Every finding on record at Oak Park Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure residents had the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's legal guardian was informed in advance and consented to a one-time dose of an antipsychotic medication administered by injection to Resident #1 on 7/17/2026. This failure could lead to residents receiving treatment without informed consent and infringement of residents' rights. Findings included:Record review of Resident #1's admission Record dated 8/04/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia in other diseases classified elsewhere, severe, with agitation [decline in mental ability with aggressive or other negative behaviors]. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #1 exhibited physical behavioral symptoms towards others on 4 to 6 days of the assessment period. Record review of Resident #1's Order Summary Report dated 8/04/2026 reflected an order dated 7/17/2026 that read as follows: Haloperidol Lactate Injection Solution 5 MG/ML(Haloperidol Lactate) Inject 1 dose intramuscularly [into the muscle] one time only for physical aggression related to GENERALIZED ANXIETY DISORDER [feelings of excessive worry that interfere with daily life] .; UNSPECIFIED DEMENTIA, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY [sic] . for 1 dayRecord review of Resident #1's July 2026 MAR dated 8/04/2026 reflected Resident #1 was administered 5mg IM of Haloperidol by LVN A on 7/17/2026 at 6:15 AM. Record review of Resident #1's medical records did not reveal a signed consent for 5mg haloperidol injection administered on 7/17/2026 at 6:15 AM. In an interview with Resident #1's legal guardian on 8/05/2026 at 11:24 AM, she said she was notified Resident #1 received the injection of Haloperidol after it was administered. She said the nurse contacted her to notify her Resident #1 was involved in an altercation with another resident, but she was not given the opportunity to consent to the medication. She said all psychoactive medications must be escalated to her supervisor for approval before she was able to consent to the administration of the medication, as required by the parameters of the legal guardianship. She said she did not feel the administration of the medication caused any harm or other negative outcome to Resident #1. In an interview with LVN A on 8/05/2026 at 10:35 AM, she said she was the primary nurse for Resident #1 on the night shift ending on 7/17/2026, and she administered the injection of Haloperidol to Resident #1. She said Resident #1 struck another resident with his fist in the early morning of 7/17/2026, and the medication was prescribed by the hospice provider after they were notified of the incident. She said the facility does not keep Haloperidol injection solution in the emergency medication kit, so it had to be delivered by the pharmacy and arrived approximately 4 to 5 hours after the incident occurred. She said she spoke with Resident #1's legal guardian after Resident #1 struck the other resident, but she was unsure if she had notified the legal guardian of the medication administration prior to administering the medication. She said Resident #1 did not object to the injection when it was administered, and he was calm at the time it was given. She said the facility process was to obtain consent for psychoactive medications prior to administering them. In an interview with the DON on 8/05/2026 at 2:43 PM, she said she was unaware LVN A did not obtain consent from Resident #1's legal guardian prior to administering the haloperidol injection to Resident #1. She was unaware the facility did not have Haloperidol in the emergency kit, and she did not know the delivery of the medication on 7/17/2026 was several hours after the incident occurred. She said in an emergency situation, the facility would obtain telephone consent prior to the administration of emergency psychoactive medications, and she was unsure of why LVN A would not have been able to discuss the medication with the legal guardian before she gave it. In a subsequent interview on 8/05/2026 at 3:30 PM, the DON said she spoke to the hospice provider, and they had told her they notified the legal guardian of the haloperidol injection.In an interview on 8/05/2026 at 4:30 PM, the HSP RN said she reviewed the clinical documentation from the nurse assigned to Resident #1, and the documentation reflected the nurse spoke with the legal guardian on 7/17/2026 at around 12:30 PM, after the medication was administered. She said the documentation reflected a discussion regarding the incident that occurred at the facility on 7/17/2026 and the hospice nurse assessment of Resident #1 in the late morning on 7/17/2026. She said obtaining consent for non-routine medications administered by the facility, such as the scenario with Resident #1 on 7/17/2026, was typically the responsibility of the facility, as their staff was performing the injection.Record review of the facility policy titled Psychotropic Medication Use undated/ digital copy provided 8/04/2026, reflected the following: . 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes:a.Indications for use;b.Dose (including duplicate therapy);c.Durationd.Adequate monitoring for efficacy and adverse consequences; ande.Preventing, identifying and responding to adverse consequences 4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a.The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 of 12 residents (Resident #12) reviewed for behavioral health services. The facility failed to ensure Resident #12's physician orders for behavioral health services (psychological care services) were followed to ensure the resident was evaluated and treated for mental illness and behaviors. This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety. The findings were: Record review of Resident #12's face sheet dated 7/22/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: wedge compression fracture of lumbar and thoracic vertebra subsequent encounter for fracture with routine healing dated 2/26/2026 (healing spinal compression fracture), generalized anxiety disorder (long term or persistent anxiety), restless and agitation, and schizoaffective disorder bipolar type (psychiatric disorder characterized by mood swings with psychosis or hallucinations). Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated he was severely cognitively impaired. The assessment indicated Resident #12 had verbal behavioral symptoms directed towards others 1 to 3 days a week and had rejections of care 1 to 3 days a week. His functional assessment revealed the resident was totally reliant on staff for all ADL care and transfers, required maximal assistance for bed movement and was non-ambulatory. Record review of Resident #12's care plan initiated on 11/13/2025 revealed the resident had a behavior problem as evidenced by throwing his foley bag, oxygen tubing, call light and blankets on the floor. A care plan for behavior dated 12/03/2025 revealed the resident was resistive to care by refusing lab draws, medication and showers at times. Interventions included anticipate and meet the residents needs and encourage as much participation interaction by the staff as possible. The Care Plan also included mood problem related to schizoaffective disorder, bipolar type initiated 3/10/2026 with interventions which included behavioral health consult as needed. Record review of Resident #12's physician orders revealed he had an order for psych care to evaluate and treat dated 6/18/2026 related to schizoaffective disorder bipolar type. During an observation and interview on 7/22/2026 at 3:00 p.m. Resident #12 was observed awake and alert in his room. He stated he felt fine. When asked additional questions, he shook his head side to side in a no fashion and did not respond. During an observation on 7/23/2026 at 10:01 a.m. CNA B was observed providing care for Resident #12 in his bed. CNA B approached Resident #12 slowly, often waiting a minute or more between approaches before reapproaching in order to reposition the resident in bed. Resident #12 would say no and push the CNA's hand away before throwing his call light and attempting to pull on his indwelling catheter. CNA B was slow and patient with her approaches, speaking to the resident quietly. CNA B provided the resident a snack and drink after completing care, watching him consume the snack while she remained in the room. During an interview on 7/23/2026 at 10:18 a.m. CNA B stated Resident #12's behaviors during care were typical of the resident. She stated today was a good day as the resident tolerated care with the promise of a snack. She stated she found a snack the easiest way to get the resident to cooperate. She stated the nursing staff was aware of his behaviors. She stated it was just part of taking care of the resident. During an interview on 7/23/2026 at 10:37 a.m., the psychological services PA (physician assistant) stated he had never assessed Resident #12. He stated his company did receive a referral, but he was unable to see the resident because there was an unknown problem with the order. He stated he was uncertain if this was communicated with the facility. During an interview on 7/23/2026 at 2:07 p.m., LVN A stated Resident #12 had psychological stuff going on. She stated psychological services PA was in the facility a couple of times a week and they could communicate with him at other times. She stated she had mentioned Resident #12 to the PA because the resident was difficult to care for and because of his refusals of care. LVN A stated the PA told her the resident needed a referral and it needed to be written a certain way (unknown) to allow the PA to prescribe for the resident. LVN A stated she wrote the order for the referral on 6/18/2026. She stated the order then when to the SW, but she was unaware of how the SW received the actual referral. She stated it was in the computer system. LVN A stated after the order went to the SW the nursing staff no longer had anything to do with the referral. LVN A stated Resident #12 was not currently receiving any psychosocial services from the psych care team. During an interview on 7/23/2026 at 2:43 p.m., the Regional Compliance Nurse who was the former DON in June 2026 revealed she was not aware the staff had concerns about providing care for Resident #12 or of any refusals of care. The Regional Compliance Nurse stated when a resident received an order for a referral for psychological services, the staff should notify the PA for psychological services. She stated in the meantime the resident was assessed and treated for behaviors by their doctor. She stated it can sometimes take 2-3 weeks for a referral, depending on their insurance. The Regional Compliance Nurse stated the PA came to the facility 2 times a week and did an excellent job with the residents. She stated the nurse, the doctor, the SW or even herself were responsible for sending referral documents to the psychological services company. She stated the SW found out about referrals during morning meetings, and she would see the PA every week and she would let him know if someone was not seen. The Regional Compliance Nurse stated she was unsure why Resident #12 was not seen. During an interview on 7/23/2026 at 4:34 p.m., the Regional Compliance Nurse stated she sent up a referral for Resident #12 to psychological services in May 2026. She stated the facility they were notified and did respond with the corrected orders on 6/3/2026 and were just waiting for psychological services to respond. During an interview on 7/24/2026 at 11:47 a.m., the Regional Compliance Nurse stated the resident had been in and out of the hospital multiple times. She stated Resident #12 did have orders for psychological services and had not been seen. She said, she sent the consent for treatment, face sheet and orders to the psychological services company on 5/26/2026 and then on 5/27/2026 because they did not have a SW at the time. She stated on 6/03/2026 she verified they got the information. She stated at that time she was told they still needed an order. She stated that's why there was the order that was viewable on 6/17/2026. The Regional Compliance Nurse stated the only thing she could say was the facility sent the order; they sent everything they were supposed to. She stated she did not know why Resident #12 was never seen. She stated residents who were exhibiting behaviors should been seen. She stated it was important because psychological care was their specialty to treat and they were the experts. During an interview on 7/24/2026 at 3:00 p.m., the DON stated she was new to the facility of three weeks. She stated she had yet to become familiar with the company policy or expectations. She stated it was important to address a resident's psychological needs to prevent a negative outcome for the resident. Record review of a facility policy titled Behavioral Assessment, Intervention, and Monitoring dated March 2019 revealed: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #7) reviewed for comprehensive care plans in that: The facility failed to ensure that there was a comprehensive care plan on file in the electronic health record for Resident #7 on 7/21/2026. These failures could place residents at risk of not having their individual care needs met and could result in a decreased quality of life.The findings included: Record review of Resident #7's face sheet dated 07/21/2026 revealed an [AGE] year old male admitted on [DATE] with diagnoses which included: spondylolysis lumbar region (presence of crack in the bone connecting the joint of the low back bones), unspecified dementia, severe, with other behavioral disturbance (impaired ability to think, remember or make decisions due to brain cell damage) and major depressive disorder (mood disorder causing feelings of sadness and loss of interest). Record review of Resident #7's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 0 which indicates that the resident has severe cognitive impairment (meaning that he has severe difficulties with memory and thinking skills). The mood and behavioral assessments revealed no issues. Assessment of functional abilities detailed that Resident #7 requires partial to moderate assistance with most of his ADL's. Record review of Resident #7's order summary report, dated 7/21/2026 revealed the following order: Admit - Resident/Resident representative has been informed of medical condition and plan of care. This was an active telephone order dated 05/09/2026. Record review of Resident #7's care plan conducted on 7/21/2026 at 2:45 p.m. revealed that there was no comprehensive care plan present for the resident in the electronic health record. Record review of Resident #7's care plan conducted on 7/24/2026 at 1:12 p.m. and 4:09 p.m. revealed a care plan that appeared to have been initiated on 7/24/2026. The care plan report printed 7/24/2026 documents a single focus as follows: I chose to have FULL CODE. Date initiated: 05/09/2026. Revision on: 07/24/2026. The goal reads: Status will be maintained through next review date. Date initiated: 07/24/2026. Target date: 08/07/2026. During an interview the ADON on 7/24/26 at 2:20 p.m., he stated that there was a comprehensive care plan present for Resident #7 dated 5/9/2026 and that the care plans get closed out every quarter and redone. He stated that the MDS nurse is more familiar with this process and she is in charge of updates to the comprehensive care plan. He stated that this care plan is necessary so that the residents receive the right care. During an interview with the MDS nurse on 7/24/2026 at 3:42pm, she displayed a care plan for Resident #7 with an initiation date of 5/09/2026. She stated that they try to keep up to date with the care plans as much as possible. She stated that she reviews the comprehensive care plans quarterly. She revealed that she had accidentally hit the delete button on Resident #7's care plan when working with it earlier today. She stated if the care plan is not updated, the electronic medical record will not be updated or accurate so the staff will not have pertinent information related to care of the resident. During an interview with DON #2 on 7/24/2026 at 3:45pm, she stated that there was a comprehensive care plan present for Resident #7 dated 5/9/2026 in the electronic medical record. She stated that the staff uses the comprehensive care plan as a guide to provide for resident care and to make needed updates to the existing care plan. She stated that the DON will also use the comprehensive care plan when conducting investigations of incidents in order to collaborate on any changes needed with the current interventions.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #5) out of 8 residents reviewed for medical records in that: Facility staff did not document details of a facility reported incident that reportedly occurred on 6/26/2026 at 5:00 p.m. in Resident #5's electronic health record. This failure could affect residents whose records were maintained by the facility and could place the residents at risk for errors in care and treatment. The findings included: Record review of Resident #5's face sheet dated 07/21/2026 revealed an [AGE] year old female admitted on [DATE] with diagnoses which included: Parkinsonism (group of brain conditions affecting movement), unspecified dementia (impaired ability to think, remember or make decisions due to brain cell damage), paranoid schizophrenia (mental health condition characterized by hallucinations, delusions and disordered thinking) and major depressive disorder (mood disorder causing feelings of sadness and loss of interest). Record review of Resident #5's comprehensive MDS dated [DATE] revealed that the resident had a BIMS score of 0 which meant that the resident had severe cognitive impairment, meaning that she had severe difficulties with memory and thinking skills. The behavioral assessment detailed that the resident had displayed physical behavioral symptoms directed towards others and rejection of care for 1-3 days during the look back period, verbal behavioral symptoms directed towards others for 4-6 days during the look back period and daily wandering activity. For functional abilities, Resident #5 required substantial/maximum assistance for performance of most tasks and was dependent on the staff for a few others. Record review of Resident #5's care plan, dated 6/03/2026 indicated focus of .is an elopement risk r/t previous attempts to leave the facility. Required placement in Memory Care Unit for safety. Date initiated: 10/06/25. Revision on: 10/06/25. Goals include: .safety will be maintained through the review date. Date initiated: 10/06/25. Revision on: 07/20/2026 and Target Date: 07/30/2026. Record review of Form 3613-A (Provider Investigation Report) faxed to complaint and incident intake department dated 07/02/2026 indicated that there was an incident involving Resident #5 and another resident 06/26/2026 at 17:00 p.m. (5:00 p.m.). The investigation documentation reviewed included a description of the incident, an assessment section that listed a description of the physical assessment performed at 17:05 p.m. (5:05 p.m.) which revealed a skin tear to Resident #5's right toe and scratch to right face of the other resident, provider response and immediate interventions provided. Record review of progress notes for Resident #5 from 06/26/2026 through 7/24/2026 did not reveal documentation in the electronic health record about the details of the facility reported incident that had occurred on 06/26/2026 at 5:00 p.m. During an interview with LVN B on 07/23/2026 at 6:30 p.m. she stated that incidents are usually documented in the incident reports, but LVN B was not able to find this report initially when she looked in the electronic medical record. She stated that there was a process to put late documentation into the electronic health record if needed, but she was not sure what the process was. About 10 minutes later, LVN B displayed documentation of the incident that had occurred on 6/26/2026 that was dated 6/26/2026 in the electronic medical record. LVN B stated that she was not sure why the documentation was not visible in the progress notes section of the electronic medical record. During an interview with ADON on 07/24/2026 at 2:20 p.m., he stated that incidents were to be documented in the chart by the staff. He looked in the electronic health record and reviewed the incident documentation for 6/26/2026. He informed me that this documentation was listed in the risk management area of the electronic health record, which was only accessible to internal staff. He stated that the information should also be documented in the progress notes or some other area that was also visible to anyone viewing the record so that everyone had access to this resident's information if needed. During an interview with the prior DON #2 on 7/24/2026 at 3:50pm she stated that she was present during the time of this incident. She verified that there was an incident involving Resident #5 and another resident that had occurred on 06/26/2026 at 5:00 p.m. She attempted to locate documentation of the 06/26/2026 incident in the electronic health record then stated that it was not present where it could be viewed by those outside of the organization. She stated that she had forgotten to document the incident in the chart. She stated that the expectation is that staff document incidents in an incident report as well as the progress notes or else the record was not complete. She stated that the facility does not have a policy specifically addressing electronic health records.

