Every finding on record at Paradigm at the Prairies

Based on interviews and record reviews, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (CR #1) out of 3 residents sampled for quality of care.The facility failed to follow professional standards of practice and their policy when Resident #1's g-tube site was noted as leaking on multiple occasions and the resident was ultimately discharged to the hospital with G-Tube complications requiring G-tube replacementThis failure could place residents at risk of not receiving appropriate G-Tube placement verification resulting in complications of poor nutrition, hydration and medication administration with G-Tube use affecting quality of care.Record review of CR #1's Transfer/Discharge Report dated 8/18/2026 revealed a [AGE] year-old female admitted to SNF on 7/20/2026. Resident #1 had diagnoses that included Cerebral Infarction due to unspecified occlusion or Stenosis of Unspecified Cerebral Artery (stroke), Chronic Kidney Disease, Stage 3 (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood), Dysphasia following Cerebral Infarction (a language disorder caused by brain damage that affects your ability to speak, understand, read, and write), Sepsis, Unspecified (life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), Encounter for attention to Gastrostomy (a medical visit for the routine care, maintenance, cleaning, or adjustment of a feeding tube site (G-tube))Record review of CR #1's Care Plan dated 8/4/2026 revealed focus area feeding tube which read in part [Resident #1] requires the use of a feeding tube for nutrition and is at risk for aspiration, unplanned weight loss, dehydration and nutritional complications. Goals read in part feeding tube will remain patent and resident will receive nutrition as ordered without evidence of aspiration, dehydration, or nutritional compromise through review date [11/2/2026]. Interventions read in part Notify the Physician of any adverse findings/changes. Placement: Monitor resident for signs/symptoms of misplacement of enteral tube: Difficulty with medications/feeding/ water administration, abnormal findings with residual checks, severe abdominal distention, or changes in the length of the tube. Site: Monitor site for s/s of infection, increased drainage, odor, changes to stoma or s/s of intolerance at site. Tolerance: Monitor residual, bowel sounds, and for s/s of nausea, vomiting, diarrhea, abdominal distention, etc.Record review of CR #1's MDS revealed Resident #1 usually makes [her]self- understood with ability to express ideas and wants. Although BIMS score was 02, which indicated severe impairment.Record review of CR #1's Order Details dated 8/4/2026 at 6:00pm read in part Enteral Feeding - Jevity 1.5 @ 55 ml/hr with 150ml/ Q4 hour (every four hours) free water flush via G-Tube continuously x 22 hours. 22 hours accounts for ADL Care. Record review of CR #1's Progress Note dated 8/15/2027 at 7:27 am read in part Narrative: Awake alert confused. Skin warm and dry. Respiration regular and even. GT patent, no residual HOB [up]. Formula infusing via pump. Abd soft. Staff provides ADLs. Incontinent care prn. Slurred speech. Bed in low position with fall mat. completed by LVN ARecord review of CR #1's Progress Note dated 8/15/2026 at 11:53 am read in part Visitor stated resident full of BM. CNA changed resident. No BM on Resident. Resident had messed with GT insertion site and formula was leaking. Dressing changed. Up to wheelchair and visitors rolled [CR #1] around facility completed by LVN ARecord review of CR #1's Progress Note dated 8/15/2026 at 1:52pm read in part Visitor called family member stating CR #1 was full of BM and smelled. Informed family member CR # 1 had just been changed and did not have BM. Reassured there was no need to send [CR#1] to ER. Vital signs given to family member. resident didn't have a smell to her. Resident does mess with GT insertion site at times and was redirected completed by LVN ARecord review of CR #1's SBAR dated 8/15/2026 at 4:58 pm read in part 1. Situation: What is the identified Change of Condition: Leakage formula appearing around GT site. 2. Background: Blood Pressure 128/73, Pulse 72 pulse type regular, Respiratory Rate 18, o2 97. 3. Assessment: What do you think is going on with the resident: Resident pulls GT, educated on not pulling on tube. Formula leakage around GT site. Abd soft and non-distended, no residual, no redness. 4. Recommendation: I suggest Other. 5. Notifications: Physician notified at 4:00pm , Responsible Party notified at 4:00pm completed by LVN ARecord review of CR #1 Order Details dated 8/15/2026 at 5:05 pm ordered by MD Enteral Feeding Site Care clean with wound cleanser and apply zinc and around GT every night shift. Every night shift for enteral tube site cleanse with normal saline, pat dry, apply fenestrated dressing daily as neededRecord review of CR #1 Progress Note dated 8/15/2026 at 10:28pm read in part Peg Tube noted to be leaking at insertion site. Resident reported pain with attempted flushing, with resistance/difficulty flushing noted. Abdomen noted to be distended with active bowel sounds present. Slight redness noted around insertion site. Site cleansed and dressing changed as indicated. Provider notified of findings and low blood pressure received order to send to ER for eval completed by RN ARecord review of CR#1 Progress Note dated 8/15/2026 at 11:23pm read in part EMS called for transport to hospital completed by RN ARecord review of CR#1 Order Details dated 8/15/2026 at 11:48pm read in part Send to ER for eval and tx verbal order by NP entered at 8:49 pm by DONRecord review of CR#1 Progress Note dated 8/16/2026 at 12:50am read in part CR #1 will be admitted for AKI (acute kidney disease) and sepsisIn an interview on 8/18/2026 at 4:00 pm with Family Member, said CR #1 went to the hospital Friday (8/14/2026) Saturday (8/15/2026). Family Member said he could smell and seen puss of yellow stuff around CR #1 G-Tube site and brought it to the attention to the nurses and CNA's. Family Member said CR #1 was worst over the weekend Friday (8/14/2026) Saturday (8/15/2026) and was not being herself and complained of stomach hurting. Family Member said he asked a nurse (did not remember the name) if she knew how to tell if the G-Tube was infected. Said the nurse told him she needed to call the doctor. Family Member said SNF called him once he got home later that evening that CR #1 was going to the ER by ambulance. Family Member told SNF he was glad CR #1 was being taken to ER to get G-Tube checked because he did not see CR #1 G-Tube assessed when he was present on 8/15/2026.In an interview on 8/18/2026 at 4:34pm with RN A stated CR#1 had a peg tube for continuous feeding with medications in peg tub. When she last worked with CR# 1 on 8/15/2026 evening shift (6pm - 6am) her condition was stable, but she had drainage from peg tube insertion site and was having pain. RN A said she informed the NP and was to send CR#1 to ER to be evaluated. RN A said there was drainage, pain, and difficulty and when RN A was trying to flush the peg tube for evening medication administration. RN A said the drainage from tub site looked like water and formula. RN A said if the tube was dislodged at the site of insertion, it would drain water or formula. RN A said there was slight redness around the insertion site and the water flush was not moving through the tube however there was no smell to the site. RN A said CR #1 did not have signs of an infection to the insertion site other than redness and complaint of pain. RN A said that was the first time CR #1 had any issues with g-tube or insertion site. RN A said she also notified DON and the family member of her findings. RN A said there was dressing on the insertion site when she observed and the dressing was wet. RN A said observation of a peg tube site was for any signs of drainage, swelling or redness as that was a sign for infection. RN A received report from LVN A that CR # 1 insertion site was leaking during medication administration, and the site was to be monitored and report findings to provider. RN A said dressing was changed by LVN A prior to RN A coming on to shift. RN A said there would be risk of the insertion site leaking because CR #1 would not receive enough nutrition and might be concerns of infection to the area causing skin breakdown.Interview on 8/18/2026 at 5:29pm with LVN A, said she last cared for CR #1 on Saturday (8/15/2026) morning shift (6am - 6pm) before CR #1 was sent out to ER. LVN said there were no issues other than CR#1 pulled on her G-Tube then CR#1 stopped. LVN A said she checked on CR #1 around lunch after being informed of a bowel movement on the bed sheet. LVN A said bowel was not on the bed sheet, what was on the sheet was about 30 cc's of formula. LVN A said there was slight leakage from CR#1 tube site. LVN A said she observed CR#1 hand around the tube. LVN A said she informed NP and was told to give treatment for zinc, clean and dress the site. LVN A said she had not seen CR#1 pull on her tube before however she would point at the site a couple of times but there was no reason for it. LVN A said CR #1 would indicate that she needed her brief to be changed by pointing. LVN A said she would check CR#1's brief hourly and were to monitor and document on a sheet of paper. LVN A said CR #1 denied pain and there were no issues with G-tube through the remainder of her shift on 8/15/2026. LVN A said she left the facility around 6pm and CR #1 drainage site was clean and dry. LVN A said there was no concern with flushing or administration of medication and no residual of medication coming out of tube during administration.In an interview on 8/19/2026 at 10:27 am LVN A, said CR #1 would use face grimace or shake head yes or no when in pain. LVN A said she would need to ask CR #1 different areas of body to know where the pain was since CR#1 was difficult to understand. LVN A said she charted the morning of 8/15/2026 that CR #1 was awake, alert