then CNA D stepped in between them. CNA E stated she heard LVN B say, I can do that too and flipped off Resident #1. LVN B told Resident #1 to go to her room. CNA E stated she should have reported, but there was a lot going on and a lot of people involved so she thought they would report because she felt they had a better account of the situation. In an interview on 6/4/25 at 4:15pm with the DON and the ADM when shown the body cam footage, the ADM stated it was abuse and feels staff thought LVN A reported and that was why they didn't report. The DON stated it was abuse and she feels all staff felt the others would report. The DON stated she did get a report from LVN A, but it was only what she saw and not all of what happened or what LVN B did. In an interview on 6/5/25 at 12:12pm with Resident #11, he stated he had not seen any staff be rude or rough to any resident. Resident #11 stated Resident #1 was very upset. Staff calmed her down. Resident #11 stated he wheeled by the nurse's station, and Resident #1 was cursing and upset. Police were there and they took her back to her room and she calmed down. Resident #11 stated he didn't see the nurse flip her off. Resident #11 stated he had never seen staff do or say anything like that. He stated he had no concerns about his care at the facility. In an interview on 6/5/25 at 12:22pm with Resident #12, he shook his head no when asked if he had ever seen staff be rude or rough with a resident. Resident #12 shook his yes when asked if he remembers the incident. Resident shook his head no, when asked if he saw the nurse be rude or say mean things to the resident. Resident shook his head no, when asked if he saw the nurse flip off the resident. Shook his head yes when asked if he felt safe. Resident #12 shook his head yes when asked if he felt staff acted appropriately. Resident #12 shook his head yes when asked if he felt staff acted quickly to keep everyone safe. Shook his head no, when asked if anyone was hurt. Resident #12 shook his head yes when asked if he was removed from the incident. In an interview on 6/5/25 at 12:33pm with Resident #13, she stated she remembered the incident. Resident #13 stated that staff were trying to get something Resident #1 had taken and Resident #1 got mean. She stated Resident #1 was cursing and throwing things. Resident #13 stated she did not see the nurse say anything rude or flip off Resident #1. Resident #13 stated she felt safe, staff took care of it, and the police came. In an interview on 6/5/25 at 1:30pm with CNA F, she stated she came out of the break room to prepare to do a round and saw Resident #1 trying to get at LVN B. She stated she saw staff got in between Resident #1 and LVN B and cops calmed her down. CNA F stated then the police left, and Resident #1 started throwing things and going after LVN B again. CNA F stated she got in between them. CNA F stated the cops came back in and they stayed for a couple of hours, and they got Resident #1 to calm and then they left. CNA F stated LVN B made comments about how the police needed to take Resident #1 and she would not calm, and she would keep doing this. CNA F stated she did not see her flip off Resident #1. CNA F stated she did here LVN B tell her multiple times she needed to go to her room. CNA F stated she did not hear abuse but did feel LVN B was agitating Resident #1. Resident #1 was very disruptive and agitated and was throwing things and staff, including CNA F removed the other residents from the area the second time the police came in and we removed the residents for their safety. CNA F stated staff didn't remove the other residents the first time when Resident #1 was just saying she would hurt LVN B. CNA F stated she did hear about LVN B flipping off Resident #1 after LVN B had been fired. Record review of LVN B employee file revealed Abuse and Neglect training on 8/7/24. Record review of In-Service Training Report dated 4/3/25 revealed LVN A, LVN B, CNA C, and CNA D had been trained on abuse and neglect. Record review of Resident Rights policy dated 4/2017 revealed .Residents shall .b. be treated as individuals in a manner that supports their dignity .g. Be free from mental, emotional, and physical abuse and neglect . On 6/04/25 at 2:09pm, an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and accepted on 06/05/25 at 4:35 pm and included: Social worker, or designee made life satisfaction rounds to residents that can be interviewed to ensure free from abuse and neglect. Staff caring for residents who are unable to be interviewed have been interviewed for any noted changes in residents' behavior. Any abuse or neglect identified will be immediately reported to the abuse coordinator and then HHSC by who ever witnessed or heard about the incident. Completed 6/5/2025.No findings of abuse reported. Administrator trained and is initiating the implementation of Neighbor rounds completing assessments on their residents for potential abuse on 6/5/2025. This will be completed daily by the leadership team during the week and Manager on Duty on weekends. Neighbor rounds are reported daily to the IDT team and will be reviewed during monthly QAPI meeting. This systemic change will ensure that all residents, whether they are able to be interviewed or not, are free from abuse. On May 18, 2025, LVN B was suspended pending the outcome of the investigation. Upon completion of the investigation, LVN B was terminated May 21,2025. On May 19, 2025, Corporate Clinical specialist in-serviced DON regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and different scenarios. Competency was verified by a quiz. DON in-serviced staff regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and scenario example discussed. Competency was verified with a quiz. Staff will not be allowed to work until they have passed the quiz. Verbal abuse quiz and in-service will be added to the new hire abuse training. Staff were trained over Approaches, Activities and Interventions in Response to Behaviors of people with Mental Health or Psychiatric Needs including how to manage different behaviors, deescalating the situation, removing aggressive resident from the area where other residents may be present or removing the other residents from the area of situation, and to immediately report incident to facility Abuse Coordinator. Completed 6/5/2025. Peer interviews over knowledge of facility's Abuse and Neglect Policy and Procedures, will be conducted weekly, with no less than 10 staff members, by Social Worker, and/or designee for 8 weeks. Following 8 weeks follow up, monthly Peer Interviews will be conducted by Social Worker and/or designee. The abuse coordinator, or designee, shall be responsible for monitoring this corrective action. Any negative findings will be reported to the facility's QA committee for review and corrective action. Completed 6/5/25. Monitoring of the Plan of Removal from 6/05/25 - 6/06/25 included the following: Record review of Inservice dated 6/5/25 with leadership team of 12 staff for neighbor rounds revealed staff are to assess residents for changes in behavior/mood; auditing/asking staff about any signs of abuse and whether sexual, physical, or verbal abuse. In an interview on 6/5/25 at 5:56pm with the ADON, she stated the SW interviewed her on abuse and what she should do to check her knowledge. The ADON stated she had been trained on neighbor rounds. She stated staff will be dividing certain hallways, certain rooms, and do morning rounds. The ADON stated staff would talk to those residents and assess for any issue. She stated staff would see if they had any issues or concerns, and address the concerns, and bring to the morning IDT meetings. The ADON stated staff also did a drill on how to clear the room of other residents, keep everyone safe, and how to approach and deescalate a resident that is aggressive or displaying behaviors. The ADON stated the facility Inserviced all staff on abuse & neglect, reiterated differences and examples of each, and who to report to and when. The ADON stated the DON was going to randomly audit staff on their training. In an interview on 6/5/25 at 6:15pm with SW, she stated she had completed resident and staff interviews regarding abuse and specifically verbal abuse and staff interviews going forward and upping the neighbor rounds program. SW stated she was to round on the second half of A hall every morning and check with residents to see how things are going. She stated she was to see if residents are well and check environmentally and if they have concerns write grievances for that, The SW stated staff are to build rapport to find the abuse if it was happening. The SW stated she had completed life satisfaction rounds and found no concerns of abuse. In an interview on 6/6/25 at 10:35 am with the Administrator and the DON, the ADM stated this day was the first day for Neighbor rounds. The ADM stated staff are assigned rooms and report on the rooms daily (no one has more than 6 rooms each), utilizing a check list. The ADM provided the checklist to the investigator. The DON stated this day was the first day. It went well, and no issues of abuse or neglect was identified. The ADM stated the rounds sheets are reviewed in the morning round each morning daily. The ADM stated on the weekend, the Manager on Duty completes the review of the sheets and reports to the Administrator directly if there is a concern. In an observation on 6/6/25 at 10:35am observed the checklist with staff to use for Neighbor rounds. Record review of Neighbor round observations for 6/6/25 at 10:54 am. All rooms and residents were observed in facility. No concerns regarding abuse and neglect identified. In an interview on 6/6/25 at 11:03 am with Resident # 15, she stated this morning a staff told her she was her neighbor and would be checking on her every day. Resident #15 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:08 am with Resident #16, she stated staff told her this morning that she was her neighbor and would be checking on her every day. Resident #16 stated she feels safe[TRUNCATED]

Based on observation, interview and record review, the facility failed to report all allegations of abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (Resident #1) of 16 residents reviewed. CNA B, CNA C, CNA E, and CNA D failed to report verbal abuse of Resident #1 to the administrator or the DON. There was police intervention between the staff and resident. As a result of not reporting, the administrative staff were not aware until surveyor intervention. Include the incident happened on 5/4/25 and administration were not aware of the verbal abuse until 5/18/25. This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. While the immediacy was removed on 6/06/25 at 1:02 pm, the facility remained out of compliance at scope of pattern and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could put the residents at risk of compromised protection and oversight, and mental anguish. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 4/30/25. Her diagnoses included: Autistic Disorder (neurodevelopmental disorder with difficulties in social interaction and social communication), Fetal Alcohol Syndrome (life-long physical, cognitive, and behavioral issues), long-term drug therapy, epilepsy (seizure disorder), tachycardia (rapid heart rate). Resident was discharged [DATE]. Record review of police report dated 5/4/25 at 6:59pm revealed When [Police officer] arrived, [Police officer] made contact with the reporting party, [LVN A], she stated they received a new patient [Resident #1] approximately 2 days ago. [LVN A] stated [Resident #1] was a psych patient who had been having a hard time adjusting to the facility. [LVN A] requested that [Police officer] speak with [Resident #1] to see if she met criteria to be assessed by [LIDDA] for a psych evaluation. [Police officer] made contact with [Resident #1] at the nurse's station, [Resident #1] was very upset at the time and was refusing to speak with [Police officer]. While [Police officer] was speaking to [Resident #1] in an attempt to build a rapport [LVN B] began walking towards the nurse's station. When [LVN B] approached the area, she began making statements like, Y'all need to take her ass somewhere. and Her [family member] needs to come get her! [LVN B] was very agitated and extremely rude. [Police officer] began asking [LVN B] for more background information on [Resident #1] because she did not speak to me. [LVN B] stated She is trying her crap. after she stated this [Resident #1] yelled at [LVN B] to shut up. [LVN B] stated, You don't scare me none, you might your [family member] but not me. I began explaining to [LVN B] our criteria and that I would not just be able to take her. [LVN B] began talking and said, Well then she needs to go to her room because she is one on one. [Resident #1] then yelled, I don't have to if I don't fucking want to! [LVN B] then turned to [Resident #1] pointed at her and yelled very angrily Go to your room! and then held her middle finger up towards [Resident #1]. That was when [Resident #1] stated I can punch you! and [LVN B] turned to [Resident #1] and waved her fingers as if inviting her over and stated, Come on! [Resident #1] stood aggressively and began walking towards [LVN B]. An aide and I stood between the two to keep things from escalating. [LVN B] stated She needs to go to jail mam! she then stated, Her [family member] dropped her here because she can't take care of her. another nurse stated neither of [Resident #1's] [family members] was answering the phone and [LVN B's] response was They don't want to have anything to do with her. [Resident #1] responded Shut up! and [LVN B] replied, Just telling the truth honey. This upset [Resident #1] to the point where she wanted to hurt [LVN B]. An aide and I continued following [Resident #1] and trying to keep her calm and away from [LVN B]. I was finally able to get [Resident #1] to separate and have a seat in the living area of the facility .[Police officer] contacted crisis line to see if she could be assessed by [LIDDA] .[LIDDA] came to the facility for the assessment and put in a referral to [Behavioral health hospital] and was denied due to [Resident #1's] IQ. LIDDA attempted an emergency detention order to the state hospital, and they refused the order. Officers remained until [Resident #1] was in bed and no longer a threat to the staff. Observation of body cam footage from police officer dated 5/4/25 from 7:12pm-7:19pm revealed the Police officer entered the building of the facility and went to the nurse's station and asked for the nurse that called and was directed down the hall to LVN A at her med cart. LVN A stated Resident #1 is a psych patient and need to see about an evaluation. LVN A pointed towards the nurse's station and stated the Police Officer could ask and aide where Resident #1 is. The Police officer walked to the nurse's station and CNA E showed Police officer who Resdient #1 was. Resident #1 was sitting in chair against the wall at the nurse's station quiet and looking around shaking her left leg and 1:1 aide (CNA E) was three chairs down from resident. Three residents sitting in chairs next to resident. Police officer attempted to speak to Resident #1, and she would not speak to the police officer. Resident #1 stated shut up to someone behind the police officer not seen on camera. Police officer turned around and LVN B wheeled her cart to the nurse's station and stated to the police officer, She's trying her crap & she needs to go to jail and Resident #1 stated shut up, shut up. LVN B stated, Don't scare me none, might your [family member] but not me. The police officer attempted to explain to LVN B that she can't just take her, and Resident #1 is not speaking to her. LVN B stated, she needs to go to her room, she's 1:1 and looks towards Resident #1. Resident #1 said, I don't have to if I don't fucking want to. LVN B stated, you need to go to your room loudly towards Resident #1 (Resident #1 not in camera view). LVN B flips Resident #1 off and states, I can do it too and Resident #1 stated, I can punch you and LVN B stated, come on and waved her fingers gesturing towards her to come, you punch me you're going to jail as Resident #1 is seen getting up and walking towards LVN B. Police officer says uh-uh and CNA D puts herself between LVN B and Resident #1. LVN B no longer in camera view. Resident #1 stated I don't care and Police officer tells her to go sit down. LVN B stated, she needs to go to jail ma'am, her [family member] left her here because she can't take care of her. They don't want to have anything to do with her. Resident #1 stated shut up and appeared to be tearing up. LVN B said, just telling the truth honey. CNA D stated, let's go for a walk, want to go for a walk with me and Resident #1 states, No, I want to punch that bitch. CNA D and Police officer said no, we are not doing that, and we have to respect our elders. CNA D stated again, want to go for a walk and LVN B (no longer in camera view) stated she's not to be out of her room for one thing. Resident #1 stated, yes I can and LVN B stated, she's on 1:1. CNA D encouraged Resident #1 to practice breathing. Resident #1 looks at her watch and a sound from watch played and Police officer stated, that's you [family member] right there. Resident #1 stated, I don't care. Police officer said, you don't want to talk to your [family member]? Resident #1 pulled a pen out of her left shorts pocket and stated, I wanna stab that bitch and CNA D stated, let's go on a walk, let's remove ourselves from the situation and we don't have to be ugly let's remove and go on a walk and calm down. We don't need to do the extra stuff. Resident #1 started walking towards the entrance of the nurse's station and CNA D walked with her and LVN C is seen at a med cart on the computer. Police and CNA D walk with Resident #1. CNA D put herself in the entry and police asked if she wanted to go walk with CNA D and Resident #1 said No and police said, we are not going over there with her and touched Resident #1's arm. Resident #1 shook police officer off and said move. The police officer said, back up, you're not going over there. Resident #1 tried to walk around CNA D and CNA D said [Resident #1], I'm not letting you in there, we can go for a walk, we can remove ourselves but that is not happening and Resident #1 stopped and stood still. Someone unknown stated, she's not supposed to be out here and Resident #1 stated yes I can. CNA D stated Let's go for a walk. LVN A is heard explaining Resident #1's actions to someone. The police officer asked Resident #1 if she wants to go outside, and she said no. CNA D stated I need you to back up, you are in my bubble and Resident #1 stepped back. CNA D thanked her. Someone from the nurse's station attempted to give Resident #1 the phone and CNA D stated your [family member] wants to talk to you. Resident #1 hung up the phone. The police officer stated How can we help you if you won't talk to anybody. We are here to help you. CNA D asked Resident #1 if she wants to go get a soda and Resident #1 shook her head no. LVN A asked CNA D she hung up? and CNA D said, oh yeah she hung up the phone. Resident #1 starts walking away. End video. In an interview on 5/18/25 at 10:45 am with Police Officer, she stated she went out to the facility for a call for a well-fare check on Resident #1. Resident #1 was very upset, and the Police officer got her to calm down. Police officer stated that LVN B told the Police Officer she needed to take her [Resident #1] ass to jail. Resident #1 