Based on observation, interview and record review the facility failed to establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source for 1 of 3 residents (Resident #12) reviewed for transfers. The facility failed to assist Resident #12's family with coordination and planning of a transfer at their request to another facility. This deficient practice could place residents at risk for residents being isolated away from family and friends. The findings were: Record review of Resident #12's face sheet dated 7/22/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: wedge compression fracture of lumbar and thoracic vertebra subsequent encounter for fracture with routine healing dated 2/26/2026 (healing spinal compression fracture), generalized anxiety disorder (long term or persistent anxiety), restless and agitation, and schizoaffective disorder bipolar type (psychiatric disorder characterized by mood swings with psychosis or hallucinations). Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated he was severely cognitively impaired. The assessment indicated Resident #12 had verbal behavioral symptoms directed towards other 1 to 3 days a week and had rejections of care 1 to 3 days a week. His functional assessment revealed the resident was totally reliant on staff for all ADL care and transfers, required maximal assistance for bed movement and was non-ambulatory. Record review of Resident #12's care plan initiated on 12/06/2025 revealed there was no plan of care for discharges or transfers. Record review of Resident #12's progress notes dated 7/08/2026 revealed Resident's [family member] called and asked about update on resident's transfer to [another state]. She stated she spoke with the SW two days ago and gave her info (information) of the place where the resident was moving to. I did then follow up with SW and let her know about resident's [family member] inquiry. I also gave SW information about [facility name and phone number in another state]. During an interview on 7/21/2026 at 4:40 p.m., Resident #12's family member stated she wanted Resident #12 to move from the facility into a facility in her home state where she could visit him more often. She stated she was unable to easily travel to the resident's current location and she could not see him. She stated she felt like she was letting her family member down by not being able to have more contact. She stated she had been in touch with the SW about her desire to transfer the resident as soon as possible. She stated she had provided the facility with the name and contact information of the facility she wanted her family member to be transferred to. She stated the SW would only say that she could not arrange a transfer because he required a lot of care and the SW did not think he could handle the trip. The family member stated the SW also stated the state would not pay for his transportation. She stated she felt like she was getting mixed messages from staff. During an observation and interview on 7/22/2026 at 3:00 p.m. Resident #12 was observed awake and alert in his room. He stated he felt fine. When asked additional questions, he shook his head side to side in a no fashion and did not respond. During an interview on 7/22/2026 at 3:33 p.m., the SW stated she had been the SW at the facility for approximately two months. She stated her job included discharge planning. She stated discharge planning began on admission. The SW stated if a resident or family member was asking to transfer to another facility, the way it works was to check the BIMS score to see if the resident was cognitively intact to make the decision. She stated if their BIMS score was 12-13 or above, they were cognitively intact. She stated if the family member wanted a transfer to another facility, she would start the process. The SW stated she would send clinical documents to the facility desired to see if they would accept the resident and then wait for their response. She stated the resident would have to be approved by the accepting facility both medically and financially. The SW stated Resident #12's family member wanted the resident transferred to the state where they resided. The SW stated the problem was the resident did not have the trunk strength to sit up or endure a transfer and he did not want to take his medications. The SW stated she did not think the resident could make the trip. She stated the doctor would have to make that decision, and the family would have to pay for a medical transport. The SW also stated Resident #12 had behavioral issues and did not think the family member could care for him. The SW stated she had talked to some of the nurses about Resident #12 and they had said, no, he can't make the trip. The SW stated she does not believe the family could afford to pay for a medical transport and the accepting facility would have to agree to pay for it because the resident's insurance would not pay for it. The SW stated she told the family member the facility was not paying for the transport. The SW stated the family member asked her to be creative with coming up with a way to get the transfer. The SW stated she had not notified the physician of the resident's family members desire to have him transferred and she had not worked on finding him an alternative placement or contacted the desired facility. She stated the administration had asked her to put her focus on another resident. The SW stated she said that because she believed the family members wish to have him transferred to another state was unrealistic due to both the family members and the resident's health conditions. During an interview on 7/23/2026 at 2:07 p.m., LVN A stated Resident #12's family member has expressed that she wants the resident in a facility closer to her. LVN A stated she relayed that information to the SW by telling her verbally and texting in a faculty group message. LVN A stated it was also documented in the daily communication notes available to all staff. She stated she was able to review the daily communication notes from the past week and saw it documented as on 7/17/2026 but believed it probably went back further than that. LVN A stated the SW was aware. During an interview on 7/23/2026 at 4:34 p.m., the Regional Compliance Nurse (former DON) stated when a family member requested a transfer, the facility would first inquire why, to see if it was a service issue and to find out where they wanted the resident transferred to. She stated once they have the information, they would reach out to the facility to see if the resident could be admitted . She stated the receiving facility who accepts the transfer comes to pick up the resident. The Regional Compliance Nurse stated she knew Resident #12's family member wanted him transferred out of state. She stated that was complex and the family would have to pay for it. She stated the facility did have a conversation with the family, and the SW brought it up in morning meetings. The Regional Compliance Nurse stated the family member did not want the resident transferred locally. She stated the family member knew it was her responsibility to arrange transportation and would let the facility know when she figured it out. She stated to her knowledge the family member never provided a specific facility. She stated there was no one person responsible for transfers at the facility, although the SW would reach out as needed. She stated she was unsure if the resident's physician or insurance company was contacted to find out what was possible. She stated that was something the SW or BOM would handle. She stated she herself did not call insurance or the accepting facility. During an interview on 7/24/2026 at 2:27 p.m., the BOM stated no one had ever come to her to ask her if Resident #12's insurance would cover transportation or to contact or coordinate with another facility to coordinate a transfer. During an interview on 7/24/2026 at 3:00 p.m. the DON stated she had been the DON for three weeks and one of those weeks she was in training and not in the building. She stated prior to surveyor entrance on 7/21/2026 she was not aware the Resident #12's family's desire to have the resident discharged . She stated the SW never discussed it during morning meetings. The DON stated she was still learning the facility's ways and was not going to assume who was responsible for coordinating the transfer. She stated her expectations for staff was to discuss it as a team, and the transfer would need to be communicated by family to staff. The DON stated it was important to respond to family members request for transfer because it was a want and they have to try to see if they could meet the need. During an interview on 7/24/2026 at 3:20 p.m. the Regional Compliance Nurse stated the facility did not have a policy for transfers for discharges. She stated they utilized State Regulations for guidance. During an interview on 7/24/2026 at 3:24 p.m., the DON stated she did not have access and was not familiar with the company's procedures. She stated she was reliant on the Regional Compliance Nurse/former DON for policies and procedures.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident that meets professional standard of quality of care within 48 hours of admission for 1 of 8 residents (Resident #7) whose medical records were reviewed for accuracy in that: The facility failed to develop a baseline care plan within 48 hours of Resident #7's admission to the facility. This failure could place residents at risk of not receiving needed care and treatment.The findings included: Record review of Resident #7's face sheet dated 07/21/2026 revealed an [AGE] year old male admitted on [DATE] with diagnoses which included: spondylolysis lumbar region (presence of crack in the bone connecting the joint of the low back bones), unspecified dementia, severe, with other behavioral disturbance (impaired ability to think, remember or make decisions due to brain cell damage) and major depressive disorder (mood disorder causing feelings of sadness and loss of interest), Record review of Resident #7's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 0 which indicated that the resident had severe cognitive impairment (meaning that he has severe difficulties with memory and thinking skills). The mood and behavioral assessments revealed no issues. Assessment of functional abilities detailed that Resident #7 required partial to moderate assistance with most of his ADLs. Record review of Resident #7's order summary report, dated 7/21/2026 revealed the following order: Admit - Resident/Resident representative has been informed of medical condition and plan of care. This was an active telephone order dated 05/09/2026. Record review of Resident #7's care plan conducted on 7/21/2026 at 2:45 p.m. revealed that there was no care plan present for the resident in the electronic health record. Record review of Resident #7's care plan conducted on 7/24/2026 at 1:12 p.m. and 4:09 p.m. revealed a care plan that appeared to have been initiated on 05/09/2026 but showed an actual initiation date of 07/24/2026 when viewed historically. There was one item listed on the care plan which was as follows: Focus. I chose to have FULL CODE. Date Initiated: 05/09/2026. Revision on: 07/24/2026. At the bottom of the care plan, it stated Date initiated: 07/24/2026. During an interview with MDS nurse on 07/24/2026 at 3:39 p.m., she stated that overall, the MDS staff is in charge of the care plans. She said the baseline care plan is done with the admitting nurse to cover the first 72 hours. She said that she accidentally hit delete earlier today which erased the existing baseline care plan but said that she was able to restore the previously documented care plan. She displayed a care plan in the electronic medical record for Resident #7 that showed an initiation date of 5/09/2026. She stated that if the care plan is not updated, then the electronic medical record is not up to date with the resident's care needs which could impact his care. During an interview with the ADON on 7/24/2026 at 2:20 p.m. he pulled up electronic medical record documentation of a care plan that appeared to be initiated on 5/09/2026. He revealed that the MDS nurse is in charge of the updates that are done to the care plan. He stated that within the first 24 hours the admitting nurse is to complete the baseline care plan with RN oversight. He stated that the care plan is necessary as it is what directs the residents care. During an interview with the DON #2 on 7/24/2026 at 3:40 p.m., she did not verify that there was a baseline care plan present for Resident #7. She stated that the staff uses the care plan as a guide to provide resident care so it should be present within 72 hours so that the staff knows how to care for the resident. Record review of the facility provided policy titled Care Plans - Baseline which was not dated, revealed the following: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 4 residents (Resident #2 and #3) reviewed for MDS assessment accuracy.1. The Quarterly MDS Assessment for Resident #2 failed to accurately document the percentage of calories the resident received through the gastrostomy tube (a tube inserted into the stomach to administer medications and nutritional supplements; a feeding tube).2. The 5-Day MDS Assessment for Resident #3 failed to accurately document the resident had an indwelling urinary catheter.This failure could lead to residents not receiving the required care and decreased quality of life.The findings included:1. Record review of Resident #2's admission Record (Face Sheet), dated 5/29/26, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intracerebral hemorrhage (bleeding in the brain), protein calorie malnutrition (inadequate intake of calories or protein), aphasia (inability to speak), dysphagia (swallowing difficulties), hemiparesis (partial paralysis), and gastrostomy tube.Record review of Resident #2's MDS, a quarterly assessment dated [DATE], revealed her BIMS score was 0 out of 15, indication of severe cognitive impairment; and Section K was coded that Resident #2 had a feeding tube and received 51% or more of her total calories through the feeding tube.Record review of Resident #2's care plans revealed a care plan initiated on 09/28/2021 for being at risk for unplanned/unexpected weight loss with an intervention of administration of 1 can of Jevity 1.5 via gastrostomy tube if meal intake less than 50% and was revised on 05/21/2026.Record review of Resident #2's Physician's Order Summary Report, dated 05/31/2026, revealed an order for a pureed diet with nectar consistency liquids with a start date of 10/26/2025.Record review of Resident #2's Physician Order Summary Report, dated 05/31/2026, revealed an order to provide 1 can of Jevity 1.5 (a high calorie enteral nutritional supplement) via the gastrostomy tube if oral intake of meal was less than 50% as needed; and there were no further orders for enteral nutritional supplements to be administered via the gastrostomy tube.Record review of Resident #2's Task Sheet for Nutrition Amount Eaten from 05/17/2026 to 05/22/2026, revealed she consumed 75-100% of her meals.Record review of Resident #2's Skilled Administration Record for May 2026 revealed Resident #2 did not receive any bolus feeding (larger volume in a short period) of the enteral nutritional formula Jevity 1.5 through the gastrostomy tube from 05/17/2026 to 05/22/2026 and had not received any calories from the formula.In an interview on 05/31/2026 at 8:41 AM, LVN C said Resident #2 had a gastrostomy tube, but she also had an oral diet which she ate really good, and the nurse had not administered the Jevity 1.5 enteral nutrition formula.In a telephone interview on 05/31/2026 at 3:00 PM, MDS Nurse RN B said Resident #2 did not receive any bolus tube feeding of the Jevity 1.5 in May 2026 after she reviewed the resident's chart, and stated she should have checked on the MDS Section K that Resident #2 received 25% or less of her total calories from the feeding tube. 2. Record review of Resident #3's admission Record, dated 05/31/2026, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy (a disease of the brain causing cognitive impairment) and neuromuscular dysfunction of the bladder (lack of bladder control due to nerve problems).Record review of Resident #3's MDS, a 5-day scheduled assessment dated [DATE], revealed a BIMS score of 0 out of 15, indication her cognitive skills were severely impaired; and under Section H it was checked the resident did not have an indwelling urinary catheter.Record review of Resident #3's care plans revealed a care plan initiated on 05/15/2026 for an indwelling urinary catheter.Record review of Resident #3's Order Summary Report, dated 05/31/2026, revealed an order for an indwelling urinary catheter and care to the catheter with a start date of 05/18/2026.Record review of Resident #3's May 2026 Skilled Administration Record revealed urinary catheter care was provided as ordered every shift from 05/18/2026 to 05/31/2026.Observation on 05/30/2026 at 11:18 AM of Resident #3 revealed she was lying in bed and had an indwelling urinary catheter.In a telephone interview on 05/31/2026 from 3:00 PM to 3:12 PM, MDS Nurse RN B said Resident #3 was recently readmitted to the facility with an indwelling urinary catheter and the MDS dated [DATE] should have been checked that the resident had an indwelling urinary catheter. MDS Nurse RN B stated she would look at the resident's physician's orders and the TARs when completing the MDS to ensure it was accurate.In an interview on 05/31/2026 from 3:20 PM to 3:48 PM, the DON said she would review quality measure reports and the CMS 802 Resident Matrix form to ensure residents' MDS assessments were completed accurately and could not think of any harm that could occur to a resident if the MDS was not accurate.In an interview on 05/31/2026 at 4:06 PM, the Administrator said daily meetings were held in the morning with the interdisciplinary team and assessments of residents would be reviewed at that time to ensure they were completed; and the MDS assessment needed to be reflect the residents' condition.Record review of CMS's RAI Version 3.0 Manual, Chapter 3: MDS Items Section K, page K16, revealed to 1. Review intake records within the last 7 days to determine actual intake through . tube feeding routes. 2. Calculate proportion of total calories received through these routes.Record review of CMS's RAI Version 3.0 Manual, Chapter 3: MDS Items Section H, page H1 to H3, revealed Steps for Assessment 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary bowel appliances.Coding Instructions: Check next to each appliance that was used at any time in the past 7 days.Record review of the Resident Assessments policy, Revised 2019, revealed A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for consents for accurate medical records.The facility failed to ensure LVN A documented wound care was provided to Resident #1 on 05/24/2026.This failure could place residents at risk for inaccurate medical records.The findings included:Record review of Resident #1's admission Record (Face Sheet), dated 05/29/2026, revealed she was admitted on [DATE], and readmitted on [DATE] and was discharged on 05/27/2026; and diagnoses of anemia (low iron stores in the blood), atrial fibrillation (irregular heartbeat), dementia (impaired cognitive function that affects activities of daily living), atherosclerotic heart disease (plaque buildup in the blood vessels), and high blood pressure.Record review of Resident #1's MDS, an annual assessment dated [DATE], revealed a BIMS score of 1 out of 15, indication of severe cognitive impairment.Record review of Resident #1's care plan revealed a care plan initiated on 06/16/2021 for the potential for pressure ulcer development related to impaired mobility was revised on 04/10/2026.Record review of Resident #1's Weekly Skin/Wound Documentation, dated 05/22/20226, revealed an unstageable pressure ulcer (bed sore) was identified on her left plantar (bottom of the foot), the physician was notified and treatment orders were placed; and Resident #1's Responsible Party was notified.Record review of Resident #1's Order Summary Report, dated 05/30/2026, revealed an order dated 05/22/2026 to cleanse the wound to left plantar [bottom of the foot] with normal saline or wound cleanser, pat dry with gauze and apply skin prep, leave open to air daily on the day shift for 14 days with a start date of 05/23/2026.Record review of Resident #1's May 2022 TAR revealed on 05/24/2026 wound care to the left plantar was not checked that it was provided to the resident.Record review of Resident #1's nurses notes revealed a late entry note from LVN A for 05/24/2026, created on 05/30/2026 at 5:28 PM for documentation for the wound care provided to Resident #1's left plantar.In an interview on 05/31/2026 at 2:13 PM, LVN A stated she had provided wound care to Resident #1 on 05/24/2026 but did not check off as completed on the TAR.In an interview on 05/31/2026 from 3:20 PM to 3:48 PM, the DON said if wound care was not documented as completed it could give an inaccurate picture of what care was provided to the residents, and she ensures the clinical records are accurate through quality assurance audits conducted by the DON or the ADONs. The DON said LVN A wrote a late-entry nurses note on 05/30/2026 to document the wound care she provided to Resident #1 on 05/24/2026.In an interview on 05/31/2026 at 4:06 PM, the Administrator said the residents' clinical records were reviewed for accuracy by the interdisciplinary team and if clinical record was not accurate, it could have a negative effect on the resident.Record review of the Wound Care policy, revised October 2010, revealed under Documentation, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care.8. The signature and title of the person recording the data.Record review of the Charting and Documentation policy, revised July 2017, revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility failed to employ a full-time social worker since April 15, 2026 when the facility was licensed for 170 beds. This failure could place residents at risk of social service and psychosocial needs not being met. The findings included:Record review of the Facility Summary Report, accessed on 05/11/2026, reflected the facility had 170 licensed beds. Record review of the facility's staff roster, undated, reflected there was no social worker employed at the facility. During an interview on 05/21/2026 at 08:50AM, ADON A revealed they did not have a social worker because this facility was a high turnover building when it came to staff. He revealed they had a part time social worker in the meantime. During an interview on 05/13/2026 at 11:45AM, the ADM revealed they did not have a full-time social worker, but they did have a part time social worker. He revealed on April 15th, 2026, the former social worker gave him a 30-day notice that he would no longer be working at the facility, but the former social worker ended up leaving on April 22nd, 2026. The ADM further revealed that the part time social worker and other staff like the MDS nurse were trying to catch up on work that was done by the social worker like resident assessments and addressing any concerns from the residents. Email communication on 05/13/2026 at 01:06 PM with the ADM revealed the facility hired a full-time social worker who would start on Monday May 18th, 2026. A policy about having a social worker was requested 05/13/2026 at 10:55 AM. The DON revealed the facility did not have the policy but followed the regulations.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 7 residents (Residents #1) reviewed for care plans. The facility failed to update Resident #1's care plan to reflect that Resident #1 did not have a video monitoring device in her room. This failure could place residents at risk of not having their needs met and not receiving appropriate care. The findings included: Record review of Resident #1's admission record, dated 05/12/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dementia (decline in cognitive functions (memory, reasoning, and thinking) which interferes with daily life) and lack of coordination. Record review of Resident #1's quarterly MDS assessment, dated 03/09/2026, reflected Resident #1 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. Record review of Resident #1's care plan, undated, reflected focus of Video Monitoring. [Resident #1]'s family have chosen to install a video monitoring device in her room., initiated 11/06/2025. During an observation and attempted interview on 05/12/2026 at 10:54 AM, Resident #1 was sitting in her wheelchair and would not respond to any questions that were being asked. Observation of Resident #1's room revealed no video cameras were in her room. During an interview on 05/13/2026 at 09:51 AM, Resident #1's RP revealed she put a video camera in Resident #1's room to monitor Resident #1. She revealed she did not know what happened with the video camera or when it went missing but had not been able to follow up with the facility about this yet. During an interview on 05/13/2026 at 11:30 AM, LVN B revealed Resident #1 did not have a video camera in her room. She revealed the resident was in another hallway before being in her current room so she assumed that the video camera may have gotten lost while the resident was being transferred or the family took the video camera home. She revealed the resident's RP visited frequently and the RP had never voiced that Resident #1 was missing a video camera in her room. LVN B reviewed Resident #1's care plan and confirmed that the care plan reflected that Resident #1 was supposed to have a video camera in her room. During an interview on 05/13/2026 at 01:30 PM, the MDS nurse revealed that Resident #1 did not have video camera in her room, so she updated Resident #1's care plan to reflect Resident #1 did not have a video camera in her room. During an interview on 05/13/2026 at 02:28 PM, the DON revealed Resident #1's care plan was not updated to reflect that Resident #1 did not have video cameras in her room. She revealed the facility did not provide video cameras so they could not follow the care plan for Resident #1. The DON revealed Resident #1 did have a video camera in her room at one point and she was unsure when the video camera went missing. Record review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, reflected .12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to implement policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility failed to ensure Resident #82's personal refrigerator was less than 41 degrees Fahrenheit.The facility failed to ensure Resident #106's personal refrigerator was cleaned and did not have 2 Styrofoam containers with no date or label. The facility failed to ensure Resident #85's personal refrigerator's freezer was properly functioning and not iced. These failures could place residents at risk for food borne illness.The findings included:3. Record review of Resident #82's admission record, dated 03/10/2026, reflected Resident #82 was a [AGE] year-old male who initially admitted [DATE] and re-admitted [DATE], with diagnoses to include type 2 diabetes (chronic condition causing high blood sugar)Record review of Resident #82's quarterly MDS assessment, dated 01/29/2026, reflected Resident #82 had a BIMS score of 15 out of 15, indicating intact cognition.In interview and observation on 03/10/2026 at 01:21 PM revealed a thermometer in Resident #82's personal refrigerator read 48 degrees Fahrenheit. There were only cans of soda in his refrigerator, but Resident #82 revealed that he used his refrigerator to store food. He further revealed he could not store ice cream in his freezer because it never got cold enough. It was observed that there was no thermometer in Resident #82's freezer. He further revealed he did not know what temperature his refrigerator should be at, and he was not sure if the facility staff was checking his refrigerator for the appropriate temperature. He revealed he wanted his refrigerator to be at the right temperature so he could store food.In an interview and record review on 03/12/2026 at 06:02 PM, ADON A revealed he oversaw temperature logs for residents' personal refrigerators. He showed a temperature log sheet that nursing staff used which had the parameters that the residents' refrigerators could be up to 46 degrees Fahrenheit. ADON A revealed Resident #82's refrigerator was above 41 degrees Fahrenheit, and he was not aware that refrigerators needed to be below 41 degrees Fahrenheit.In an interview on 03/12/2026 at 06:37 PM, ADON B revealed he oversaw infection surveillance, and there were no gastrointestinal issues (GI) or spread of GI issues in the facility in the last 3 months. He further revealed the temperature log the nursing staff used to track temperatures of residents' personal refrigerators had a temperature range of 36 to 46 degrees Fahrenheit of what the residents' personal refrigerator thermometers should read.In an interview on 03/12/2026 at 06:50 PM, the RD revealed the nursing staff oversaw the residents' refrigerators and the expectation would be that the refrigerators were below 40 degrees Fahrenheit. In an interview on 03/13/2026 at 10:18 AM, the DON revealed she was not aware of what the temperature range needed to be for refrigerators. She revealed the sheet that nursing staff used to write temperatures for the residents' refrigerators reflected the refrigerator temperature could be up to 46 degrees Fahrenheit. She revealed the nursing staff oversaw that 4.Record review of Resident #106's admission Record dated 03/13/2026 was documented she was admitted on [DATE], re-admitted on [DATE].Record review of Resident #106's Annual MDS dated [DATE] was documented a BIMS score of 15/15 (cognitive intact).Record review of Resident #106's care plan dated 03/13/2026 was documented for eating she required set-up or clean up.Record review of Resident #106's personal effects inventory dated 11/20/206 was documented she had an electric wheelchair, pair of glasses and a refrigerator.Observation and interview on 03/11/2026 at 04:32 PM, revealed Resident #106 had a personal refrigerator in her room. It was dirty, had a Styrofoam container not labeled, Styrofoam container unknown foods and was not labeled. Resident #106 stated the refrigerator was hers, and she was not willing to say when the refrigerator was cleaned or how long the Styrofoam containers were in the refrigerator. 