confused because CR#1 was throwing her legs out of the bed and was not understanding to keep legs in bed and that she was going to fall however stated that was normal behavior for CR #1. LVN A said she checked the tube placement around noon on 8/15/2026 and saw drainage at the site. LVN A said the way to check placement of G-Tube was by the use of a stethoscope. LVN A said she checked placement by placing air in syringe, then into the g-tube then using a stethoscope to hear for air in the g-tube. LVN A said drainage at the g-tube site indicates CR#1 pulled on the tube at the insertion site but denied observing CR#1 hand on the insertion site. LVN A said signs of infection were redness, leakage if it continued, and pain and there would be risk of aspiration, or infection from tube site not being in proper area.In an interview on 8/18/2026 at 6:58pm Local Hospital Charge Nurse said CR #1 was sent to Emergency Department/emergency room because g-tube was not working. Charge Nurse said Emergency Department replaced the tube with a new one. Charge Nurse said she was not sure how long CR#1 G-Tube was clogged or leaking before replaced at ED. Charge Nurse said CR #1 was treated with antibiotics. Charge Nurse said CR #1 previous diagnosis of sepsis would contribute to infection depending on how long the tube was leaking outside her stomach. Charge Nurse said best course of action was to get a X-ray of the site to see if it was dislodged or misplaced when G-Tube first started to leak.In an interview on 8/19/2026 at 11:23pm NP said CR#1 was sent out to ER for peg tube to be replaced, and it had a malfunction. NP said her concern was placement of the peg tube and abdominal pain of CR#1. NP said she did not want to send CR #1 for testing when she was told the peg tube was malfunctioning around the evening of 8/15/2026 and ordered for ER visit. NP was told the peg tube leaked around insertion site and it may have been a placement issue and needed to be changed. NP said she did not receive any other concerns that day regarding CR#1. NP said usually when there was a malfunction with peg tube or peg tube site an appointment would be scheduled to have it changed. NP said when the placement was leaking around insertion site it is to be observed if it is flushing properly. NP said the facility was to follow the protocol/ policy with peg tube care.In an interview on 8/19/2026 at 11:37 pm MD said NP has seen and rounded on CR #1. MD said peg tube care was to check the function and if it was usable. MD said peg tube care was to check peg tube site for infection. MD said if peg tube was not working properly chances are it was misplaced or had a malfunction.In an interview on 8/19/2026 at 2:36pm DON said G-tube dressings are to be changed every day on the night shift. DON said leakage at the insertion site could be a position issue of the tube caused by either tugging or residents arms, body movements. DON said when there was leakage, the nurses were to inform the doctor the amount of leakage and what was going on with the resident. DON said leakage at the insertion site needed to be checked by x-ray and the nurse can recommend to the doctor for an x-ray, but it was up to the doctor to order the Xray. DON said G-tube positioning issues can happen if the G-tube was pulled. DON said an x-ray would see if G-Tube was in place. DON said if the G-Tube was not positioned properly the risk would be the flow of formula would not move to receive nutrition or hydration. DON said she was called by RN A around the evening of 8/15/2026 regarding CR #1 pain at insertion site and redness and was to be sent out via NP. DON said RN A told her about drainage of formula leakage at the insertion site of the G-tube. DON said she spoke to LVN A on 8/15/2026 about CR#1 formula drainage and LVN A completed an SBAR around the same time of the call. DON said policy for checking placement was to listen using stethoscope. DON said use of G-tube with leakage at the G-tube insertion site was able to be used after verification of placement with x-ray, doctor awareness and assessment of the g-tube and insertion site. DON said LVN A did not state any other interventions were used other than notifying doctor and completing an SBAR.Interview on 8/19/2026 at 2:41pm CNA A said on 8/15/2026 she changed CR#1 before lunch and noticed the feeding was leaking and dressing was wet. CNA A said she notified LVN A there was leakage and LVN A changed the dressing. CNA A changed CR#1 after lunch and noticed the dressing was a little wet notified the LVN A to change the dressing again.Record review of Facility Policy dated 9/2023 Policy The facility with provide adequate care for residents with enteral feeding tubes to prevent complications. Types - Gastrostomy Tube.Placement Verification Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in correct or incorrect location. If the resident shows signs or symptoms of enteral tube dislodgement (difficulty with administration, abnormal findings with residual check, severe abdominal distention, or changes in the length of enteral tube) an x-ray confirmation would be the most accurate indicator of enteral feeding placement. In the event that the enteral tube is dislodged, the charge nurse will obtain orders from the physician to send the resident to an entity that can replace the tube. Facility may consult with a physician for a physician-performed bedside replacementRecord review of Facility LVN Job Description not dated read in part Provide direct nursing care, under direct supervision of a registered nurse of physician, in accordance with the nurse practice act, federal and state regulations, facility policies and procedures, and prudent nursing judgement . Have knowledge of and utilize of the facility's written policies and procedures that govern the day-to-day functions of the nursing department

Based on interviews and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure LVN A notified the resident's responsible party/medical power of attorney within a reasonable time when Resident # 1's x-ray's result revealed she had bronchitis ( an inflammation of the tubes that carry air to the lungs).This failure could place residents at risk of not having their responsible party/medical power of attorney notified of changes, which could result in a delay in timely intervention and a decline in condition. Findings included:Record review of Resident #1's face sheet dated 07/17/2026 revealed she was an [AGE] year-old female who was originally admitted into the facility on [DATE] with the following diagnoses: Dementia (loss of thinking, remembering, and reasoning skills), pulmonary edema (fluid build-up in the lungs), heart failure (the heart muscle is unable to pump enough blood and oxygen), kidney disease ( when the kidneys cannot filter waste and excess fluids from the blood), urinary tract infection ( bacteria in the urinary system), high blood pressure, diabetes (high levels of sugar in the blood), anemia (not enough oxygen in the blood) and urinary incontinence.Record review of Resident #1's MDS dated [DATE] revealed her BIMS score was not graded-indicating she was unable to complete the interview. Section Q-Participating in assessment and goal setting indicated family. Section Q0500-Information source indicated family.Record review of Resident #1's care plan dated 08/02/2024 revised on 07/03/2026 revealed: Respiratory illness. Goal: Will have no adverse effects from developing or being at risk for respiratory viral illnesses. Intervention: Monitor resident for signs/symptoms of respiratory illnesses (fever, chills, fatigue, cough, runny nose and headaches). Notify the Physician for new symptoms (of respiratory illnesses and recommend testing for viral respiratory illnesses where appropriate.In an interview with the Nurse practitioner on 07/21/2026 at 12:20 p.m., she said prior to Resident # 1 being hospitalized for bronchitis, she had discussed the option of hospice with the family. The NP said after she and the Doctor assessed Resident #1, and they ordered chest x-ray. When they received the report from the nurse, she ordered antibiotics, breathing treatment, steroid and cough medication. She said when the nurse called and said that Resident #1 was further declining, she gave orders for the resident to be transferred to the hospital for a higher level of care. She was diagnosed with aspiration pneumonia (when you breath food, liquid, vomit, or saliva into your airways instead of swallowing it down your stomach)which could have resulted from her own secretions, food or fluids.In an interview with RN A on 07/21/2026 at 1:16 p.m., she said it is the responsibility of the nurse who received the X-ray result to have notified the family with the result. She said she expected the nurse who provided care to Resident #1 on the day the x-ray was ordered to have notified the responsible party before and after the x-ray was completed of the result. She said the fact that important information was not communicated to the responsible party who knows their loved one best, could have resulted in delayed care.In an interview with LVN A on 07/21/2026 at 1:30 p.m., she said she notified Resident #1's responsible party number one before the x-ray was completed. She said the x-ray result revealed Resident #1 had bronchitis. LVN A said she did not remember if she had notified the responsible parties of the x-ray result. She said she did not document in the resident's chart that she notified the responsible parties. She said as nurses if there was no documentation, it meant she did not notify the responsible parties.Interview with Resident # 1's two responsible parties on 07/21/2026 at 1:56 p.m., they both said they were not notified of the x-ray result. The primary party responsible said she was called by LVN A prior to the x-ray, but no one called her with the result. She said she complained to the ADM whose response was we did not have to tell you. Both responsible parties said, if they were notified in