was right there so she heard LVN B. LVN B stated Resident #1's [family member] needed to come get her and Resident #1 needed to be in her room on 1:1. The Police officer stated Resident #1 stated she did not have to be in her room and LVN B flipped off Resident #1 and Resident #1 flipped off LVN B and then LVN B stated that's why nobody wants you. That's why she [[family member]] dropped you off to Resident #1. The police officer stated that Resident #1 said she was going to hit LVN B and LVN B said, do it. Police officer said she got in between them and there were lots of staff around and nobody removed LVN B. The Police Officer stated it was not against the law and there was no immediate threat for Resident #1, and she had another nurse, and the police de-escalated the situation, so it was not enough to take LVN B in. LVN A was the nurse that called 911 to check on Resident #1. In an interview on 5/18/25 at 1:30pm with DON, The DON stated she had never been told about the incident with LVN B by anyone until right now. Resident #1 was trying to hurt herself while she was here and was here for 5 days and was never without staff supervision. DON stated she was never told about LVN B acting that way and would report it now and start an investigation now. DON stated she would have reported it had she been made aware. DON stated the previous administrator was no longer at the facility and the new administrator starts tomorrow. In an interview on 5/18/25 at 4:20pm with CNA A, she stated she had been trained on abuse and neglect and she would report it to her abuse coordinator which is the administrator or DON. CNA A stated the facility has had some administrator changes so the current abuse coordinator is the DON. In an interview on 5/18/25 at 6:35pm with CNA B, she stated she did not see the abuse to Resident #1, but she was told about it by other aides. CNA B stated she had been trained on abuse and neglect and she would contact her abuse coordinator. CNA B stated she did not report the allegation from the other aides because she thought they would. In an interview on 5/18/25 at 6:48pm with CNA D, she stated that on 5/4/25, Resident #1 was frustrated and agitated and was trying to get out of the facility and was on 1:1. CNA D stated the police had been called and LVN B said to Resident #1, you are here because your mother can't deal with you and you need to go to jail. Resident #1 said shut up, bitch and flipped off LVN B. LVN B flipped off Resident #1 and said, I can do it too. Resident #1 called LVN B a bitch and LVN B said, you need to go to jail and need to go to a mental hospital to Resident #1. CNA D stated Resident #1 said, shut up bitch, I'm gonna punch you and LVN B said, come on and punch me and I want you to punch me and CNA D stated she got up and tried to redirect Resident #1 and LVN B kept talking trash to Resdient #1. CNA D stated she failed and should have reported LVN B to the DON. CNA D stated she thought other nurses would have reported. CNA D stated she had been trained on abuse and neglect and she should have reported to DON because DON is Abuse coordinator and failure to report would not happen again. In an interview on 5/18/25 at 7:05pm with CNA C, she stated LVN B was agitating Resident #1 and told Resident #1 she needed to go to jail, and her [family member] dropped her off because nobody wanted her. CNA C stated Resident #1 got upset and said, shut up bitch and flipped off LVN B and LVN B kept going and flipped her off back. CNA C stated she could not believe this was happening right in front of the cops. CNA C stated Resident #1 went after LVN B and facility staff intervened and the cops didn't do anything. CNA C stated she thought the police would do something and take care of it. CNA C stated she came into work the next day to report it to the DON, but DON was not there and then CNA C was off for a couple of days and time just went by. CNA C stated she did not report the incident because she thought others would and she should have reported it herself. CNA C stated she has been trained on abuse and neglect and she should report to the DON, the abuse coordinator. CNA C stated she feels she can report to the DON and has in the past. In an observation on 5/19/25 at 9:44am, sign on the wall in the lobby revealed Abuse Coordinator as DON and her contact phone number. In an interview on 5/19/25 at 4:54pm with LVN B, she stated Resident #1 was trying to get at patients and knocking things off the nurse's station and was psycho and 300 pounds. LVN B stated [Resident #1] was supposed to be on 1:1 in her room for suicide watch and coming to the front agitating other patients. LVN B stated, Resident #1 was [AGE] years old acting like a smart ass and would not mind staff. LVN B stated she was passing medications, parked her cart, and Resident #1 threw her the finger and LVN B did the same thing back. LVN B stated that Resident #1 needed to be in a mental institution and the facility was not appropriate, and staff were just babysitting. LVN B stated she told Resident #1 to go to her room and Resident #1 flipped her off and LVN B could not handle disrespectful children. LVN B stated she did flip off Resident #1 but did not say anything. LVN B stated it was a reaction because Resident #1 was pushing buttons. LVN B then stated she did tell the police they needed to take Resident #1 because she would not calm down. In an interview on 6/4/25 at 8:40am with CNA E, she stated she was Resident #1's 1:1 on the evening of the incident and it was her first time working with Resident #1. Resident #1 was throwing everything, books, and pens off the nurse's station. Resident #1 would be yelling, and she called CNA E a bitch for following her and she said she didn't need a 1:1. CNA E stated other residents did see, maybe 2 or 3 residents at the nurse's station. They were staring at Resident #1, and one lady said we needed to call the cops. CNA E stated she did not see Resident #1 try to hurt herself. CNA E stated Resident #1 went outside because she did not want to be there. CNA E stated there were CNA's, residents, and nurses around during the incident. CNA E stated Resident #1 was calling LVN B a bitch and flipped her off and LVN B flipped her off back and Resident #1 tried to hit LVN B, and another aide got in between them. CNA E stated she had moved back so she did not see everything. The cops calmed Resident #1 down. Then CNA D stepped in between them. CNA E stated she heard LVN B say, I can do that too and flipped off Resident #1. LVN B told Resident #1 to go to her room. CNA E stated she had been trained on abuse and neglect and should report to ADM Immediately. CNA E stated she should have reported but there was a lot going on and a lot of people involved so she thought they would report because she felt they had a better account of the situation. In an interview on 5/19/25 at 12:56pm with ADON, she stated that all staff have been trained on abuse and neglect. ADON stated all staff have been trained on what abuse would look like and who to report to. ADON stated that they report to the DON, abuse coordinator. ADON stated she was not aware and had not heard anything about LVN B being abusive. ADON stated LVN B should be terminated for abuse, and CNA C and CNA D were placed on final warning for not reporting it. In a follow up interview on 5/20/25 at 12:48pm with DON, she stated all staff had been trained on abuse and neglect a bunch of times. DON stated she had her number posted and was the abuse coordinator. DON stated at the time of the incident with LVN B, the abuse coordinator was administrator and DON was back up abuse coordinator. DON stated she had never heard of, and no one reported abuse form LVN B to Resdient #1. DON stated she had started 1:1 training with each staff member to prevent this in the future. DON stated staff failed to report and she had retrained, counseled, and wrote up the staff that failed to report. LVN B worked approximately 10 shifts between 05/04/2025 and 05/18/2025. Record review of In-Service Training Report dated 4/3/25 revealed CNA C, and CNA D had been trained on abuse and neglect. Record review of Abuse Prohibition Policy dated 5/17/2024 revealed, .Identification: 1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately .Reporting/Response: 1. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. On 6/04/25 at 2:09pm, an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and accepted on 06/05/25 at 4:35 pm and included: Social worker, or designee made life satisfaction rounds to residents that can be interviewed to ensure free from abuse and neglect. Staff caring for residents who are unable to be interviewed have been interviewed for any noted changes in residents' behavior. Any abuse or neglect identified will be immediately reported to the abuse coordinator and then HHSC by who ever witnessed or heard about the incident. Completed 6/5/2025.No findings of abuse reported. Administrator trained and is initiating the implementation of Neighbor rounds completing assessments on their residents for potential abuse on 6/5/2025. This will be completed daily by the leadership team during the week and Manager on Duty on weekends. Neighbor rounds are reported daily to the IDT team and will be reviewed during monthly QAPI meeting. This systemic change will ensure that all residents, whether they are able to be interviewed or not, are free from abuse. On May 18, 2025, LVN B was suspended pending the outcome of the investigation. Upon completion of the investigation, LVN B was terminated May 21,2025. On May 19, 2025, Corporate Clinical specialist in-serviced DON regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and different scenarios. Competency was verified by a quiz. DON in-serviced staff regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and scenario example discussed. Competency was verified with a quiz. Staff will not be allowed to work until they have passed the quiz. Verbal abuse quiz and in-service will be added to the new hire abuse training. Staff were trained over Approaches, Activities and Interventions in Response to Behaviors of people with Mental Health or Psychiatric Needs including how to manage different behaviors, deescalating the situation, removing aggressive resident from the area where other residents may be present or removing the other residents from the area of situation, and to immediately report incident to facility Abuse Coordinator. Completed 6/5/2025. Peer interviews over knowledge of facility's Abuse and Neglect Policy and Procedures, will be conducted weekly, with no less than 10 staff members, by Social Worker, and/or designee for 8 weeks. Following 8 weeks follow up, monthly Peer Interviews will be conducted by Social Worker and/or designee. The abuse coordinator, or designee, shall be responsible for monitoring this corrective action. Any negative findings will be reported to the facility's QA committee for review and corrective action. Completed 6/5/25. Monitoring of the Plan of Removal from 6/05/25 included the following: Record review of Inservice dated 6/5/25 with leadership team of 12 staff for neighbor rounds revealed staff are to assess residents for changes in behavior/mood; auditing/asking staff about any signs of abuse and whether sexual, physical, or verbal abuse. In an interview on 6/5/25 at 5:56pm with the ADON, she stated the SW interviewed her on abuse and what she should do to check her knowledge. The ADON stated she had been trained on neighbor rounds. She stated staff will be dividing certain hallways, certain rooms, and do morning rounds. The ADON stated staff would talk to those residents and assess for any issue. She stated staff would see if they had any issues or concerns, and address the concerns, and bring to the morning IDT meetings. The ADON stated staff also did a drill on how to clear the room of other residents, keep everyone safe, and how to approach and deescalate a resident that is aggressive or displaying behaviors. The ADON stated the facility Inserviced all staff on abuse & neglect, reiterated differences and examples of each, and who to report to and when. The ADON stated the DON was going to randomly audit staff on their training. In an interview on 6/5/25 at 6:15pm with SW, she stated she had completed resident and staff interviews regarding abuse and specifically verbal abuse and staff interviews going forward and upping the neighbor rounds program. SW stated she was to round on the second half of A hall every morning and check with residents to see how things are going. She stated she was to see if residents are well and check environmentally and if they have concerns write grievances for that, The SW stated staff are to build rapport to find the abuse if it was happening. The SW stated she had completed life satisfaction rounds and found no concerns of abuse. In an interview on 6/6/25 at 10:35 am with the Administrator and the DON, the ADM stated this day was the first day for Neighbor rounds. The ADM stated staff are assigned rooms and report on the rooms daily (no one has more than 6 rooms each), utilizing a check list. The ADM provided the checklist to the investigator. The DON stated this day was the first day. It went well, and no issues of abuse or neglect was identified. The ADM stated the rounds sheets are reviewed in the morning round each morning daily. The ADM stated on the weekend, the Manager on Duty completes the review of the sheets and reports to the Administrator directly if there is a concern. In an observation on 6/6/25 at 10:35am observed the checklist with staff to use for Neighbor rounds. Record review of Neighbor round observations for 6/6/25 at 10:54 am. All rooms and residents were observed in facility. No concerns regarding abuse and neglect identified. In an interview on 6/6/25 at 11:03 am with Resident # 15, she stated this morning a staff told her she was her neighbor and would be checking on her every day. Resident #15 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:08 am with Resident #16, she stated staff told her this morning that she was her neighbor and would be checking on her every day. Resident #16 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:09 am with Resident #17, she stated a staff told her this morning that she was her neighbor and would be checking on her every day. Resident #17 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:10 am with Resident #14, she stated a staff told her this morning that she was her neighbor and would be checking on her every day. Resident #14 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:12 am with Resident #18, he stated a staff member met with him this morning and stated they were his Neighbor and would be meeting with him every morning to make sure he was ok. He stated he feels safe and there were no concerns with care. In an interview on 6/6/25 at 11:14 am with Resident #19, she stated a staff met with her this morning and stated they were her neighbor and would be checking on her every morning to make sure she was good. She stated she feels safe and there were no concerns with care. Record review of Life Satisfaction rounds dated 6/5/25 revealed One staff completed satisfaction rounds for hall A for 11 residents with no concerns found. Second staff completed satisfaction rounds for hall B for 14 residents with no concerns noted. C Hall staff satisfaction round for 14 residents found no concerns. D hall satisfaction rounds for 18 residents found no current concerns. F hall satisfaction rounds for 4 residents with no concerns found. NON-Verbal rounds: A hall satisfaction rounds for 3 residents with no concerns. Random B/C/E hall satisfaction round for 12 residents with no concerns noted. D hall satisfaction rounds for 6 residents with no concerns notes. Record review of Inservice dated 5/19/25 for abuse & neglect for DON. Record review of Verbal competency quiz dated 6/5/25 for 18 staff. All staff passed. Record review of Verbal competency quiz dated 5/20/25 for 19 staff. All staff passed. Record review of Verbal competency quiz dated 5/18/25-5/19/25 for 49 staff. All staff passed. In an interview on 6/5/25 at 4:41pm with LVN E, she stated she had been trained on abuse and neglect. Verbal abuse is any cuss words, gestures, or words that are meant to hurt someone. LVN E stated she was just trained on this day and about a couple of weeks ago. She stated she was quizzed and made 100%. LVN E stated she had been trained on residents with mental health and aggressive behaviors and remove the resident and the other residents in the area. LVN E stated if she was told or see or hear about any allegation of abuse, report it to the ADM immediately, no matter the time of day. The ADM & the DON went over scenarios about different types of abuse and examples. In an interview on 6/5/25 at 5:12pm with LVN D, she stated she was trained on abuse and neglect on that day, and she stated staff did it a week and half ago, also. LVN D stated if anyone alleges abuse, she was to tell the ADM immediately and call anytime as soon as it happens. LVN D stated they trained on types of abuse like verbal abuse: yelling at them, and/or gesturing. She stated neglect is not changing residents. LVN D stated she was quizzed and passed. LVN D stated she had been trained on behavioral patients, and to use a calm voice, and remove other residents if you can't redirect them. She stated to also give them their space because too many people asking questions and getting at them can cause issue to. In an interview on 6/5/25 at 5:25pm with CNA H stated he had been trained on abuse and neglect. We did one last week and one today. CNA H stated he was trained on types of abuse. Example of abuse is derogatory marks or cursing at residents and gesturing. They quizzed CNA H and he passed. CNA H stated he had been trained on deescalating conflict and individuals with behaviors. If they are aggressive, we try to guide the individual away for the situation and try to help them and calm. But if that doesn't work, we try to remove the other residents and have staff assist me. Then if it is abuse, I report to ADM immediately. In an interview on 6/5/25 at 5:35pm with the ADM, she stated she added the verbal abuse quiz to emphasize it on the new hire check list. Record review of New Hire, Rehire & Transfer information form revised 6/02/25 revealed verbal abuse competency quiz was added. Record review Inservice for Clear the area drill dated 6/5/25 for all direct care staff. Record review of Inservice dated 6/5/25 for approaching, activities & interventions in response to behavior and people with mental health/psychiatric needs. Record review of Inservice dated 5/18/25 for verbal abuse scenario/drill for 52 staff. Record review of Inservice dated 5/18/25 for abuse & neglect - policy & procedure for 47 staff. In an interview on 6/6/25 at 11:02 am with CMA, she stated she had received training on ANE, how to clear an area and steps to help deescalate and respond to behaviors. She stated if she sees a concern she is to report it to the Abuse Coordinator or the DON. CMA stated she would report a nurse if needed. CMA stated that 1:1 residents can come out of their rooms. CMA stated she is aware of the Neighbor Program that started this morning. In an interview on 6/6/25 at 11:05 am with CNA I, she stated she had received training on ANE, how to clear an area and steps to help deescalate and respond to behaviors. She stated if she sees a concern she is to report it to the Abuse Coordinator or the DON. CNA I stated she would report a nurse if needed and she is aware of the Neighbor Program that started this morning. In an interview on 6/6/25 at 11:07 am with CNA J, she stated she has received training on ANE, how to clear an area and steps to help deescalate and respond to behaviors. She stated if she sees a concern she is to report it to the Abuse Coordinator or the DON. She stated she would report a nurse if needed. In an interview on 6/6/25 at 11:11am with CNA K. sitting as 1:1 with a resident stated she has received training on ANE, how to clear an area and steps to help deescalate and respond to behaviors. She stated if she sees a concern she is to report it to the Abuse Coordinator or the DON. She stated she would report a nurse if needed. CNA K stated 1:1 residents can come out of their rooms and she is aware of the Neighbor Program that started this morning. In an interview on 6/6/25 at 11:15 am with CNA L, she stated she has received training on ANE, how to clear an area and steps to help deescalate and respond to behaviors. She stated if she sees a concern she is to report it to[TRUNCATED]