5. Record review of Resident #85's admission Record dated 03/13/2026 he was admitted on [DATE], re-admitted on [DATE] with diagnoses of type 2 diabetes.Record review of Resident #85's Quarterly MDS dated [DATE] was documented his BIMs score was 15/15 (cognitive intact), and was independent with eating with no weight loss, and current weight was 274 pounds. Record review of Resident #85's care plan dated 09/23/2025 was documented for eating was set up or clean up assistance. Adjust diet to accommodate chewing, swallowing or eating issues in order to maximize independence and nutritional intake. Record review of Resident #85's personal effects inventory dated 05/31/2025 revealed he had a personal refrigerator. Observation and interview on 03/10/2026 at 10:44 AM in Resident #85's room revealed he had a personal refrigerator; the freezer was iced over. It looked like a ball of ice was in it. Resident #85 revealed the freezer was iced over, for a while. In an interview on 03/13/2026 at 03:00 PM with the Maintenance Director revealed he was responsible for the residents' personal refrigerators. Maintenance stated he was not aware that Resident #106 and #85's personal refrigerators had issues and would get to it right away. Maintenance stated the staff/residents usually verbally told him or puts it in a computer log for maintenance to fix. Maintenance stated the nurse on the night shift looked at and wrote resident personal refrigerator temperatures. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and. Record review of the facility's policy Refrigerators and Freezers, revised November 2022, reflected 1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit.9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Record review of the facility's policy Foods Brought by Family/Visitors, revised March 2022, reflected, Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The nursing and/or food service staff will discard any foods prepared for the resident that show any signs of potential foodborne danger. Record review of the facility's policy Food Receiving and Storage, revised November 2022, Refrigerated/Frozen Storage. 3. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 of 5 residents (Residents #16, #35, #68 and #94) reviewed for abuse.The facility failed to ensure a resident-to-resident altercation on 2/2/2026 between Residents #16 and #35 was reported to the SSA. The facility failed to ensure Resident #68's allegation of exploitation was reported to the SSA. The facility failed to report an incident where Resident #94 was hospitalized for suicidal ideation on 12/15/2025. These findings could result in a lack of oversight of residents. 2. Record review of Resident #68's admission record, dated 03/13/2026, reflected Resident #68 was a [AGE] year-old male who admitted [DATE], with diagnoses to include major depressive disorder (persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities) and anxiety disorder (excessive fear or worry). Record review of Resident #68's quarterly MDS assessment, dated 01/30/2026, reflected Resident #68 had a BIMS score of 14 out of 15, indicating intact cognition. The MDS reflected Resident #68 did not have delusions or hallucinations. Record review of Resident #68's care plan, undated, reflected [Resident #68] has a behavior problem r/t making false allegations against staff and facility., initiated 12/09/2025. Record review of Grievance Form about Resident #68, dated 02/03/2026 and authored by the SW, reflected they keep taking my money. I think they may be doing this to me on purpose, I am supposed to be getting about $70.00 every month. I only received $35.00. Record review of Grievance Form about Resident #68, dated 02/09/2026 and authored by the SW, reflected the money lady is personally taking my social security money. Interview on 03/10/2026 at 12:18 PM Resident #68 revealed he had not seen his checks. He revealed he was supposed to be getting $75 per month, but the facility was taking his money. He revealed the BOM was ignoring him, and the ADM did not have time to help him. Interview on 03/13/2026 at 12:45 PM, the SW revealed Resident #68 claimed the BOM was specifically targeting him and taking his money. He revealed Resident #68 presented with confusion and he had 3 to 4 attempts to discuss social security. The SW further revealed Resident #68 said he was being exploited. The SW stated, He uses some powerful words. The SW was reviewing his notes and mentioned psych said Resident #68 presented with logical thought processes and his judgment was fair. The SW revealed he may have brought this up in the morning meetings and the ADM may know about this situation. He revealed he investigated this situation and thought Resident #68 was confused so he did not think it needed to be reported to the ADM. He revealed he was unsure if he had to report to the ADM when he heard Resident #68 mention exploitation. Interview on 03/13/2026 at 01:44PM, the BOM revealed she was aware that Resident #68 accused the facility of stealing his money. She revealed she explained how his social security checks worked and he seemed fine, but then he would bring up the same concern again. She revealed she did not know if Resident #68 was just not remembering their conversations. She revealed she told the former ADM that Resident #68 thought she was stealing his money. She revealed she was not aware the resident was using the word exploitation otherwise this should have been reported right away. Record review of facility's policy Grievances/Complaints, Filing, revised April 2017, reflected 9. The grievance officer will coordinate actions with appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines of reporting abuse, neglect and misappropriation of property, as per state law. 3. Record review of Resident #94's admission record, dated 03/10/2026, reflected Resident #94 was a [AGE] year-old female who initially admitted on [DATE] and re-admitted [DATE], with diagnoses to include major depressive disorder (persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities), anxiety disorder (excessive fear or worry), bipolar disorder (mental health condition that causes extreme mood swings), schizoaffective disorder (mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, along with symptoms of mood disorder, such as mania (period of abnormally elevated, extreme changes in mood or emotions, energy level or activity level) and depression). Record review of Resident #94's quarterly MDS assessment, dated 11/27/2025 (before 12/15/2025 incident), reflected Resident #94 had a BIMS score of 14 out of 15, indicating intact cognition. The MDS reflected Resident #94 did not have delusions or hallucinations, did not feel down, depressed, or hopeless, and did not feel little interest or pleasure in doing things. Record review of Resident #94's quarterly MDS assessment, dated 02/27/2026, reflected Resident #94 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The MDS reflected Resident #94 did not have delusions or hallucinations, did not feel down, depressed, or hopeless, and did not feel little interest or pleasure in doing things. Record review of Resident #94's care plan, undated, reflected [Resident #94] has a potential behavior problem by inflicting self-harm r/t poor impulse control d/t schizophrenia, bipolar disorder., initiated 12/16/2025, with intervention Intervene as necessary to protect the rights and safety of others. Record review of the Resident #94's order summary report, dated 03/10/2026, reflected Senior Psychological to eval and treat, with order date 12/18/2025. Record review of incident report for Resident #94, authored by RN E and dated 12/15/2025 at 01:15 PM, reflected The resident came to the nurse's station with a sharp object and said she was going to end her own life and put a sharp object to her throat, while nurse retrieved object from [Resident #94] for her safety. [Resident #94] expressed, 'I can't take it anymore. The nurse attempted to calm her down reminding her that her daughter and family need her. [Resident #94] was placed on a one to one until EMS arrived. Management, DON, ADONs, Administrator, RP, MD, and head of psych MD notified. It further reflected that Resident #94 had an abrasion on her chest. Record review of Resident #94's hospital documentation, dated 12/15/2025, reflected chief complaint Suicidal. ([Resident #94] from a nursing facility here because she had scissors to her neck and told the nursing staff, she was going to kill herself. Per officer, nursing staff took the scissors a way but [Resident #94] was able to scratch herself with her fingernails. [Resident #94] does have several abrasions to right side of her neck. [Resident #94] states 'I try to kill myself, but I need to be home by 10pm today' Interview on 03/11/2026 at 08:10 AM, Resident #94 revealed she could not recall a time when she was hospitalized for suicidal ideation and said since she had been to this facility she did not have a moment when she was depressed. Resident #94 would not answer any further questions about this incident. Interview on 03/12/26 at 09:38AM, RN E revealed Resident #94 was typically happy and her behavior on 12/15/2025 was not her normal behavior. She revealed Resident #94 was upset because another resident did not want to talk to her. She revealed Resident #94 had child-safe scissors and said she was going to kill herself. RN E revealed she took the scissors from the resident, kept Resident #94 in her line of sight until someone was able to follow the resident until EMS arrived at the facility, and let the appropriate parties know what happened. Interview on 03/12/2026 at 05:23 PM, the DON revealed Resident #94 did not actually hurt herself so she would not have reported this incident. She revealed the provider letter (Long-Term Care Regulation Provider Letter) did not mention self-harm so there was no guidance for reporting this incident. Interview on 03/13/2026 at 01:55PM, the ADM revealed he reviewed the grievances and was aware of Resident #68's claims of his money being taken. He revealed he investigated this grievance, met with the BOM and the SW, and found that Resident #68 appeared confused and forgetful. The ADM revealed the BOM would explain how his social security checks worked but he did not want to accept her explanation. He further revealed that he did not know if he would have reported Resident #94's incident because he did not know all the facts. Record review of the Long-Term Care Regulation Provider Letter, dated 08/29/2024, reflected A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect, exploitation. Record review of TULIP, dated 03/10/2026 at 03:45 PM, reflected no self-reports of Resident #68's allegations of exploitation or Resident #94's hospitalization for suicidal ideation on 12/15/2025. Record review of Resident #16's admission Record dated 3/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia (a progress condition affecting memory and reasoning). Record review of Resident #16's annual MDS submitted 1/30/2026 reflected a BIMS score of 0, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #16 exhibited physical and verbal behavioral symptoms towards other for 1-3 days of the assessment period. Record review of Resident #16's Care Plan Report printed 3/12/2026 revealed the following: Behavior [Resident #16] has a behavior problem r/t RESISTIVE TO CARE [sic] Potential to be verbally and physically aggressive. d/t Dementia dx noted to have a verbal altercation on 1/3/26 with another resident. Seen by [psychiatry provider] Date Initiated: 10/16/2025 Revision on: 03/10/2026 verbally agressive [sic] r/t Dementia, Poor impulse control 2/2/26 resident allegedly was involved in a physical aggression altercation where resident was the initiator. Date Initiated: 03/10/2026 Revision on: 03/10/2026 Record review of Resident #16's progress notes revealed an entry dated 2/2/2026 at 4:30 PM by LVN G: Another resident informed staff that this resident walked into his room, was told this was not his room, he slapped the other resident in the face. Resident states he does not remember hitting anyone. Pt. teaching to ask staff for assistance if he forgets where his room is. Placed call informed [DON] of incident, [MD] here in facility informed him of incident, informed [Administrator], informed [psychiatry provider] and [legal guardian], [hospice provider] also notified. Resident placed on q 15 minute checks to monitor behavior. Record review of Resident #35's admission Record dated 3/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included unspecified developmental delays. Record review of Resident #35's quarterly MDS submitted 1/15/2026 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS revealed Resident #35 exhibited physical and verbal behavioral symptoms towards other for 4 to 6 days of the assessment period. Record review of Resident #35's Care Plan Report printed 3/13/2025 revealed the following: [Resident #35] has potential to be physically aggressive r/t Dementia Potential [sic] to be verbally aggressive at times. Date Initiated: 08/14/2025 Record review of Resident #35's progress notes revealed an entry dated 2/2/2026 at 4:30 PM by LVN G: Resident told [CNA D] that another resident was in his room he told him this is not your room and the other resident slapped him on his left side of face resident had helmet on at the time, no injury noted. Informed [DON], [Administrator], and [MD]. Record review on 3/12/2026 at 10:41 AM of the facility's self-reported incidents on TULIP did not reveal a submission related to the incident between Residents #16 and #35 on 2/2/2026. In an interview on 3/13/2026 at 8:25 AM, Resident #35 said another resident had slapped him in the face, but he was unsure when or where the incident occurred. He was unsure which resident had slapped him. He said the slap was painful. In an interview with the DON on 3/13/2026 at 10:55 AM, she said she was aware of the incident between Residents #16 and #35. She said she interviewed both residents immediately after the incident was reported to her by LVN G, and Resident #35 denied he had been slapped. She said Resident #35 also denied hitting anyone. She said her investigation of the incident included obtaining laboratory specimens from both residents to determine if the alleged behaviors had underlying medical causes and both residents were evaluated by the psychiatry provider. She said the incident was not reported to the SSA because she felt it did not meet the reporting criteria based on the cognitive impairments of both residents. She said the verbiage of the provider letter that clarifies intent causes confusion when applying the standards to cognitively impaired residents. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed the following: 9. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to discard a pan of chicken pot pie with discard date 03/04/2026.The facility failed to ensure boxes of food products were stored properly on the top shelf in the walk-in freezer. These failures could place residents at risk for food borne illness.The findings included: The findings included:Observation on 03/10/2026 at 09:15 AM revealed there was a pan of chicken pot pie with discard date 03/04/2026 in the walk-in refrigerator.Observation on 03/10/2026 at 09:15 AM revealed there were 3 boxes of food products stored on the top shelf in the walk-in freezer that appeared too close to the ceiling (exact distance unknown).During an interview and observation on 03/12/2026 at 02:40 PM, the Dietary Manager revealed the boxes of frozen food products in the walk-in freezer were too close to the ceiling and could interfere with the sprinkler system if the sprinkler system went off. It was important so that it did not block the water from the fire sprinkler from getting to something around these boxes, in case of an emergency. She revealed everyone in the kitchen oversaw throwing out foods that passed the discard date and the pan of chicken pot pie should have been thrown away. [NAME] F revealed she was trained on throwing out food products once it passed discard dates. [NAME] F revealed she would have to throw it out because the food was not good for the residents to eat.During an interview on 03/12/2026 at 06:50 PM, the RD revealed the boxes of food products needed to be 18 inches away from the ceiling for food storage, but she was unsure why. That's a problem if it was less because it can be too close to the ceiling. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and. Record review of the facility's policy Refrigerators and Freezers, revised November 2022, reflected 1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit.9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Record review of the facility's policy Foods Brought by Family/Visitors, revised March 2022, reflected, Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The nursing and/or food service staff will discard any foods prepared for the resident that show any signs of potential foodborne danger. Record review of the facility's policy Food Receiving and Storage, revised November 2022, Refrigerated/Frozen Storage. 3. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on interview and record review, the facility failed to ensure that the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #4) of 8 residents reviewed for resident rights. The facility failed to obtain informed consent for the use of Ziprasidone HCL (an antipsychotic medication) for Resident #4. This failure could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.Findings included:Record review of Resident #4's admission record dated 3/13/2026, reflected that she was [AGE] years old, initial admission on [DATE] and re-admitted on [DATE]. The resident was diagnosed with diabetes mellitus (condition that occurs when the body cannot properly use blood sugar), anxiety (a feeling of worry, nervousness, or unease), and intermittent explosive disorder (mental health condition characterized by sudden, intense outbursts of anger or aggression that are disproportionate to the situation).Record review of Resident #4's Quarterly MDS dated [DATE] reflected resident had clear speech, had the ability to understand others, clear comprehension, BIMS score indicated moderately impaired cognition, Section D: Mood severity score of 4, indicating that she had been observed with a mood disorder, Section E: Behaviors indicated the resident had no behaviors.Section GG: Functional Status reflected the resident was dependent on staff for substantial/maximal assistance for ADLs and required the use of a wheelchair. Section J: Health Conditions reflected the resident had pain occasional interference with day-to-day activities and was at risk of SOB. Section K Swallowing/Nutritional Status reflected Resident #4 had complaints of difficulty or pain with swallowing. Section M skin: reflected the resident was at risk of PU. Resident #4 required the use of a Pressure reducing mattress, and application of ointments. Section N: Medications reflected the resident took an antipsychotic, antidepressant, opioid, and hypoglycemic.Record review of Resident #4's Care Plan dated 8/28/2025 and revised 11/06/2025 reflected she had an ADL self-careperformance deficit related to disease process, used psychotropic/antipsychotic medications (Ziprasidone HCI) related to intermittent explosive disorder (characterized by sudden episodes of unwarranted anger and violent outbursts) and antidepressant medication (Sertraline and Trazodone) related to Depression/Insomnia and resident had a psychosocial well-being problem related to anxiety, Dependent behavior, Disease Process, worsening condition, nursing home placement. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability.During an observation and interview on 3/11/2026 at 11:22 a.m., Resident #4 was in the hallway heading towards her room ambulating in her manual wheelchair, she was dressed well, groomed appropriately, no odor. She was upset and said an employee stole her money from her bank and she reported it to the ADM and SW. She said the staff who stole her money is hiding in the restroom and constantly laughs at her. Resident #4's memory and events were difficult to understand, she was unable to keep a clear conversation, and she would lose her train of thought. She said the theft was reported to the management team, they filed a report and are investigating it. She was unable to recall when this event occurred and could not provide information about the date or the staff member.Record review of Resident #4's MAR from 2/01/2026 to 2/28/2026 reflected the resident received her Ziprasidone HCl Oral Capsule 60 MG via PEG-Tube two times a day every day (28) for the month of February at 9:00 a.m. and 8 p.m. for schizophrenia.Record review of Resident #4's Physician Progress Note dated 1/14/2026 reflected the resident had a Mental Illness (MI), schizophrenia.physician ordered ziprasidone. Record review of Resident #4's physician's orders, dated 11/06/2025, reflected the resident had the order of Ziprasidone HCl Oral Capsule 60 MG (Ziprasidone HCl) Give 60 mg via PEG-Tube two times a day for Schizophrenia. Record review of Resident #4's hospital Discharge summary dated [DATE], reflected the resident diagnosis list included: Undifferentiated schizophrenia as of 8/5/2023. medications listed Ziprasidone, 60 mg. During an interview on 3/13/2026 at 1:44 p.m., the DON said there was consent in Resident #4's medical record regarding Ziprasidone, but that she was not sure which form was in her medical record and that she would speak with ADON A to investigate this further.During an interview on 3/13/2026 at 2:18 p.m., ADON A said psychotropic medication required consent to administer medications and without one psychotropic medication should not be administered. He said not having the proper psychotropic consent forms in resident's medical record could harm the resident and the care they receive. ADON A said Resident #4's medical record contained the proper psychotropic consent forms. He said Resident #4's psychotropic medication, Ziprasidone did not require the completion of Form 3713, Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment and the facility's standard Psychoactive Consent form in Resident #4's medical record was sufficient for this medication. He said he reached out to the psychiatrist and was informed that Ziprasidone did not require Form 3713.Record review of the facility document titled, Statement of Resident Rights, undated, reflected: (23) Receive Information about prescribed psychoactive medication from the person who prescribes the medication or that person's designee, to have psychoactive medications prescribed and administered In a responsible manner, as mandated by the Health and Safety CODE, 242.505, andto refuse to consent to the prescription of psychoactive medications.Record review of the facility's document titled, Care Plans, Comprehensive Person-Centered dated December 2016 reflected: 5. The resident will be informed of his or her right to participate in his or her treatment.Record review of the facility's document titled, SELF DETERMINATION ACT Resident Policy and Resident Statement undated, reflected: 1. [Facility] recognizes the dignity and value of each resident's life and the right of each resident to make decisions regarding his or her care.Record review of the facility's document titled, Acknowledgement/ Receipt of Privacy Practices undated reflected: [Facility] and my physicians will create and keep a written record of my care. The record will Include my health history, diagnosis, evaluations and test results, medications, treatments, care plan and objectives, and advance directives, If any. The record Is for use in documenting care and treatment provided, planning care, communication among care givers, a source of Information for billing and collection of health care services provided and for assessing the quality of care and services provided.Record review of the facility's document titled, Pharmacy Services Overview dated April 2019 reflected: 9. The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): (4) facility staff roles and responsibilities during the receipt and storage of medication. documentation of processes, as applicable.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 13 residents (Resident #5) reviewed for assessments. The facility failed to ensure Resident #5's quarterly MDS submitted 2/24/2026 accurately reflected that she does not use a restraint device. This failure could result in residents receiving inappropriate care.Findings include: Record review of Resident #5's admission Record dated 3/10/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included other reduced mobility.Record review of Resident #5's quarterly MDS submitted 2/24/2026 reflected a BIMS score of 12, which indicated moderately impaired cognition. Section P0100 reflected Resident #5 used a trunk [torso] restraint on a less than daily basis. Record review of Resident #5's Order Summary Report dated 3/10/2026 did not reveal a physician's order for a restraint device. Record review of Resident #5's Care Plan Report printed 3/10/2026 did not reveal care planning for a restraint device. In an observation on 3/11/2026 at 9:15 AM, Resident #5 was observed in her wheelchair without a trunk restraint. In a subsequent observation and interview on 3/11/2026 at 2:52 PM, Resident #5 was again observed in her wheelchair without a trunk restraint. Resident #5 was unsure if her wheelchair had a seatbelt or other restraining device. In an interview with ADON B on 3/11/2026 at 3:00 PM, he said there were no residents at the facility who used seatbelts or other trunk restraints on their wheelchairs. He said the facility was a restraint-free facility. In an interview with MDS on 3/12/2026 at 1:41 PM, she said Resident #5 does not use any type of restraint, and the information was entered in error. She said she would submit a correction for the submission. A facility policy regarding MDS assessments and/or accuracy of assessments was requested on 3/13/2026 at 10:19 AM but not provided prior to survey exit.