a timely manner of the x-ray result, they would have requested Resident #1 to be transferred to the hospital immediately.In an interview with the ADON on 07/21/2026 at 2:31 p.m., she said after an x-ray the Doctor and the family should have been notified because it was part of the resident's care. The family should have been notified of any changes. She said nurses were expected to document every communication. She said the fact that LVN A did not document her communication with the responsible parties after the x-ray was completed with the result meant she did not notify them. She said that was a break in communication. The ADON said the consequence of delayed communication could be delay in care. She said if care was delayed, the situation might not improve.In an interview with the DON on 07/21/2026 at 2:31 p.m., she said it was the responsibility of the nurse to report the x-ray result to the Doctor and the family. She said the x-ray report was not communicated to the family in a timely manner, it could have resulted in hospitalization. She said she would in-service the staff to prevent this from happening in the future.In an interview with the ADM on 07/21/2026 at 3;50 p.m.,, she said if she had to follow best practice, if the staff had notified the family of the x-ray orders, she should have notified the Responsibility party of the result and documented her communication with the family. She said if the nurse did not notify the family, they would be annoyed.Record review of the facility's Job description: Licensed Vocational Nurse, revealed: Utilize established methods for coordination and communication of nursing services with other resident services to ensure the continuity of the residents' total regime of care.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 21 (Resident #4, Resident #12, Resident #14, and Resident #67) residents reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive care plan that included the code status for Resident #67.The facility failed to develop a comprehensive care plan that included the discharge goals for Resident #4, Resident #12, Resident #14, and Resident #67. These deficient practices could place residents in the facility at risk of not being provided the necessary care or services to meet their needs and deficits.Findings included: Record review of Resident #4's electronic face sheet, dated 07/09/2026, revealed an [AGE] year-old female initially admitted on [DATE] and most recent admission date of 08/04/2022 with diagnoses including: dementia (a decline in mental ability sever enough to interfere with daily life affecting memory, communication, and reasoning), Type II diabetes (body cannot use insulin correctly and sugar builds up in the blood), and Atrial Fibrillation (irregular heart beat that could lead to blood clots dislodging from the heart and moving around in the body. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS Score of 00 indicating severe cognitive impairment. Record review of Resident #4's Comprehensive Care Plan, reviewed on 07/09/2026, revealed there was no focus, goal, or interventions for the resident's discharge goal. Record review of Resident #12's electronic face sheet, dated 07/07/2026, revealed a [AGE] year-old male who was admitted on [DATE] with medical diagnoses including: osteomyelitis of vertebra, sacral, and sacrococcygeal region (bone infection of different areas of the spine), and pressure ulcer of sacral region stage 4 (the most severe form of pressure injuries, involving full-thickness tissue loss with exposure of muscle, tendon, or bone to the sacral region end of spine). Record review of Resident #12's Quarterly MDS, dated [DATE], revealed a BIMS Score of 15 meaning cognitively intact. Record review of Resident #12's Comprehensive Care Plan, reviewed on 07/09/2026, revealed there was no focus, goal, or interventions for the resident's discharge goal. Review of Resident #14's electronic face sheet, dated 07/09/2026, revealed a [AGE] year-old male initially admitted on [DATE] and most recent admission on [DATE] with diagnoses including: encephalopathy (swelling in brain), unspecified sequelae of cerebral infarction (deficits after a stroke), and Type II diabetes (body cannot use insulin correctly and sugar builds up in the blood). Review of Resident #14 Quarterly MDS, dated [DATE], revealed Resident #14 could not or rarely was understood and BIMS was not performed. Review of Resident #14's Comprehensive Care Plan, reviewed on 07/09/2026 revealed there was no focus, goal, or interventions for the resident's discharge goal. Review of Resident #67's electronic face sheet, dated 07/09/2026, revealed an [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE] with medical diagnoses including: sepsis (body's extreme response to an infection), malignant neoplasm of rectosigmoid junction (rectal cancer), and severe protein-calorie malnutrition (occurs when the body does not receive enough protein and calories to maintain proper health and functioning). Review of Resident #67's Quarterly MDS, dated [DATE], revealed a BIMS score of 05 indicating severe cognitive impairment. Record review of Resident #67's electronic physician's orders, dated 02/02/2026, revealed Resident #67 had an order for DNR. Review of Resident #67's Comprehensive Care Plan, reviewed on 07/09/2026, revealed there was no focus, goal, or interventions for resident's discharge goal or DNR code status.During an interview on 07/09/2026 at 1:40 p.m., the MDS Nurse stated she was responsible for making sure that care plans were updated with discharge goals and code statuses. She stated the care plans should have had discharge goals on them. She stated in the care plan meetings the Social Worker or she would go over discharge goals and code status but that should be relayed on the comprehensive care plan. She stated she usually looked at the orders and when a code status was ordered or changed. She stated Resident #67's physician' ordered the code status of DNR on 2/2/2026. She stated she would review the orders and make sure the care plans matched but just missed it on Resident #67. She stated she did not know why the discharge status was not on the care plans. She stated the DON was monitoring the care plans but the ADONs monitored now. She stated the care plans not being updated could cause staff to have to take an extra step to look up information. She stated the code status could be found on the orders and the DNR in the chart and did not feel it would cause a delay in care. She stated the only item on the MDS that would trigger a discharge CAA would be return to community referral which would not be appropriate for the long-term care residents and could be why the discharge goals were missed. During an interview on 07/09/2026 at 1:55 p.m. the SW stated she facilitated the care plan meetings. She stated she did not update the care plans, but they would discuss in the care plan meetings the code statuses and the discharge plans with IDT members, residents and their families. She stated the MDS nurse would update the care plans as needed during those meetings. During an interview on 07/09/2026 at 1:55 p.m., ADON B stated the DNR did need to be on the care plan. She stated the DON monitored the care plans but she and the other ADON were doing that now due to the facility was in-between DONs and waiting on the new DON to start next week. She stated not having the DNR status in the care plan would not stall in resident care in an emergency because the crash carts had a list of residents and their code status there. She stated she was unsure of the facility policy on if the discharge plan needed to be on the comprehensive care plan. During an interview on 07/09/2026 at 2:31p.m., the RCN stated the code status did need to be on the care plans. She stated the discharge goals should have been in the comprehensive care plan. She stated the MDS Nurse was responsible for making sure the code status and discharge goals were on the care plan. She did not know why those items were not on the care plans but stated the MDS Nurse was doing a 100% audit right now to make sure the care plans had all code statuses and discharge goals. She denied that the care of the residents would have been impacted due to the care plans not including the code status or the discharge plans. She stated the nursing staff would look at the crash cart for resident code statuses in an emergency and would also look at physicians' orders before they were to look at the care plans. She stated the SW reviewed resident goal of discharge during the care plan meetings and would know if additional services were needed to discharge at that time. She provided a policy titled Care Planning and stated that if the policy did not specify what needed to be included on the care plans then she expected for the regulations to be followed. She stated she would look for another policy with more detail on what needed to be included on the care plans.Record review of the facility's policy titled, Care Planning, revision dated 06/2019, revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Procedure: 1. A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment. 2. The care plan is developed by the IDT which includes, but is not limited to the following professionals: A. Attending Physician B. Registered Nurse responsible for the resident.D. Social Services staff member responsible for the resident.Director of Nursing Services (as applicable).6. Scheduling and preparation of the care plan meeting calendar is completed by the MDS Coordinator or designee. There was no evidence of what items needed to be included on the comprehensive care plan.At the time of exit on 07/09/2026 at 6:00 p.m., no other policies about comprehensive care plan were received.