Based on observation, interview, and record review, the facility failed to keep the residents free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 16 residents reviewed. The facility failed to prevent verbal abuse to Resident #1 by LVN B. This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. While the immediacy was removed on 6/06/25 at 1:02 pm, the facility remained out of compliance at scope of pattern and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place the residents at risk of serious emotional, psychological, and physical anguish. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 4/30/25. Her diagnoses included: Autistic Disorder (neurodevelopmental disorder with difficulties in social interaction and social communication), Fetal Alcohol Syndrome (life-long physical, cognitive, and behavioral issues), long-term drug therapy, epilepsy (seizure disorder), tachycardia (rapid heart rate). Resident was discharged on 05/05/2025. Record review of police report dated 5/4/25 at 6:59pm revealed When [Police officer] arrived, [Police officer] made contact with the reporting party, [LVN A], she stated they received a new patient [Resident #1] approximately 2 days ago. [LVN A] stated [Resident #1] was a psych patient who had been having a hard time adjusting to the facility. [LVN A] requested that [Police officer] speak with [Resident #1] to see if she met criteria to be assessed by [LIDDA] for a psych evaluation. [Police officer] made contact with [Resident #1] at the nurse's station, [Resident #1] was very upset at the time and was refusing to speak with [Police officer]. While [Police officer] was speaking to [Resident #1] in an attempt to build a rapport [LVN B] began walking towards the nurse's station. When [LVN B] approached the area, she began making statements like, Y'all need to take her ass somewhere. and Her [family member] needs to come get her! [LVN B] was very agitated and extremely rude. [Police officer] began asking [LVN B] for more background information on [Resident #1] because she did not speak to me. [LVN B] stated She is trying her crap. after she stated this [Resident #1] yelled at [LVN B] to shut up. [LVN B] stated, You don't scare me none, you might your [family member] but not me. I began explaining to [LVN B] our criteria and that I would not just be able to take her. [LVN B] began talking and said, Well then she needs to go to her room because she is one on one. [Resident #1] then yelled, I don't have to if I don't fucking want to! [LVN B] then turned to [Resident #1] pointed at her and yelled very angrily Go to your room! and then held her middle finger up towards [Resident #1]. That was when [Resident #1] stated I can punch you! and [LVN B] turned to [Resident #1] and waved her fingers as if inviting her over and stated, Come on! [Resident #1] stood aggressively and began walking towards [LVN B]. An aide and I stood between the two to keep things from escalating. [LVN B] stated She needs to go to jail mam! she then stated, Her [family member] dropped her here because she can't take care of her. another nurse stated neither of [Resident #1's] [family members] was answering the phone and [LVN B's] response was They don't want to have anything to do with her. [Resident #1] responded Shut up! and [LVN B] replied, Just telling the truth honey. This upset [Resident #1] to the point where she wanted to hurt [LVN B]. An aide and I continued following [Resident #1] and trying to keep her calm and away from [LVN B]. I was finally able to get [Resident #1] to separate and have a seat in the living area of the facility .[Police officer] contacted crisis line to see if she could be assessed by [LIDDA] .[LIDDA] came to the facility for the assessment and put in a referral to [Behavioral health hospital] and was denied due to [Resident #1's] IQ. LIDDA attempted an emergency detention order to the state hospital, and they refused the order. Officers remained until [Resident #1] was in bed and no longer a threat to the staff. Observation of body cam footage from police officer dated 5/4/25 from 7:12pm-7:19pm revealed the Police officer entered the building of the facility and went to the nurse's station and asked for the nurse that called and was directed down the hall to LVN A at her med cart. LVN A stated Resident #1 is a psych patient and need to see about an evaluation. LVN A pointed towards the nurse's station and stated the Police Officer could ask and aide where Resident #1 is. The Police officer walked to the nurse's station and CNA E showed Police officer who Resdient #1 was. Resident #1 was sitting in chair against the wall at the nurse's station quiet and looking around shaking her left leg and 1:1 aide (CNA E) was three chairs down from resident. Three residents sitting in chairs next to resident. Police officer attempted to speak to Resident #1, and she would not speak to the police officer. Resident #1 stated shut up to someone behind the police officer not seen on camera. Police officer turned around and LVN B wheeled her cart to the nurse's station and stated to the police officer, She's trying her crap & she needs to go to jail and Resident #1 stated shut up, shut up. LVN B stated, Don't scare me none, might your [family member] but not me. The police officer attempted to explain to LVN B that she can't just take her, and Resident #1 is not speaking to her. LVN B stated, she needs to go to her room, she's 1:1 and looks towards Resident #1. Resident #1 said, I don't have to if I don't fucking want to. LVN B stated, you need to go to your room loudly towards Resident #1 (Resident #1 not in camera view). LVN B flips Resident #1 off and states, I can do it too and Resident #1 stated, I can punch you and LVN B stated, come on and waved her fingers gesturing towards her to come, you punch me you're going to jail as Resident #1 is seen getting up and walking towards LVN B. Police officer says uh-uh and CNA D puts herself between LVN B and Resident #1. LVN B no longer in camera view. Resident #1 stated I don't care and Police officer tells her to go sit down. LVN B stated, she needs to go to jail ma'am, her [family member] left her here because she can't take care of her. They don't want to have anything to do with her. Resident #1 stated shut up and appeared to be tearing up. LVN B said, just telling the truth honey. CNA D stated, let's go for a walk, want to go for a walk with me and Resident #1 states, No, I want to punch that bitch. CNA D and Police officer said no, we are not doing that, and we have to respect our elders. CNA D stated again, want to go for a walk and LVN B (no longer in camera view) stated she's not to be out of her room for one thing. Resident #1 stated, yes I can and LVN B stated, she's on 1:1. CNA D encouraged Resident #1 to practice breathing. Resident #1 looks at her watch and a sound from watch played and Police officer stated, that's you [family member] right there. Resident #1 stated, I don't care. Police officer said, you don't want to talk to your [family member]? Resident #1 pulled a pen out of her left shorts pocket and stated, I wanna stab that bitch and CNA D stated, let's go on a walk, let's remove ourselves from the situation and we don't have to be ugly let's remove and go on a walk and calm down. We don't need to do the extra stuff. Resident #1 started walking towards the entrance of the nurse's station and CNA D walked with her and LVN C is seen at a med cart on the computer. Police and CNA D walk with Resident #1. CNA D put herself in the entry and police asked if she wanted to go walk with CNA D and Resident #1 said No and police said, we are not going over there with her and touched Resident #1's arm. Resident #1 shook police officer off and said move. The police officer said, back up, you're not going over there. Resident #1 tried to walk around CNA D and CNA D said [Resident #1], I'm not letting you in there, we can go for a walk, we can remove ourselves but that is not happening and Resident #1 stopped and stood still. Someone unknown stated, she's not supposed to be out here and Resident #1 stated yes I can. CNA D stated Let's go for a walk. LVN A is heard explaining Resident #1's actions to someone. The police officer asked Resident #1 if she wants to go outside, and she said no. CNA D stated I need you to back up, you are in my bubble and Resident #1 stepped back. CNA D thanked her. Someone from the nurse's station attempted to give Resident #1 the phone and CNA D stated your [family member] wants to talk to you. Resident #1 hung up the phone. The police officer stated How can we help you if you won't talk to anybody. We are here to help you. CNA D asked Resident #1 if she wants to go get a soda and Resident #1 shook her head no. LVN A asked CNA D she hung up? and CNA D said, oh yeah she hung up the phone. Resident #1 starts walking away. End video. In an interview on 5/18/25 at 10:45 am with the Police Officer, she stated she went out to the facility for a call for a welfare check on Resident #1 by LVN A. Resident #1 was very upset, and the Police officer got her to calm down. The Police officer stated that LVN B told the Police Officer she needed to take her [Resident #1] ass to jail. Resident #1 was right there so she heard LVN B. LVN B stated Resident #1's [family member] needed to come get her and Resident #1 needed to be in her room on 1:1. The Police officer stated Resident #1 stated she did not have to be in her room and LVN B flipped off Resident #1 and Resident #1 flipped off LVN B and then LVN B stated that's why nobody wants you. That's why she (family member) dropped you off to Resident #1. The police officer stated that Resident #1 said she was going to hit LVN B and LVN B said, do it. The Police officer said she got in between them and there were lots of staff around and nobody removed LVN B. The Police Officer stated it was not against the law, there was no immediate threat for Resident #1, and she had another nurse, and the police de-escalate the situation, so it was not enough to take LVN B in. LVN A was the nurse that called 911 to come check on Resident #1. In an interview on 5/18/25 at 1:30pm with DON, the DON stated she had never been told about the incident with LVN B by anyone until right then. Resident #1 was trying to hurt herself while she was at the facility and was there for 5 days, and was never without staff supervision. The DON stated she was never told about LVN B acting that way and would report it now and start an investigation now. She would have reported it at the time had she been made aware. The DON stated the Administrator, at the time, was no longer there. The DON stated he was the abuse coordinator and DON was the backup abuse coordinator at that time. In an interview on 5/18/25 at 5:50pm with LVN A, she stated she spoke with the police and witnessed Resident #1 trying to get at LVN B, but she did not know what initiated it. LVN A stated the aides prevented Resident #1 from getting LVN B so Resident #1 started throwing things down the hall. LVN A stated Resident #1 did calm down, went back to her room with her 1:1 staff, and went to sleep. LVN A stated she called Guardian A, and she was out of town, so LVN A tried to call Guardian B and he did not answer, so she called 911. LVN A stated she called because Resident #1 had grabbed an ink pen and started carving her arm and the police were right there. LVN A stated she told Resident #1 to stop, and she did. LVN A stated there was no injury. LVN A stated she did not see LVN B flip off Resident #1 or curse at her or tell her she was not wanted anywhere. In an interview on 5/18/25 at 6:48pm with CNA D, she stated that on 5/4/25, Resident #1 was frustrated and agitated, was trying to get out of the facility, and was on 1:1. CNA D stated the police had been called and LVN B said to Resident #1, you are here because your [family member] can't deal with you and you need to go to jail. Resident #1 said shut up, bitch and flipped off LVN B. LVN B flipped off Resident #1 and said, I can do it too. Resident #1 called LVN B a bitch and LVN B said, you need to go to jail and need to go to a mental hospital to Resident #1. CNA D stated Resident #1 said, shut up bitch, I'm gonna punch you and LVN B said, come on and punch me and I want you to punch me and CNA D stated she got up and tried to redirect Resident #1 and LVN B kept talking trash to Resident #1. CNA D stated she thought other nurses would have reported. CNA D stated she had been trained on abuse and neglect and she should have reported to the DON immediately because the DON was the Abuse coordinator and failure to report would not happen again. In an interview on 5/18/25 at 7:05pm with CNA C, she stated LVN B was agitating Resident #1 and told Resident #1 she needed to go to jail, and her [family member] dropped her off because nobody wanted her. CNA C stated Resident #1 got upset and said, shut up bitch and flipped off LVN B and LVN B kept going and flipped her off back. CNA C stated she could not believe this was happening right in front of the cops. CNA C stated Resident #1 went after LVN B and the aides intervened, and the cops didn't do anything. CNA C stated she thought the police would do something and take care of it. CNA C stated she came into work the next day to report it to the DON, but she was not there and then CNA C was off for a couple of days and time just went by. CNA C stated she did not report the incident because she thought others would and she should have reported it herself immediately. CNA C stated she had been trained on abuse and neglect and she should report to the DON, the abuse coordinator. CNA C stated she feels she can report to the DON and has in the past. In an interview on 5/19/25 at 12:24pm with Guardian A, she stated she did not want this writer to speak to Resident #1 as there were no current effects, but Guardian A did not want to upset Resident #1 and cause behaviors. Guardian A stated Resident #1 did tell her after discharge from the facility that a nurse flipped her off and told her they wanted her to go to jail. Resident #1 told Guardian A that the police saw the nurse do it. In an interview on 5/19/25 at 12:56pm with the ADON, she stated that all staff had been trained on abuse and neglect. The ADON stated all staff had been trained on what abuse would look like and who to report to. The ADON stated that they should report to the DON, abuse coordinator. The ADON stated she was not aware and had not heard anything about LVN B being abusive. The ADON stated what she had been told was that Resident #1 was throwing computers and laptops and swinging at nurses. The ADON stated she was told that by LVN A and LVN B. The ADON stated she spoke with the DON about it and the DON told the ADON she had went and checked on Resident #1 the next morning and she was fine and did not report anything. The ADON stated Guardian B requested Resident #1 be sent to the state hospital. The ADON stated LVN B would be terminated, and CNA C and CNA D were placed on final warning for not reporting it. In an interview on 5/19/25 at 4:54pm with LVN B, she stated Resident #1 was trying to get at patients and knocking things off the nurse's station and was psycho and 300 pounds. LVN B stated [Resident #1] was supposed to be on 1:1 in her room for suicide watch and coming to the front agitating other patients. LVN B stated, Resident #1 was [AGE] years old acting like a smart ass and would not mind staff. LVN B stated she was passing medications, parked her cart, and Resident #1 threw her the finger and LVN B did the same thing back. LVN B stated that Resident #1 needed to be in a mental institution and the facility was not appropriate, and staff were just babysitting. LVN B stated she told Resident #1 to go to her room and Resident #1 flipped her off and LVN B could not handle disrespectful children. LVN B stated she did flip off Resident #1 but did not say anything. LVN B stated it was a reaction because Resident #1 was pushing buttons. LVN B then stated she did tell the police they needed to take Resident #1 because she would not calm down. In a follow up interview on 5/20/25 at 12:48pm with the DON, she stated all staff had been trained on abuse and neglect a bunch of times. The DON stated she had her number posted and was the abuse coordinator. The DON stated at the time of the incident with LVN B, the abuse coordinator was the administrator, and the DON was back up abuse coordinator. The DON stated she had never heard of, and no one reported abuse from LVN B to Resident #1. The DON stated she had started 1:1 training with each staff member to prevent this in the future. The DON stated staff failed to report and she had retrained, counseled, and wrote up the staff that failed to report. The DON stated LVN B was suspended as soon as this writer informed DON about allegation, and LVN B was now terminated. LVN B worked approximately 10 shifts between 05/04/2025 and 05/18/2025. In an interview on 6/3/25 at 3:35pm with LVN C, she stated she was on another hall, and walked up to the nurse's station. LVN C stated she saw Resident #1 yelling at LVN B and LVN B was yelling back at her. LVN C stated she was attending to the other residents and LVN B was talking to Resident #1 about how she hated taking care of residents like her and stuff like that, something to that affect. LVN C stated LVN B did say Resident #1 needed to go to jail. LVN B said Resident #1's [family member] dropped her at the facility because she couldn't handle her. LVN C stated she did not see LVN B flip off Resident #1. LVN C stated, it was verbal abuse. LVN C stated she was going to report to the DON, but LVN A, the night nurse, was on the phone with her at that time, right after the incident, and she said, yes I'm talking to her right now. So, LVN C stated she didn't and thought LVN A reported it. LVN C stated LVN A said she was on the phone with the DON after the incident, but she did not know what she reported. LVN C stated she was covering the shift and was late to her shift because she got called in and never worked the night shift before. LVN C stated she said to LVN A, you got this, you are reporting it and LVN A said yes, she was talking to the DON right then. LVN C stated she went back to passing meds. In a follow up interview on 6/3/25 at 4:11pm with the DON, she stated LVN A did call her that night at 7:24pm and said Resident #1 was having behaviors, throwing things at the nurse's station, and grabbing pens and the cops were there. The DON advised LVN A to call the [family