Based on observation, interview, and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 8 residents (Resident #100) reviewed for PASARR services.The facility failed to ensure Resident #100's PASRR Level 1 Screening was completed accurately with mental illness diagnosis to secure a Level 2 Evaluation by the Local Authority.This deficient practice could place residents at risk of not receiving services identified by the local authority.The findings included:Record review of Resident #100's admission record dated 3/13/2026, reflected that he was [AGE] years old admitted on [DATE]. The resident was diagnosed with schizoaffective disorder, bipolar type (mental health condition that combines symptoms of schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves) with manic episodes (period of abnormally elevated, expansive or irritable mood accompanied by increased energy and activity)) bipolar disorder (psychological condition that causes dramatic changes in a person's mood, ability to think clearly, and energy), unspecified (significant, abnormal mood elevations), seizures (sudden surge of abnormal electrical activity in the brain that can affect behavior, movements, sensations, and consciousness), and chronic obstructive pulmonary disease, unspecified (chronic obstructive pulmonary disease, unspecified).Record review of Resident #100's Quarterly MDS dated [DATE], reflected resident had clear speech, had the ability to understand others, BIMS score indicated moderately impaired cognition, Section D: Mood severity score of 0, indicating he had not been observed with a mood disorder, Section E: Behaviors indicated the resident had no behaviors.Section GG: Functional Status reflected the resident was dependent on staff for all ADLs and required 2 person assistance to complete activity. Section I: Active Diagnoses reflected the resident had active diagnoses of bipolar disorder and schizophrenia. Section M skin: reflected the resident was at risk of PU. Resident #100 required the use of a Pressure reducing mattress. Section N: Medications reflected the resident took an antipsychotic and anticonvulsant.Record review of Resident #100's Care Plan dated 8/06/2022 reflected he had impaired thought processes related to schizophrenia [revised 11/11/2025), used antipsychotic medications Risperdal related to schizoaffective disorder, bipolar type [revised 8/06/2022] and resident had a psychosocial well-being mood problem related to schizoaffective disorder, bipolar type [revised 8/06/2022].Record review of Resident #100's Psychiatry Visit Note dated 2/26/2026 reflected the resident had a Mental Illness (MI), schizoaffective disorder and PA ordered Risperdal.During an observation on 3/11/2026 at 11:40 a.m., Resident #100 was not interested in interviewing with surveyor and did not communicate. Resident #100 was observed lying in bed falling asleep, no odor, smell, clean environment. Resident #100's eyes were open, and he turned his head and stared at surveyor and then went back to sleep.During an interview on 3/13/2026 at 4:00 p.m., the MDS Coordinator said Resident #100's PASRR Level 1 Screening did not identify resident as having a PASRR condition and PASRR Level 2 Evaluation was not required. The MDS Coordinator and surveyor completed record review together and MDS said Resident #100 had schizophrenia and bipolar diagnoses and PASRR Level 1 Screening should have triggered positive prompting a Level 2 Evaluation to be performed by the Local Authority (LA). She said she had been auditing files after she was hired on four months back, but there are so many residents to review that she had yet to get to Resident #100's medical record to make changes but would be making changes today and submitting Form 1012 (used in nursing facilities to evaluate residents for mental illness and dementia) to request a PASRR 2 evaluation.Record review of the facility document titled, Rights and Obligations of the Resident undated reflected: MDS Privacy Act Notification, Facility is required by Medicare and Medicaid regulations to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status.Record review of the facility's document titled, Acknowledgement/ Receipt of Privacy Practices undated reflected: [Facility] and my physicians will create and keep a written record of my care. The record will Include my health history, diagnosis, evaluations and test results, medications, treatments, care plan and objectives, and advance directives, If any. The record Is for use in documentingcare and treatment provided, planning care, communication among care givers, a source of Information for billing and collection of health care services provided and for assessing the quality of care and services provided.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 residents (Resident #81) reviewed for care planning. The facility failed to ensure Resident #81's comprehensive care plan accurately reflected the required safety interventions for smoking.This failure could result in residents not receiving the level of intended care. Findings included:Record review of Resident #81's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (a disorder in which a person has difficulty distinguishing reality from hallucinations or delusions). Record review of Resident #81's annual MDS submitted 12/12/2025 reflected a BIMS of 00, which indicated severely impaired cognition. Record review of Resident #81's Smoking Safety Screen dated 2/19/2026 reflected the following:1. notes on safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident require [sic] monitoring while smokingRecord review of Resident #81's Care Plan Report printed 3/10/2026 reflected the following:[Resident #81] is a smoker. Unsafe to smoke. May smoke WITH SUPERVISON [sic] and smoking apron in place. Has been educated on facility smoking policy. Date Initiated: 12/05/202The resident requires a smoking apron while smoking. Date Initiated: 02/18/2026The resident requires SUPERVISION [sic] while smoking. Date Initiated: 02/18/2026In an observation on 3/10/2026 at 3:11 PM, Resident #81 was observed in the designated smoking area of the memory care unit without a smoking apron. In an interview on 3/12/2026 at 10:26 AM, CNA D said that Resident #81 was the only resident who smoked in the male memory care unit, and he did not require a smoking apron. In an interview with ADON A on 3/12/2026 at 1:30 PM, he said Resident #81 did not require a smoking apron. He said Resident #81 had never required a smoking apron, and he was unaware Resident #81's care plan contained the intervention for an apron. He said the care plan should contain accurate interventions to ensure residents receive the intended care.In an interview with MDS on 3/12/2026 at 1:41 PM, she said she was responsible for the care planning related to smoking safety. She was unsure why Resident #81's care plan contained a smoking apron because she said he had never required one. She said the care plan should be accurate to provide care. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised December 2016 reflected the following:9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

Based on observations, interviews, and record review the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #74) residents reviewed for grooming in that: Resident #74 had facial hair on upper lip and chin. This failure could place residents with unwanted facial hair at risk of low self-esteem. The Findings:Record review of Resident #74's admission Record dated 3/13/2026 revealed she was admitted on [DATE], age of 58, and was diagnosed with nicotine dependence, lack of coordination, auditory hallucinations and major depressive disorder. Record review of Resident #74's admission MDS dated [DATE] was documented as impaired vision, usually understood, had a BIMs score of 7/15 (severely cognitively impaired), had hallucinations, she mobilized with a manual wheelchair, and required partial/moderate assistance with personal hygiene (the ability to maintain personal hygiene, including shaving). Record review of Resident #74's care plan dated 1/20/2026 revealed she required personal hygiene, the resident requires assistance by 1 staff with personal hygiene. Observation on 3/10/2026 at 3:57 PM and 3/11/2026 at 3:50 PM with Resident #74 revealed she was outside, sitting in wheelchair and had facial hair on upper lip and on her chin. Observation on 3/11/2026 at 3:50 PM with Resident #74 revealed she was outside, sitting in wheelchair and had facial hair on upper lip and on her chin. Observation on 3/12/2026 at 3:50 PM, ADON B was in Resident #74's room and observed facial hair on the upper lip and chin area. Interview on 3/11/2026 at 3:51 PM, Resident #74 stated she was embarrassed and felt like other resident's stared at her, because of her facial hair. Resident #74 stated she has had facial hair for about 2 weeks. Resident #74 stated the aides do the showers and do the grooming. Resident #74 stated she was not aware of the facial hair and did not ask staff about it. Interview on 3/12/2026 at 4 PM, ADON B stated he was not aware of Resident #74 having facial hair. ADON B stated residents are usually groomed during their showers. ADON B stated he will get the aide to care for Resident #74. Interview on 3/12/2026 at 4:27 PM, CNA G stated she cares for Resident #74's showers/grooming and did not see her facial hair and did not ask if she wanted it to shave off. Interview on 3/13/2026 at 1:30 PM, CNA H stated she did care for Resident #74 and did not notice her facial hair and did not ask her if she wanted to shave. Interview on 3/13/2026 at 2:30 PM, LVN I stated he did care for Resident #74 and had not noticed facial hair on her. Interview on 3/13/2026 at 5:51 PM, the DON stated she was not aware of Resident #74 having facial hair. The DON stated it would cause Resident #74 to be sad, and she might not want to come out of her room. Record review of Policy titled, Dignity dated February 2021 documented, Each resident shall be cared for in a manner that promotes and enhances his of her sense of well-being, level of satisfaction with life, and feelings of self- worth and self-esteem. 1. Residents are treated with dignity and respect at all time. 5. When assisting with care, residents are supported in exercising their rights. For example, residents area. groomed as they with to be groomed (facial hair).

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 13 residents (Resident #81) reviewed for accidents and hazards. The facility failed to ensure Resident #81 was supervised while smoking on 3/10/2026. This failure could result in injury. Findings included: Record review of Resident #81's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (a disorder in which a person has difficulty distinguishing reality from hallucinations or delusions). Record review of Resident #81's annual MDS assessment submitted 12/12/2025 reflected a BIMS of 00, which indicated severely impaired cognition. Record review of Resident #81's Care Plan Report printed 3/10/2026 reflected the following:[Resident #81] is a smoker. Unsafe to smoke. May smoke WITH SUPERVISON [sic] and smoking apron in place. Has been educated on facility smoking policy. Date Initiated: 12/05/202The resident requires a smoking apron while smoking. Date Initiated: 02/18/2026The resident requires SUPERVISION [sic] while smoking. Date Initiated: 02/18/2026 Record review of Resident #81's Smoking Safety Screen dated 2/19/2026 reflected the following:1. notes on safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident require [sic] monitoring while smoking In an observation on 3/10/2026 at 3:11 PM, Resident #81 was observed in the designated smoking area of the memory care unit without staff supervision. The door to the designated smoking area leading into the memory care unit was observed to be propped open at 3:17 PM, and no staff were within eyesight of Resident #81, who was still outside smoking. In an observation and interview at 3:18 PM, CNA D emerged from a closed door and said he was the staff member responsible for supervising Resident #81, but he stepped away to obtain a trash bag from a supply closet. He said Resident #81 finished smoking at the time of the interview, so it was okay to leave him unsupervised. In an interview with ADON A on 3/12/2026 at 1:30 PM, he said Resident #81 requires supervision while smoking. He said staff supervising smokers should be outside directly supervising residents who require supervision while smoking, and the staff should not leave them unattended. Record review of the facility policy titled Smoking/ Vaping/ Electronic Cigarette Policy- Residents revised July 2017 reflected the following: .11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking .

Based on observation, interview, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 residents (Resident #4) reviewed for medically related social services. The facility failed to ensure Resident #4 was assisted in obtaining psychology/psychiatry consultation as ordered by physician on 1/29/2026 and developing interventions that are targeted and meaningful to the resident.This failure could place residents who have a mental illness diagnoses at risk of not receiving needed mental and psychosocial counseling services.Findings included: Record review of Resident #4's admission record dated 3/13/2026, reflected that she was [AGE] years old, initial admission was on 8/27/2025 and she re-admitted on [DATE]. The resident was diagnosed with diabetes mellitus (condition that occurs when the body cannot properly use blood sugar), anxiety (a feeling of worry, nervousness, or unease), and intermittent explosive disorder (mental health condition characterized by sudden, intense outbursts of anger or aggression that are disproportionate to the situation).Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected the resident had clear speech, had the ability to understand others, clear comprehension, BIMS score of 12 indicated moderately impaired cognition, Section D: Mood severity score of 4, indicating that she had been observed with a mood disorder, Section E: Behaviors indicated the resident had no behaviors.Section GG: Functional Status reflected the resident was dependent on staff for substantial/maximal assistance for ADLs and required the use of a wheelchair. Section J: Health Conditions reflected the resident had occasional pain interference with day-to-day activities and was at risk of SOB. Section K Swallowing/Nutritional Status reflected Resident #4 had complaints of difficulty or pain with swallowing. Section M skin: reflected the resident was at risk of PU. Resident #4 required the use of a pressure reducing mattress, and application of ointments. Section N: Medications reflected the resident took an antipsychotic, antidepressant, opioid, and hypoglycemic.Record review of Resident #4's Care Plan dated 8/28/2025 and revised 11/06/2025 reflected she had an ADL self-care performance deficit related to disease process, used psychotropic/antipsychotic medications (Ziprasidone HCI) related to intermittent explosive disorder and antidepressant medication (Sertraline and Trazodone) related to Depression/Insomnia and resident had a psychosocial well-being problem related to anxiety, Dependent behavior, Disease Process, worsening condition, nursing home placement. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability.Record review of Resident #4's physician orders dated 11/06/2025 Ziprasidone HCl Give 60 mg via PEG-Tube two times a day for Schizophrenia.Sertraline HCl Oral Tablet 100 MG Give 1 tablet via PEG-Tube in the morning for antidepressant.Monitoring -ANTIDEPRESSANTS.physician orders dated 12/13/2025 Behavior Monitoring -ANTIDEPRESSANTS. Behavior Monitoring -ANTIPSYCHOTIC.physician orders dated 1/29/2026 Behavior Monitoring -SEDATIVE/HYPNOTICS. physician orders dated 3/10/2026 Behavior Monitoring -ANTIANXIETY. Side Effect Monitoring -ANTIANXIETY.Record review of Resident #4's Psychoactive Consent dated 3/04/2026 reflected that she was prescribed psychoactive medication: Geodon 60 mg BID, antipsychotic to target behaviors: delusions, paranoia, hallucinations for diagnosis of intermittent explosive disorder.Record review of Resident #4's Consent for Antipsychotic or Neuroleptic Medication Treatment 3713 Form dated 8/27/2025 reflected her diagnosis was based on the following diagnostic criteria and assessment findings exhibited: psychotic behavior and the course of therapy with antipsychotic or neuroleptic medication is proposed with the following medication, dosage, and frequency: Risperidone 60 mg BID.Record review of Resident #4's Progress Note dated 1/29/2026 reflected the NP's ASSESSMENT/PLAN: Encourage alternative medications, nursing and psychology techniques for anxiety and sleep management. - Consider psychology/psychiatry consult as needed.Record review of Resident #4's Physician Progress Note dated 1/14/2026 reflected the resident had a Mental Illness (MI), schizophrenia.physician ordered ziprasidone. Record review of Resident #4's hospital Discharge summary dated [DATE] reflected diagnosis list included: Undifferentiated schizophrenia as of 8/5/2023. medications listed Ziprasidone, 60 mg, Oral, BID with meals.During an observation and interview on 3/11/2026 at 11:22 a.m. of Resident #4, was observed in the hallway heading towards her room ambulating in her manual wheelchair. She was dressed well, groomed appropriately, and had no odors. She was upset and said an employee stole her money from her bank and she reported it to the ADM and SW. She said the staff who stole her money was hiding in the restroom and constantly laughed at her. It was difficult to understand and keep up with Resident #4's memory and events. She was unable to keep a clear conversation, and she would lose her train of thought. She said the theft was reported to the management team, they filed a report and are investigating it. She stated she was unable to recall when the theft occurred, and she could not provide information about the date or the staff member.During an interview and record review on 3/13/2026 at 2:47 p.m. with the MDS Coordinator, she said she had been employed for four months at the facility and training on entering diagnoses for new admissions, MDS assessments, PASRR screenings, PASRR evaluations, and care plan revisions were provided by the regional staff and from online self-pace webinars. She said inaccuracy of medical records could be a problem for residents and the care they receive. She said Resident #4 did not have a MI or related condition at the time of admission and her Level I screening was negative. However, a referral was made to the appropriate state-designated authority for a Level II PASARR evaluation, and the determination of no services needed. The MDS Coordinator reviewed Resident #4's initial facility admission records, hospital discharge summary, diagnosis list, and psychiatric medication orders she admitted with, and said Resident #4 did not have a valid diagnosis of schizophrenia as she was trained that unless the supporting documentation was coming from a psychiatrist, it could not be used as a diagnosis. MDS Coordinator and surveyor reviewed Resident #4's hospital Discharge summary dated [DATE] listing Undifferentiated schizophrenia diagnosis as of 8/5/2023 and medication ordered for treatment, Ziprasidone 60 mg, and physician orders dated 11/06/2025 for Ziprasidone HCl Give 60 mg via PEG-Tube two times a day for Schizophrenia, the MDS Coordinator said after reviewing all these documents together, she believed an error in Resident #4's medical diagnosis was made. She said Resident #4's diagnoses at admission should have included MI diagnosis, schizophrenia, and should have been listed on the resident's assessment and care plan.During an interview on 3/13/2026 at 3:18 p.m., the DON said she did not know Resident #4 had a MI diagnosis of schizophrenia. She said she would need to check with psych services as to why an evaluation and follow up had not been completed for Resident #4 as ordered by the physician.During an interview on 3/13/2026 at 4:23 p.m., the DON said physician order to evaluate and treat for psych services was written, and the nursing staff is responsible for writing referrals for psych evaluation and the SW sends the referral over to the psych agency. She said SW had been employed for less than a month and believed the referral may have been lost and it was not sent over to the psych agency. She said the referral was sent over to psych services on 3/13/2026. She said the MDS Coordinator is responsible for reviewing resident electronic medical record for medical history and inputting an accurate diagnosis. After reviewing the initial admission record for Resident #4, the DON said the medical record sources documenting diagnoses and mediation orders treating schizophrenia would have been sufficient to list diagnoses in Resident #4's medical record. She said the medical record sources do not need to come from a psychiatrist. She said this error would cause the resident's assessment and care plan to not include a significant diagnosis, which could cause the resident to not receive the necessary services. During an interview on 3/13/2026 at 6:47 p.m., the SW said he had been employed with the facility for less than one month. He said he had not been given the responsibility of submitting psych referrals and was not given a psych referral for Resident #4. Record review of the facility document titled, Care Plans, Comprehensive Person-Centered dated December 2016 reflected: A 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. 1 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 comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; m. aid in preventing or reducing decline in the resident's functional status and/or functional levels; o. reflect currently recognized standards of practice for problem areas and conditions. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. b. The resident's physician (or primary healthcare provider) is integral to this process.Record review of the facility's undated document titled, Rights and Obligations of the Resident reflected: MDS Privacy Act Notification, Facility is required by Medicare and Medicaid regulations to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status.Record review of the facility's undated document titled, Acknowledgement/ Receipt of Privacy Practices reflected: [Facility] and my physicians will create and keep a written record of my care. The record will Include my health history, diagnosis, evaluations and test results, medications, treatments, care plan and objectives, and advance directives, If any. The record Is for use in documenting care and treatment provided, planning care, communication among care givers, a source of Information for billing and collection of health care services provided and for assessing the quality of care and services provided.