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for resident rooms for 8 of 16 (Rooms #56, 61, 62, 63, 65, 29, 48 and 76) rooms reviewed for environmental concerns. Resident rooms #56, 61, 62, 63, and 65 had damaged window blinds. Resident rooms #48 and 76 had floors with dried glue embedded in the floor tile. Resident room [ROOM NUMBER] had ceiling damage over the resident bed. Resident room [ROOM NUMBER] had damaged window trim with a gap between the windowpane and wall. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observation on 7/7/26 at 7:10am revealed in Rooms #56, #61, #62, #63, and #65 had window blinds, white 1-inch vinyl blinds, that were damaged, with broken blades, missing blades, cords in knots, were inoperable. Interview on 7/7/26 at 8:03am with Resident 77, room [ROOM NUMBER], revealed that the window blinds and window trim had been damaged for a long time. Resident 77 stated that it made the room look cheap and not well maintained. Interview on 7/7/26 at 8:47am with Resident 69, room [ROOM NUMBER], revealed that the damaged window blinds were an eye sore and made the room look unkept. Resident 69 stated he would like the window blinds to be replaced. Observations for 7/7/26 at 9:10am revealed damaged window blinds in Rooms #62, #63, and #65. Residents in the rooms were assessed with severe cognitive impairment and were non-interview able. Observation and interview on 7/9/26 at 1:15pm of room [ROOM NUMBER] revealed dried glue that had smeared and hardened on the floor next to Resident 5's bed. Resident 5 stated that the smear had been on the floor since she arrived at the facility. The resident sated it looked dirty and unsanitary. Interview on 7/9/26 at 2:30pm, with Resident 80, room [ROOM NUMBER], revealed some dried substance that had embedded into the tile on the floor next to resident's recliner. Resident 80 stated that the floor was clean but looked unclean and she did not allow her young family member to play on floor when visiting. Resident 80 stated she would like something to be done. Observation for 7/9/26 at 3:10pm of room [ROOM NUMBER], revealed that the ceiling had damage causing peeling of the ceiling tile located over resident's bed in bed-B. Interview for 7/9/26 at 3:11pm Resident 12 stated that the ceiling had been damaged for a long time, and made the room look bad. Resident 12 stated he has mentioned the damage before but cannot recall the date or whom he spoke with. Resident 12 stated he wants ceiling repaired, that good money is being paid, and the rooms should look good. Interview for 7/7/26 at 8:03am with Resident 77, room [ROOM NUMBER], revealed damaged and missing window trim. Resident 77 stated that the window trim had been damaged for a long time. Resident 77 stated that it makes the room look cheap and not well maintained. Interview for 7/9/26 at 1:10pm, Housekeeper D stated when damage to rooms is found or reported that staff are to place a work order in Tells (email system used for communication). Housekeeper D was not sure what the smeared substance on the floors in Rooms #48 and #79 was but would try and remove the smears or report to Tells. Housekeeper D stated that rooms that look unclean are not a homelike environment for tge residents and should be kept in good repair. Interview for 7/9/26 at 2:40pm CNA E stated that when damaged equipment is found in resident's rooms, a request is made to Tells and that will let maintenance know. CNA E states she was not aware of damaged window blinds or unkept floors in resident's rooms. Interview for 7/9/26 at 4:00pm the Maintenance Director stated it was his responsibility to check Tells throughout the day and make repairs as needed or fine vender that can make repairs. The Maintenance Director stated he was aware of the damaged window blinds in rooms but had only just received his order for replacement blinds a few days ago. The Maintenance Director stated that he was aware of the damaged window trim in room [ROOM NUMBER] and plans to repair but the exact time is unknown. The Maintenance Director was aware of the damaged ceiling in room [ROOM NUMBER] and has plans to repair it but the exact time is unknown. Interview for 7/9/26 at 4:20pm the Administrator stated she was aware of damaged window blinds and had approved order for replacements. The Administrator stated she was aware of damage to window trim in room [ROOM NUMBER] and ceiling damage in room [ROOM NUMBER] but maintenance has not yet had time to address. The Administrator states that rooms need to be in good repair for the mental well-being of residents, and to promote a homelike environment. Facility Operations Policies and Procedures, revised 6/2019, revealed Procedures:13). The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 6 (Station 2 Medication cart) medication carts reviewed for medication storage The facility failed to ensure the Station 2 medication cart was secured and locked. This failure could place the residents at risk for drug diversion. Findings included: During an observation on 7/7/2026 at 5:55am revealed the medication cart for Station 2 was parked along the wall in the hallway unattended and unlocked. There were no residents, staff or visitors observed in the hallway. During an interview on 7/7/2026 at 6:00 am with ADON A, she stated she was not aware of who was responsible for the Station 2 medication cart as she had just entered the facility and shift change had just occurred. ADON A locked the medication cart and walked to the nurses station to locate staff responsible for the medication cart. During an interview with LVN C on 7/7/2026 at 6:05 am she stated LVN D was the night shift nurse who had been responsible for the medication cart. LNV C stated LVN D left the facility when state entered this morning without counting medications/narcotics. LVN-C stated the Medication Aide for the cart had not arrived to the facility, leaving LVN-C responsible for the medications and contents of the medication cart. LVN-C stated facility policy was for the medication cart to be locked unless it was actively being used. LVN-C stated a possible negative outcome of a medication cart being left unlocked and unattended could result in anyone getting into the cart and taking anything they wanted from it. During an interview with ADON A on 7/7/2025 at 6:25 am, she stated her expectation was for medication carts to be locked at all times if out of sight of staff. A negative outcome of a medication cart being unlocked could result in any resident or staff grabbing any medication out of the medication cart. On 7/7/2026 at approximately 9:00am, attempted to contact LVN D for interview. The call was not answered and no return call was received. During an interview with the ADMN on 7/9/2026 at 8:45am she stated her expectation was all medication carts to remain locked when not in use. A negative result of a medication cart being unlocked could result in someone could reach into the cart and grab medications out or rearranging the contents of the cart. The worst case could result in death by taking medications out of the cart. In a review of the policy titled Nursing Policies and Procedures, subject: Medication Administration and Management revised on 6/2019 revealed [in part]: Security and Safety Guidelines:3. Medication cart is kept in sight or locked at all times. 5. Between medication passes, the cart is kept locked or secured within a locked room which is accessible by only authorized personnel.

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 handwash sink in the kitchen reviewed for food service in that: The facility failed to have a kitchen handwash sink operational with hot water. This failure could place residents at risk of foodborne illnesses.Findings include: On 7/7/26 at 6:00am, during kitchen observation it was revealed the hand wash sink located between the food preparation area and dish washing area did not have hot water supplied to sink for handwashing. Interview on 7/7/26 at 6:20am, the Dietary Manager stated that the handwash sink had not had hot water for several weeks, but staff were still washing hands. The Dietary Manager stated that hot water was important for handwashing and preventing cross-contamination. The Dietary Manager could not recall if she reported handwash sink not providing hot water to maintenance. Interview on 7/9/26 at 2:30pm the Maintenance Director stated he made repairs to water lines in the kitchen a few weeks ago and had forgotten to turn on the hot water to kitchen handwash sink. Interview on 7/9/26 at 4:00pm the Administrator stated that it was her expectation that any repairs be turned in timely and repairs made as soon as possible. The Administrator stated that having hot water supplied to handwash sink in dietary was very important for proper handwashing and sanitation. Facility Policies and Procedures Kitchen Sanitation: Revised 5/2025 revealed, Equipment: Maintained in proper working conditions. Equipment: Maintained in proper working conditions.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food and nutrition services. 1. The facility failed to ensure the kitchen floor in the food preparation area was not soiled with food particles imbedded in the tile grout. This failure could place residents at risk for foodborne illness and a decline in health status.The findings included: Observations on 07/07/2026 at 6:00am, during the initial tour of the facility kitchen, revealed the following:-the floor was soiled with food debris which had been embedded in between the tile gout all though the kitchen area. In an interview on 07/07/26 at 7:40 AM, the Dietary Manager stated her kitchen staff followed a cleaning schedule, and floors were mopped daily or as needed. She further stated, It's important that the kitchen floors be kept clean to prevent from attracting pests. In an interview on 07/09/2026 at 2:00 PM, the Administrator stated his expectation was for the dietary department to follow their cleaning schedule per dietary department policy and make sure that floors are cleaned and sanitized. Facility Policies and Procedures Kitchen Sanitation: General Sanitation Standards: The kitchen and all dietary areas will be maintained in a clean, orderly, and sanitary condition.