member] because the cops would not take Resident #1 but maybe they would calm her. The DON said LVN A never told her about LVN B, and LVN B was never even mentioned, and she wasn't even the patients nurse, so the DON did not think to ask anything about that. The DON stated she went to see Resident #1 the next morning and checked on her first thing that morning and Resident #1 never told the DON that happened either. In an interview on 6/4/25 at 8:40am with CNA E, she stated she was Resident #1's 1:1 on the evening of the incident and it was her first time working with Resident #1. Resident #1 was throwing everything, books, and pens off the nurse's station. Resident #1 would be yelling, and she called CNA E a bitch for following her and she said she didn't need a 1:1. CNA E stated other residents did see, maybe 2 or 3 residents at the nurse's station. They were staring at Resident #1, and one lady said we (staff) needed to call the cops. CNA E stated she did not see Resident #1 try to hurt herself. CNA E stated Resident #1 went outside because she did not want to be there at the facility. CNA E stated there were CNAs, residents, and nurses around during the incident. CNA E stated Resident #1 was calling LVN B a bitch and flipped her off. She stated LVN B flipped her off back, Resident #1 tried to hit LVN B, and another aide got in between them. CNA E stated she had moved back so she did not see everything. She stated the cops calmed Resident #1 down. Then CNA D stepped in between them. CNA E stated she heard LVN B say, I can do that too and flipped off Resident #1. LVN B told Resident #1 to go to her room. CNA E stated she should have reported, but there was a lot going on and a lot of people involved so she thought they would report because she felt they had a better account of the situation. In an interview on 6/4/25 at 4:15pm with the DON and the ADM when shown the body cam footage, the ADM stated it was abuse and feels staff thought LVN A reported and that was why they didn't report. The DON stated it was abuse and she feels all staff felt the others would report. The DON stated she did get a report from LVN A, but it was only what she saw and not all of what happened or what LVN B did. In an interview on 6/5/25 at 12:12pm with Resident #11, he stated he had not seen any staff be rude or rough to any resident. Resident #11 stated Resident #1 was very upset. Staff calmed her down. Resident #11 stated he wheeled by the nurse's station, and Resident #1 was cursing and upset. Police were there and they took her back to her room and she calmed down. Resident #11 stated he didn't see the nurse flip her off. Resident #11 stated he had never seen staff do or say anything like that. He stated he had no concerns about his care at the facility. In an interview on 6/5/25 at 12:22pm with Resident #12, he shook his head no when asked if he had ever seen staff be rude or rough with a resident. Resident #12 shook his yes when asked if he remembers the incident. Resident shook his head no, when asked if he saw the nurse be rude or say mean things to the resident. Resident shook his head no, when asked if he saw the nurse flip off the resident. Shook his head yes when asked if he felt safe. Resident #12 shook his head yes when asked if he felt staff acted appropriately. Resident #12 shook his head yes when asked if he felt staff acted quickly to keep everyone safe. Shook his head no, when asked if anyone was hurt. Resident #12 shook his head yes when asked if he was removed from the incident. In an interview on 6/5/25 at 12:33pm with Resident #13, she stated she remembered the incident. Resident #13 stated that staff were trying to get something Resident #1 had taken and Resident #1 got mean. She stated Resident #1 was cursing and throwing things. Resident #13 stated she did not see the nurse say anything rude or flip off Resident #1. Resident #13 stated she felt safe, staff took care of it, and the police came. In an interview on 6/5/25 at 1:30pm with CNA F, she stated she came out of the break room to prepare to do a round and saw Resident #1 trying to get at LVN B. She stated she saw staff got in between Resident #1 and LVN B and cops calmed her down. CNA F stated then the police left, and Resident #1 started throwing things and going after LVN B again. CNA F stated she got in between them. CNA F stated the cops came back in and they stayed for a couple of hours, and they got Resident #1 to calm and then they left. CNA F stated LVN B made comments about how the police needed to take Resident #1 and she would not calm, and she would keep doing this. CNA F stated she did not see her flip off Resident #1. CNA F stated she did here LVN B tell her multiple times she needed to go to her room. CNA F stated she did not hear abuse but did feel LVN B was agitating Resident #1. Resident #1 was very disruptive and agitated and was throwing things and staff, including CNA F removed the other residents from the area the second time the police came in and we removed the residents for their safety. CNA F stated staff didn't remove the other residents the first time when Resident #1 was just saying she would hurt LVN B. CNA F stated she did hear about LVN B flipping off Resident #1 after LVN B had been fired. Record review of LVN B employee file revealed Abuse and Neglect training on 8/7/24. Record review of In-Service Training Report dated 4/3/25 revealed LVN A, LVN B, CNA C, and CNA D had been trained on abuse and neglect. Record review of the facility's Abuse Prohibition Policy dated 5/17/2024, revealed Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse.Verbal Abuse is defined as the use of, oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Record review of Resident Rights policy dated 4/2017 revealed .Residents shall .b. be treated as individuals in a manner that supports their dignity .g. Be free from mental, emotional, and physical abuse and neglect . On 6/04/25 at 2:09pm, an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and accepted on 06/05/25 at 4:35 pm and included: Social worker, or designee made life satisfaction rounds to residents that can be interviewed to ensure free from abuse and neglect. Staff caring for residents who are unable to be interviewed have been interviewed for any noted changes in residents' behavior. Any abuse or neglect identified will be immediately reported to the abuse coordinator and then HHSC by who ever witnessed or heard about the incident. Completed 6/5/2025.No findings of abuse reported. Administrator trained and is initiating the implementation of Neighbor rounds completing assessments on their residents for potential abuse on 6/5/2025. This will be completed daily by the leadership team during the week and Manager on Duty on weekends. Neighbor rounds are reported daily to the IDT team and will be reviewed during monthly QAPI meeting. This systemic change will ensure that all residents, whether they are able to be interviewed or not, are free from abuse. On May 18, 2025, LVN B was suspended pending the outcome of the investigation. Upon completion of the investigation, LVN B was terminated May 21,2025. On May 19, 2025, Corporate Clinical specialist in-serviced DON regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and different scenarios. Competency was verified by a quiz. DON in-serviced staff regarding Abuse and Neglect policies and procedures, with emphasis on definition of verbal abuse and scenario example discussed. Competency was verified with a quiz. Staff will not be allowed to work until they have passed the quiz. Verbal abuse quiz and in-service will be added to the new hire abuse training. Staff were trained over Approaches, Activities and Interventions in Response to Behaviors of people with Mental Health or Psychiatric Needs including how to manage different behaviors, deescalating the situation, removing aggressive resident from the area where other residents may be present or removing the other residents from the area of situation, and to immediately report incident to facility Abuse Coordinator. Completed 6/5/2025. Peer interviews over knowledge of facility's Abuse and Neglect Policy and Procedures, will be conducted weekly, with no less than 10 staff members, by Social Worker, and/or designee for 8 weeks. Following 8 weeks follow up, monthly Peer Interviews will be conducted by Social Worker and/or designee. The abuse coordinator, or designee, shall be responsible for monitoring this corrective action. Any negative findings will be reported to the facility's QA committee for review and corrective action. Completed 6/5/25. Monitoring of the Plan of Removal from 6/05/25 - 6/06/25 included the following: Record review of Inservice dated 6/5/25 with leadership team of 12 staff for neighbor rounds revealed staff are to assess residents for changes in behavior/mood; auditing/asking staff about any signs of abuse and whether sexual, physical, or verbal abuse. In an interview on 6/5/25 at 5:56pm with the ADON, she stated the SW interviewed her on abuse and what she should do to check her knowledge. The ADON stated she had been trained on neighbor rounds. She stated staff will be dividing certain hallways, certain rooms, and do morning rounds. The ADON stated staff would talk to those residents and assess for any issue. She stated staff would see if they had any issues or concerns, and address the concerns, and bring to the morning IDT meetings. The ADON stated staff also did a drill on how to clear the room of other residents, keep everyone safe, and how to approach and deescalate a resident that is aggressive or displaying behaviors. The ADON stated the facility Inserviced all staff on abuse & neglect, reiterated differences and examples of each, and who to report to and when. The ADON stated the DON was going to randomly audit staff on their training. In an interview on 6/5/25 at 6:15pm with SW, she stated she had completed resident and staff interviews regarding abuse and specifically verbal abuse and staff interviews going forward and upping the neighbor rounds program. SW stated she was to round on the second half of A hall every morning and check with residents to see how things are going. She stated she was to see if residents are well and check environmentally and if they have concerns write grievances for that, The SW stated staff are to build rapport to find the abuse if it was happening. The SW stated she had completed life satisfaction rounds and found no concerns of abuse. In an interview on 6/6/25 at 10:35 am with the Administrator and the DON, the ADM stated this day was the first day for Neighbor rounds. The ADM stated staff are assigned rooms and report on the rooms daily (no one has more than 6 rooms each), utilizing a check list. The ADM provided the checklist to the investigator. The DON stated this day was the first day. It went well, and no issues of abuse or neglect was identified. The ADM stated the rounds sheets are reviewed in the morning round each morning daily. The ADM stated on the weekend, the Manager on Duty completes the review of the sheets and reports to the Administrator directly if there is a concern. In an observation on 6/6/25 at 10:35am observed the checklist with staff to use for Neighbor rounds. Record review of Neighbor round observations for 6/6/25 at 10:54 am. All rooms and residents were observed in facility. No concerns regarding abuse and neglect identified. In an interview on 6/6/25 at 11:03 am with Resident # 15, she stated this morning a staff told her she was her neighbor and would be checking on her every day. Resident #15 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:08 am with Resident #16, she stated staff told her this morning that she was her neighbor and would be checking on her every day. Resident #16 stated she feels safe and had no concerns with care. In an interview on 6/6/25 at 11:09 am with Resident #17, she stated a staff told her this morning that she was her neighbor and would be checking on her every day. Resident #17 stated she feels safe a[TRUNCATED]

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, in that: 1. Appliance surfaces were soiled with dried food, grease and burned food. 2. Bulk storage container lids were soiled with food particles and dust. 3. Opened food item packages in the refrigerator, freezer, and dry food storage room were not placed in sealed containers, were not labeled with the contents, and were not dated when opened. 4. Expired milk was stored on the shelves in the refrigerator. 5. Cartons of expired prune juice was stored on a shelf in the dry food storage room. 6. Cooking utensils and pans were stored with their sanitized surfaces exposed to contaminants in the air. 7. A live fly moved throughout the main kitchen and food preparation area during a follow-up visit to the kitchen on [DATE]. This failure could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included: Observations and interviews starting at [DATE] at 9:18 AM, during the initial tour of facility kitchen, revealed the following: - the hand washing sink interior surface was soiled with dried brown colored spots; - the manual can opener, mounted to the end of the stainless-steel food preparation counter, food contact surface was soiled with dark colored substance build-up; - the toaster surface was soiled and rusted; - the stainless steel counter above toaster was soiled with spilled spices, dust and grease; - 3 bulk storage containers beneath the food preparation counter were used for storing food thickener, granulated sugar, and flour and had soiled lids; a piece of grated cheese was stuck to the inside of the lid for the food thickener; - the storage container for corn meal had a soiled lid; - the convection oven top exterior surface was soiled with dust and grease; the interior surface soiled with spilled burned food; - the top exterior surface of the steamer was soiled with dust and grease; - the 2 gas ovens had spilled and burned food on their interior bottom surfaces; - the deep fryer unit had dark colored cooking oil; the interior surface was soiled with fried food crumbs; the 2 fryer baskets were soiled with fried food crumbs - the unit was not in use; - the commercial refrigerator used for bread and milk contained 3 one-half gallon cartons of lactose free milk with a manufacturer's expiration dates of [DATE] (unopened) and 3 one-half gallon containers of buttermilk with expiration dates of [DATE] (unopened) - the Dietary Manager removed the cartons and placed them on a cart to throw them away; - the nonperishable food storage room had wire rack shelf units with 9 unopened 46-ounce cartons of prune juice with ,d+[DATE] written with a black marker pen on them and had manufacturer's expiration dates of [DATE] - the Dietary Manager stated they were delivered [DATE]; she removed the 9 cartons of prune juice and placed them on the cart with the milk and buttermilk to dispose of them; - an open bag of cookie pieces was wrapped with plastic and dated [DATE] (not in a sealed container or resealable bag); - an open of bag white cake mix was wrapped in plastic and dated [DATE]; - an open bag of pound cake mix was wrapped in plastic and not dated when opened; - an open pouch of blueberry muffin mix was in a resealable bag and was not labeled and dated; - an open 50-pound paper bag with pancake mix had the top of opened bag rolled to close; the Dietary Manager proceeded to use a marker pen and wrote ,d+[DATE] on the bag and stated it should have tape on it; - an open bag with dry spaghetti was tied/knotted closed and was not labeled or dated; - an open bag with dry pasta was closed with a binder clips and was not labeled and dated; - the walk-in refrigerator contained cheese slices wrapped in plastic that were not labeled and dated; deli ham slices were in a resealable bag that was not labeled and dated; breaded ribs were in a resealable bag dated ,d+[DATE] - the Dietary Manager stated the ribs were in the freezer and she was not sure why they were taken out; - raw ground beef was wrapped in plastic and not labeled and dated on a shelf in the walk-in freezer; the Dietary Manager removed the frozen ground beef from the freezer; - a reach-in freezer unit against the wall in the food preparation area contained open packages of mixed vegetables that were not labeled and dated, with 1 bag wrapped in plastic and 1 bag tied/knotted closed; an opened bag of broccoli wrapped in plastic and not labeled and dated; an opened bag with biscuit dough was tied/knotted closed and was not labeled and dated; raw beef patties were stored in a large resealable bag and were not labeled and dated; - cooking utensils, including a wire whisk, serving spoons and scoops were hanging from a metal panel on the wall above the steam table with their sanitized surfaces exposed to contaminants in the air; - the beverage station area of the kitchen had an ice machine; the top exterior surface of the ice machine was soiled with dust; - the beverage station area of the kitchen had a residential style refrigerator with top freezer compartment; the top exterior surface was soiled with dust. Observation and interview on [DATE] at 4:37 PM, during preparation of the evening meal, revealed a live fly moving in the area of the food preparation counter. The fly landed on the lid to the bulk storage container used for food thickener on the shelf beneath the counter. [NAME] A stated the flies had been bad this year. She stated the flies came in when the doors to the outside were opened, especially the door to the designated smoking area off Hall C. During an interview and record review on [DATE] at 2:58 PM, the Dietary Manager stated the cooks and dietary aides had cleaning schedules for daily cleaning tasks to be completed during the morning and evening shifts. She stated the forms were kept in a binder notebook on a shelf in the kitchen. Review of the cleaning schedule forms revealed the staff initialed assigned tasks as completed. During an observation and interview on [DATE] at 3:05 PM, the serving utensils continued to hang from the metal panel on the wall above the steam table with their sanitized food surfaces exposed to the open air and any contaminants in the air. The Dietary Manager started removing the utensils and stated she would find a storage bin with a lid to put them in. Review of the facility policy and procedure for Sanitization, dated as revised [DATE], specified the following [in part]: Policy Statement The food service area is maintained in a clean and sanitary condition. Policy Interpretation and Implementation 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair . Review of the facility policy and procedure for Food Receiving and Storage, dated [DATE], specified the following [in part]: Policy Statement Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Review of the facility policy and procedure for Dry Storage, dated [DATE], specified [in part]: 4. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated. 5. All expired foods must be removed from the store room . 9. If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If using large bags to seal open items in their original packaging, the bag may be reused, but needs to be re-dated. If the food is directly in the bag, the bag must be labeled and dated, and when the bag is emptied, it should be discarded. Bags must be sealed . The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food ,d+[DATE].15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on interview and record review, the facility failed to act promptly upon the grievances of the resident group concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 2 of 3 Resident Council Meetings, in that: 1. Concerns voiced during the monthly Resident Council Meetings were not addressed following meetings held on 4/17/2024 and 5/20/2024. 