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (R #2) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #2 to prevent an act of sexual abuse on 05/04/2024 by R#1. On 05/04/24 around 9:30 PM, R #1, intoxicated and aggressive, was not monitored and left unsupervised in his room for 15 minutes. R #1 left his room and was found at 9:45 PM by CNA C engaged in a sexual act with R#2 (non-consenting adult). R#1 had undressed R#2's top and engaged in sucking her breast. The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for sexual abuse, suffering injury, a diminished quality of life, psychosocial harm, and/or death. The findings were: Record review of R #1's EMR and face sheet, dated 12/02/24, reflected an admitted [DATE], readmitted [DATE], discharged [DATE] with diagnoses that included: alcohol abuse with alcohol induced anxiety disorder, alcohol use, major depressive disorder, lack of coordination, and difficulty in walking. The resident was a male age [AGE] years old. Resident #1 was his own RP and had a family listed as an emergency contact. Record review of R# 1's Care Plan, dated 04/05/24, did not include the resident drank alcohol. Record review of R#1's MDS, dated [DATE], reflected: the resident's BIMS Score was 15 (cognitively intact). ADLs included: R #1 had a urostomy and was occasionally incontinent of bowel. Range of motion was upper extremity no impairment, lower extremity impairment on one side. R #1 utilized a wheelchair. Independent with walking/transfers (01/20/24 MDS). Record review of R#1's order summary dated 05/06/24 reflected: diagnoses given to the resident included Alcohol Abuse with alcohol-induced anxiety .Alcohol Use, unspecified with unspecified alcohol-induced disorder . No orders were present involving any interventions for alcohol abuse or use. No order to stop medications when the resident was actively drinking. Order existed for managing anxiety and depression. Resident had order for anxiety (Duloxetine 30 mg 1 tab for Major Depression). Record review of R#2's EMR and face sheet, dated 12/02/24, reflected an admitted [DATE] and re-admission 07/19/23 with diagnoses that included: dementia unspecified severity with other behavioral disturbance, anxiety disorder, need for assistance with personal care, seizures, depression, and history of falling. The resident was a female age [AGE] years old. Resident #2 was listed as her own RP. Record review of R#2's Care Plan, dated 09/26/24, revealed, the goals and interventions included: (hospice care) dementia and administer medications as scheduled, ADL self-care deficit, impaired cognitive function/impaired thought processes related to dementia-administer medications as ordered and keep the routine consistent and try to provide consistent care givers as much as possible to decrease confusion. R#2 had communication problem related to cognition and senile degeneration of brain. R #2 also had impaired visual function. Record review of R#2 's MDS, dated [DATE], reflected: BIMS Score was 00 (severe impairment). ADLs were listed as always incontinent. Transfer and bed Mobility were dependent on staff assistance. ROM was listed as no impairment. Record review of facility's Form 3613 dated 05/10/24 reflected: Incident: R#1went into R#2's room and was witnessed making sexual contact on R#2's breast. R#2 was assessed with no injuries or psychosocial trauma. R#1 was placed on one-to-one monitoring pending arrest by law enforcement. R#1 was arrested for public intoxication and immediately discharged from the facility. Form 3613 read, [R#1] was issued a citation for coming in contact with [R#2's] breast while she was sleeping. Record review of R#1's nurse note dated 5/5/24 authored LVN B reflected: law enforcement was called and Case # assigned (SAPD 24097970 officer #1786). R#2 was arrested for PI. Record review of R#2's nurse note dated 05/04/24 at 10:50 PM, authored by LVN B, reflected resident was assessed and no negative findings. Q 15 minutes checks were initiated. Record review of R#2's 72-hour 15 minutes monitoring sheet revealed checks were done every 15 minutes from 5/04/24 to 5/06/24 every shift. Record review of R#2's nurse note dated 05/05/24 authored by LVN B reflected resident was sent to the ER for an assessment and returned the same day. Observation and interview on 12/02/24 at 2:30 PM, R#2 was in bed, not alert or oriented. Music playing as an activity. Resident yelled out noises with no meaning. Resident could not answer any direct questions. Resident did not recognize or acknowledged the presence of the surveyor in the room. During an interview on 12/02/24 at 2:45 PM, Hospice LVN D stated: the resident was under hospice care for senile degeneration of the brain since May 2024 LVN D stated the resident was unable to protect herself or yell out for help. LVN D stated that another resident [R#1] walked into her room in the past [05/04/24], and the resident [R#2] was sent to the ER for an evaluation involving an allegation of sexual abuse. During an interview on 12/02/24 at 3:15 PM, LVN E stated, nursing practice was to notify the MD and law enforcement when a resident was belligerent, under the influence, and refused an assessment. LVN E stated that a belligerent resident who could be a danger to self or others would need close monitoring pending new orders from the MD; and any directions from law enforcement. During an interview on 12/02/24 at 4:44 PM, the DON stated: she did not know what nurse allowed R#1 who was intoxicated to enter the facility on 05/04/24. The DON stated that the nursing practice for an intoxicated resident was to check vitals, call MD for guidance and monitor the resident for vital sign, and changes and behaviors. The DON stated that resident had to be monitored; but she could not give an explanation why R#1 was not monitored for a lapse of 10-15 minutes on 5/4/24 from 9:30 PM-9:45 PM. During an interview on 12/03/24 at 9:20 AM, LVN D stated she got a call from either LVN E or the DON that R#1 was found in R#2's room and suckling R#2's nipple or breast. LVN D stated by nursing practice the nurse that escorted the resident to the room should had maintain visual contact of the resident pending MD or nurse management guidance. During a telephone interview on 12/03/24 at 9:55 AM, LVN B stated: R#1 returned late at night intoxicated by himself and LVN A let him in the facility. LVN B stated, no assessment outside the facility was done because resident was belligerent. LVN B stated, whenever a resident was drinking an assessment was required; but the resident refused. LVN B sated, We took him [R#1] to his room and call 911 and the MD, because the resident was belligerent and refused an assessment. By the time the police came the resident was not in his room. [ CNA C] found him in another room performing an inappropriate sexual act. LVN B stated I had to do documentation and lost sight of the resident. When the law enforcement arrived, it was when we realized the resident was missing It was 15 minutes I lost sight of the resident. LVN stated, that through hindsight she would have had the other nurse [LVN A] watch over R#1. During an interview on 12/03/24 at 11:00 AM, the Administrator stated: HHS was contacted on 05/04/24 at 11:45 PM; incident occurred on 05/04/24 at 10:30 PM. The Administrator stated the Incident involved R #1 going into R#2's 's room and was witnessed making sexual contact on R#2's breast. R#2 was assessed with no injuries or psychosocial trauma. The Administrator stated R#1 was placed on one-to-one monitoring pending arrest by law enforcement. The Administrator stated that an assessment needed to be completed when a resident returned intoxicated or smelled of alcohol and it required that the MD was notified. The Administrator stated that monitoring of a resident did not require constant visual contact and every two hours check on the resident was nursing practice. The Administrator stated that R#1 had issues with alcohol. The Administrator stated that it was not the first time the resident appeared to use alcohol in the past; but the resident was not a sexual predator. The Administrator stated that in the past the facility would allow the resident back into his room; but there were no documented interventions for R#1's use of alcohol. The Administrator stated the nursing staff based on history believed the resident would remain in his room. The Administrator stated, It did not rise to the level of one-on-one .we let him stay in his room .cannot explain what was going through his head .there was no indication he was going to do this . The Administrator stated that there was no indication that R#1was a danger to self or others requiring constant one on one monitoring. The Administrator stated, after the incident preventative measures put in place included: non-verbal residents were assigned roommates; R#1 was arrested. Staff completed 100 % in-service on abuse and neglect. The Administrator stated a head-to-toe assessment was done on all non-verbal residents. R#1 was assigned a temporary roommate and moved closer to the nurse station. During telephone interview on 12/03/24 at 2:25 PM, Law Enforcement Officer F stated that R#1 was arrested on 05/04/24 for public intoxication and was a suspect for sexual abuse of R#2. During telephone interview on 12/03/24 at 5:00 PM, LVN A stated the timeline was: she and LVN B escorted R#1 into the facility on [DATE] around 8:30 PM. R#1 was intoxicated and belligerent and refused an assessment. The ADON [LVN E] and MD were called. The ADON recommended to LVN A and LVN B to call law enforcement. Pending the arrival of law enforcement R#1 was taken to his room in Hall 300. LVN A stated that she returned to her duties in another hall and expected LVN B to monitor R#1. LVN A stated that when the resident [R#1] was not found in his room around 9:30 PM, she participated in the search of R#1. LVN A stated that around 9:45 PM, R#1 was found in R#2's room by CNA C. During a telephone interview on 12/4/24 at 8:00 PM, CNA C, (employed for 9 weeks), stated,: on 05/4/24 she was in another hall doing ADL care for a resident. She responded to LVN A's request at 9:30 PM to assist in the search for R#1 in Hall 300. CNA C stated she found R#1, at 9:45 PM, in R#2's room kneeling on the floor mat and having in his mouth R#2's breast. CNA C startled R#1 and he stopped the behavior and said nothing about the incident. CNA C requested nursing assistance and R#1 was escorted to his room and monitored one-on-one until law enforcement arrived. Record review of written statement dated 05/04/24 authored by CNA C stated: around 9:30 PM, LVN A walked in the facility with paramedics in search of R#1. LVN A stated that R#1 was not in his room (room [ROOM NUMBER]) and a search was started and R#1 was found in R#2's room where I (CNA C) witnessed [R#2] asleep in bed with her eyes closed and [R#1] on his knees on the floor mat kneeling over [R#2] with her shirt up .I loudly said, what are you doing? [R#1] at this time removed his mouth off [R#2's] left breast . LVN A and LVN B were informed of the incident. CNA C stayed with R#1 until he was escorted by the police out of the facility. Record review of LVN B's written statement undated reflected: R#1 was escorted to facility by [LVN A] given the resident had fallen outside. R#1 was under the influence of alcohol and refused an assessment and was belligerent. LVN B called the ADON and was directed to call 911. LVN B stated, By the time the police arrived, and fire dept. arrived patient went out of his room. The resident was found in R#2's room. Record review of R#1's Nurse note dated 05/05/24 by LVN B repeated the same information as the written statement namely: R#1 was escorted to facility by [LVN A] given the resident had fallen outside. R#1 was under the influence of alcohol and refused an assessment and was belligerent. LVN B called the ADON and was directed to call 911. LVN B stated, By the time the police arrived, and fire dept. arrived patient went out of his room. The resident was found in R#2's room. Observation on 12/05/24 at 1:45 PM to 1:52 PM of Snap shots from the Administrator's iPhone reflected that at 20:30 (8:30 PM) R#1 was at the nurse station near hall 300. Next snapshot reflected that R#1 came out of his room at 21:27 (9:27 PM). No other snapshots were provided by the Administrator after R#1 exited his room at 9:27 PM. During an interview on 12.05/24 at 1:52 PM, after observing the snap shots with the administrator, the administrator stated: from 8:30 PM to 9:27 PM the resident was being monitored by nursing staff. The Administrator stated that based on the CNA's note (CNA C) the resident had left his room between 9:30 PM to 9:45 PM. Administrated stated, based on CNA C's written statement, R#1 was found at 9:45 PM in R#2's room involved in an inappropriate sexual behavior. The Administrator stated that no documentation existed that the facility did 15-minute checks from 8:30 PM to 9:27 PM. [surveyor requested evidence that 15-minute checks were done and documented on 05/04/24 because the facility stated 15 minutes checked were done.]. Record review of the facility's Abuse policy dated April 2001 read: 2. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. a Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. c. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . 3. Sexual abuse is non-consensual sexual conduct of any type with a resident. a. Sexual contact with a resident who lacks the cognitive ability to consent is considered non-consensual and therefore, constitutes abuse. b. Consent that is obtained through intimidation, coercion or fear is not valid. c. The resident's capacity to consent to sexual conduct is carefully evaluated as part of the initial assessment and care planning process. Verification of PNC Observation on 12/05/24 at 9:50 AM, R#2 was in her room, door open, sitting on a special W/C facing TV (TV was on). R#2 was not alert or oriented. Resident was clean, no smell of odors. There was no signs of pain or distress. Resident did not have a roommate. Observation on 12/05/24 from 3:00 PM-3:15 PM reflected three residents with dementia and a BIMS of zero and could not communicate had a roommate that was alert and oriented. During interviews on 12/03/24 from 11:00 AM to 12/04/24 to 9:30 AM, 9 day shift staff 1 (7 AM-3 PM) (1 SW, 5 LVN, 2 CNA, and 1 Housekeeper), and 2 staff evening shift (3 PM-11PM) and 2 nigh shift staff (2 LVN) reflected return demonstration on abuse and neglect with the highlight to report any act or suspicion of abuse or neglect to the Abuse Coordinator, the Administrator. Record review of facility's investigation file reflected: HHS contacted on 5/4/24 at 11:45 PM; incident occurred on 05/05/24 at 10:30 PM. t R#2 was assessed and showed no signs and symptoms of injuries or change of conditions or behaviors. R#1 was immediately discharged from the facility. Inservice training was started 05/05/24 and ended 11/25/24. Police report # 24097970 was present; type of offense was PI. Head to toe assessment for all non-interview-able residents was completed. Interview with all verbal residents reflect no abuse. Lastly, alert, and oriented residents were placed with residents with dementia that could not communicate. Record review of R#1's nurse note dated 5/5/24 authored LVN B reflected: law enforcement was called and Case # assigned (SAPD 24097970 officer #1786). R#2 was arrested for PI. Record review of R#2's nurse note dated 05/04/24 at 10:50 PM, authored by LVN B, reflected resident was assessed and no negative findings. Q 15 minutes checks were initiated. Record review of R#2's 72-hour 15 minutes monitoring sheet revealed checks were done every 15 minutes from 5/04/24 to 5/06/24 every shift. Record review of R#2's nurse note dated 05/05/24 authored by LVN B reflected resident was sent to the ER for an assessment and returned the same day. Record review of R#2's skin assessments dated 05/01/24 and 05/06/24 reflected skin intact. Record review of R#2's pain assessment dated [DATE] reflected no distress, pain, or discomfort. Record review of facility's assessment of resident safety sheets dated 05/04/24 reflected that 10 interview-able residents were interviewed, and all felt safe. Record review of facility's staff roster dated 12/02/24 reflected 158 employees. Record review of facility's abuse/neglect signed in sheets reflected 100 % of staff attended the training from 05/05/24 to 11/25/25 [total staff on 12/02/24 was 158]. Record review of list provided by facility on 12/05/24 reflected three alert and oriented residents were placed with residents with dementia and a BIMs of zero and could not communicate. R#2 had no roommate. Record review of facility's Abuse, neglect, Exploitation or Misappropriation policy, dated revised April 2021, reflected one was present and in effect and required staff to report incidents or suspicion of abuse and/or neglect. The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. The facility had corrected the non-compliance before the survey began. At exit, the Administrator did not provide written evidence that on 05/04/24 from 8:30 PM to 9:27 PM the facility documented 15-minute checks for R#1 while resident was in his room.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care, in that; The facility failed to ensure Resident #1 received a wound vac or wound care for a surgical wound as ordered by a physician which resulted in re-hospitalization of the resident on 11/15/2021. These failures resulted in identification of Immediate Jeopardy (IJ) on 11/16/2021. While the immediacy was removed on 11/24/2021, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This deficient practice affected residents with surgical wounds and resulted in re-hospitalization for one resident and had the potential to result in development of infection, [CONDITION(S)], and pain and a decline in health. The findings were: Record review of Resident #1's face sheet, dated 11/ 21 revealed a [AGE] year-old male admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's discharge hospital records dated 11/12/2021 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge instruction: standard skin and wound vac monitoring and care Equipment and supplies: wound vac, change 3 times a week, call surgeon for any concerns. Record review of a local hospital Service Agreement dated 11/12/2021 between the local hospital and the nursing facility for Resident #1 revealed: -Article I Services and Covenants of Facility: The Provider (nursing facility) will provide patient (Resident #1) with the following nursing care services including, but not limited to: A high-level and quality of inpatient, skilled nursing services to patients as provider offers to its other patients, without discriminating on the basis of source of payment, gender, nationality ethnicity, age or disability. Coordination of medication of medical services with the patient's healthcare providers when his condition warrants. Medications, prescription and over the counter. Record review of Resident #1's Skilled Nurses Note, dated 11/12/2021 at 10:30 pm revealed Resident #1 was alert and oriented x 4 (person, place, time and situation and indicated the resident was cognitively intact). Further review of Section G Skin/Wound revealed Resident #1 had no new changes to skin integrity. Wound Care was left blank and not filled in and the surgical wound was not documented. Signed by LVN G. Record review of Resident #1's consolidated physician orders for November 2021 revealed the order dated 11/12/2021 to admit Resident #1 to the facility. Further review revealed the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Deliver(y) Ticket-Wound Vac for Resident #1 dated 11/12/2021 revealed the wound vac was delivered to the facility on [DATE] (unknown time) to ADON C. Record review of Resident #1's progress notes: -11/12/2021 at 2:46 pm revealed Resident #1 arrived at the facility via wheelchair from a local hospital with an abdominal wound due to abdominal surgery pending wound vac delivery. Notify physician of increased pain, swelling, redness, tenderness, bleeding, fevers, confusion, constipation and diarrhea. Signed by Agency Staff D. -11/12/2021 at 6:01 pm revealed Resident #1 arrived at the facility around 3:00 pm . Signed by MDS Coordinator --11/15/2021 at 11:37 a.m. revealed Removed dressing to abdominal incision/surgical site. Noted large amount of dark red drainage, foul odor noted, cleansed site gently with normal saline, noted stapled clean dry and intact and 2 areas of wound dehiscence (unintentional opening of surgical wound). #1 superior site noted yellow eschar inside wound bed, #2 inferior wound bed yellow eschar noted/black eschar. Applied wound vac as per physician order. Foam firm and compressed at 125 mm/hg. Signed by LVN F (Agency). Record review of a 24-hour Nurses Report/Change of Condition Report (undated) revealed: Resident #1: .Pending a vac for abdominal wound. Record review of a 24-hour Nurses Report/Change of Condition Report dated 11/14/2021 revealed: Resident #1: pending wound vac. Wound Nurse to place initial dressing. Signed by RN D. Record review of Resident #1's initial Care Plan initiated on 11/15/2021 revealed a plan of care for a surgical wound to the abdomen with interventions to include a continuous abdominal wound vac set at 125 mm/hg changed Monday, Wednesday and Friday and as needed for soiling on every shift. Record review of Resident #1's TAR (Treatment Administration Record) revealed a physician's order for Abdominal Wound Vac c125 mm/hg continuous. Change Monday, Wednesday and Friday and PRN (as needed) for soiling, once a day on day shift for surgical abdominal wound with a start date of 11/16/2021 (after discharge). Further review revealed there was no evidence of wound care or wound vac application documented on the TAR. During an observation on 11/15/2021 at 1:00 pm Resident #1 was observed sitting on the edge of a chair alone in the Social Workers office. During an observation on 11/15/2021 at 1:10 p.m., Resident #1 was observed sitting on the edge of the chair in the Social Workers office. The resident was wearing a white abdominal binder under his clothing that covered his abdomen. There was a dark red/brown stain consistent with dried blood that was approximately 6 inches long and 3 inches high. A wound vac was observed on a desk nearby connected by tubing to the resident. Resident #1 declined direct observation of the wound at this time. During an observation on 11/15/2021 at 2:45 pm Resident #1 was observed sitting in a chair with the Social Worker seated nearby in the SW office. During an interview on 11/15/2021 at 12:10 p.m., the Administrator stated Resident #1 had stated he didn't feel safe in the facility and had complained he didn't get a wound vac applied over the weekend. The Administrator stated because Resident #1 had indicated he didn't feel safe he sent the SW to check on the resident and was now sitting in the SW office. During an interview on 11/15/2021 12:55 a.m. Charge Nurse, LVN F confirmed wound care including application of a wound vac was not completed over the weekend (11/12/2021-11/14/2021). LVN F stated Resident #1 had many issues with care over the weekend. She stated she notified ADON C on Monday 11/15/2021, who then retrieved the wound care supplies which had been located in the Wound Care Nurses office, and LVN F applied the wound vac to Resident #1. LVN F stated the wound supplies and wound vac had been in the building over the weekend but staff were not supposed to go into the wound care office. LVN F stated she thought the incident was a result of miscommunication between staff members. During an interview on 11/15/2021 at 1:02 p.m. in the SW office, Resident #1 stated he wasn't feeling well and had anxiety because he had not received treatment to his wound since he had been admitted and wanted to leave the facility because he did not feel safe. Resident #1 stated he did not receive a wound vac application or wound care to his abdominal surgical wound over the weekend like he was supposed to. He further stated he had a surgical wound to his abdomen because he had an intestinal blockage. Resident #1 stated he arrived at the nursing facility on Friday (11/12/2021) with a wound that was well dressed from the hospital with no drainage noted. He stated the Wound Care Nurse said supplies for the wound had been ordered. Resident #1 said on Sunday he saw quite a bit of discharge on the abdominal binder covering the wound dressing. He also noted an odor but thought it was body odor at the time. Resident #1 stated he told the nurse on duty on 11/15/2021 when she came in. The nurse (LVN F) told him it was unacceptable and that problems could arrive from uncleanliness. Resident #1 stated he did not inform nursing staff of the wound care issues over the weekend because he did not feel safe. He stated during the weekend he overheard staff, identified as ADON C in the hallway talking and they referred to him as a Drama Queen. Resident #1 stated I am in no position to protect myself. He further stated he had doctor's orders to return to the hospital. During an interview on 11/15/2021 at 2:06 p.m. the SW stated Resident #1 was leaving at 3:00 p.m. via private ambulance transport service and would be direct admit to a local hospital. She stated Resident #1 requested to remain in the SW office. During further interview on 11/15/2021 at 2:08 p.m., LVN F described Resident #1's surgical wound as an approximate 6 inches in length midline abdominal incision which included the belly button and was closed with surgical staples. Two areas of the incision were open, with clean shaped circular opening that looked intentional and did not have sutures. LVN F stated she initially thought the open areas were areas of dehiscence (wound that has opened up or burst open and can be a sign of infection), but she wasn't sure because that specific area did not contain staples. LVN F stated the dressing covering the incision was observed as dirty and saturated with a moderate amount of dark red old blood which had a foul odor and inside the wound bed were wet gauze. She stated the dressing was dated 11/12/202. LVN F stated she had spoken with Resident #1's surgeon was not happy about the lack of wound care and lack of wound vac application. She stated the surgeon asked, He was there for wound care and he didn't get it? During an interview on 11/15/2021 at 2:31 p.m. with Resident #1's oncological (cancer) surgeon stated he had spoken with Resident #1 and nurse (identified as LVN F) at the nursing home facility on 11/15/2021. The Surgeon stated he was informed Resident #1 did not have application of a wound vac and did not receive wound care while at the nursing home. The surgeon stated he was told the wound vac was not applied. He further stated if the facility did not have immediate access to a wound vac, a wet to dry dressing change should have been completed. The Surgeon stated Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He further stated the reason for the wound vac was for initiate rapid healing of the surgical wound. The Surgeon stated Resident #1 could not have [CONDITION(S)] until his wound had healed and the longer the resident waited to receive [CONDITION(S)], the further it put his health at risk. The Surgeon confirmed Resident #1 would need to be readmitted to the hospital for wound care and stated it was substandard care if the resident did not receive wound care for several days. The Surgeon stated the substandard care put Resident #1's health at risk. He stated when Resident #1 was discharged from the hospital with a clean wound with no [CONDITION(S)]. The Surgeon once again stressed that leaving the wound undressed was dangerous for Resident #1's health. During an interview on 11/15/2021 at 2:50 p.m., the Administrator stated he checked on Resident #1 over the weekend and Resident #1 did not mention concerns and the resident did not mention he did not have a wound vac. He further stated the newly hired, soon to be DON was in the facility over the weekend but did not see Resident #1 to his knowledge, but he was still waiting for her official report from the weekend. The Administrator state no staff reported concerns for Resident #1's wound vac. He further stated, on Monday morning 11/15/2021 Resident #1 stated he did not feel safe. When asked to elaborate on why Resident #1 did not feel safe the Administrator stated Resident #1 had been in contact with his physician and was currently sitting in the SW office. During an interview on 11/15/2021 at 3:59 p.m., the Wound Care Nurse confirmed Resident #1 did not receive wound care treatment including application of a wound vac as ordered by a physician on 11/12/2021 until 11/15/2021. The Wound Care Nurse stated she was new to the Wound Care position and had only worked for two weeks caring for wounds. She stated she had worked as a PRN LVN and had not received formal training in wound care. The Wound Care Nurse stated on Thursday 11/11/2021 she learned she was receiving a patient with a wound vac. She stated she notified ADON A and ADON B that she didn't know how to use or place a wound vac and had never had a patient with one. She further stated the facility did not have a DON. She stated the facility did not have a wound vac in-house and one had to be ordered. The Wound Care Nurse stated she did not know who ordered the vac or where it was ordered from. She stated when she left the faciity on Friday, 11/12/2021 at 5:30 p.m. the vac was not there. The Wound Care Nurse stated she was on-call for the weekend and on Saturday 11/13/2021 she came to the facility at 4:30 pm to work at a floor nurse. She stated a nurse (unknown name) informed her Resident #1 did not have the wound vac on. She stated she located the wound vac in her office and asked the RN on duty (RN D) if she could help by putting on the wound vac. The Wound Care Nurse stated she told RN D she didn't know how to put the wound vac on and asked her to do it. The Wound