Based on interview, record review, and observation the facility failed to follow and implement care plan interventions for 1 out of 1 resident (Resident # 1) for assistance with ADLs. The facility failed to provide extensive assist with 1 support person during meals for Resident #1's therapeutic puree diet as per Care Plan interventions due to Resident # 1 visual impairment. This failure places ADL dependent residents with the need of feeding assistance at risk of choking, aspiration and safety due to not following or implementing care plan intervention in place.Record review of Resident #1's admission record revealed a [AGE] year-old male, admitted [DATE], with diagnoses of Encephalopathy (syndrome characterized by an altered mental state, causing symptoms like confusion, memory loss, personality changes, and in severe cases, coma or death), Legal Blindness, Generalized Muscle Weakness, Lack of Coordination, Unspecified Sequelae of Cerebral Infraction (long-term, lasting neurological or functional deficits that remain after a stroke, where the specific symptoms (like paralysis, aphasia, or cognitive decline) are not detailed or broken down in the medical documentation), Dysphagia following Cerebrovascular Disease (a clinical condition where a patient experiences lasting difficulty swallowing due to a specific, non-routine brain vascular event).Record review of Resident #1's Care Plan dated 3/23/2026revealed ADL self-care deficits and risk for further decline in ADL functioning and injury due to vision impairment. Staff interventions revision date of 3/19/2026 indicated staff were to provide extensive assistance of 1 support person for eating for Resident #1. Care Plan for therapeutic diet indicated Resident #1 required assistance with eating.Observation on 6/2/2026 at 11:53 a.m., Resident #1 was observed lying in bed with the head of the bed elevated approximately 90 degrees. A bedside table was positioned in front of him with a meal tray containing a plate of pureed food. The resident's eyes were closed, his head was slumped to the right side, and food was noted on the left side of his mouth and face. A spoon containing food was resting on the resident's abdomen. Resident # 1's name was called and received no response. Resident # 1 was touched on the left leg and called his name again, at which time the resident awakened and began speaking in Spanish. Upon awakening, the resident reached toward the meal tray with his right hand and began feeding himself by scooping food directly from the plate with his hand and placing it into his mouth. Observation of Resident # 1 was completed into the hallway and observed one CNA A standing at the end of the hall near the exit door speaking with another person. No staff were present at the resident's bedside. The surveyor continued to observe the resident from the doorway as he consumed the remainder of his meal without staff assistance or supervision. After finishing the meal, the resident immediately rested his head back to the side and closed his eyes. The resident consumed 100% of the food on the tray. At the conclusion of the observation, food remained on the resident's face and hands, and no staff had approached the resident to supervise the meal during the observation.In an interview on 6/2/2026 at 1:05 pm CNA A said Resident # 1 only needed assistance with feeding every now and then. CNA A said after 5 or so minutes she would check if Resident # 1 ate his meal and after she completed meal tray pass, she would assist him. She said she would ask if he wanted to eat his food, but he was able to feed himself. CNA A said she would tell Resident # 1 where the items were on his tray and have the items within arm's reach when he was in bed for meals. She said she helped Resident # 1 when she saw he dropped his spoon and placed it back in his hand or on the tray. CNA A said Resident # 1 never spilled items like food or coffee on himself and did not need supervision while he ate as he had no issues with feeding himself.Interview via telephone on 6/2/2026 at 1:43 pm, LVN A said normally CNAs or Nurses have Resident # 1 in the dining area with other staff once meals were served and placed on tables. LVN A said Resident # 1 was typically in areas with multiple staff either walking passed, or during an activity, to be better monitored. LVN A said there was not a particular staff assigned to Resident # 1 however when he was in groups or open areas other residents and staff would inform them when Resident # 1 was self-propelled. LVN B said Resident #1 did not need assistance with eating and normally ate his meals in the dining area since there were multiple staff present. LVN A said Resident # 1 needed someone to tell him where everything was on his plate/ tray and hand him his food. LVN A said she would ask if Resident # 1 wanted the meal, if Resident # 1 did not eat. LVN A said when Resident # 1 ate in his room CNAs and Nurses help assist him in the feeding process as it seemed harder for him in bed than it seemed in the dining area.In an interview on 6/2/2026 at 2:42 pm, ADON A and ADON B said Resident #1 should not use a wheelchair on his own to get to the dining area and that CNAs will set Resident #1 up and he could feed himself and did not need supervision or physical assistance when he ate and there was no concern if Resident #1 ate in his room without assistance. Resident #1 requested items like coffee or sandwich which he could eat without assistance.In an Interview on 6/2/2026 at 6:54 pm, the Administrator said she was recently the Administrator as of this week. Administrator said Resident # 1 was blind and he would need assistance with meals for safety as a risk would be Resident # 1 could choke or attempt to eat something not edible. Record review of the facility policy titled, Risk Management - Incidents & Accidents, dated 1/2024, read in part The facility will assess residents for risk factors of potential accidents/ hazards. The facility will recognize signs of incidents/accidents and assist residents, staff members, and visitors as indicated.

Based on interviews, record review, and observation, the facility failed to ensure a safe, functional, sanitary environment for residents for 1 of 2 residents (Resident # 2) quality of care.The facility failed to maintain toilet in Resident # 2 bathroom was securely bolted for useThis failure can cause risks to residents health and safety by transfer assistance or independent use of toilet in resident's private bathroomFindings included:Record review of Resident # 2's admission record revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE], with diagnoses of Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery (a type of ischemic stroke. It occurs when a blood clot (thrombus) forms locally inside a brain artery that has not been specifically identified, cutting off blood and oxygen to brain tissue and causing cells to die), Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (classic neurological deficits caused by damage to the left hemisphere of the brain), Dementia in other Diseases classified Elsewhere (identifies cognitive decline and memory loss that occur as a complication or secondary symptom of another primary medical condition), Unspecified Severity(lacks enough data, testing, or documentation to pinpoint the exact stage or severity) , without Behavioral Disturbance , Psychotic Disturbance, Mood Disturbance (the individual is not exhibiting symptoms like aggression, hallucinations, agitation, or socially inappropriate behavior), and Anxiety (feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), and Aphasia (a neurological communication disorder that impairs the ability to speak, understand, read, and write)During an interview and observation on 6/2/2026 at 9:37 a.m., Resident # 2 stated his broken toilet in his room that was not bolted down. Resident #2 was able to move toilet side to side indicating it was not securely bolted into the floor. Resident # 2 said he asked for help to repair the toilet, but it was broken for a long time. Resident # 2 said he could not get on the toilet because it moved even when he received transfer assistance.In interview on 6/2/2026 at 5:58 pm, Maintenance Director said he started at the facility this week and had not completed all inspections for every resident room. The Maintenance Director said he was aware of sink faucets and knobs not turning completely off and the light bulbs not working and the covers were off as of recently but was not aware of toilet concerns in resident rooms. The Maintenance Director said nursing staff could put in a work order in the online system so he could see what needed to be prioritized and completed first. The Maintenance Director said he would inspect the toilet today (June 2, 2026) to be repaired for safety of the resident.In an interview on 6/2/2026 at 6:12 pm, Maintenance Technician said he has been at the facility a little while however the previous Maintenance Director only taught him to find things that need to be fixed and did not give him any work orders or inspection sheets to use and trained himself on using the online work order system. The Maintenance Technician said he was not aware of a toilet issue in Resident # 2's room. The Maintenance Technician said the new director was training him on how to complete inspections of resident rooms, kitchen, nurses station and other facility areas.During an interview on 6/2/2026 at 6:54 p.m., the Administrator said this was her first week and was unaware of resident toilet concerns. The Administrator said it was not safe with a non-bolted toilet for Resident # 2 to use and informed the Maintenance Director to repair the issue.Record review of the facility's policy titled, Risk Management - Incidents & Accidents, dated 1/2024, read in part, The facility will assess residents for risk factors of potential accidents/ hazards. The facility will recognize signs of incidents/accidents and assist residents, staff members, and visitors as indicated.Record review of the facility policy titled, Environmental: Resident's Room, Resident's Rights, dated 6/2019, read in part, The facility must provide a safe, functional, sanitary, and comfortable environment for each resident, staff, and the public.