2. The Resident Council members were not notified regarding facility action taken to address and resolve concerns voiced in prior Resident Council Meetings during the next monthly meetings held on 5/20/2024 and 6/04/2024. 3. The follow-up to Resident Council concerns and discussion of old business were not documented as reviewed, read, resolved, or unresolved on the Resident Council Minutes form dated 5/20/2024. These failure placed the residents at risk for a decreased quality of life and a decreased feeling of well-being within their living environment. The findings included: Review of the Resident Council Meeting Minutes revealed the following: 5/20/24 - 9 residents attended and the Activity Director was present. The documented concerns included beds not being changed, more dental care/dentist visits were desired, and the residents wanted larger portions of food and more hamburger toppings. 6/04/24 - 10 residents and the Activity Director attended. The Activity Director reviewed previous Council Minutes and reviewed the smoking policy and outdoor area. New concerns: want the dentist to come to the building more often; discussed food preferences; question regarding why residents could not go out the back door - discussed by Administrator. 7/02/24 - 10 residents and Activity Director attended. New concerns: COVID (an acute and severe respiratory illness) screening before admission; cable for the television does not always work; food portions were too small; and headphones were needed for residents with 2 televisions in the room. Review of the Grievance Log Reports for the Resident Council revealed a total of 12 grievance reports had been completed following the Resident Council Meetings. In an interview on 7/10/24 at 9:12 AM, the Social Worker stated the grievance reports were entered into the computer. In an interview on 7/10/24 at 9:17 AM, the Resident Council President stated Resident Council Meetings were held monthly and the Activity Director wrote the meeting minutes. He stated concerns were conveyed to the Administrator and the Administrator decided if a grievance report needed to be filed. The Resident Council President stated the Council was not told the outcome of their concerns, but they could usually see an improvement or difference. He stated the Administrator and the Dietary Manager were both invited to attend the last meeting but did not attend. During an interview and record review on 7/10/24 at 9:32 AM, the Social Worker provided a Grievance Log Report dated 1/01/24 - 7/10/24. She stated the Resident Council grievances were listed under the Resident Council President's name and were printed on a separate report. Interview on 7/11/24 at 9:12 AM, during a confidential Resident Council Meeting attended by 11 residents and the Assistant Ombudsman, the residents stated Resident Council concerns were not addressed by the Administrator, there was no follow-up with the Resident Council regarding the action that was taken to address their concerns, and their concerns were not resolved. The residents conveyed that the Administrator said, We will see what we can do, and nothing was ever done. The residents stated they would go to the Social Worker to file a grievance and could also tell the RN - MDS Nurse. The Resident Council President stated about 3 weeks ago during the smoke break, the Administrator went to the smoke break area and told the residents he did not want people to go outside to the smoking area earlier than the scheduled time. He said the residents who did not smoke were not supposed to go to the smoking area. In an interview on 7/12/24 at 11:19 AM, the Social Worker stated she tracked the grievance reports in the computer and no grievance reports resulted from the June 2024 Resident Council meeting. In an interview on 7/12/24 at 11:23 AM, the Activity Director stated she gave a copy of the Resident Council meeting minutes to the Social Worker, who then completed a grievance report form and gave the form to whichever department it applied to and needed to address the grievance. The Social Worker then entered the completed form into the computer and the Administrator reviewed the forms and signed them electronically. The Activity Director stated she did not give the Resident Council a follow-up response to their complaints. She stated she did not see the grievance reports after they were completed and did not know what action had been taken or what had been done to resolve the problems. She stated she did not know if she was allowed to see the reports after they had been completed. The Activity Director stated she told the residents to keep complaining until something changed and grievance reports would be filed until the concerns were resolved. The Activity Director stated the Resident Council President invited department supervisors to the Resident Council meeting before telling her. The Activity Director stated last week she did not know the Dietary Manager and Administrator were invited and did not attend. She stated she tried to remind staff when their attendance was requested at Resident Council meetings. She stated she mentioned it to staff in the morning meetings. The Activity Director thought the Administrator had a prior commitment or appointment during the last Resident Council meeting time. She stated the Administrator did meet with a group of residents who smoke on 7/02/24 at 11:00 AM. She stated the Administrator told the residents they needed to use separate patio areas for the smokers and non-smokers due to limited space in the smoking area. The list of resident smokers had increased. In an interview on 7/12/24 at 11:31 AM, the facility Social Worker stated the Administrator went and talked to the Resident Council President and discussed the grievances and told him what had been done. She stated the list of residents who smoke had increased and they had complained about the designated smoking area located off Hall C outside the laundry building. The Social Worker stated she was the Grievance Officer but the Administrator needed to sign off on the grievance reports. In an interview on 7/12/24 at 12:44 PM, the Administrator stated he met with a group of resident smokers on 7/02/24 at 11:00 AM in the smoking area and went over the smoking policy and the rule regarding no unsupervised smoking. He stated the residents were required to give all cigarettes, lighters, matches and paraphernalia to the staff to keep in the box locked in the medication room. He stated there was a resident who would go out to the smoking area and beg and [NAME] other residents to give her a cigarette. He stated the non-smoking residents were told they were not to be out in the smoking area. The residents who smoke were told if they could not or would not comply with the smoking policy and continued to put other residents' lives at risk, they would receive a 30-day written discharge notice. The Administrator stated he had spoken to the residents about it two times now. He stated so far the residents were ok with it. The Administrator stated he followed up with the Resident Council President regarding all Resident Council complaints and grievances. He stated he would start giving the completed grievance reports to the Activity Director to review with the Resident Council during their next meetings. Review of the facility's policy and procedure for Filing Grievances/Complaints, dated as revised 6/2024, indicated the following [in part]: Policy Statement: Our facility will assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1. Any resident, his or her representative (sponsor), family member or advocate may file a grievance or complaint concerning his or her treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of discrimination, threat or reprisal in any form. 2. Grievances and/or complaints my be submitted orally, in writing, or electronically and may be filed anonymously. 3. All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing (if requested), including a rationale for the response . 11. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed verbally and in writing (if requested) of the findings of the investigation and the actions that will be taken to correct any identified problems . Review of the policy for Grievance Procedures - Residents, dated as revised 12/2020, indicated the following [in part]: Policy: .to provide an open line of communication and a process which allows residents the opportunity for expressing suggestions, questions, concerns, and complaints without fear of retribution. Procedure: Resident Council: In order to facilitate communication in the community in an organized manner, a Resident Council is established. Meetings each month provide a forum for all residents to make suggestions, recommendations, and voice concerns regarding items such as policies and procedures .and the functioning of resident committees. Staff members will attend meetings by invitation only. Minutes of the monthly meetings are to be taken and a copy given to Executive Director (Administrator). The Activity Director will attend and serve as a liaison between the council and administration. The Activity Director will also record the minutes of the meeting. Issues of concern shall be addressed with the Executive Director (Administrator) or designee who will communicate the resolution of such issues of concern to the residents in a timely fashion .

Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for 2 of 2 resident rooms reviewed for homelike environment. (Resident #3 and Resident #2) The facility failed to properly clean the sheets for Resident #3. The facility failed to properly clean the walls, privacy curtain, and floors in Resident #2's room. This deficient practice could place residents at risk of an unclean and homelike environment. Findings included: During an observation on 11/01/2023 at 2:40 PM Resident #3 was lying in bed, her sheets were soiled and dried on the left side of the resident. During an observation on 11/02/2023 at 1:35 PM in Resident #2's room, revealed the following: -Two of the walls from floor to ceiling were covered with an orange sticky substance. -Privacy curtain had large liquid brown spots that were light in color and dark in color, as well as small brown spots on the lower part of the privacy curtain that contained a brown crusty smeared substance. -Debris, hair, dust, trash and spilled liquid spots under the bed. -Spots on the floors that were dirty. -Two (2) large trash bags of soiled laundry on a bed. During an interview on 11/01/2023 at 2:00 PM, Resident #3's responsible party, revealed Resident #3 often had dirty soiled sheets. She revealed that she had complained to the staff and the DON. She revealed that it had gotten better, but that at times, there were still issues. She revealed that the issues with the soiled linens were usually at night. She revealed that Resident #3 was dependent on staff for all ADLs and that she helped with Resident #3's care and with cleaning her room. During an interview on 11/01/2023 at 2:30 PM, the DON revealed that her expectations are for all resident's sheets to be changed when soiled. She revealed that the failure could place the resident at risk for unsanitary conditions. During an interview on 11/02/2023 at 1:45 PM, Resident #2 and her family said they have requested numerous times that laundry come and pick up Resident #2's dirty laundry. Resident #2 revealed that she did not file a grievance. The family were told that laundry was behind and would get to it when they could. The family said that the stains on the wall were from the previous resident. The family said that the resident would get mad and throw orange juice at the walls. The family said that it had been like that for a long time, at least a few months. The family said that the stains on the privacy curtain were from coffee being spilt over time. The family said that after the previous resident was moved out, the facility never came in to clean the room. The family said that under her bad was dirty and that the facility was trying to keep it clean, but the facility did not have enough staff. The family said that they could not remember the last time the resident's room had been thoroughly cleaned. The family said that they helped keep the room clean when staff could not. During an interview and observation on 11/06/2023 at 1:28 PM, the Housekeeping Manager observed Resident #2's room and said that the walls and the privacy curtain being dirty was unacceptable. She said that somehow it was missed, and she would resolve the issue immediately. She revealed that if it was her room, she would want that clean. She revealed that it was not a homelike environment and that she would make sure the issues were corrected. Review of the facility's Homelike Environment Policies and Procedures dated February 2021, reflect the following: Policy Statement: Residents are provided with a safe, clean, comfortable in home like environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 1). Staff provides person centered care that emphasizes the residence comfort, independence and Personal needs and preferences. 2). The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean sanitary and orderly environment clean bed and bath linens that are in good condition.

Based on interview and record review, the facility failed to maintain medical records on each resident were complete in accordance with accepted professional standards and practices for 1 of 15 residents (Resident #1) whose clinical records were reviewed for accuracy. The facility failed to ensure Resident #1's clinical record had a physician's orders entered for the 1 on 1 observations, scheduled documentation of the observations, missing signatures of who wrote the notes on the 1 on 1 observations on the paper documentation. This failure could place residents at risk for inaccurate or incomplete clinical records. Findings included: Record review of Resident #1's Admission record dated 11/07/2023, revealed Resident #1 was [AGE] years-old and was admitted to facility on 07/29/2023 with a diagnoses of encephalopathy (brain disease that alters brain function), Alzheimer's Disease (neurodegenerative disease that destroys memory and other important mental function), Altered Mental Status (changes in consciousness, appearance, behavior, mood, affect, motor activity or cognitive function) and Delirium (serious disturbance in mental abilities that result in confused thinking and reduced thinking and reduced awareness of surroundings). Record review of Resident #1's Admission MDS assessment Cognitive Patterns section dated 08/05/2023 revealed Resident #1 had a BIMS of 05 indicated severe impaired cognition; signs and symptoms of delirium such as exhibited inattention behavior and disorganized thinking behavior that was continuously present. Further review of the admission MDS Behaviors section revealed Resident #1 did not exhibit physical behaviors toward others; however, did exhibit verbal behaviors towards others 4 to 6 days a week and the behaviors did not place residents at significant risk for physical illness or injury, nor significantly interfere with the resident's care, nor significantly intrude on the privacy or activity of others, nor significantly disrupt the care or living environment of others. Further review of admission MDS Behaviors section revealed Resident #1 exhibited rejection of care and wandered 1 to 3 days a week; however, Resident #1 did not wander or intrude on the privacy or activities of others. Further review of Resident #1's Admission MDS assessment medication section revealed Resident #1 did not receive any medications for anxiety. Further review of Resident #1's Admission MDS assessment restraint and alarm sections revealed Resident #1 wore a wander guard alarm. Record review of Resident #1's Comprehensive Care Plan completed on 08/16/2023 revealed Resident #1 was evaluated as a wandering risk related to decreased safety awareness, confusion and wandering behaviors; staff were to observe Resident #1 for signs and symptoms of agitation, pacing, repetitive verbalization's of wanting to leave/go home, restlessness. Staff were to also report increased behaviors to nurses for further interventions. Further review of Resident #1's Comprehensive Care Plan revealed that the resident had the potential to be verbally aggressive, yelling loudly, throws arms in the air. Resident #1 was to verbalize his understanding of the need to control his verbally abusive behaviors. Resident #1 was an elopement risk related to being disoriented to place with history of attempts to leave the facility unattended, impaired safety awareness, and wandered aimlessly. Record review revealed that Resident #1's consolidated Physician's Orders dated 11/02/2023 revealed no evidence of a physician's order for 1 on 1 observations. Review of Resident #1's of 1:1 (1 Resident with 1 Staff) handwritten observation sheets from 08/15/2023 to 11/05/2023 revealed Resident #1 had 1:1 staffing every day from 08/15/2023 to 11/05/2023 during the day. During a confidential interview on 11/02/2023 at 11:45 AM., it was said Resident #1 was aggressive daily towards staff and tried to get out of the building, so he was placed on 1:1 observation. The confidential interviewee said the facility staff were told not to document the 1:1 observation in the resident's record. During a confidential interview on 11/02/2023 at 12:30 PM., it was said that Resident #1's 1 to 1 observations were not being documented so that another facility would accept him. During a confidential interview on 11/02/2023 at 1:50 PM., it was said that Resident #1 was 1 on 1 in the day and not at night. During an interview on 11/06/2023 at 9:05 AM, the DON said that she should have put an order in for the 1 on 1 observation since they were doing the 1 to 1 observation and she had verbally ordered the staff to do it. She said that corporate told her that she did not have to document it. She said that these issues placed the resident at risk of not improving or receiving the care that should be provided. She said that there was limited documentation done on the resident due to them not scheduling it in EMAR or accurately documenting the resident's 1 on 1 observations. She revealed that the facility was actively trying to transfer the resident to another facility. The facility's policy and procedures titled: Charting and Documentation policy dated July 2017 revealed the following: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the residents' medical, physical, functional, or psychosocial condition, she'll be documented in the residence medical chart. The medical record should facilitate communication between the introduced disciplinary team regarding the resident's condition in response to care. Policy interpretation and implementation: 7. Documentation of procedures and treatments will include care specific details, including: a) The date and time the procedure/treatment was provided. b) The name and title of the individuals who provided the care. c) The assessment data and/or any unusual findings obtained during the procedure/treatment. d)How the resident tolerated the procedures/treatment. e) Whether the resident refuse a procedure/treatment. f) Notification of family, physician, or other staff, if indicated. g) The signature in title of the individual documenting.