Care Nurse stated she went to see Resident #1 but did not assess the wound because she did not feel comfortable removing the dressing without applying the wound vac. She stated the area around the wound not covered by the dressing looked fine and the dressing was clean and dry. She stated when she left the resident room, she told RN D there was another nurse on duty with her and suggested RN D ask the other nurse for assistance. The Wound Care Nurse stated she found out on 11/15/2021 the wound vac was never put on Resident #1. The Wound Care Nurse stated when she told ADON A she didn't know how to apply a wound vac, ADON A indicated she would show her how to do it because she had been the Wound Care Nurse at the facility at a previous time. The Wound Care nurse stated ADON B did not respond when told she didn't know how to apply a wound vac. The Wound Care nurse stated she never reviewed the physician orders for wound care for Resident #1 but was told on Friday 11/12/2021 he had wet to dry dressing changes but did not remember who told her. The Wound Care nurse confirmed she did not notify the physician that the wound vac was not in the facility or that she was unable to apply the vac. She stated she did not have wound care experience and had not been trained. She stated she had never run across this type of issue and just hoped someone would help her out. The Wound Care nurse stated in her absence the floor nurses were responsible for wound care. During an interview on 11/15/2021 at 4:29 pm ADON A stated on Thursday 11/11/2021 she received a referral that had been approved by Corporate for the admission of Resident #1. She stated that evening she ordered a wound vac from a local medical supply company. ADON A confirmed the wound vac arrived at the facility on Friday, 11/12/2021 but was unsure what time it arrived. She stated to her knowledge no one signed for the delivery. ADON A confirmed the Wound Care nurse had informed her she did not know how to apply the wound vac and had never done a wound vac before. The ADON stated she told the Wound Care nurse she would talk her through the procedure, but the Wound Care nurse stated she would feel more comfortable if someone was with her the first time. ADON A stated Resident #1's evening nurse was an RN (unknown name, identified as RN D) and had experience with wound vacs. ADON A stated she knew the Agency RN had experience with wound vacs because she heard her talking about it before. ADON A stated she left for the day on Friday and then heard on Monday 11/15/2021 that the wound vac was never placed. ADON A stated within minutes of hearing the wound vac was not on Resident #1 ADON C and Agency LVN F placed the vac on the resident. ADON A stated she never observed or assessed Resident #1's wound and had not even met the resident until Monday, 11/15/2021. ADON A stated the Wound Care nurse was responsible for wound care Monday thru Friday from 8-5 pm. She further stated if the Wound Care nurse is not in the facility the floor charge nurse would be responsible regardless of shift worked. ADON A confirmed Resident #1 should have receive dressing changes of wet to dry as an alternate to having a wound vac. She stated it was the responsibility of the admitting nurse (RN D) to get a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON A confirmed she had not received Resident #1's medical record and did not know what his wound care orders were but stated ADON B was aware of the orders. ADON A confirmed the facility did not have a DON. During an interview on 11/15/2021 at 4:48 p.m., ADON B stated she was aware that Resident #1 was going to be admitted to the facility and needed a wound vac. She stated she did not observe or assess Resident #1's wound and did not assist with the wound vac because each unit was assigned a different ADON and Resident #1 was not her resident to check on. She stated ADON C was assigned to Resident #1 unit. ADON B stated she did participate in a discussion with the other two ADON's and the Wound Care nurse about Resident #1's wound vac. In that discussion, the Wound Care nurse stated she did not know how to apply a wound vac and was going to let ADON A teach her how. ADON B stated she told the Wound Care nurse to call the wound care NP (Nurse Practitioner) for assistance. ADON B stated Resident #1 was not currently receiving wound care services from the wound care NP but felt like he was available to the facility for assistance and it was the reasonable thing to do. ADON B stated the floor charge nurses were responsible for new admissions and they can call the NP or physician for orders. ADON B stated the Wound Care nurse should have found someone else who knew how to apply the wound vac to do it. ADON stated the facility had hired a new DON but she wasn't working at the facility as the newly hired (with anticipated start date of 12/06/2021) DON but would pop in and out of the facility from time to time. During an interview on 11/15/2021 at 5:06 pm the CCO approached this surveyor and stated he intended to terminate ADON C's employment at the facility after she was interviewed. The CCO stated he was terminating her employment because he looked up Resident #1's orders for wound care and no orders were placed into the computer by her at admission. He further stated he had confirmed ADON C had signed for the wound vac on Friday, 11/12/2021 when it was delivered. During an interview on 11/15/2021 at 5:12 p.m., ADON C confirmed Resident #1 did not receive application of a physician ordered wound vac or wound care since admission to the facility. ADON C stated Resident #1 arrived at 4:15 on Friday 11/12/2021. She stated and Agency RN, identified as RN D was assigned as charge nurse for Resident #1 and was responsible for the admission. ADON C stated RN D stated she didn't need anything, so ADON C left the facility for the day. ADON C stated, although she herself know how to apply a wound vac, it was Friday evening and she had plans for the weekend. She stated she clocked out of the facility at 5:07 p.m. She stated she was informed she was receiving the resident and he needed a wound vac which ADON A had ordered. ADON C stated she was aware that the Wound Care nurse did not know how to put on a wound vac. ADON C stated both the Wound Care nurse and ADON A were working the next day and assumed they would put the wound vac on. ADON C stated later Friday night she received a text with management included that indicated Resident #1 was leaving AMA. ADON C stated she called Agency staff D who indicated Resident #1 was not happy and he wanted pain medication, so she ordered the medication. ADON C stated she never reviewed Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she didn't do these things because ADON A stated she was going to do it. It was a miscommunication that he was leaving AMA. ADON C stated the Wound Care nurse never called her during the weekend to tell her the wound vac wasn't on. She stated, she never talked to the Wound Care nurse and didn't see her while she was in the facility and no other nurse informed her there was an issue. ADON C stated her job duties and responsibilities as a member of management included reviewing records and reports, making rounds on residents, ensuring services such as lab and x-ray are complete, ordering supplies, pharmacy reviews. She stated the charge nurses are responsible for admissions, but she will check the next morning to ensure assessments are completed. She stated if she is not in the facility the next day she will review on Monday. ADON C stated the Admissions Nurse, RN D should have assessed Resident #1's wound and then called the on-call weekend staff who was the Wound Care Nurse or ADON A because she (the Wound Care Nurse) was next in line to receive calls. ADON C stated RN D was an agency nurse and had completed computer training through the agency. ADON C stated she felt RN D was qualified to be the Admissions Nurse because had worked at the facility many shifts. She stated RN D should have at least completed a wet-to-dry dressing change on the wound over the weekend. ADON C stated she could not comment on Resident #1's wound care orders because she was already on her way home at 5:00 p.m. and no one called to tell her what was going on. She stated Resident #1's wound issues had been addressed today (11/15/2021) so she did not review the admission or wound care orders. During further interview on 11/15/2021 at 5:33 p.m., the Administrator stated he was terminating ADON C immediately. He stated he was in the middle of an investigation and did not know what happened. The Administrator stated, You and I are on the same page making sure residents are taken care of. During an interview on 11/15/2021 at 6:08 p.m. the soon-to-be DON stated she was the current DON at another facility. She stated she was in this nursing facility on Saturday 11/13/2021. She said while she was in the facility, she went to each nurses' station and no one indicated anything was wrong. The soon-to-be DON stated she looked at resident orders to make sure they were in the computer and check-in with residents. She stated she did not check on Resident #1 and did not know of any issues or concerns with the wound vac. She further stated she didn't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the staff should have called the hospital to verify the orders. She stated she would expect her staff to clarify orders of a resident with a surgical wound. The soon-to-be DON stated the nurses could have done wet-to-dry dressing changes, but again they needed to call the doctor to clarify. She stated she did not see or speak to the Wound Care Nurse when she was in the facility. During an interview on 11/16/2021 at 1:31 pm the CCO stated he had terminated the Wound Care nurse because he asked her to step down from the Wound Care nurse position based on what had occurred with Resident #1 and she declined to accept a floor nurse position. The CCO stated the Wound Care nurse had been checked off on competencies. He further stated he did not know who had hired her to the position but would find out. During an interview on 11/16/2021 at 2:03 pm Resident #1's Surgeon stated he had been unable to assess Resident #1's wound in person but based on reports from nursing staff at the local hospital after a full day of application of the wound vac and wound cleaning, there appeared to be no significant visual worsening of the wound. He further stated the re-hospitalization was absolutely necessary and indicated because of the lack of wound care the wound was back to square one with Resident #1's surgical would and the wound would require a reset before healing could occur. The Surgeon stated hospitalization was necessary to ensure Resident #1 received proper wound care. During an interview on 11/16/2021 at 3:02 pm Wound Care NP Y stated not receiving wound care for 1 day would likely not cause significant injury but wounds not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Not receiving wound care over a weekend was not acceptable and someone needs to be assigned to take care of wounds. NP Y stated he has discussed with facility management the importance of wound care as he isn't in the facility to provide wound care every day. He further stated if a facility goes without a treatment or wound care nurse for a long period of time, he will not renew the facilities contract. NP Y stated he came to the facility, 1 time a week to see residents and confirmed Resident #1 was not one of his patients. NP Y stated if the facility had a new Wound Care nurse he could help train them by allowing them to watch what he was doing when he provided care, but if a Wound Care nurse were to call him and state she did not know how to do a wound vac he would ask them, Then why did you accept this position? NP Y stated he is always available for assistance if it is really needed. He further stated in lieu of application of a wound vac a wet to dry dressing changed daily could be applied. During an interview on 11/16/2021 at 3:59 pm the Social Worker stated on Monday, 11/15/2021 at approximately 8:30 a.m. she was called to Resident #1's room. He was lying down and the nurse (identified as LVN F) stated the resident was upset about the wound vac. The SW stated Resident #1 indicated he was very unsatisfied about not having the wound vac or receiving wound care and felt the facility was disorderly. He felt if we couldn't even get the wound vac then this wasn't the place he wanted to be. She stated Resident #1 wanted to leave immediately. The SW stated she notified the Administrator that Resident #1 was unsatisfied and was upset about the wound vac. She stated the Administrator was shocked and worried. He stated he was about to have morning meeting but asked me to stay with the resident. The SW stated Resident #1 wanted to go outside so she went with a walk with him outside, and then went back to my office. The SW stated Resident #1 did not want to go back to his room so she told him he could stay in her office. The resident stated he did not feel safe here at the facility and was very unsatisfied with the care. He was inconsolable and didn't want anyone to talk to him except for me. The SW stated Resident #1 left the faciity on [DATE] at 3:00 pm via a local private ambulance transport to go to the hospital. During an interview on 11/16/2021 at 4:17 pm the MDS Coordinator stated Resident #1 stated he was leaving the facility on Friday 11/12/2021 at 7:20 pm. She stated she told him there was a form he needed to fill out, she educated him on his wound and told him there could be complications and told him the facility needed to care for his wound. The MDS Coordinator stated Resident #1 agreed to stay one more day. She stated his answers were short and he didn't want to talk about anything. The MDS Coordinator stated Resident #1 stated nobody was taking care of him. She stated she reminded Resident #1 they had given him dinner. The MDS Coordinator stated she was not aware of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she first learned it had not been applied on 11/15/2021 during morning meeting (a meeting of management staff that occurred M-F at the beginning of the day). During an interview on 11/16/2021 at 4:45 pm RN D confirmed she was a Registered Nurse. Agency staff D she did not know she was getting a new admission until Resident #1 was wheeled into the facility in a wheelchair. She stated she was very upset and angry by this and didn't get a report from the hospital prior to his admission. RN D stated she performed vitals and a skin assessment and noted a dressing to his abdomen. She stated she read his discharge hospital paperwork and noted there were no orders for wound care. RN D stated she called the Wound Care Nurse to do a wound assessment, but she refused because she said she was expecting a wound vac. This occurred at the end of the business day at approximately 4:00 pm on Friday 11/12/2021. RN D stated she did not notify any member of management about the lack of wound care orders or wound care assessment because the Wound Care Nurse was a member of management and she could not go above her. RN D stated she thought it was weird Resident #1 did not have orders for wound care but did not notify the residents physician to obtain wound care orders because most of the time the Wound Care Nurse takes on that responsibility. She stated, Why am I supposed to get orders if I have already been told we are waiting on a wound vac? She further stated that's what the Wound Care Nurse was supposed to do. RN D stated she talked to ADON C on Friday 11/12/2021 and asked her if she had a report for Resident #1 and I asked about the wound vac. ADON C told her the Wound Care Nurse would come to her. RN D stated she asked the Wound Care Nurse about the wound vac and she said the vac had not been delivered. I did not know the wound vac was already in the building. Agency Staff D stated she did not know how to apply a wound vac and had never been trained in setting a vac up. She stated she could change a dressing if she had been asked to do it, but no one asked. When asked if she knew who took the report from the hospital, RN D stated the ADON's can take report (of a new Admission), but she did not know who received it. During an interview on 11/17/2021 at 10:31 a.m., the Regional Director of Marketing stated she reviewed Resident #1's clinical information prior to arrival at the facility and noted he had cancer with [CONDITION(S)]. The Regional Director of Marketing stated there was an email thread between herself and department heads, ADON A, ADON B, ADON C, the Administrator, DON, Director of Rehab, MDS Coordinator, Corporate team and BOM with all clinical findings including updates and referral. She confirmed the hospital sent Resident #1's clinical information to the facility via email. She stated since the facility did not have a full time DON at the current time, she sent a form with a list of supplies the resident needed to ADON A, letting her know the resident required a wound vac. She confirmed the message was sent and delivered on 11/11/2021 at 4:45 p.m. During an interview on 11/17/2021 at 11:23 a.m. LVN G confirmed she completed the Skilled Nurses Assessment for Resident #1. She stated she did not do a complete assessment and left the skin observation blank because RN D was assigned as the Resident #1's nurse and she had already completed an assessment. LVN G stated she witnessed both RN D and the Wound Care Nurse exited Resident #1's room at the same time and knew he had a surgical wound. LVN G stated RN D did not want to open the wound dressing without the Wound Care Nurse. LVN G stated Resident #1 wanted to leave the facility immediately but she didn't know the details because she was not assigned as Resident #1's nurse. During an interview on 11/17/2021 at 11:36 a.m., the Administrator stated the Admissions Coordinator was responsible for coordinating new admission, but the facility did not have a current staff member for that position.

Based on observation, interview, and record review the facility failed to ensure the nursing staff had the competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 8 residents (Resident #1 and 2 of 16 staff (RN D and Wound Care Nurse) reviewed for competency, in that; 1. The facility failed to ensure RN D had the appropriate competencies to ensure appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] a. Resident #1's when RN D failed to appropriately dispense and administer narcotic pain medication and when RN D failed to assess, treat or apply a surgical wound vac as ordered by a physician which resulted in re-hospitalization of Resident #1. 2. The facility failed to ensure the Wound Care Nurse had the appropriate competencies to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] These failures resulted in identification of Immediate Jeopardy (IJ) on 11/18/2021. While the immediacy was removed on 11/24/2021, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. These failures placed residents at the facility at risk for not receiving care and services from staff who are properly trained and resulted in anxiety, pain, a decline in health, and rehospitalization for one resident and could result in inappropriate or inaccurate dispensing of medication, inappropriate or incorrectly applied nursing services, and inadequate supervision and monitoring of residents. The findings were: 1. Record review of Resident #1's face sheet, dated 11/ 21 revealed a [AGE] year-old male admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's discharge hospital records dated 11/12/2021 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge instruction: standard skin and wound vac monitoring and care Equipment and supplies: wound vac, change 3 times a week, call surgeon for any concerns. Record review of a local hospital Service Agreement dated 11/12/2021 between the local hospital and the nursing facility for Resident #1 revealed: -Article I Services and Covenants of Facility: The Provider (nursing facility) will provide patient (Resident #1) with the following nursing care services including, but not limited to: A high-level and quality of inpatient, skilled nursing services to patients as provider offers to its other patients, without discriminating on the basis of source of payment, gender, nationality ethnicity, age or disability. Coordination of medication of medical services with the patient's healthcare providers when his condition warrants. Medications, prescription and over the counter. Record review of Resident #1's Skilled Nurses Note, dated 11/12/2021 at 10:30 pm revealed Resident #1 was alert and oriented x 4 (person, place, time and situation and indicated the resident was cognitively intact). Further review of Section G Skin/Wound revealed Resident #1 had no new changes to skin integrity. Wound Care was left blank and not filled in and the surgical wound was not documented. Signed by LVN G. Record review of Resident #1's consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MAR for November 2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the document revealed no documentation of administrator of [MEDICATION(S)] until Monday, 11/15/2021 by LVN F. Record review of a Narcotic Reconciliation sheet dated 11/13/2021 revealed [MEDICATION(S)] 50 mg tablets, give 2 tablets by mouth every six hours as needed for pain. Further review revealed RN D documented she removed 1 50 mg tablet on 11/13/2021 at 8:00 am, 1 tablet on 11/13/2021 at 1200 a.m., 1 tablet on 11/13/2021 at 4:00 p.m., 1 tab on 11/13/2021 at 8:00 pm. 2 tablets on 11/14/2021 at 8:00 a.m. and 2 tablets on 11/14/2021 at 8:00 pm. Record review of Resident #1's progress notes: -11/12/2021 at 2:46 pm revealed Resident #1 arrived at the facility via wheelchair from a local hospital with an abdominal wound due to abdominal surgery pending wound vac delivery. Notify physician of increased pain, swelling, redness, tenderness, bleeding, fevers, confusion, constipation and diarrhea. Signed by Agency Staff D. --11/15/2021 at 11:37 a.m. revealed Removed dressing to abdominal incision/surgical site. Noted large amount of dark red drainage, foul odor noted, cleansed site gently with normal saline, noted stapled clean dry and intact and 2 areas of wound dehiscence (unintentional opening of surgical wound). #1 superior site noted yellow eschar inside wound bed, #2 inferior wound bed yellow eschar noted/black eschar. Applied wound vac as per physician order. Foam firm and compressed at 125 mm/hg. Signed by LVN F (Agency). Record review of a 24-hour Nurses Report/Change of Condition Report (undated) revealed: Resident #1: New admit day 1 of 3. Insisted (sic) to leaving AMA. Next of kin to visit tomorrow. Pending a vac for abdominal wound. Record review of a 24-hour Nurses Report/Change of Condition Report dated 11/14/2021 revealed: Resident #1: pending wound vac. Wound Nurse to place initial dressing. Signed by RN D. Record review of Resident #1's initial Care Plan initiated on 11/15/2021 revealed a plan of care for a surgical wound to the abdomen with interventions to include a continuous abdominal wound vac set at 125 mm/hg changed Monday, Wednesday and Friday and as needed for soiling on every shift. Record review of Resident #1's TAR (Treatment Administration Record) revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change Monday, Wednesday and Friday and PRN (as needed) for soiling, every day shift for surgical abdominal wound with a start date of 11/16/2021 (after discharge) Further review revealed there was no evidence of wound care or wound vac application documented on the TAR. During an observation on 11/15/2021 at 1:10 p.m., Resident #1 was observed sitting on the edge of the chair in the Social Workers office. The resident was wearing a white abdominal binder under his clothing that covered his abdomen. There was a dark red/brown stain consistent with dried blood that was approximately 6 inches long and 3 inches high. A wound vac was observed on a desk nearby connected by tubing to the resident. Resident #1 declined direct observation of the wound at this time. During an interview on 11/15/2021 12:55 am LVN F confirmed wound care including application of a wound vac was not completed over the weekend (11/12/2021-11/14/2021). LVN F stated Resident #1 had many issues with care over the weekend. She further stated she notified ADON C on Monday 11/15/2021, who then retrieved the wound care supplies which had been located in the Wound Care Nurses office, and LVN F applied the wound vac to Resident #1. LVN F stated the wound supplies and wound vac had been in the building over the weekend but staff were not supposed to go into the wound care office. LVN F stated she thought the incident was a result of miscommunication between staff members. During an interview of Resident #1 on 11/15/2021 at 1:02 p.m. in the SW office, Resident #1 stated he wasn't feeling well and had anxiety because he had not received treatment to his wound since he had been admitted and wanted to leave the facility because he did not feel safe. Resident #1 stated he did not receive a wound vac application or wound care to his abdominal surgical wound over the weekend like he was supposed to. He further stated he had a surgical wound to his abdomen because he had an intestinal blockage. Resident #1 stated he arrived at the nursing facility on Friday (11/12/2021) with a wound that was well dressed from the hospital with no drainage noted. He stated the Wound Care Nurse said supplies for the wound had been ordered. Resident #1 said on Sunday he saw quite a bit of discharge on the abdominal binder covering the wound dressing. He also noted an odor but thought it was body odor at the time. Resident #1 stated he told the nurse on duty on 11/15/2021 when she came in. The nurse (LVN F) told him it was unacceptable and that problems could arrive from uncleanliness. Resident #1 stated I am in no position to protect myself. He further stated he had doctor's orders to return to the hospital. During an interview on 11/15/2021 at 2:06 p.m. the SW stated Resident #1 was leaving at 3:00 p.m. via private ambulance transport service and would be direct admit to a local hospital. She further revealed Resident #1 requested to remain in the SW office. During an interview on 11/15/2021 at 3:24 pm ADON B stated a majority of the nursing staff, approximately 85% was agency staff. During an interview on 11/15/2021 at 