Based on record review, observation, and interview, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 out 5 residents reviewed for quality of care (Resident # 1 and Resident # 2)The facility failed to have staff interventions in place for supervision for Resident #1 and Resident #2 resulting in physical aggression.This failure could place residents at risk of physical harm, and a decrease in safety due to the lack of staff supervision.Findings include:Record review of Resident #1's admission record revealed a [AGE] year-old male, admitted [DATE], with diagnoses of Encephalopathy (syndrome characterized by an altered mental state, causing symptoms like confusion, memory loss, personality changes, and in severe cases, coma or death), Legal Blindness, Generalized Muscle Weakness, Lack of Coordination, Unspecified Sequelae of Cerebral Infraction (long-term, lasting neurological or functional deficits that remain after a stroke, where the specific symptoms (like paralysis, aphasia, or cognitive decline) are not detailed or broken down in the medical documentation), Dysphagia following Cerebrovascular Disease (a clinical condition where a patient experiences lasting difficulty swallowing due to a specific, non-routine brain vascular event).Record review of Resident #1's Care Plan dated 3/23/2026revealed ADL self-care deficits and risk for further decline in ADL functioning and injury due to vision impairment. Staff interventions revision date of 3/19/2026 included to provide extensive assistance of 1 support person for locomotion on/off unit and walking in room or down corridor and to keep environment free of clutter. Care Plan also indicated Resident #1 had potential to be verbally aggressive using abusive language to staff with interventions indicated a revision date of 3/192023 to intervene before agitation escalated, guide away from source of distress, and engage calmly in conversation.Record review of Resident # 2's admission record revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE], with diagnoses of Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery (a type of ischemic stroke. It occurs when a blood clot (thrombus) forms locally inside a brain artery that has not been specifically identified, cutting off blood and oxygen to brain tissue and causing cells to die), Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (classic neurological deficits caused by damage to the left hemisphere of the brain), Dementia in other Diseases classified Elsewhere (identifies cognitive decline and memory loss that occur as a complication or secondary symptom of another primary medical condition), Unspecified Severity(lacks enough data, testing, or documentation to pinpoint the exact stage or severity) , without Behavioral Disturbance , Psychotic Disturbance, Mood Disturbance (the individual is not exhibiting symptoms like aggression, hallucinations, agitation, or socially inappropriate behavior), and Anxiety (feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), and Aphasia (a neurological communication disorder that impairs the ability to speak, understand, read, and write)Record review of Resident # 2's Care Plan dated 3/25/2026 , indicated ADL self-care deficits and risk of further decline due to impaired mobility and impaired cognition. Interventions indicated staff were to provide supervision assistance of 1 support person for locomotion on/off unit. The care plan for communication impairment indicated intervention revision date of 10/22/2025 to reduce or remove interfering environmental stimuli. Care Plan also indicated a revision date of2/12/2025 for behaviors and episodes of physical aggression, staff interventions included to observe for early warning signs of behavior - approach in a clam manner, call by name, remove from unwanted stimuli.During an observation and interview on 6/2/2026 at 9:37 a.m., Resident #2 was seated in wheelchair and able to self-propel. Resident # 2 had an issue with a resident(unable to name the resident) that pushed him in his wheelchair although he asked staff to move the resident from near him. Resident #2 said the staff watched before they intervened. Resident #2 could not move well and was paralyzed on one side of his body and needed assistance when in his wheelchair. Resident #2 said one resident that was in his space was blind and ambulated by wheelchair also. Resident # 2 said the other resident was touching him with his arms out. Staff were not around at that time to move the other resident away from him. Resident # 2 tried to move the other resident himself by pushing him away. and Resident #2 pushed the resident off him. Resident #2 said the resident was moved from his hall to a new hall. Resident #2 said there were no staff present when the resident (Resident #1) went around and pushed other residents by hand, like Resident #2, was pushed. Resident #2 said he told LVN A what happened and LVN A handled the situation and talked to other residents about respecting each other's space.During an observation at 10:45 a.m., Resident #1 was in bed covered with a blanket and wearing a baseball cap. Resident #1 did not respond when prompted by name.In an interview on 6/2/2026 at 10:47 a.m., RN A said she was trained to redirect residents and deescalate the situation before it got physical. RN A said Resident #1 was blind and needed transfer assistance into the wheelchair but could self-propel in station 3, where his room was located. She stated she worked with Resident # 1 recently and kept him in station 3 or his room during meals for supervision and safety. RN A said she was unaware of any issues with Resident #1 and Resident #2 and was not present for the incident with the residents. RN A said Resident #1 did not have issues with physical aggression that she was aware of.In an interview on 6/2/2026 at 10:59 am, CNA A said her duties were to help feed and serve residents their meals, grooming, and to assist residents in wheelchairs to different areas of the facility. CNA A said the facility once had hospitality aides to assist with feeding and serving residents meals however recently CNAs completed that task along with other tasks. CNA A said there was not a staffing issue; however, it did help when the facility had hospitality aides. CNA A said Resident #1 was blind and needed assistance into his wheelchair but he could propel the wheelchair himself. CNA A said Resident #1 felt around with his hands on the wall when he propelled in his wheelchair. CNA A said she was not aware of any issues with residents when he used his hands to feel and get around the facility. CNA A said she had not heard or seen Resident #1 or Resident #2 with issue or in an altercation. CNA A said if she had seen an altercation she would have separated the residents and reported to the Administrator about the incident.During an observation on 6/2/2026 at 1:05 pm, Resident # 1 was in front of his room door in wheelchair with blanket covering his face in front of the nurses' station. Resident # 1 did not speak when prompted with hello or addressed by name. Resident # 1 was not in distress. Observed 3 staff at nurses' station and CNA A in Resident # 1's room cleaning the floor and changing bed sheets.During an interview via telephone on 6/2/2026 at 1:36 pm, CNA B said she was walking across dining area hallway to clock out around 6:30 a.m. and observed Resident # 1 and Resident # 2 in a physical altercation where Resident # 2 knocked Resident # 1's hat off. CNA B said she went to inform RN B and was told to write a statement about what happened. CNA B said Resident # 1 cursed in Spanish and called someone a puto. CNA B said Resident # 1 used his hands to get around by touching the wall and told Resident # 2 that Resident # 1 was blind and did not curse at him or touch him on purpose. Resident # 2 said bullshit in response that Resident # 1 knew what he did. CNA B said someone , either the nurse or CNA, placed Resident # 1 at the nurse's station to prevent Resident # 1 from a fall . to monitor him. CNA B said she did not know if Resident # 1 was to be on a one on one or supervised by someone. CNA B said Resident #1 was not their resident however there were no other CNAs or Nurses in the dining area during that time. CNA B said CNAs used the resident's care plans information when CNAs worked with the residents. CNA B said if there were any changes to the care plan, or resident needs, it would show on the kiosk located in the hallways.Interview via telephone on 6/2/2026 at 1:43 pm, LVN A said she did not see what happened with Resident # 1 and Resident # 2 and was down the hall when the incident happened. LVN A said one of the CNA's (CNA B) told her that the two residents were in the dining room and there was an altercation. LVN A said she asked CNA B if CNA B saw the altercation in which CNA B said she only saw Resident # 2 knock off Resident # 1's hat and separated them. LVN A said she spoke to Resident # 2 and informed Resident # 2 that Resident # 1 did not purposely hit or approach him as Resident # 1 was blind and used his hands to feel around the area he used his wheelchair in. LVN A said Resident # 1 was usually not up that early but night shift had him up for some reason. LVN A said normally CNAs or Nurses have Resident # 1 in the dining area with other staff once meals were served and placed on tables. LVN A said Resident # 1 was typically in areas with multiple staff either walking passed, or during an activity, to be better monitored. LVN A said there was not a particular staff assigned to Resident # 1 however when he was in groups or open areas other residents and staff would inform them when Resident # 1 was self-propelled. LVN A said there would not be a risk or lack of supervision since the incident had not happened before. However, CNAs and Nurses were aware to keep an eye on Resident # 1 since he would go around and use his hands and did not want him touching other residents or grabbing at other residents when he ambulated around the facility.During an interview on 6/2/2026 at 2: 34 pm with the DON said she was not present for the incident with Resident # 1 and Resident # 2. DON said she was told Resident # 2 knocked off Resident # 1's hat. The DON said the only staff present was CNA B and was not aware if other staff were present. The DON said the previous Administrator completed the incident report and the allegation was determined by the previous Administrator and the ADONs. The DON said she reviewed the investigation report and any skin checks, interventions, and other tasks were completed. The DON said the allegation of resident to resident altercation was accurate and did not believe any other allegation or concern should be investigated.In an interview on 6/2/2026 at 2:42 pm, ADON A and ADON B said they were not present when the incident with Resident #1 and Resident #1 happened. ADON A and ADON B stated neither completed or worked on the investigation report that was sent to state for review. ADON B stated she looked into the incident with statements that Resident #2 wheeled towards Resident # 1 and knocked his hat off his head. Neither ADON A nor ADON B said there were no other concerns with the incident besides the Resident-to-Resident altercation. Neither resident was on a 1-person supervision need. Resident #1 was moved to a new station away from Resident # 2 which was right across