Based on observation, interview, and record review the facility failed to have assessments that accurately reflect the status of 1 of 3 residents (Resident #1) reviewed for resident assessments. Resident #1's Annual MDS did not reflect his current behavioral state. This failure could place residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings Include: Record review of Resident #1's Admission record dated 11/07/2023, revealed Resident #1 was [AGE] years-old and was admitted to facility on 07/29/2023 with a diagnoses of encephalopathy (brain disease that alters brain function), Alzheimer's Disease (neurodegenerative disease that destroys memory and other important mental function), Altered Mental Status (changes in consciousness, appearance, behavior, mood, affect, motor activity or cognitive function) and Delirium (serious disturbance in mental abilities that result in confused thinking and reduced thinking and reduced awareness of surroundings). Resident #1 was discharged to another facility on 11/07/2023. Record review of Resident #1's Admission MDS assessment Cognitive Patterns section dated 08/05/2023 revealed Resident #1 had a BIMS of 05 which indicated severe impaired cognition; signs and symptoms of delirium such as exhibited inattention behavior and disorganized thinking behavior that was continuously present. Further review of the admission MDS Behaviors section revealed Resident #1 did not exhibit physical behaviors toward others; however, did exhibit verbal behaviors towards others 4 to 6 days a week and the behaviors did not place residents at significant risk for physical illness or injury, nor significantly interfere with the resident's care, nor significantly intrude on the privacy or activity of others, nor significantly disrupt the care or living environment of others. Further review of admission MDS Behaviors section revealed Resident #1 exhibited rejection of care and wandered 1 to 3 days a week; however, Resident #1 did not wander or intrude on the privacy or activities of others. Further review of Resident #1's Admission MDS assessment medication section revealed Resident #1 did not receive any medications for anxiety. Further review of Resident #1's Admission MDS assessment restraint and alarm sections revealed Resident #1 wore a wander guard alarm. Record review of Resident #1's Comprehensive Care Plan completed on 08/16/2023 revealed Resident #1 was evaluated as a wandering risk related to decreased safety awareness, confusion and wandering behaviors; staff were to observe Resident #1 for signs and symptoms of agitation, pacing, repetitive verbalization's of wanting to leave/go home, restlessness. Staff were to also report increased behaviors to nurses for further interventions. Further review of Resident #1's Comprehensive Care Plan revealed that the resident had the potential to be verbally aggressive, yelling loudly, throws arms in the air. Resident #1 was to verbalize his understanding of the need to control his verbally abusive behaviors. Resident #1 was an elopement risk related to being disoriented to place with history of attempts to leave the facility unattended, impaired safety awareness, and wandered aimlessly. Review of Resident #1's of 1:1 (1 Resident with 1 Staff) handwritten observation sheets from 08/15/2023 to 11/05/2023 revealed Resident #1 had 1:1 staffing every day from 08/15/2023 to 11/05/2023 during the day. During a confidential interview on 11/02/2023 at 11:45 AM., it was said Resident #1 was aggressive daily towards staff and tried to get out of the building, so he was placed on 1:1 observation. The confidential interviewee said the facility staff were told not to document the 1:1 observation in the resident's record. During a confidential interview on 11/02/2023 at 12:30 PM., it was said that Resident #1's 1 to 1 observations were not being documented so that another facility would accept him. During a confidential interview on 11/02/2023 at 1:50 PM., it was said that Resident #1 was 1 on 1 in the day and not at night. During an interview on 11/06/2023 at 9:05 AM, the DON said that Resident #1 had a physical and mental decline since he admitted to the facility, which was not captured on the Admission MDS assessment. She said it was due to the MDS Coordinator not capturing the assessment correctly. She said that this could cause issues in capturing an accurate picture of the resident. During an interview on 11/06/2023 at 2:13 PM., the MDS Coordinator said that she was new in the position, and she started May 25, 2023. She said she requested help and training with the DON and Corporate. She said that she was not adequately trained, and she let the Admin, DON and corporate know that she did not know what she was doing. She revealed that this failure could place the residents at risk for not assessing all their care needs. A policy on Accuracy of Assessments was requested on 11/06/2023 at 3:00 PM to the DON and was not provided by the time of exit.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which included measurable objectives and time frames to meet residents' mental and psychosocial needs, for one (Resident #1) of three residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #1's physical, verbal, and sexual aggressive behaviors towards staff, visual function, risk for falls, risk for pressure ulcers, antianxiety medications, and 1:1 staffing. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met. The findings were: Record review of Resident #1's Admission record dated 11/07/2023, revealed Resident #1 was [AGE] years-old and was admitted to facility on 07/29/2023 with a diagnoses of encephalopathy (brain disease that alters brain function), Alzheimer's Disease (neurodegenerative disease that destroys memory and other important mental function), Altered Mental Status (changes in consciousness, appearance, behavior, mood, affect, motor activity or cognitive function) and Delirium (serious disturbance in mental abilities that result in confused thinking and reduced thinking and reduced awareness of surroundings). Resident was discharged to another facility on 11/07/2023. Record review of Resident #1's Admission Minimum Data Set (MDS) assessment Cognitive Patterns Section, dated 08/05/2023, revealed Resident #1 had a BIMS of 05 which indicated severe impaired cognition. Further review of the Admission MDS Care Area Assessment Summary section revealed Resident #1 was triggered to have care plan interventions for Cognitive loss/ Dementia, Visual Function, Communication, ADL Function, Behaviors, Falls, and Risk of Pressure Ulcers. Record review of Resident #1's Comprehensive Care plan, completed on 08/16/2023, revealed no evidence of care plan interventions for Cognitive loss/ Dementia, Visual Function, Communication, ADL Function, Behaviors, Falls, and Risk of Pressure Ulcers. During an interview on 11/06/2023 at 9:05 AM, the DON said that Resident #1's care plan should have captured his 1 to 1 observation, his antianxiety medications, and his behaviors when his Comprehensive Care Plan Assessment was completed. She said that she was not part of the care plan process, and her expectations were for those issues to be addressed. She said that this could cause issues in capturing an accurate picture of the resident. During an interview on 11/06/2023 at 2:13 PM., the MDS Coordinator said that she was responsible for the Comprehensive Care Plan assessments, and she was new in this position when she started May 25, 2023. She had requested help and additional training from the DON and Corporate. She said that she should have captured on the care plan that Resident #1 was receiving 1 to 1 observation, behaviors, his risk for pressure ulcers, his visual loss and his risk for falls, but she did not know that the CAAS areas should have been captured in the care plan. She said that this could cause the resident to not receive to care they need. A copy of the facilities policy and procedures titled Care Plans, Comprehensive Person- Centered was received on 11/06/2023 at 3:00 PM by the DON, revealed the following: Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residence physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The intra-disciplinary team IDT, is conjunction with the resident and his or her family or legal representative, develop and implement a comprehensive person-centered care plan for each resident. 2. The care plan interventions are derived from my thorough analysis of the gathered information as part of the comprehensive assessment. 8. The comprehensive person-centered care plan will: g. Incorporate identified the problem areas. h. incorporates risk factors associated with identified problems: k. reflects treatment goals, timetables, and objectives in measurable outcomes. m. Aid in preventing or reducing decline in the residence functional status and, or functional levels enhance the optimal functioning of the resident by focusing on rehabilitative program. 13. Assessments of residents are ongoing, and care plans a revised as information about the resident and the residence condition change 14. The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the residence condition.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for one of two residents (Resident #3) reviewed for activities of daily living. The facility failed to provide Resident #3 with assistance with ADLs as care planned. This failure placed residents at risk of not maintaining good hygiene and assistance with ADL's. Findings include: Review of Resident #3's Quarterly MDS dated [DATE] indicated the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory) and hypertension (high blood pressure). Review of the Quarterly MDS dated [DATE] revealed the Resident #3 had the following: Section C- BIMS (Brief Interview of Mental Status) score of 0, (severely cognitively impaired). Section GG- ADL's (Functional Abilities) score of 1, dependent (helper does all of the effort, resident does none of the effort). Review of Resident #3's Care plan dated 04/13/2023 indicated the resident needed extensive assistance from staff to complete all activities of daily living. Record review of Resident #3's ADL Documentation Report for July 2023 revealed no evidence of ADLs for bed mobility, dressing, locomotion on and off the unit, personal hygiene, toilet use, transferring, and bladder elimination was not completed on 07/04/2023, 07/10/2023, 07/12/2023, 07/13/2023, 07/18/2023 through 07/24/2023, and 07/27/2023. Further review of ADL documentation report revealed that on the days Resident #3 received ADL care was only once a day. Record review of Resident #3's ADL Documentation Report for August 2023 revealed no evidence of ADLs for bed mobility, dressing, locomotion on and off the unit, personal hygiene, toilet use, transferring, and bladder elimination was not completed 08/02/2023, 08/03/2023, 08/05/2023 through 08/09/2023, 08/11/2023, 08/14/2023 through 08/16/2023, 08/19/2023, 08/20/2023 through 08/23/2023, 08/25/2023, 08/26/2023, and 08/29/2023 to 08/31/2023. Further review of ADL documentation report revealed that on the days Resident #3 received ADL care was only once a day. Record review of Resident #3's ADL Documentation Report for September 2023 was requested and not provided. Record review of Resident #3's ADL Documentation Report for October 2023 revealed no evidence of ADL for bed mobility, dressing, locomotion on and off the unit, personal hygiene, toilet use, transferring, and bladder elimination was not completed 10/01/2023 through 10/31/2023. During an interview on 11/01/2023 at 2:23 PM, Resident #3's Representative said that she had complaints with Resident #3's personal care. She said that there are times Resident #3 was not changed at night and that Resident #3's sheets were dirty. She said that the facility told her that the facility was going to start limiting the residents' briefs and that of the other residents. She said that things have gotten better since she installed a camera in Resident #3's room. She revealed that Resident #3 did not answer to questions, and Resident #3 required full help with ADL's. During an observation on 11/01/2023 at 2:40 PM, Resident #3 was asleep in her bed. She did not respond to knocking or asking to come in. She did not make eye contact, but her eyes did open slightly. Her sheets were dirty with dried brown smeared marks on the left side of the resident. During an interview on 11/02/2023 at 1:50 PM, Confidential Staff stated the staffing sheet did not reflect staffing accurately because the DON would pull staff members to do other things. She said that there have been residents that have needed more care than usual. She said that staff were not completing ADL's and care areas and that she and others have notified the DON. During an interview on 11/02/2023 at 1:40 PM, the DON said that the facility did not do any showers on 11/01/2023 due to the shower nurse calling in. She said she did not know about it until today. She said that the facility was having issues with ADL's being completed and documented, especially by the night shift. She said that her reports showed that there were days where it showed 0% of ADL's were completed for that shift. She could not say for sure that it was or was not completed. She said that if it was not documented, it did not happen. She said that she was working with staff to correct these issues. She said she had been out on medical leave and things just got behind. She said this failure could cause skin issues, and other concerns. A copy of the facilities policy and procedures titled Activities of Daily Living (ADL's), dated March 2018 revealed the following: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their abilities to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1) Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL's is unavoidable. 2) Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with : a) Hygiene (bathing, dressing, grooming and oral care) b) Mobility (transfer and ambulation, including walking)

Based on observation, interview and record review, the facility failed to ensure medications were secured on 2 of 2 medication carts reviewed for pharmacy services. The facility did not ensure medications carts were secured and locked. This failure could place the residents at risk of a drug diversion. Findings included: During an observation on 11/06/2023 at 10:23 AM, LVN F left a medication cart unlocked for hall D and unattended with residents near the medication cart. She did not have visual of the medication cart and was unaware she left the medication cart unlocked. The medication cart contained over the counter medications, and prescription (non-controlled) medications. During an observation on 11/06/2023 at 2:30 PM, the ADON left a medication cart unlocked for hall A and unattended with residents walking near the medication cart. She did not have visual of the medication cart and was unaware she left the medication cart unlocked. The medication cart contained over the counter medications, and prescription medications. During an interview on 11/06/2023 at 10:30 AM, LVN F said that she walked away to go to the medication room. She said that she should have locked the medication cart before she left it unattended with residents around it. She said that this could cause a patient to get into it. During an interview on 11/06/2023 at 10:45 AM, the DON said that her expectations were for the medication carts to be locked anytime a nurse walks away from it. She said that she did training and in-service to make sure staff members knew to always lock their carts. She said that staff knew the risk involved with a medication cart that was unlocked and unattended. During an interview on 11/06/2023 at 2:30 PM, the ADON said that she walked away to go to the medication room due to a call light going off down the hall. She revealed that she is not used to working the floor and did not remember to lock it or check if it was locked before she walked off. She revealed that she was out of sight and could not visualize the medication cart. She revealed this failure could possibly put the 5 residents that were by the medication cart in danger, if one of them got ahold of the prescription medications that were in it. A policy and procedure titled Storage of Medication, dated April 1029 revealed the following: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use.

Based on observation and interview the facility failed to ensure that the daily nurse staffing was posted and readily accessible to residents and visitors as required for 1 of 2 days reviewed for nurse staffing The facility failed to update the daily staffing information posting from 10/27/2023 to 11/01/2023. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: During an observation on 11/01/2023 at 1:40 PM, the daily staffing pattern was posted on the wall by the copier room and the DON's office with a date of 10/27/2023. During an interview on 11/01/2023 at 1:45 PM, the DON stated she knew that the Nurse Staffing Posting was to be updated and posted daily. She said the nurse staffing posting had not been changed on 10/28/2023, 10/29/2023, 10/30/2023, 10/31/2023 and 11/01/2023, due to being short staffed and the person who changed it did not do it, she revealed she did not know who was responsible for it that morning, but said that she was the one responsible for making sure that it was completed after she delegated it. She further stated the failure could cause confusion on staffing and resident care issues. During an interview on 11/01/2023/23 at 2:30 PM, the Administrator stated the facility DON was responsible for the daily Nurse Staffing Posting. A copy of the facilities policy and procedure titled Posting Direct Care Daily Staffing Numbers dated September 2022 was received on 11/07/2023 at 2:00 PM, revealed the following: Policy Statement: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residence. Policy interpretation and implementation. 1) Within two hours the beginning of each shift, the number of licensed nurses (RN's LPN's and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care it will be posted in a prominent location accessible to residence and 2visitors and in a clear and readable format. 2) Directly responsible for resident care means that individuals are responsible for resident's total care or some aspect of the residence care including, but not limited to, assisting with activities of daily living (ADL's) performing gastrointestinal feeds, giving medication, supervising care given by CNA's, and performing nursing assessments to admit residents or notifying physicians of change of conditions.

Based on observation, interview and record review, the facility failed to follow the menu for all residents reviewed for food preferences. The facility failed to provide an acceptable substitute for dessert at lunch when they served whipped cream with graham cracker crumbs instead of the scheduled Key Lime pie. This failure could place residents at risk of feeling that their preferences are not being met. Findings include: Observation on 05/22/2023 at 12:00 PM revealed residents, sitting in the dining room, were served small, clear plastic bowls filled with whipped cream, sprinkled with graham cracker crumbs. Observation on 05/22/2023 at 12:02 PM revealed food trays for residents, dining in their rooms, contained bowls that appeared to be whipped cream covered with graham cracker crumbs. Observation on 05/22/2023 at 12:05 PM revealed the daily posted menu listed Key Lime pie as the dessert for the day. Observation on 05/22/2023 at 12:15 PM revealed a test tray which contained a bowl of whipped cream sprinkled with graham cracker crumbs. The dessert was sampled and was not flavored in any way. In interview on 05/22/2023 at 12:04 PM, with Residents #41 and #20, sitting in the dining room, revealed the facility never served Key Lime pie and just put whipped cream flavored with lime juice in a bowl and called it dessert. In an interview on 05/22/2023 at 12:09 PM, the DM said they did not make or buy Key Lime pie for the residents and she forgot to buy lime juice to add to the whipped cream. She said they did not make a substitute for the residents. The substitute that day was pudding. Record review of the facility policy titled Substitutions, Administrative Policies, 2001 MED-PASS, Inc (Revised March 2004) revealed the following: Policy Statement Food substitution will be made as appropriate or necessary. Policy Interpretation and Implementation 1. The food services manager, in conjunction with the clinical dietician, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when necessary. 2. The food services manager will maintain an exchange list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietician prior to making the substitution. 3. Residents' likes and dislikes will be considered when making substitutions. 4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution. 5. The food services manager will review the substitutions regularly to avoid recurrences when possible.