2:50 p.m., The Administrator stated he checked on Resident #1 over the weekend and he didn't mention concerns and he didn't mention he didn't have a wound vac. He further stated the new DON was in the facility over the weekend but did not see Resident #1 to his knowledge, but he was still waiting for her official report from the weekend. The Administrator state no staff reported concerns for Resident #1's wound vac. He further stated, on Monday morning 11/15/2021 Resident #1 stated he did not feel safe. When asked to elaborate on why Resident #1 did not feel safe the Administrator stated Resident #1 had been in contact with his physician and was currently sitting in the SW office. During an interview on 11/15/2021 at 4:29 pm ADON A stated on Thursday 11/11/2021 she received a referral that had been approved by Corporate for the admission of Resident #1. She stated that evening she ordered a wound vac from a local medical supply company. ADON A confirmed the wound vac arrived at the facility on Friday, 11/12/2021 but was unsure what time it arrived. She stated to her knowledge no one signed for the delivery. ADON A confirmed the Wound Care nurse had informed her she did not know how to apply the wound vac and had never done a wound vac before. The ADON stated she told the Wound Care nurse she would talk her through the procedure, but the Wound Care nurse stated she would feel more comfortable if someone was with her the first time. ADON A stated Resident #1's evening nurse was an RN (unknown name, identified as RN D) and had experience with wound vacs. ADON A stated she knew the Agency RN had experience with wound vacs because she heard her talking about it before. ADON A stated she left for the day on Friday and then heard on Monday 11/15/2021 that the wound vac was never placed. ADON A stated within minutes of hearing the wound vac was not on Resident #1 ADON C and Agency LVN F placed the vac on the resident. ADON A stated she never observed or assessed Resident #1's wound and had not even met the resident until Monday, 11/15/2021. ADON A stated the Wound Care nurse was responsible for wound care Monday thru Friday from 8-5 pm. She further stated if the Wound Care nurse is not in the facility the floor charge nurse would be responsible regardless of shift worked. ADON A confirmed Resident #1 should have receive dressing changes of wet to dry as an alternate to having a wound vac. She stated it was the responsibility of the admitting nurse to get a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON A confirmed she had not received Resident #1's medical record and did not know what his wound care orders were but stated ADON B was aware of the orders. ADON A confirmed the facility did not have a DON. During an interview on 11/15/2021 at 4:48 p.m., ADON B stated she was aware that Resident #1 was going to be admitted to the facility and needed a wound vac. She stated she did not observe or assess Resident #1's wound and did not assist with the wound vac because each unit was assigned a different ADON and Resident #1 was not her resident to check on. She stated ADON C was assigned to Resident #1 unit. ADON B stated she did participate in a discussion with the other two ADON's and the Wound Care nurse about Resident #1's wound vac. In that discussion, the Wound Care nurse stated she did not know how to apply a wound vac and was going to let ADON A teach her how. ADON B stated she told the Wound Care nurse to call the wound care NP (Nurse Practitioner) for assistance. ADON B stated Resident #1 was not currently receiving wound care services from the wound care NP but felt like he was available to the facility for assistance and it was the reasonable thing to do. ADON B stated the floor charge nurses were responsible for new admissions and they can call the NP or physician for orders. ADON B stated the Wound Care nurse should have found someone else who knew how to apply the wound vac to do it. ADON stated the facility had hired a new DON but she wasn't working at the facility as the DON but would pop in and out of the facility from time to time. During an interview on 11/15/2021 at 5:06 pm the stated he had confirmed ADON C had signed for the wound vac on Friday, 11/12/2021 when it was delivered. During an interview on 11/15/2021 at 5:12 p.m., ADON C confirmed Resident #1 did not receive application of a physician ordered wound vac or wound care since admission to the facility. ADON C stated Resident #1 arrived at 4:15 on Friday 11/12/2021. She stated and Agency RN, identified as RN D was assigned as charge nurse for Resident #1. ADON C stated RN D stated she didn't need anything, so ADON C left the facility for the day. ADON C stated it was Friday evening and she had plans for the weekend. She stated she clocked out of the facility at 5:07 p.m. She stated RN D was informed she was receiving the resident and he needed a wound vac which ADON A had ordered. ADON C stated she was aware that the Wound Care nurse did not know how to put on a wound vac. ADON C stated both the Wound Care nurse and ADON A were working the next day and assumed they would put the wound vac on. ADON C stated she called Agency staff D who indicated Resident #1 was not happy and he wanted pain medication, so she ordered the medication. ADON C stated she never review Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she didn't do these things because ADON A stated she was going to do it. ADON C stated the Wound Care nurse never called her during the weekend to tell her the wound vac wasn't on. She stated, she never talked to the Wound Care nurse and didn't see her while she was in the facility and no other nurse informed her there was an issue. ADON C stated her job duties and responsibilities as a member of management included reviewing records and reports, making rounds on residents, ensuring services such as lab and x-ray are complete, ordering supplies, pharmacy reviews. She stated the charge nurses are responsible for admissions, but she will check the next morning to ensure assessments are completed. She stated if she is not in the facility the next day she will review on Monday. ADON C stated the Admissions Nurse, RN D should have assessed Resident #1's wound and then called the on-call weekend staff who was the Wound Care Nurse or ADON A because she was next in line to receive calls. ADON C stated RN D was an agency nurse and had completed computer training through the agency. ADON C stated she felt RN D was qualified to be the Admissions Nurse because had worked at the facility many shifts. She further stated RN D should have at least completed a wet-to-dry dressing change on the wound over the weekend. ADON C stated she could not comment of Resident #1's wound care orders because she was already on her way home at 5:00 p.m. and no one called to tell her what was going on. She further added Resident #1's wound issues had been addressed today (11/15/2021) so she did not review the admission or wound care orders. During an interview on 11/15/2021 at 6:08 p.m. the soon-to-be DON stated she was the current DON at another facility. She stated she was in this nursing facility on Saturday 11/13/2021. She said while she was in the facility, she went to each nurse's station and no one indicated anything was wrong. The soon-to-be DON stated she looked at resident orders to make sure they were in the computer and check-in with residents. She stated she did not check on Resident #1 and did not know of any issues or concerns with the wound vac. She further stated she didn't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the staff should have called the hospital to verify the orders. She further stated she would expect her staff to clarify orders of a resident with a surgical wound. The soon-to-be DON stated the nurses could have done wet-to-dry dressing changes, but again they needed to call the doctor to clarify. She confirmed she did not see or speak to the Wound Care Nurse when she was in the facility. During an interview on 11/16/2021 at 2:03 pm Resident #1's Surgeon stated he had been unable to assess Resident #1's wound in person but based on reports from nursing staff at the local hospital after a full day of application of the wound vac and wound cleaning, there appeared to be no significant visual worsening of the wound. He further stated the re-hospitalization was absolutely necessary and indicated because of the lack of wound care the wound was back to square one with Resident #1's surgical wound and the wound would require a reset before healing could occur. The Surgeon stated hospitalization was necessary to ensure Resident #1 received proper wound care. During an interview on 11/16/2021 at 3:59 pm the Social Worker stated on Monday, 11/15/2021 at approximately 8:30 a.m. she was called to Resident #1's room. He was lying down and the nurse (identified as LVN F) stated the resident was upset about the wound vac. The SW stated Resident #1 indicated he was very unsatisfied about not having the wound vac or receiving wound care and felt the facility was disorderly. He felt if we couldn't even get the wound vac then this wasn't the place he wanted to be. She further stated Resident #1 wanted to leave immediately. The SW stated she notified the Administrator that Resident #1 was unsatisfied and was upset about the wound vac. She stated the Administrator was shocked and worried. He stated he was about to have morning meeting but asked me to stay with the resident. The SW stated Resident #1 wanted to go outside so she went with a walk with him outside, and then went back to my office. The SW stated Resident #1 did not want to go back to his room so she told him he could stay in her office. The resident stated he did not feel safe here at the facility and was very unsatisfied with the care. He was inconsolable and didn't want anyone to talk to him except for me. The SW stated Resident #1 left the faciity on [DATE] at 3:00 pm via a local private ambulance transport to go to the hospital. During an interview on 11/16/2021 at 4:45 pm RN D confirmed she was a Registered Nurse and confirmed she did not have a name badge on. Agency staff D she did not know she was getting a new admission until Resident #1 was wheeled into the facility in a wheelchair. She stated she was very upset and angry by this and didn't get a report from the hospital prior to his admission. RN D stated she performed vitals and a skin assessment and noted a dressing to his abdomen. She stated she read his discharge hospital paperwork and noted there were no orders for wound care. RN D stated she performed assessment and vitals on Resident #1 and noted he had a surgical wound. She stated she called MD H and reviewed medications and asked for pain medications for the resident. RN D stated she called the Wound Care Nurse to do a wound assessment, but she refused because she said she was expecting a wound vac and stated she would come back later to do the assessment. This occurred at the end of the business day at approximately 4:00 pm on Friday 11/12/2021. RN D stated she did not notify any member of management about the lack of wound care orders or wound care assessment because the Wound Care Nurse was a member of management and she could not go above her. She further stated she was not supposed to do the assessment, the Wound Care Nurse was supposed to do the assessment of the wound. RN D stated she thought it was weird Resident #1 did not have orders for wound care but did not notify the residents physician to obtain wound care orders because most of the time the Wound Care Nurse takes on that responsibility. She stated, Why am I supposed to get orders if I have already been told we are waiting on a wound vac? RN D stated no one asked her to place the wound vac on Resident #1. She further stated that's what the Wound Care Nurse was supposed to do. RN D stated she did not ask for wound care orders from MD H when she spoke to him. She stated she didn't ask the doctor about the wound because it was the Wound Care Nurses responsibility to talk to the doctor about wounds. RN D stated she talked to ADON C on Friday 11/12/2021 and asked her if she had a report for Resident #1 and I asked about the wound vac. ADON C told her the Wound Care Nurse would come to her. RN D stated she asked the Wound Care Nurse about the wound vac and she said the vac had not been delivered. I did not know the wound vac was already in the building. Agency Staff D stated she did not know how to apply a wound vac and had never been trained in setting a vac up. She stated she could change a dressing if she had been asked to do it, but no one asked. When asked if she knew who took the report from the hospital, Agency Staff D stated the ADON's can take report, but she did not know who received it. RN D confirmed she did not perform wound care of Resident #4 or any other resident because no resident required wound care over the weekend. During further interview on 11/16/2021 at 5:05 p.m., RN D confirmed she removed 4 [MEDICATION(S)] on 11/13/2021 for Resident #1 and didn't document that she had administered the medication. She stated she had not received any training on documentation and did not know how to do it. She said she did not know how to use the computer. RN D confirmed Resident #1 had complained of pain on admission, but he didn't have any pain medication ordered so she called MD H. She further confirmed the order was to administer 2 tablets [MEDICATION(S)] 50 mg every 6 hours as needed for pain. RN D stated she checked out 1 tablet and wrote 1 pill then added extra time or something to make the (narcotic) count come out right. She stated she couldn't remember if she administered Tylenol to Resident #1 and confirmed she didn't document the administrator of it. Surveyors asked her to explain again for clarify and account for the trauma. She stated, most of the time I give residents 1 pill. RN D stated So I put 1, 1, 1, 1 at different times instead of two pills. RN D stated she pulled the trauma, read how many she was supposed to give to Resident #1 and then something happened with the resident (unknown) and she got distracted. She stated approximately 6 hours later she noticed something (unknown) so she told the night shift about her documentation on the narcotic count sheet. RN D stated the night shift didn't say anything. RN D stated she called ADON C's phone number, but no one answered (unknown date or time). She stated she didn't have the phone number to any other ADON and didn't know the Administrator's phone number. Surveyors showed RN D that the Administrator's phone number was posted all throughout the facility on posters on the wall. She declined to answer when asked if she was aware of the postings. At the end of the interview, RN D asked if she was in trouble. During an interview on 11/17/2021 at 11:36 a.m., the Administrator stated the Admissions Coordinator was responsible for coordinating new admission, but the facility did not have a current staff member for that position. The Administrator stated in lieu of an Admissions Coordinator the ADON's were responsible. He stated the ADON's duties included following doctors' orders and making notifications of physicians and RP's and notifying him if an admission was not going as planned. The Administrator stated he was in the facility over the weekend and Resident #1 was not in any distress. He further stated he didn't hear Resident #1 yell or call out Help Me. The Administrator stated he did not go to Resident #1's room, but the resident could have contacted me if he needed anything. The Administrator stated nursing staff is responsible for transcription of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator raised his hand and stated he was ultimately responsible, then paused and said, that is a tough one. He further stated he did not have the qualifications for application of a wound vac, but he was responsible for providing the necessary equipment for staff to do their jobs. The Administrator stated he monitored the facility by having morning meetings where new admissions, resident concerns, grievances, skin issues and other very comprehensive patient information was discussed. He stated all department heads are in morning meetings and all three ADON's are in attendance. The Administrator stated there are no assigned residents, although the ADON's have assigned areas of supervision, they are expected to help where needed. The Administrator stated the new DON would start in approximately 2 weeks but did come to the facility as needed but not in the capacity as DON. The Administrator stated the DON did receive a paycheck from the facility this last pay period and he thought she might have worked as a floor nurse but was not going to answer the question because he was not certain. The Administrator stated he further monitored the facility by having stand down meetings in the afternoon to address issues brought up in the morning meeting to ensure those things were done. He stated the stand down meeting do not occur every day, but there was a stand down on Friday 11/12/2021. The Administrator stated new admissions were discussed, including Resident #1. He stated the wound vac was in the facility on Friday. The Administrator stated the Wound Care Nurse was responsible for ensuring wound care is performed. He further stated the Wound Care Nurse was in the building on Friday 11/12/2021. He stated over the weekend the charge nurses perform wound care. The Administrator stated the charge nurses monitor wound care and the ADON's. He stated he thought the CCO was also responsible, but he wasn't sure and would have to check and get back to that question. The Administrator stated he makes rounds, speaks with families, was available 24/7, in serviced his staff and gave his number to everyone no questions asked. The Administrator stated the facility had systems in place which included skin observations that are documented. He stated I know those are being completed because the CCO monitors for completeness. The Administrator exited the interview at this time and declined further interview. During an interview on 11/17/2021 at 12:46 pm ADON A confirmed all narcotics, including RN (as needed) narcotics should also be signed out in PC and on the narcotic reconciliation sheet. She further stated staff should not be signed out on shift change log and not on a piece of paper. ADON A stated since there is no DON, narcotic destruction had not been completed and narcotics not currently in use were not being destroyed, instead they were left in the medication carts. She stated she confirmed the nurses were counting narcotics between shifts. ADON A stated new admissions receive an assessment and a nurse reviews new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if it's after 8:00 pm, the nurses are supposed to call the pharmacy, so the medication is available the next morning. ADON A stated while waiting for medication to arrive from the pharmacy the facility has a Pyxis (medication dispensing machine) for needed medication. The nurses have to call the pharmacy for an access code to open the Pixies. She confirmed [MEDICATION(S)] was available in the Pyxis machine. ADON A stated agency staff do not have access to the Pyxis, but regular staff do. She stated agency staff have been told to call the ADON's for concerns. ADON A stated she could not think of any reason for a resident to not get pain medication. She confirmed Resident #1 did not have documentation of administration of [MEDICATION(S)] (controlled substance, pain medication) until the date of his discharge (11/15/2021). ADON A further confirmed there was no documentation of administration of Tylenol either. ADON A confirmed the ADON's were not monitoring the narcotic sheets and that unused narcotic sheets should remain in the book. She further stated she did not know who was monitoring narcotics. During an interview on 11/17/2021 at 12:49 p.m. ADON B stated agency staff come already certified (competencies) and do not get a house orientation. She further stated they come trained in PC (computerized medical records). She stated the agency staff have access to the ADON's phone numbers Agency staff come certified. Do not get a house orientation. All have access to ADON's phone numbers. They said they are trained in PC. ADON B stated nurse to nurse (charge/floor nurses) monitor narcotics sheet and the nurses would let know her know there is a discrepancy. ADON B confirmed the ADON's were not monitoring narcotic sheets. She stated she did not know who was monitoring narcotics. She further confirmed the facility did not have a DON. During an interview on 11/17/2021 at 2:50 p.m., the CCO stated narcotic counts were done at change of shift, nurse to nurse with random audits done by the ADON's. He further stated the facility was spot checks with no set date and stated there is no regulation that an audit had to be done. The CCO stated the regulations said nurse to nurse account had to be done. He further stated, it was not part of his responsibility to monitor drug administration, drug destruction or drug management. He stated, those were systems that should be monitored by DON. He stated, since there was no DON he was acting as interim DON in this position for 2 weeks (new hire). The CCO stated, last week we had state in here as well. He stated he had observed narcotic count during morning and evening shift and had not had opportunity to monitor drug destruction, or narcotic sheets. He stated, since ADON's are all LVN's they are still responsible for monitory narcotics because this was a task that they can do. The CCO stated he had interviewed Agency RN D, who reported she administered 2 tablets every 6 hours (to Resident #1). He stated she should have notified nursing administration (of the documenting discrepancy). The CCO stated he had not been able to find missing narcotic sheet (for Resident #1's [MEDICATION(S)] 50 mg). The CCO confirmed Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/2021 at 3:16 p.m., the CCO stat

Based on interviews, record review, the facility failed to develop and implement written policies and procedures to prevented abuse and thoroughly investigate allegations of abuse for 3 of 7 residents (Residents #1, #3 and #15) reviewed for abuse, in that; 1. The Administrator and DON failed to report to HHSC, investigate after becoming aware of the following allegations: Resident #15 reported on 10/3/21 that LVN C withheld his pain medications, closed the door and isolated him against his wished, and yelled and used intimidation to prevent Resident #15 from using the call light which caused the resident to be fearful and experience anxiety. This was reported to an unknown nurse on the morning of 10/4/21 but was not reported to the DON, Administrator, or HHSC. This was not investigated, and protections were not put in place. Resident #3 reported to the administrator on an unknown date that LVN C attempted to provide incontinent care against her will and used intimidation which made the resident fear for her safety. MA B reported to the DON on 10/1/21 that LVN C yelled at resident #1 and told him to shut up. This was not reported to the administrator and was not investigated, and protections were not put in place. 2. The facility failed to follow their own hiring policy when the hired LVN C without reviewing his application, performing reference checks, without considering his past behaviors and out ensuring he had the competencies to perform the job duties. These failures resulted in identification of Immediate Jeopardy (IJ) on 10/05/2021 at 6:03 p.m. While the immediacy was removed on 10/09/2021, the facility remained out of compliance at for actual harm that was not immediate jeopardy with a scope of pattern due to the need to monitor the implementation and effectiveness of its Plan of Removal (POR). These failures resulted in a delay in identifying abuse within the facility and unnecessarily exposed residents to abuse which caused emotional and mental psychosocial harm to residents and placed residents at risk for continued abuse. The Findings were: Record review of a facility policy, titled Abuse Prohibition Standards of Practice dated 11/2017 revealed: 483.12 (b) The facility must develop and implement written policies and procedures that: 1. prohibit and prevent abuse, neglect and exploitation of residents .2. Establish policies and procedures to investigate any such allegations, and 3. Include training as required at paragraph 483.95. 1. Screening Potential Employees: A. Obtain a minimum of two professional reference checks on all candidates prior to employment B. Obtain criminal background check. Where applicable State law, the sex offender's registry will be checked as part of the screening of potential employees. F. Obtain a negative pre-employment drug testing screening. II. Training Employees: A. All new staff will receive training on the following information during general orientation. 1. What constitutes abuse, neglect, and misappropriation of resident property. 2. How to report a suspicion of a crime, or witnessed abuse, neglect or misappropriation of resident's property. 3. Reassure staff that reporting a reasonable suspicion of a crime can be done without fear of retaliation. Further review of a facility policy, titled Abuse Prohibition Standards of Practice dated 11/2017 revealed: Standard of Practice: The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrator's designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) will be notified in accordance with federal and state law. Any reasonable suspicion of a crime against a resident will be reported to appropriate law enforcement no later than 2 hours or forming the suspicion. Prohibition of Abuse: Place residents in accommodations and environments that keep them calm Recognize signs of burnout, frustration and stress in employees that may lead to abuse. React to all allegations or questions of abuse by residents, staff, family members or visitor. Take appropriate actions when abuse, neglect or exploitation is suspected. Provide residents, staff and family member's information on how, when and to who they may report concerns, incidents and grievances without fear of retaliation. Supervise staff to identify appropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care .Investigation: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Interview all witnesses separately. Interview cognitively intact residents on the same hall or those that have received care from the alleged staff member and residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate standard of practice. Document entire investigation chronologically. Protection: The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending outcome of the investigation. Protect staff, resident's and/or family members from retaliation. Reporting and response to Alleged Incidents: Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source .shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. 