the nurse station to better monitor. Resident #1 was able to move around and followed the tables in the dining room by hand and felt the wall for ambulation. Resident #1 should not use a wheelchair on his own to get to the dining area. There have not been other incidents of Resident #1 and other residents due to his use of hands to feel around different areas when in the facility. ADON B said they (Facility Management) have talked about extra staff during the day and night for each shift to add an extra nurse at night to each station to increase supervision and educate on incidents.In an interview and observation on 6/2/2026 at 2:58pm Observed Resident #1 in same position in front of room door with his blanket covering him. Resident #1 did not speak to surveyor when prompted with hello or by name. Resident #1 was not seen in distress.In an Interview on 6/2/2026 at 6:54 pm, the Administrator said she had been the Administrator for 2 days and was not aware except through reading the incident report of Resident # 1 and Resident # 2. Administrator said residents need to be supervised when there was a history of physical behaviors and it had been care planned. Resident # 1 and Resident # 2 have a history of aggressive behaviors and staff should be in the area with either resident to avoid an incident. Administrator said there would be a risk of a physical altercation with both Resident # 1 and Resident # 1.Record review of the facility policy titled, Abuse, Neglect, and Exploitation Prohibition, dated 10/2024, read in part The facility will implement an appropriate plan of care for resident's with a history of self-injurious or abusive behaviors and update the plan of care as needed .Record review of the facility policy titled, Risk Management - Incidents & Accidents, dated 1/2024, read in part The facility will assess residents for risk factors of potential accidents/ hazards. The facility will recognize signs of incidents/accidents and assist residents, staff members, and visitors as indicated.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents right to make choices about aspects of his or her life in the facility that are significant to the resident, healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 3 of 9 residents (Residents #1, #2 and #3) reviewed for resident rights. The facility failed to support Resident #3 choice to use Medical Transportation B for transportation to and from medical appointments. The facility failed to support Residents #1 and #2's choice to use Medical Transportation B for transportation to and from medical appointments when their family members requested it. This failure could place residents at risk of loss of self-determination resulting in loss of independence, frustration or sadness, and diminished quality of life.Findings included:Resident #3 Record review of Resident #3's admission Record generated on [DATE] revealed she was admitted to the facility on [DATE] with diagnoses of type II diabetes, (a chronic, non-insulin-dependent condition where the body develops insulin resistance or fails to produce enough insulin, causing high blood sugar levels), heart failure (a chronic, progressive condition where the heart muscle cannot pump blood efficiently, leading to fluid buildup in the lungs and body, fatigue, and shortness of breath), chronic angle closure glaucoma (a slow-progressing, often asymptomatic eye disease where the iris gradually blocks the eye's drainage, causing high pressure and permanent damage to the optic nerve), chronic obstructive pulmonary disease (a progressive, incurable lung disease causing chronic airflow obstruction, breathlessness, and cough), and end stage renal disease (the final, permanent stage of chronic kidney disease, occurring when kidney function drops below 10-15% and they can no longer support life). She was [AGE] years of age. Record review of Resident #3's Care Plan dated [DATE] revealed she received dialysis three times a week at an offsite dialysis clinic. The transportation company was listed as Medical Transportation A. Record review of Resident #3's admission MDS assessment dated [DATE] revealed she had the ability to express ideas and wants and had the ability to understand others. She had a BIMS of 11, indicating she had moderate cognitive impairment. In an interview on [DATE] at 11:47am, Resident #3 stated she told two staff members that she wanted to use Medical Transportation B and they said no. Resident #3 said the staff members told her Medical Transportation B could not come on the premises. She said there was nothing wrong with Medical Transportation A, but .you get used to who you get used to.Resident #1Record review of Resident #1's admission Record generated on [DATE] revealed he was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a medical emergency caused by blocked blood flow to the brain, leading to tissue death), dysphagia (difficulty swallowing) and end state regnal disease. He was [AGE] years of age. Family Member D was listed as Resident #1's emergency contact and responsible party. Record review of Resident #1's Care Plan dated [DATE] revealed he received dialysis three times a week at an offsite dialysis clinic. Record review of Resident #1's Care Plan dated [DATE] revealed he had a communication problem related to an impaired ability to make self- understood and an impaired ability to understand others. Record review of Resident #1's Nursing Progress Note dated [DATE] at 11:32am, written by the DON read, Spoke with (Family Member D) regarding transportation to and from dialysis. [Family Member D] was assured that the facility has set the resident up has (sic) safe and reliable transportation via stretcher through [Medical Transportation A] for dialysis visits. [Family Member D] states as long as we get him there that is al that she is worried about. Again, reassured the (family member) that transportation was already set up. In an observation and attempted interview on [DATE] at 10:35am, Resident #1 was in his room in bed. He could respond to yes and no questions, however he did respond to questions regarding dialysis or medical appointments. In a telephone interview on [DATE] at 5:00pm, Family Member D said Resident #1 used Medical Transportation A for transportation to and from dialysis. Family Member D said Resident #1 used Medical Transportation B when he was at home. I asked if they could use (Medical Transportation B) and they said no. She said the DON told her Medical Transportation A had a contract with the facility and they did not have a contract with Medical Transportation B and they did not allow Medical Transportation B in their facility. Family Member D said, Why can't I use who I want to use? I really have no choice. Resident #2 Record review of Resident #2's admission Record generated on [DATE] revealed he was admitted to the facility on [DATE] with diagnoses of traumatic amputation of left lower leg, encephalopathy (any disease, damage, or malfunction that affects brain structure and function, leading to altered mental states like confusion, dementia, seizures, or coma), end stage renal disease, type II diabetes, and chronic obstructive pulmonary disease. He was [AGE] years of age. Family Member C was listed as Resident #2's emergency contact and healthcare power of attorney. Resident #2 expired on [DATE]. Record review of Resident #2's Care Plan dated [DATE] revealed he received dialysis three times a week at an offsite dialysis clinic. The transportation company was listed as Medical Transportation A. Record review of Resident #2's Care Plan dated [DATE] revealed Resident #2 had impaired cognitive function or impaired thought processes. Interventions included communicating with the resident, family and caregivers regarding resident's capabilities and needs, and keeping the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. In a telephone interview on [DATE] at 3:54pm, Family Member C said Resident #2 required transportation to and from dialysis and scheduled medical appointments. Family Member C said they preferred to use Medical Transportation B. Family Member C said she asked facility staff if they could call Medical Transportation B to see if they had availability for his appointments. Family Member C said facility staff told her Medical Transportation B was not allowed to come into the facility because the nursing facility's parent company would not allow it. She could not recall the facility staff members' names. Family Member C said Resident #2 had been using Medical Transportation B three times a week for years when he lived at home. Family Member C said, They know (Resident #2), and the less change possible would be beneficial to him. In a telephone interview on [DATE] at 4:55pm, the Administrator of Medical Transportation B said any time their patients were placed at the facility, they were not allowed to provide transportation. She said they provided services in the area for 18 years. She said their patients were like family. She said if a patient was established with their company, then it would be easy to continue transportation at the nursing home. She said she had spoken to the Administrator and the DON at the facility, and they told her they only use Medical Transportation A. In an interview on [DATE] at 6:15pm, ADON A 6:15pm said some of the resident's family members and or residents had set up transportation on their own. She said it was important for residents to be able to request their own ambulance company because it would be their right to choose. In an interview on [DATE] at 6:45pm, the Administrator said Resident #3 requested to use another ambulance service when she admitted to the facility. She could not recall other requests from other residents. She said when Resident #3 asked to use Medical Transportation B, the Administrator told Resident #3 that Medical Transportation B did not pick up any residents from their facility. She did not believe that they serviced their area. She said they used Medical Transportation A because it was the only one in town. In an interview on [DATE] at 2:25pm, the DON said Medical Transportation A was local to their area. She said a year ago, they used Medical Transportation B, but there was legal action involved. She could not recall the outcome of the legal action. When asked why it would be important for residents to choose their own transportation company, she said it was because of resident rights. Record review of facility Education regarding Resident Rights, Dignity and Privacy (undated) read, Resident Rights: Legal rights protected under federal law. These rights ensure that residents in Medicare- and Medicaid-certified nursing facility are treated with dignity and respect. Resident Rights. Right to Make Independent Choices. Choose personal scheduled, activities, clothing, and visitors. Manage your own finances or choose someone to do it for you. Record review of the Resident admission Agreement dated [DATE] read, Transportation. The Resident/Responsible Party is generally responsible for transporting the Resident to and from medical appointments, dental appointments, and any other off-siteappointments. The Facility may, upon request of the Resident/Responsible Party, transport or arrange for the transport of non-Medicaid residents to their medical and health care providers at the Facility's standard rates for such services.