Based on observation, interview and record review the facility failed to promptly notify the ordering physician of laboratory results that fell outside of the clinical reference ranges, in accordance with facility policy and procedures for notification for 2 (resident #1 and 2) of 3 residents reviewed for therapeutic drug levels. The facility failed to: a. notify resident # 1's ordering physician D of the low [MEDICATION NAME] (medication used for the treatment and prevention of [MEDICAL CONDITION]) level results dated 4/16/2018. Resident # 1 required hospitalization for [MEDICAL CONDITION] activity on 5/06/2018 and b. notify resident # 2's physician of the low [MEDICATION NAME] level results dated 5/22/2018 placing resident # 2 at an increased risk of [MEDICAL CONDITION]. This failure by the facility affected the 2 residents who were taking [MEDICATION NAME]. The findings included: Resident # 1: Record review of the face sheet dated 5/01/2018 documented resident # 1 a [AGE] year old male admitted on [DATE]. Resident # 1 [DIAGNOSES REDACTED]. Record review of the physicians orders dated (MONTH) (YEAR) documented an order for [REDACTED].> - [MEDICATION NAME] 100 mg ER (extended release) 3 caps given by mouth at bedtime daily - [MEDICATION NAME] 100 mg ER 1 capsule given by mouth daily at 12 noon. - An order to ensure patient swallows all meds. - See Doctor E for neurology - [MEDICATION NAME] level monthly Record review of the [MEDICATION NAME] level dated 4/16/2018 documented a level of 7.3 with a therapeutic reference range of 10.0 - 20.0. At the bottom of the results page it was documented as 'Noted 4/16/18 LVN B'. The current [MEDICATION NAME] dosage was written in the middle of the page, it did not identify who wrote the current dose. Undated initials were also written at the bottom of the page. Record review of the [MEDICATION NAME] level dated 5/14/2018 documented a level of 6.5. The lab test had a stamp on it that read 'FAXED' and 5/14 was written in the box. The page had undated initials on it. Record review of the nurses notes for resident # 1 dated for the months of (MONTH) (YEAR) and (MONTH) (YEAR) did not identify any notes related to to the [MEDICATION NAME] levels. Notes dated 5/06/2018 at 9:36 PM documented resident # 1 was transferred to the hospital for decreased level of consciousness. Record review of the hospital record documented: A: History and Physical dated 5/06/2018 documented resident # 1 was brought to the hospital on [DATE] at 2207 (10:07PM) with complaint of acute - on - chronic [MEDICAL CONDITION] secondary to medical noncompliance. Resident # 1 did see a neurologist - Physician E. The family was documented to report possible increased [MEDICAL CONDITION], having one earlier that day prior to being transferred to the ER. Resident # 1 was in the CT (computed tomography) scan room and had a [MEDICAL CONDITION], he was then admitted to the ICU unit. A loading dose of [MEDICATION NAME] was administered in the ER. Resident # 1's [MEDICATION NAME] level was documented to be low, 7.1 on admission. Resident # 1 was placed in 4 point restraints due to the thrashing about and agitation. B: General notes dated 5/06/2018 at 2041 (8:41 PM) a [AGE] year old male presented to the ER by EMS (ambulance) status [REDACTED]. Patient has history of [MEDICAL CONDITION]. EMS reported they were called to the facility for resident # 1 who had a [MEDICAL CONDITION] and was unresponsive when they arrived. Resident # 1 was documented to now be responsive and said he thought he had a [MEDICAL CONDITION]. Record review of the hospital discharge orders dated 5/11/2018 documented resident # 1 was discharged back to the facility on [DATE] on Hospice care. Observation and interview on 5/24/2018 at 2:03 PM resident # 1 was lying in his bed, he was awake, alert and oriented to time, person, and place. He said he made his own decisions, he did refuse baths and his Mom was to be contacted about his care needs. He said he did not remember much about before going to he hospital, he had had a [MEDICAL CONDITION]. Interview on 5/25/2018 at 12:05 PM CMA C said she gives resident # 1 his medications most of the time and resident # 1 did not refused his medications to her knowledge. Interview on 5/25/2018 at 1:27 PM LVN B said labs were put in the RNP's book. The RNP usually comes through once a week and signs (initials) the labs then. If feels a lab needs to be better addressed it is left in the book. The lab results for resident # 1 fell through the cracks. Interview on 5/25/2018 at 2:12 PM the ADON said she was not aware of resident # 1 refusing his medications. Resident # 1's labs were to be sent to his neurologist - Physician E. Resident # 2: Record review of the face sheet dated 5/29/2018 documented resident # 2 as an [AGE] year old admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the physicians order dated (MONTH) (YEAR) documented resident # 2 had an order for [REDACTED]. Record review of the lab values for resident # 2 documented on 5/22/2018 a [MEDICATION NAME] (generic for [MEDICATION NAME]) level of 3.7 with the same reference range of 10.0 - 20.0 as normal therapeutic range. At the bottom of the page was written 'FAXED 5/22/18'. There was no other documentation on the page. Observation and interview on 5/24/218 at 3:40 PM resident # 2 was in bed, did not respond to attempt to wake resident. Record review of the nurse notes for resident # 2 for the months on (MONTH) and (MONTH) 218 did not document any [MEDICAL CONDITION] activity. The notes did not reveal any documentation of the [MEDICATION NAME] level or attempts to notify the physician of the low levels. Record review of the facility (undated) Lab/Diagnostic Test Policy a Diagnostic Test Tracking Form was to be kept in the Nurses MAR binder. When results were received they were to be documented on the form as abnormal or not. Abnormal values were to be communicated to the physician by a telephone call, not faxed. If the physician does not return the call that shift the following shift is to continue to try to communicate with the physician. The needed communication is to be documented on the 24 hour report and all attempts to communicate with the physician are to be documented in the Nurses notes. If the physician does not respond in a timely manner the DON is to be made aware. Interview on 5/25/2018 at 3:43 PM the ADON said she was putting a call into resident # 2's physician about the [MEDICATION NAME] level and would report to the nurses to ensure it was followed up on. The ADON said there were 2 residents taking [MEDICATION NAME], resident # 1 and 2.

Based on observation, interview, and record review, the facility failed to ensure 2 (CNA " A " and CMA " B " ) of 4 CNAs observed demonstrated competency in techniques to care for 1 of 6 residents reviewed for proficiency of staff assistance with transfers and neglect. (Resident # 1) CNA " A " and CMA " B " did not use a Hoyer lift to transfer Resident # 1 on 3/09/12 and had to sit resident # 1 in floor. The staff did not report the incident to the charge nurse. Resident # 1 was found to have a fracture of her left leg later that day. This failure could place 10 residents who required transfers using the Hoyer lift at risk of injury. Findings included: Record review of the face sheet for resident # 1 revealed she was a [AGE] year old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. During an observation on 3/23/12 at 7:06 a.m. student nurses were assisting resident # 1 with her bed bath. Resident # 1 was wearing a leg brace on her left leg; her left foot was rotated inward at the ankle. Resident # 1 had a Hoyer lift sign posted by her bed. Clinical record review for resident # 1 revealed a careplan dated 9/06/11 documented resident # 1 ' s potential for injury and interventions of: - Handle gently due to fragile bones, - Use extreme caution when turning resident, using log roll when possible, - Notify physician immediately for possible injury/fracture. Resident # 1 ' s careplan also documented she required assistance with all her ADL ' s including transfers using the Hoyer lift and 2 person assistance. In an interview on 3/23/12 at 8:12 a.m. CNA " E " said each resident had a sign in the room showing what type of transfer each resident required. Resident # 1 required the use of a Hoyer lift. Training was done during orientation about resident transfers and the staff knew what type of lift to use. Staff was to report incidents to the nurse immediately. During an interview on 3/23/12 at 8:16 a.m. CNA " G " said the facility trained staff about transfers, there were signs in each room to identify the type of transfer each resident required and a sign posted in the closet shown the type of care each resident required. Incidents were to be reported to the nurse immediately. During an interview on 3/23/12 at 8:48 a.m. resident # 1 said her leg hurt, she did fall in the shower, the staff was there and they did not use the lift. During an interview on 3/23/12 at 9:10 a.m. CNA " G " said resident # 1 had become a Hoyer lift resident 6 to 9 months ago because she was too stiff and heavy to lift anymore. Signs in room document care needs, are kept updated by nurse and are accurate. During an interview on 3/23/12 at 9:12 a.m. CNA " E " said residents had careplan signs posted in their closets that gave instructions on the care each resident required, the signs also documented the type of lift required for them. Signs were updated routinely and accurate. CNA " E " then pointed out the careplan sign posted inside resident # 1 ' s closet. Observation of resident # 1 ' s careplan inside her closet documented the use of the Hoyer lift at all times. During an interview on 3/23/12 at 10:00 a.m., the DON said on 3/08/12 a staff had reported some staff was not using the Hoyer lift when they were supposed to. The facility started training immediately. CNA " A " had done the inservice training on 3/08/12, the day before the incident occurred. During an interview on 3/23/12 at 10:00 a.m. LVN " F " said the staff did not report the incident to her until later in the day on 3/09/12, when resident # 1 was complaining of left leg pain; LVN " F " then provided a written statement. The incident occurred around 6:30 a.m. and the staff did not report it until about 12:30 p.m. Record review of LVN " F ' s " written statement dated 3/23/12 revealed on 3/09/12 at approximately 12:30 p.m. CNA " C " came to find her stating CNA "C" and CNA " D " were putting resident # 1 in bed and resident # 1 had yelled in pain more than usual. LVN " F " wrote she went to check resident # 1 and found her left lower leg swollen and beginning to be discolored. LVN " F " wrote she then asked CNA " C " and CNA " D " what happened. The CNA ' s then told her resident # 1 had been transferred from the shower chair to wheelchair without using the Hoyer lift at about 6:00 a.m. and had become too heavy for CNA " A " and CMA " B " to transfer; they had sat resident # 1 on the floor, CNA "C " and CMA " D " had entered the shower room and helped assist with getting resident # 1 off the floor. In a telephone interview on 2/23/12 at 10:38 a.m. CNA " A " said she and CMA " B " did get resident # 1 up for her shower without using the Hoyer lift, resident # 1 became too heavy for them to lift and they had to sit her on the floor and call for help. Two other staff came, helped get resident # 1 up. CNA " A " said she did not report the incident to the charge nurse, resident # 1 did not appear hurt. CNA " A " said she did not know why they did not use the Hoyer lift; they both knew resident # 1 required the lift. CNA " A " said she had been trained by the facility on when to use the Hoyer lift. A message was left for CMA " B " to return a call on 3/23/12, no return call was received. During a telephone interview on 3/23/12 at 11:20 a.m. CNA " C " said CNA " A " and CMA " B " had sat resident # 1 in the floor in the shower, they had transferred her without using the Hoyer lift and she had been too heavy for them to lift and transfer. CNA " C " said she and CNA " D " then helped lift resident # 1 to the chair. Resident # 1had complained of pain at the time. CNA " A " then took resident # 1 out to the hall. When resident # 1 was continuing to complain of pain about 11:30 a.m. CNA " C " said she got the nurse to look at resident # 1 and told the nurse what had happened that morning. Record review of the facility inservice training dated 3/08/12 documented inservice training that stated all residents identified to require the lift were to have it used at shower times also; CNA " A " and CMA " B " had signed the inservice sheet on 3/8/12. Record review of the employee file for CNA " A " revealed CNA " A " had originally been trained for transfers, including the Hoyer lift on 7/12/11. Record review of the employee file for CMA " B " revealed CMA " B " had originally been trained for transfers, including the Hoyer lift on 1/19/12. The CMS 672 dated 3/23/12 indicated 27 residents were totally dependent on staff for transfers. The DON provided a list of 10 residents requiring the Hoyer lift for transfers.

Based on observation, interview, and record review, the facility failed to prohibit neglect of 1 of 4 sampled residents (ID #1) who was on fall precautions and utilized a bed and chair alarm. The facility failed to ensure: A. CNA "I" and LVN "J" checked resident ID #1's bed alarm, in accordance with physician orders, to ensure it was functioning properly on 08/31/2011. Resident ID #1 fell on [DATE] in his room, while attempting to ambulate to the restroom unassisted, sustaining a left [MEDICAL CONDITION], and was sent to the local hospital. Resident ID #1 was admitted to the hospital for medical stabilization on 08/31/2011 and returned to the facility with a decline in functional ability, in which he was no longer able to get out of bed, on 09/04/2011. The facility's failure to check resident bed alarms to ensure they are functioning properly could affect any of the 18 residents with bed alarms by increasing their risk of injury from falling, resulting in a physical and psychosocial decline in health. The findings included: Resident ID #1 A record review of resident ID #1's Face Sheet, dated 10/27/2010, documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of resident ID #1's quarterly MDS Assessment, dated 06/10/2011, documented the following: he had a cognitive score of 04/15, indicative of severe cognitive impairment; he required extensive assistance of one person for bed mobility, transfer, dressing, personal hygiene, and bathing; he required limited assistance of one person for locomotion on the unit and utilized a wheelchair; he had no impairment in functional range of motion. A record review of resident ID #1's August 2011 Physician order [REDACTED]. A record review of resident ID #1's August 2011 TAR revealed the nurses had been initialing daily on each shift for the "bed alarm to bed at all times" order, except for the 2PM-10PM shift on 08/12/2011. A record review of resident ID #1's August 2011 CNA Flowsheet revealed the CNAs had been initialing daily on each shift for the "bed alarm to bed at all times" order, except for the 2PM-10PM shift on 08/29/2011. A record review of resident ID #1's Fall Risk scoring sheet, dated 08/25/2011, 08/31/2011, and 09/04/2011, documented he was a high fall risk. A record review of the facility's Incident Report Log for August 2011 documented resident ID #1 had fallen on 08/25/2011 and 08/31/2011. A record review of resident ID #1's Comprehensive Plan of Care, dated 08/26/2011, documented he was at risk for falls, would have a chair and bed alarm to remind him to ask for assistance with ambulating and a call light in reach and answered promptly. A record review of resident ID #1's Incident/Accident Report, dated 08/31/2011, documented he was lying on his bathroom floor on his left side and was sent to the local emergency room via ambulance. A record review of resident ID #1's Investigation Follow-Up, dated 08/31/2011, documented resident ID #1 complained of left side hip pain, his bed alarm did not go off, and he was admitted to the hospital with [REDACTED]. A record review of resident ID #1's hospital Patient's Progress Notes, dated 09/01/2011 through 09/04/2011, documented risks associated with surgery were explained to resident ID #1's responsible party, who declined surgical repair of resident ID #1's left [MEDICAL CONDITION], and resident ID #1 was discharged back to the nursing facility. A record review of resident ID #1's Resident Summary for Re-admission, dated 09/04/2011, documented he was admitted back to the facility with a left [MEDICAL CONDITION], was non-weight bearing to his left lower extremity, and could be up to the geri-chair only. A record review of resident ID #1's Physician's Telephone Orders documented the following: 09/07/2011- "D/C (discontinue) getting up in geri chair;" 09/07/2011- "Pt (patient) will remain in bed. Do not get OOB (out of bed);" 09/08/2011- "Resident will remain on falling star program related to fall precautions;" 09/08/2011- "Resident is to have bed alarm checked q (every) shift by nurse d/t (due to) fall precautions." A record review of resident ID #1's September 2011 MAR/TAR revealed his bed alarm checks every shift were not documented by the nurses. A record review of resident ID #1's Skilled Daily Nurses Note, dated 09/08/2011 through 09/22/2011, revealed resident ID #1's bed alarm was not documented each shift. A record review of resident ID #1's CNA Flowsheet for September 2011 revealed the CNAs did not initial for the "bed alarm at all times order" on the 10PM-6AM shift on 09/18/2011 or the 2PM-10PM shift on 09/19/2011 and 09/21/2011. A record review of resident ID #1's significant change MDS Assessment, dated 09/13/2011, documented the following: he had a cognitive summary score of 03/15, indicative of a severe cognitive deficit; he was totally dependent upon two or more persons for bed mobility and dressing; he was totally dependent upon one person for personal hygiene and bathing; transfer and locomotion on unit did not occur; he had impaired functional limitation in range of motion of both lower extremities. In an interview on 09/22/2011 at 11:00 PM, LVN "A" stated the facility recently in-serviced her to check bed alarms to make sure they were plugged in and working. She stated residents with alarms should be checked on every two hours. In an interview on 09/22/2011 at 11:02 PM, LVN "B" stated the facility had an in-service for bed alarms about a week ago. She stated the alarms were supposed to be kept plugged in, and residents with alarms should be checked every hour. In an interview on 09/22/2011 at 11:05 PM, CNA "C" stated she assisted CNA "I" get resident ID #1 off the floor. She stated resident ID #1 was assisted to bed, then the charge nurse took over. CNA "C" stated resident ID #1's bed alarm was unplugged. She stated the facility in-serviced her to check bed alarms, making sure they were plugged in and working, after the incident. In an interview on 09/22/2011 at 11:20 PM, LVN "D" stated bed alarms were supposed to be checked to make sure they were working and documented on the TAR. She stated the facility recently in-serviced staff to make sure the alarms were intact and working for each resident. In an interview on 09/22/2011 at 11:25 PM, the ADON stated the nurses and CNAs were to check residents' bed alarms every shift and document on the TAR or CNA Flowsheet. She stated resident ID #1 had an order for [REDACTED]. The ADON then stated the nurses were documenting the bed alarm checks for resident ID #1 in the nurse notes. In an interview on 09/22/2011 at 11:40 PM, CNA "E" stated if a bed alarm was not working, she would report to her nurse. She stated she only worked weekends, and she had not received any in-servicing from the facility regarding bed alarms or fall prevention. A record review of the facility's In-Service Training Report, dated 09/12/2011, documented the following staff were trained to check chair alarms and bed alarms frequently, every time they entered or left a residents room. The report revealed CNA "E" did not attend. In an interview on 09/23/2011 at 10:45 PM, CNA "I" stated resident ID #1 had been getting up a lot the night he fell . She stated she always encouraged him to use the call-light. CNA "I" stated resident ID #1's bed alarm had been unplugged the prior three nights, and she plugged it back in. She stated resident ID #1 did not use his call-light when he fell , and she had forgotten to check to bed alarm that night. She stated she found him lying on the floor just outside his restroom door and called the charge nurse. CNA "I" stated the facility recently in-serviced her to check all bed alarms every shift and document in the flow sheets. In an interview on 09/23/2011 at 12:30 PM, LVN "G" stated the facility recently in-serviced her to check bed alarms every shift. She stated nurses were supposed to document the checks on the TAR. She stated she had been checking resident ID #1's bed alarm every shift, because she knew he had an order to check it. LVN "G" stated she did not know if resident ID #1's bed alarm order was on the TAR. In an interview on 09/23/2011 at 12:32 PM, CNA "F" stated she received an in-service two weeks ago to make sure residents' bed alarms were plugged in and working correctly. In an interview on 09/23/2011 at 12:50 PM, CNA "H" stated she was recently in-serviced to keep bed alarms on and plugged in. She stated they should be checked every shift and all during the day. She stated there was not anywhere to document the bed alarm checks. In an interview on 09/26/2011 at 11:10 AM, LVN "J" stated she was notified just after midnight on 08/31/2011 by CNA "I" that resident ID #1 had fallen. She stated resident ID #1 had a bed alarm, but it didn't go off. LVN "J" stated resident ID #1 complained of hip pain after he was assisted up from the floor. She stated she realized resident ID #1's bed alarm was not plugged in when she began to put a new alarm on his bed. LVN "J" stated resident ID #1 tried to get up frequently. She stated he did not have an order to check his bed alarm every shift, and she had not been trained or in-serviced by the facility regarding the need to check bed alarms prior to the incident. She stated the in-services only covered answering and responding to bed alarms. In an interview on 09/26/2011 at 12:42 PM, CNA "K" stated bed alarms should be checked every time someone gets a resident up or assists a resident to bed. She stated she was in-serviced by the facility to check bed alarms two weeks ago. In an interview on 09/26/2011 at 1:05 PM, CNA "M" stated bed alarms were supposed to be checked at the beginning, middle, and end of every shift to make sure they were working properly and documented on the CNA flow sheet. In an interview on 09/26/2011 at 1:55 PM, LVN "N" stated the facility provided an in-service two weeks ago for staff to check bed alarms every time they were in a resident's room. She stated sometimes residents would unplug their alarms. LVN "N" stated bed alarms were supposed to be documented on the MAR. In an interview on 09/26/2011 at 12:53 PM, the ADON stated there were no additional in-service or training records for the surveyor to review. In an observation on 09/26/2011 at 12:24 PM, during facility rounds on F hall, a bed alarm was sounding. At 12:28 PM, the surveyor was able to hear the alarm at the end of the hall. At 12:31 PM, the alarm was still sounding, and the surveyor was able to hear the alarm from the nurses' station, where two facility staff were observed sitting at the desk. At 12:34 PM (ten minutes later), CNA "M" went down the hall and responded to the bed alarm. In an interview on 09/26/2011 at 1:05 PM, CNA "M" stated when a bed alarm is sounding, staff should respond immediately. In an interview on 09/26/2011 at 12:42 PM, CNA "K" stated someone should respond to a bed alarm immediately. In an interview on 09/26/2011 at 1:55 PM, LVN "N" stated she was able to hear residents' bed alarms from the nurses' station. She stated someone should respond immediately if an alarm was sounding. LVN "N" stated the CNAs on her hall would let her know if they were going to be "tied up." In an interview on 09/26/2011 at 1:53 PM, the ADON stated someone should respond to a sounding bed alarm within one to two minutes. In an interview on 09/26/2011 at 1:53 PM, the DON stated staff should respond to a sounding bed alarm within five minutes or less. In an interview on 09/26/2011 at 2:00 PM, the DON stated the facility regularly covers the topic of keeping resident call-lights in reach and answering lights and alarms in at timely manner during the monthly in-services. A record review of the facility's Incidents and Accidents Prevention System Fall Prevention Program, revised 05/2010, documented the following: (in part) "All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of the assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. For each resident with a fall, assure that the following are done: review resident for call light within reach; bed maintained in lowest position." A record review of the facility's Abuse Program, revised 05/2010, documented the following: (in part) "Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. The facility will prohibit neglect, mental or physical abuse, including voluntary seclusion and the misappropriation of property or finances of residents. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." A record review of the facility's Physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance was provided to 2 of 4 sampled residents (ID #1 and #2) who were on fall precautions and utilized a bed and chair alarm. The facility failed to ensure: A. CNA "I" and LVN "J" checked resident ID #1's bed alarm, in accordance with physician orders, to ensure it was functioning properly on 08/31/2011. Resident ID #1 fell on [DATE] in his room, while attempting to ambulate to the restroom unassisted, sustaining a left hip fracture, and was sent to the local hospital. Resident ID #1 was admitted to the hospital for medical stabilization on 08/31/2011 and returned to the facility with a decline in functional ability on 09/04/2011. B. Resident ID #2's call light was in reach when he was sitting up on the bedside unattended. The facility's failure to check resident bed alarms to ensure they were functioning properly and leave call-lights in residents' reach could affect any of the 18 residents with bed alarms by increasing their risk of injury from falling, resulting in a physical and psychosocial decline in health. The findings included: Resident ID #1 A record review of resident ID #1's Face Sheet, dated 10/27/2010, documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of resident ID #1's quarterly MDS Assessment, dated 06/10/2011, documented the following: he had a cognitive score of 04/15, indicative of severe cognitive impairment; he required extensive assistance of one person for bed mobility, transfer, dressing, personal hygiene, and bathing; he required limited assistance of one person for locomotion on the unit and utilized a wheelchair; he had no impairment in functional range of motion. A record review of resident ID #1's August 2011 Physician order [REDACTED]. A record review of resident ID #1's August 2011 TAR revealed the nurses had been initialing daily on each shift for the "bed alarm to bed at all times" order, except for the 2PM-10PM shift on 08/12/2011. A record review of resident ID #1's August 2011 CNA Flowsheet revealed the CNAs had been initialing daily on each shift for the "bed alarm to bed at all times" order, except for the 2PM-10PM shift on 08/29/2011. A record review of resident ID #1's Fall Risk scoring sheet, dated 08/25/2011, 08/31/2011, and 09/04/2011, documented he was a high fall risk. A record review of the facility's Incident Report Log for August 2011 documented resident ID #1 had fallen on 08/25/2011 and 08/31/2011. A record review of resident ID #1's Comprehensive Plan of Care, dated 08/26/2011, documented he was at risk for falls, would have a chair and bed alarm to remind him to ask for assistance with ambulating and a call light in reach and answered promptly. A record review of resident ID #1's Incident/Accident Report, dated 08/31/2011, documented he was lying on his bathroom floor on his left side and was sent to the local emergency room via ambulance. A record review of resident ID #1's Investigation Follow-Up, dated 08/31/2011, documented resident ID #1 complained of left side hip pain, his bed alarm did not go off, and he was admitted to the hospital with [REDACTED]. A record review of resident ID #1's hospital Patient's Progress Notes, dated 09/01/2011 through 09/04/2011, documented risks associated with surgery were explained to resident ID #1's responsible party, who declined surgical repair of resident ID #1's left hip fracture, and resident ID #1 was discharged back to the nursing facility. A record review of resident ID #1's Resident Summary for Re-admission, dated 09/04/2011, documented he was admitted back to the facility with a left hip fracture, was non-weight bearing to his left lower extremity, and could be up to the geri-chair only. A record review of resident ID #1's Physician's Telephone Orders documented the following: 09/07/2011- "D/C (discontinue) getting up in geri chair;" 09/07/2011- "Pt (patient) will remain in bed. Do not get OOB (out of bed);" 09/08/2011- "Resident will remain on falling star program related to fall precautions;" 09/08/2011- "Resident is to have bed alarm checked q (every) shift by nurse d/t (due to) fall precautions." A record review of resident ID #1's September 2011 MAR/TAR revealed his bed alarm checks every shift were not documented by the nurses. A record review of resident ID #1's Skilled Daily Nurses Note, dated 09/08/2011 through 09/22/2011, revealed resident ID #1's bed alarm was not documented each shift. A record review of resident ID #1's CNA Flowsheet for September 2011 revealed the CNAs did not initial for the "bed alarm at all times order" on the 10PM-6AM shift on 09/18/2011 or the 2PM-10PM shift on 09/19/2011 and 09/21/2011. A record review of resident ID #1's significant change MDS Assessment, dated 09/13/2011, documented the following: he had a cognitive summary score of 03/15, indicative of a severe cognitive deficit; he was totally dependent upon two or more persons for bed mobility and dressing; he was totally dependent upon one person for personal hygiene and bathing; transfer and locomotion on unit did not occur; he had impaired functional limitation in range of motion of both lower extremities. In an interview on 09/22/2011 at 11:00 PM, LVN "A" stated the facility recently in-serviced her to check bed alarms to make sure they were plugged in and working. She stated residents with alarms should be checked on every two hours. In an interview on 09/22/2011 at 11:02 PM, LVN "B" stated the facility had an in-service for bed alarms about a week ago. She stated the alarms were supposed to be kept plugged in, and residents with alarms should be checked every hour. In an interview on 09/22/2011 at 11:05 PM, CNA "C" stated she assisted CNA "I" get resident ID #1 off the floor. She stated resident ID #1 was assisted to bed, then the charge nurse took over. CNA "C" stated resident ID #1's bed alarm was unplugged. She stated the facility in-serviced her to check bed alarms, making sure they were plugged in and working, after the incident. In an interview on 09/22/2011 at 11:20 PM, LVN "D" stated bed alarms were supposed to be checked to make sure they were working and documented on the TAR. She stated the facility recently in-serviced staff to make sure the alarms were intact and working for each resident. In an interview on 09/22/2011 at 11:25 PM, the ADON stated the nurses and CNAs were to check residents' bed alarms every shift and document on the TAR or CNA Flowsheet. She stated resident ID #1 had an order for [REDACTED]. The ADON then stated the nurses were documenting the bed alarm checks for resident ID #1 in the nurse notes. In an interview on 09/22/2011 at 11:40 PM, CNA "E" stated if a bed alarm was not working, she would report to her nurse. She stated she only worked weekends, and she had not received any in-servicing from the facility regarding bed alarms or fall prevention. A record review of the facility's In-Service Training Report, dated 09/12/2011, documented the following staff were trained to check chair alarms and bed alarms frequently, every time they entered or left a residents room. The report revealed CNA "E" did not attend. In an interview on 09/23/2011 at 10:45 PM, CNA "I" stated resident ID #1 had been getting up a lot the night he fell . She stated she always encouraged him to use the call-light. CNA "I" stated resident ID #1's bed alarm had been unplugged the prior three nights, and she plugged it back in. She stated resident ID #1 did not use his call-light when he fell , and she had forgotten to check to bed alarm that night. She stated she found him lying on the floor just outside his restroom door and called the charge nurse. CNA "I" stated the facility recently in-serviced her to check all bed alarms every shift and document in the flow sheets. In an interview on 09/23/2011 at 12:30 PM, LVN "G" stated the facility recently in-serviced her to check bed alarms every shift. She stated nurses were supposed to document the checks on the TAR. She stated she had been checking resident ID #1's bed alarm every shift, because she knew he had an order to check it. LVN "G" stated she did not know if resident ID #1's bed alarm order was on the TAR. In an interview on 09/23/2011 at 12:32 PM, CNA "F" stated she received an in-service two weeks ago to make sure residents' bed alarms were plugged in and working correctly. In an interview on 09/23/2011 at 12:50 PM, CNA "H" stated she was recently in-serviced to keep bed alarms on and plugged in. She stated they should be checked every shift and all during the day. She stated there was not anywhere to document the bed alarm checks. In an interview on 09/26/2011 at 11:10 AM, LVN "J" stated she was notified just after midnight on 08/31/2011 by CNA "I" that resident ID #1 had fallen. She stated resident ID #1 had a bed alarm, but it didn't go off. LVN "J" stated resident ID #1 complained of hip pain after he was assisted up from the floor. She stated she realized resident ID #1's bed alarm was not plugged in when she began to put a new alarm on his bed. LVN "J" stated resident ID #1 tried to get up frequently. She stated he did not have an order to check his bed alarm every shift, and she had not been trained or in-serviced by the facility regarding the need to check bed alarms prior to the incident. She stated the in-services only covered answering and responding to bed alarms. In an interview on 09/26/2011 at 12:42 PM, CNA "K" stated bed alarms should be checked every time someone gets a resident up or assists a resident to bed. She stated she was in-serviced by the facility to check bed alarms two weeks ago. In an interview on 09/26/2011 at 1:05 PM, CNA "M" stated bed alarms were supposed to be checked at the beginning, middle, and end of every shift to make sure they were working properly and documented on the CNA flow sheet. In an interview on 09/26/2011 at 1:55 PM, LVN "N" stated the facility provided an in-service two weeks ago for staff to check bed alarms every time they were in a resident's room. She stated sometimes residents would unplug their alarms. LVN "N" stated bed alarms were supposed to be documented on the MAR. In an interview on 09/26/2011 at 12:53 PM, the ADON stated there were no additional in-service or training records for the surveyor to review. In an observation on 09/26/2011 at 12:24 PM, during facility rounds on F hall, a bed alarm was sounding. At 12:28 PM, the surveyor was able to hear the alarm at the end of the hall. At 12:31 PM, the alarm was still sounding, and the surveyor was able to hear the alarm from the nurses' station, where two facility staff were observed sitting at the desk. At 12:34 PM (ten minutes later), CNA "M" went down the hall and responded to the bed alarm. In an interview on 09/26/2011 at 1:05 PM, CNA "M" stated when a bed alarm is sounding, staff should respond immediately. In an interview on 09/26/2011 at 12:42 PM, CNA "K" stated someone should respond to a bed alarm immediately. In an interview on 09/26/2011 at 1:55 PM, LVN "N" stated she was able to hear residents' bed alarms from the nurses' station. She stated someone should respond immediately if an alarm was sounding. LVN "N" stated the CNAs on her hall would let her know if they were going to be "tied up." In an interview on 09/26/2011 at 1:53 PM, the ADON stated someone should respond to a sounding bed alarm within one to two minutes. In an interview on 09/26/2011 at 1:53 PM, the DON stated staff should respond to a sounding bed alarm within five minutes or less. Resident ID #2 A record review of resident ID #2's September 2011 TAR documented he was an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A record review of the facility's August 2011 Incident Report Log documented resident ID #2 fell on [DATE] trying to transfer himself, 08/16/2011 trying to transfer himself, and 08/19/2011 with confusion and an unsteady gait. A record review of resident ID #2's Fall Risk scoring sheet, dated 08/16/2011, documented he was a high fall risk. A record review of resident ID #2's Incident/Accident Report, dated 08/16/2011, documented he fell in his restroom trying to get off the toilet without assistance, and he was disoriented. A record review of resident ID #2's September 2011 TAR revealed the following order, dated 08/17/2011: "tab alarm to wc (wheelchair) when in usage." A record review of resident ID #2's Incident/Accident Report, dated 09/04/2011, documented he was found on the floor across the hall from his room and was confused. A record review of resident ID #2's Investigation Follow-up, dated 09/04/2011, documented he had a chair and bed alarm in place. A record review of resident ID #2's September 2011 TAR documented the following order, dated 09/13/2011: "May have hi/low bed with bedside mat d/t (due to) falls." In an interview on 09/22/2011 at 11:40 PM, CNA "E" stated residents on fall precautions should be reminded often to use the call-light for assistance. In an interview on 09/23/2011 at 12:32 PM, CNA "F" stated resident ID #2 would often take his bed alarm off, and he needed to be checked more frequently and reminded to use his call-light for assistance. In an interview on 09/23/2011 at 12:30 PM, LVN "G" stated resident ID #2 tried to get out of bed unassisted all the time and had to be reminded often to use the call-light. In an observation on 09/26/2011 at 12:43 PM, resident ID #2 was sitting up on the bedside eating. His bed was raised approximately three feet, as he was sitting up with his feet flat on the floor. He was sitting on the bed alarm, and he was looking for his call-light. Resident ID #2 told the surveyor he needed his call-light to ask for water, and he continued looking on his bedside table and bed for the call-light. At 12:50 PM (seven minutes later), CNA "L" entered resident ID #2's room. After the surveyor told her resident ID #2 could not find his call-light, CNA "L" began looking for resident ID #2's call-light . CNA "L" had to move the bed and pull the mattress away from the wall to retrieve the call-light. CNA "L" then gave the call-light to resident ID #2. In an interview on 09/26/2011 at 12:51 PM, CNA "L" stated she had just changed resident ID #2's brief, because he was soiled. She stated she had taken his dirty linens off the bed, and she was coming right back to put new linens on resident ID #2's bed as soon as he finished eating. In an interview on 09/26/2011 at 2:00 PM, the DON stated the facility regularly covers the topic of keeping resident call-lights in reach and answering lights and alarms in at timely manner during the monthly in-services. A record review of the facility's Incidents and Accidents Prevention System Fall Prevention Program, revised 05/2010, documented the following: (in part) "All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of the assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. For each resident with a fall, assure that the following are done: review resident for call light within reach; bed maintained in lowest position." A record review of the facility's Physician order [REDACTED].