1a. Record review of Resident #15's face sheet, dated 10/09/2021 revealed a [AGE] year-old-male admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's quarterly MDS dated [DATE] revealed a BIM's score of 15 (scale of 0-15, with 15 representing the highest level of cognitive functioning) which indicated an intact, high functioning cognitive status. Further review revealed no evidence of [CONDITION(S)], [CONDITION(S)] or behaviors. The assessment revealed Resident #15 required extensive assistant to total assistance from two staff members for care. Record review of Resident #15's Care Plan initiated on 6/07/2021 revealed the resident was had an ADL (activities of daily living) performance deficit related to [CONDITION(S)] with interventions which included: Encourage the resident to use bell to call for assistance. Further review revealed Resident #15 had communication problem related to difficulty in hearing with interventions which included: Anticipate and meet needs. Ensure/provide a safe environment. Call light in reach, adequate low glare light, bed in lowest position and wheels locked. Avoid isolation. The Care Plan Revealed Resident #15 was on pain medication with a goal to be free of any discomfort with interventions which included: Administer analgesic (pain relieving) medications as ordered by physician. Record review of Resident #15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed orders for [MEDICATION(S)] tablet 0.25 mg, give 1 tablet by mouth every 12 hours as needed for anxiety. Record review of Resident #15's October 2021 MARS revealed there was no documentation the resident had been medicated for pain with [MEDICATION(S)]-acetaminophen or anxiety with [MEDICATION(S)] by LVN C. During an interview on 10/08/2021 at 1:55 p.m., Resident #15 stated he had been abused by LVN C. Resident #15 stated he was in pain on Saturday 10/03/2021 during the night shift from a past shoulder surgery. He further described the pain as 8 out of 10. He stated he asked LVN C for pain medication which was ignored. Resident #15 stated he could hear LVN C in the hallway gossiping about being pulled over by police, so he asked LVN C again for pain medication. He stated LVN C yelled at him. Resident #15 stated LVN C yelled What else do you want me to do for you? in a loud angry voice. Resident #15 stated he estimated it was at least two hours before he got any pain medication. During the interview Resident #15 appeared angry and frustrated at the situation until this point in the conversation where he began crying. Resident #15 tearfully stated When I asked for the pain medication, LVN C closed the door on me leaving me in my room all alone. Resident #15 stated later he pushed the call light and LVN C came into the room and yelled, Turn off that call light in a demanding tone of voice. Resident #15 stated he immediately complied and turned the call light off as requested. He stated he asked for ice water and LVN C stated, you already have water on your table. Resident #15 stated he then asked for ice for his water in which LVN C stated, we don't have ice. Resident #15 stated LVN C closed the door on him and laughed. He stated he could hear LVN C laughing in the hallway, like it was funny. Resident #15 stated it gave him anxiety all night and it made him cry. He further stated he didn't normally cry, but LVN C made him cry. Resident #15 turned his head to the side and a tear ran down his cheek which he wiped away. Resident #15 stated a day shift nurse came in after LVN C left and was really nice to him and told him not to cry. He stated he reported the abuse to her and told her he wanted the incident reported. Resident #15 stated no one else from the facility or management had come to talk to him about the incident until the next day. He stated, that next day someone told him LVN C didn't work here anymore and that made him feel a little better. During an interview on 10/08/2021 at 1:55 p.m. the Administrator confirmed she had reviewed the Abuse Prevention: Resident Interview Worksheet from Resident #15 which indicated the resident had concerns for abuse. The Administrator confirmed she had not interviewed Resident #15 and had not followed up on the information by investigating the incident and had not notified HHSC of the abuse. The Administrator stated she did not follow the facility policy for investigating and reporting the incident because LVN C no longer worked at the facility and she knew she was already getting the tag. The Administrator stated as soon as the Maintenance Supervisor reported to her the questions surveyors were asking about reporting, she felt a knot in her stomach and knew she was going to get cited. The Administrator confirmed she had not attempted to call LVN C and had not spoken to him since he left the faciity on [DATE]. During an interview on 10/08/2021 at 2:45 p.m., the Administrator stated she spoke to Resident #15 after speaking with surveyors and he confirmed the allegations of abuse. She stated Resident #15 stated LVN C told him to stop turning on his call light. He also stated he reported it to a nurse. The Administrator stated she sent to SW told talk to the resident and offered psychiatric/psychological assistance to the resident which was accepted. 1b. Record review of Resident #3's face sheet, dated 10/10/2021 revealed an [AGE] year-old female, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's annual MDS dated [DATE] revealed a BIM's score of 15 (scale of 0-15 with 15 representing the highest level of cognitive functioning) which indicated an intact, high functioning cognitive status. Further review revealed no signs and symptoms of [CONDITION(S)] and behaviors were not present. The assessment indicated there were no indication of [CONDITION(S)] and no behaviors related to [CONDITION(S)]. Resident #1 was totally dependent on two staff members for assistance including bed mobility and toileting. In an interview on 10/4/21 at 10:28 a.m. Resident #3 was able to state the year 2021, she knew she was in a nursing home, she knew her name, and she knew she needed lots of help which was why she was in the nursing home. Resident #3 revealed she knew the facility was shorthanded with staff, but the residents were paying to be cared for. When LVN C was mentioned Resident #3 turned her head very quickly and said, Oh no, I do not want him in my room anymore! Resident #3 revealed LVN C came into her room (unknown date) with a chip on his shoulder, with a big-time attitude, and said he needed to change her (Incontinent care), and she said no you don't, send someone else, but LVN C told her there was no one else. Resident #3 revealed she would not let LVN C touch her, but he tried to touch her, Resident #3 said, I guess I fought hard enough. During this interview Resident #3 used her hands to guard her chest area and her peri area. Resident #3 revealed she felt threatened by LVN C because of his stature, and his voice was louder than it should have been, she reported her concern to a family member, and a facility staff member, but she could not remember the staff member's name. During an interview on 10/04/2021 at 1:40 p.m., the DON initially denied knowledge of allegations of any staff member yelling at any resident, using a harsh tone of voice, speaking loudly to a resident or abuse. The DON stated she had attempted to have a conversation with LVN C on the morning of 10/04/2021, but he had refused. The DON stated she had requested a conference with LVN C as he was leaving his night shift because LVN E made a complaint (unknown date/time) that he was loud, boisterous, spoke inappropriately and stated she was not going to take any more of his s**t. The DON stated LVN E also stated LVN C had stated sexually inappropriate things to her and called himself a slut. The DON did not provide any further detail when asked to elaborate and provide answers to additional questions about detail. She stated she could not remember but didn't think anyone had stated residents were involved. The DON stated she received the complaint from LVN E at approximately 3:00 a.m. on 10/04/2021 about LVN C but couldn't remember details. She confirmed she did not come to the facility or notify the Administrator at 3:00 am because she was sleeping. The DON stated at an unknown time on 10/4/2021 she notified the Administrator and CCO who game her permission to terminate LVN C employment. During an interview on 10/04/2021 at 2:12 p.m., the Administrator confirmed she was the Abuse Coordinator and stated no one in the facility had reported any allegations of abuse. The Administrator stated she was on vacation from 9/26/2021 thru 10/3/2021. She stated she was accessible by phone to facility staff. During an interview on 10/05/2021 at 4:25 p.m., Resident #3 revealed she felt scared when LVN C came into her room, and if he came in again, it would make her very anxious. During an interview on 10/06/2021 at 10:20 a.m. Resident #3 stated the facility had told her LVN C had no longer worked at the facility but she remained afraid he would return. During an interview on 10/07/2021 at 10:36 a.m., Resident #3 stated she wasn't doing very well today because she did not feel safe at the facility. During an interview on 10/07/2021 at 11:52 a.m., the Social Worker confirmed she had not followed up with Resident #1 or Resident #3 following allegations of abuse. She further confirmed she had not performed a social or emotional assessment of the residents. The Social Worker stated she had worked at the facility for 2-3 weeks. She stated she had followed up with a few residents after the IJ was called, but not Resident #1 or Resident #3. The Social Worker stated no residents had expressed concerns for abuse or neglect to her knowledge. During an interview on 10/08/2021 at 2:45 p.m., the Administrator stated she spoke to Resident #3 after speaking with surveyors and the resident stated she felt unsafe. The Administrator stated Resident #3 was worried that LVN C would come back. She stated she sent SW told talk to the resident and offered psychiatric/psychological assistance to the resident which was accepted. 1c. Record review of Resident #1's face sheet, dated 9/30/2021 revealed a [AGE] year-old-male admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's significant change MDS dated [DATE] revealed a BIM's score could not be assessed due to the resident's poor cognitive status and inability to communicate or be understood and indicated the resident had severely impaired cognitive skills and never/rarely made decisions. Further review revealed Resident #1 was totally dependent on two staff members for care. Record review of Resident #1's Care Plan dated 7/29/2021 and last revised on 8/28/2021 revealed the resident had an impaired cognitive function/impaired thought process with interventions which included: Cue, reorient and supervise as needed. Further review revealed Resident #1 had a communication problem related to [CONDITION(S)] with interventions which included: anticipate/meet needs and monitor/document for physical/nonverbal indications of discomfort or distress and follow-up as needed. During an interview on 10/04/2021 at 1:10 p.m. MA B stated on 10/01/2021 in the evening, right around shift change she heard Resident #1 cry out and yell help, help, help like he does when he had pain. MA B stated Resident #1 had just returned from the hospital and she was standing at her medication cart near the nurse's station and heard LVN C yell at Resident #1 who was 2-3 doors down the hallway. MA B stated LVN C yelled at Resident #1 Shut up. I am right here. Stop doing that. MA B stated LVN C yelled louder than Resident #1 had cried out/yelled. She stated she was scared for the resident's safety and scared for her own safety. MA B stated she didn't go into Resident #1's room to check on the resident and didn't try to intervene because she was too scared. MA B stated she talked to the Maintenance Supervisor (MS) briefly and he confirmed LVN C was yelling at Resident #1. MA B stated LVN C just sat at the nurse's station for the rest of the night and never got up to do anything. She stated he had not administered medications. MA B stated LVN C asked her to take over his shift because he was tired and wanted to go home and he asked her to check off medications as given on the electronic medical record. MA B stated she refused to click off medications as given that she had not actually administered. MA B stated when she refused LVN C became very angry, he appeared super stressed and he was screaming at her. MA B stated she called the DON at 12:00 a.m. and reported that LVN C had yelled at Resident #1. MA B stated the DON was shocked and didn't know what to do about the situation. MA B stated the DON asked if LVN C had made any sexual advances to her because he had to other women. MA B stated the DON agreed with her that something needed to be done because another nurse (unknown) had just quit because of LVN C. MA B stated the DON told her LVN K had worked with LVN C at another facility and LVN C had cornered her at that facility. MA B stated she was trained to report abuse to her supervisor, which she had done when she notified the DON. MA B stated she was also trained to notify the Administrator. MA B stated she had not notified the Administrator because she wasn't in the facility during the night and she didn't have her phone number. MA B further stated she had last received abuse training on 8/03/2021. During an interview on 10/04/2021 at 1:30 p.m., the Maintenance Supervisor stated LVN C spoke loudly over Resident #1, who was yelling. The MS stated he didn't think it was best practice for LVN C to speak to Resident #1 in that manner, but he did not feel like it was abuse. The MS stated during the interaction between LVN C and Resident #1 he was underneath the residents bed working on repairing the bed and was not sure exactly what was said to the resident but it sounded like Hold on, I am trying to help you. The MS confirmed a female nursing staff member (unknown name) stopped him and expressed concern for the interaction and about LVN C's demeanor and how he spoke. The MS stated LVN C's personality was a little weird to me but was unable to articulate how he was weird. The MS stated LVN C kept interrupting his work and kept talking to him while he was trying to work. The MS stated he didn't report the incident to anyone because he did not consider it abusive. During an interview on 10/04/2021 at 1:47 p.m., the DON stated MA B stated LVN C made her uncomfortable and reported LVN C had spoken loudly to Resident #1. MA B also reported that LVN C stated, I can't help you if you are yelling loud. The DON stated MA B reported she felt LVN C was talking loud to a patient but didn't say she felt there was abuse. The DON stated LVN C normally speaks super super loud and Resident #1 yelled really loud when he was in pain. The DON also stated, she would not yell at Resident #1 because he could not help that he had pain. She further stated she would expect staff to be calm and speak to Resident #1 in a manner that they would want their own family spoken to. The DON stated Resident #1 had a lot of equipment in his room including an oxygen concentrator which could be loud. She stated, what MA B reported sounded more like I want to help you, but I do not know what you want. The DON stated in response to the report she called LVN C and told him staff had reported that he had yelled loudly. The DON stated LVN C stated Resident #1 had already received his pain medications and she felt like the situation was resolved. The DON confirmed she did not remove LVN C from care areas or interview other residents or staff and did not investigate the allegation. The DON confirmed she did get a report another resident (unknown) was upset, but she could not remember. The DON confirmed she did not notify the Administrator. The DON confirmed staff did not have to say the word abuse for it to be abuse. During an interview on 10/08/2021 at 11:38 a.m. the NP stated it would not be appropriate for a staff member to speak over a resident who was crying out in pain. She further stated she would consider that a micro-aggression from a staff member. She stated she was unsure how it would impact Resident #1. During an interview on 10/10/2021 at 11:49 a.m. LVN V stated she did not work directly with LVN C but had met him during shift change. She stated LVN C had invaded her personal space and was hitting on her at work. LVN V stated LVN C made inappropriate comments, called her beautiful and put his hand on her knee which made her feel uncomfortable. LVN V confirmed she had cared for Resident #15 on Sunday 10/04/2021 during day shift and had probably medicated the resident for pain. LVN V stated she could not remember if Resident #15 had reported abuse or concerns about care provided by LVN C and she couldn't remember if she had reported LVN C inappropriate actions to anyone. During an interview on 10/05/2021 at 8:21 a.m., LVN E stated on the weekend of 10/3/2021-10/04/2021 between evening and night shift, LVN C worked on the 300/400 hallways (Resident #3 and Resident #15's hallway) and said vulgar things to her. Some of the comments included: I am a slut. I have been f***ing and f***ing and f***ing my whole life. She stated he made racial comments said other inappropriate things. He told a resident he was a Star Wars Slut. LVN E stated she tried to stay away from him because he made her very very nervous. LVN E stated she was not comfortable in the building with LVN C because he screamed at her. LVN C stated he yelled and was angry. Too angry for the situation. LVN E stated the CNA (unknown) who was working with LVN C refused to work with him when she came back on break and refused to say why. LVN E stated they had to rearrange the staff because the CNA stated she was leaving if forced to work with him. LVN E stated LVN C stated black women didn't respect him. He told LVN E she looked like his wife. LVN E stated there were a lot of red flags. She stated LVN C saw or perceives things that did not exist, especially from women. LVN E stated his behavior freaked her out and scared her. She stated LVN C had issues and wouldn't stop his behaviors. LVN E stated LVN C asked her to turn in circles in front of him and used his finger to gesture to her to turn around. LVN E stated they had a disagreement on which hallway she was working when she came in. She further stated she was discussing the assignment with LVN A when he screamed, I don't give a damn. LVN E stated at that point she had enough of his screaming and told him not to scream at her. She stated she reminded him that he had already gotten in trouble for screaming. She stated she told him I don't feel safe around you. She stated she also told him she was calling her husband to come pick her up from work because she wasn't staying, and she didn't feel safe. LVN E stated LVN C stated, Tell him to bring a gun. LVN E stated she told LVN A she had called the ADON and reported she didn't feel safe and was not working in the building overnight with him. She stated she informed management that he had sexually harassed her on a previous date, and I told them about the gun comment. LVN E stated she told the ADON when he evoked a gun, he crossed the line, especially in a nursing home. She further stated she had encounters with LVN C on 9/28/2021, 9/29/2021, 10/3/2021 and 10/4/2021. Staff members were discussing LVN C, but nobody knew what to do about it. LVN E stated she informed the ADON on 10/3/2021 before the night shift started. LVN E stated the ADON responded by stating she was hearing a lot of things about LVN C and would take care of it in the morning. LVN E stated she had not reported the allegations to the Administrator because she was a new hire and had not completed orientation and had not had abuse training. LVN E stated she knew the Administrator was the Abuse Coordinator but thought it was only for the residents to report abuse. She stated she had gone to new hire orientation and had not received abuse training because she was working on the floor. During an interview on 10/05/2021 at 4:42 p.m., LVN A (Weekend Supervisor) confirmed there had been concerns brought to her attention regarding LVN C. LVN A stated LVN C was overstepping his bounds, so she asked him not to speak or address people and to be mindful of the way he spoke. LVN A stated she told LVN C to stop and think about the way he was addressing people. He responded like it wasn't a serious concern and like it was a joke and he was just being his normal self. LVN A stated she witnessed LVN C speaking to people (unidentified) and said words that sounded off and were offensive. He made derogatory comments about women. LVN A stated LVN C was rambling and not making sense and was always going to places where women staff where even when they didn't want him there and had made it clear they didn't want to speak to him. LVN A stated staff reported that LVN C was interrupting their work in an intimidating manner, especially to women. LVN A stated she had received reports of LVN C's behavior from LVN W and LVN E. LVN A stated she witnessed an altercation between LVN E and LVN C where LVN E refused her assignment because she didn't want to work with LVN C. LVN E told LVN C she didn't appreciate the way he had addressed her. LVN A further stated when LVN E said this to LVN C he became aggressive in voice and tone and intimidating in manner. LVN A stated she heard reference to a gun but did not recall what was said. During further interview on 10/05/2021 at 4:48 p.m., LVN A stated several residents, (unknown names) had complained about the way LVN C was doing things. She stated she didn't know which residents were involved and had not investigated. LVN A stated she reported this situation to the ADON on Saturday 10/03/2021 between 11:00 p.m.-12:00 midnight when the situation occurred. She stated she told the ADON that female staff were complaining about LVN C and she did not like the way the situation was escalating. LVN A stated LVN C's behaviors were escalating and he was imposing. LVN A stated she felt intimidated by LVN C and felt like the whole situation was a travesty where so many people were unhappy. LVN A stated the ADON responded by telling her not to worry because the management was going to have a conference with LVN C. LVN A stated she did not notify the DON because the ADON stated she was communicating with her. She further stated she did not notify the Administrator because no decisions could be made in the facility without first consulting with the DON. LVN A stated she didn't call the police because LVN E refused her assignment and left the building and she didn't see a visible gun on LVN C. LVN A stated she felt like LVN C was just throwing words referencing a gun and she didn't really understand the issue or story behind the gun reference. She stated she was unclear about the details. During an interview on 10/05/2021 at 11:28 a.m. LVN C stated it was inappropriate for him to answer any questions and ended the call. During an interview on 10/05/2021 at 12:41 p.m., the DON stated she had never experienced anything like she was experiencing in this facility in all her life. She further stated she didn't know what was going on, but she had a lot of disgruntled employees and the facility was in chaos. The DON stated she didn't think she ever wanted to be a DON again. She further stated she was tired and didn't think she could handle anymore and felt like everything was falling on her shoulders. The DON stated staff unprofessionalism at the facility was overwhelming and she was doing the best that she could do. She stated she had been trying to help staff. During further interview on 10/05/2021 at 2:26 p.m. the DON confirmed LVN E had reported to her some inappropriate things and she stated didn't feel comfortable staying in the building with LVN C. The DON stated LVN E reported that LVN C asked, Does your husband own a gun? The DON stated she also received reports that LVN C was saying I am a slut. I have f***ed and f***ed and f***ed all of my life. She also heard reports that he was cursing LVN E out but none of the reports were of inappropriate things in front of residents. The DON stated he didn't say he had a gun, he said I hope your husband has a gun. The DON stated she had attempted to talk to him as he was leaving the facility as this surveyor was walking into the facility on [DATE]. She stated LVN C had refused to talk to her and walked out. The DON stated she had received authorization from Corporate to terminate LVN C's employment on 10/04/2021. The DON stated she received the report of inappropriate conduct via a text message on 10/03/2021 at approximately 10:56 p.m. but she didn't see the text until 3:00 a.m. because she was sleeping. The DON stated the text said LVN E is freaking out and indicated LVN E didn't want to work with LVN C and was sent by LVN W. The DON stated in response to the text message she had called the facility, but no one answered. The DON stated she wasn't worried about the gun reference and she was not worried when nobody answering the facility phone because she believed it was just a disagreement between two staff members. The DON confirmed she did not go to the facility to check on the residents. She stated, I notified the Administrator of the incident on 10/04/2021 (unknown time). The DON confirmed she did not investigate the allegations of abuse or misconduct, did not remove LVN C away from resident contact after receiving reports of misconduct and did not report to HHSC because it was the Administrators responsibility and she does not do it unless the Administrator asks her to do it. On 10/05/2021 at 8:28 p.m. this surveyor received a call from LVN C's phone number which stopped after the first ring (unanswered). On 8:28 p.m. this surveyor received a second call from LVN C's phone [TRUNCATED]