Based on record review and interview, the facility failed to provide written notice as soon as practicable before transfer or discharge to resident and resident's representative and the reason for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman 1 of 2 resident (CR #10) reviewed for transfer and discharge rights.-The facility failed to provide a written notice of transfer to CR #10, CR #10's representative and the long-term care ombudsman as soon as practicable when CR #10 was transferred to another nursing facility on 3/5/26. This failure placed residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .Findings included: Record review of CR #10's admission Record generated on 4/16/26 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (a general term for a progressive decline in cognitive function-memory, thinking, and behavior-that interferes with daily life), malignant neoplasm of the prostate (a cancerous tumor forming in the prostate gland's epithelial tissue), anxiety disorder (the body's natural reaction to stress, causing persistent, excessive worry and physical symptoms like rapid heart rate, sweating, and tension), and psychosis (a mental health symptom, not a specific illness, characterized by a disconnection from reality, including hallucinations {seeing, hearing things} and delusions [false, firm beliefs]. He was [AGE] years of age. Guardian E was listed as his emergency contact. He was discharged on 3/5/26. Record review of CR #10's Care Plan dated 8/23/24 revealed he had impaired cognition with short term memory loss and impaired decision making. The care plan indicated he had a legal guardian. Interventions included contacting his legal guardian for all changes and/or decision making. Record review of CR #10's Nurse Progress Note dated 3/5/26 at 9:09am revealed CR #10 was transferred to a sister facility (other nursing facility). Record review of CR #10's electronic medical record on 4/16/26 at 4:34pm indicated no record of a discharge notice or transfer notice. Record review of a Provider Investigation Report dated 3/9/26 read, [CR #10] was propelling down the hallway.he saw [Resident #4] and propelled himself to [Resident #4] and immediately hit him, once in the chest and again in the left arm. These two gentleman had previously been involved in a resident -to- resident alteration on 2/20/26, an altercation initiated by [Resident #4] and received by [CR #10].Since the initial incident, the facility has been actively seeking alternate placement for [Resident #4].[CR #10]. has been transferred temporarily to a sister facility until we can secure alternate placement for [Resident #4]. In a telephone interview on 4/16/26 at 4:38pm, Guardian E said a facility staff member called to inform her that CR #10 was going to be moved to another nursing facility because of an incident that happened. Guardian E said they informed her it was not CR #10's fault, but they were going to move him. Guardian E said they did not give written discharge notice or give her an option of which facility he would go to. She said she agreed to the transfer plan. In an interview on 4/16/26 at 6:45pm, the Administrator said after the incident between CR #10 and Resident #4, she called Guardian E. She said she informed Guardian E that they placed CR #10 at a sister facility, but they were not kicking him out. She said they were trying to get him to a safe place. She said Guardian E understood. She said they did not complete a written transfer or discharge notice. She said she was thinking about safety first.Record review of the facility's Discharge/Transfer policy and procedure dated 6/2025 read, Involuntary discharges.The Facility must provide a discharge notice as soon as practicable.if: The safety of an individual in the facility would be endangered. The Facility should provide as much specific information as possible in the discharge notice to notify the resident why he or she is being discharged and how the discharge meets discharge criteria.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 3 nursing stations (Station 3) reviewed for sufficient staff.The facility failed to have sufficient staff to ensure staff were always present in the locked memory care unit that housed 14 residents with dementia. This failure could place residents at risk of decreased supervision, accidents, abuse and injuries.Findings included:Record review of the facility's Daily Census dated 4/15/26 revealed there were 14 residents residing on the memory care unit and 13 residents residing on Station 3. Record review of the facility's Resident Matrix dated 4/16/26 revealed 13 of 14 residents residing on the memory care unit had a diagnosis of dementia or Alzheimer's disease. In an observation and interview on 4/16/26 at 1:10pm, Family Member F was visiting a resident in the memory care unit. Family Member F said her family member was in the memory care unit due to dementia. She said the care she received on night shift and weekends was poor quality. Family Member F said they do not check on her enough at night and they leave her in the common area too late. Family Member F said one Saturday night when she visited there were no staff in the memory care unit. In an interview on 4/16/26 at 5:54pm, Medication Aide U, she said she worked during the day shift. She said she covered Station 3 and the memory care unit. She said she had to leave the memory care unit to pass medications on Station 3, leaving one CNA on the unit. She said some of the memory care residents acted out. She said the nurse and other aides could help, but they aide had assignments, including showers and rounds. She said they could not always supervise the residents in the memory care unit. Facility administration had not advised her on what to do when the other aide/nurse was busy and she had to leave the unit, leaving the residents without supervision. In an interview on 4/16/26 at 5:57pm, LVN R said she primarily worked on the day shift. When asked if there were enough staff to meet the residents' needs, she said there were not enough staff on the floor at night, and they were constantly running back and forth. She said during the day shift, they had one CNA and one medication aide for Station 3 and the memory care unit. She said at night, there was only one CNA assigned to Station 3 and the memory care unit. She said some residents were dependent on staff on Station 3. She said the CNA had to leave the memory care unit to care for residents on the other side of the locked unit in Station 3. In an observation on 4/16/26 at 5:58pm, the memory care unit was noted to be one hallway with a locked glass door on one end and a common area with a couch and dining tables on the other end. You could see through the glass door and see the hallway where Station 3 residents resided. There were 5 residents in the common area. Resident #5 stood up from a chair at a dining room table, walked to a medication cart and grabbed a blood pressure cuff, then sat back down in the same chair. Three residents were walking down the hallway and entering resident rooms. CNA W stated to one resident that she entered the wrong room and to go to her room. In an interview on 4/16/26 at 6:00pm, CNA W said the memory care unit needed to be staffed with two CNAs. She felt like she had to rush when the residents needed help. Many of the memory care residents are moving the whole day. She said when one resident got up, they all got up to follow at times. She said it could get a little busy on the memory care unit.In an interview on 4/16/26 at 6:25pm, ADON B said there should be two people at all times in the memory care unit. She said during the day, it was usually a medication aide and a CNA. If the medication aide or the CNA had to step out, then the nurse, another CNA or activity personnel are on the floor. She said at night there was one staff member. She said the resident's needs were met by the staff. In an interview on 4/16/26 at 6:45pm, the Administrator stated Family Member F brought staffing concerns to her and reported that she visited one night and there were no staff on the memory care unit. The Administrator told Family Member F that just because you did not see the staff did not mean they were not there. The Administrator said she interviewed a few staff members and the Administrator determined there was someone on the memory care unit the night Family Member F reported there were no staff on the hall. She said when they review staffing ratios, they look at PPD (a key healthcare metric, primarily in skilled nursing, representing the average cost, hours, or supply usage allocated to one patient over 24 hours) and if residents had higher acuity they would staff more. She said if there was an increase in falls or skin issues then they would look at increasing the staffing ratio. In an observation on 4/19/26 at 10:16pm, LVN O was sitting at the nurse's station on Station 3. CNA N was walking down the hallway toward Station 2 with another staff member. No staff were observed on the memory care unit. In an observation on 4/19/26 at 10:18pm, CNA N entered the memory care unit with the state surveyor. There were no other staff members observed on the unit. In an interview on 4/19/26 at 10:20pm, CNA N said she thought the facility was staffed well. She said some residents wanted care right away and they could not provide that. She said she made rounds to all residents on station 3 and memory care with no problems. CNA N said she was the only aide assigned to the memory care unit tonight. She said she primarily worked during the night shift. In an and interview on 4/19/26 at 11:32pm, LVN P said she primarily worked the night shift. She said there were only two nurses after 10:00pm at the facility. She said when the nurse left at 10:00pm, she covered both station 2 and station 3, caring for about 50 residents. She said if there was a change of condition or a resident admission, it could get busy. She further said she had to pass medications. She said there should always be someone in the memory care unit. She said the CNA assigned to memory care also cared for the residents on Station 3. She worried about the residents in the memory care unit because they were at risk of falls, behaviors and needed supervision. She thought that they needed 2 CNAs on the hall. In an interview on 4/19/26 at 11:45pm, the DON said LVN O worked from 6pm-10pm on station 3, then moved over to station 1 at midnight. She said the nurse who worked on station 1 worked from 6pm to midnight. When asked if there were only 2 nurses at night, the DON said she was a little unfamiliar with the schedule because she had been off for medical leave. In a telephone interview on 4/20/26 at 8:44am, LVN O said she did not think the facility was staffed appropriately. She said they had two nurses who worked the night shift, with four CNAs. She said the CNAs were running around answering call lights, doing rounds, then had to do rounds all over again. She said the CNAs were not taking a lunch break. She said she had took her concerns to the DON. She said someone should always be in the memory care unit. She said the residents in the memory care unit did not sleep at times and some residents had behaviors. She said the aide had to leave the memory care unit to check on the other residents on Station 3. She said they tried their best to keep someone on the unit. In a telephone interview on 4/20/26 at 11:30am, CNA T said the facility was not sufficiently staffed in the memory care unit. She said there should be two people in the unit at all times. She said there were residents in the common area, and some were in the room, and they could not monitor and supervise all of them. She said she would be on the memory care unit by herself at times. She said some residents had behaviors like going in other residents' rooms and taking other residents' belongs. In an interview on 4/20/26 at 2:25pm, the DON said the memory care unit should always have a staff member. When the state surveyor informed the DON that there were no staff members in the memory care unit on the night of 4/19/26, she said it was surprising. She said it was the charge nurses' responsibility to direct their CNAs and tell them who to care for. She said staff needed to ensure that someone was there all the time, and if they stepped out of the memory care unit then they needed to call someone for help. The DON said the nurses would always ask for more staff, regardless of how many people were working. She said 2 nurses and 5 CNAs was appropriate for their census. Record review of the facility policy and procedure for Contingency Staffing dated 1/2025 read, The facility is committed to maintaining adequate staffing levels to ensure the safety and well-being of residents.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 2 of 8 residents (Resident #1 and #2) reviewed for abuse and neglect, in that; Resident #2 made repeated hateful remarks toward Resident #1 and struck Resident #1 with her wheelchair. Following the incident of being struck by Resident #2's wheelchair, Resident #1 reported increased right shoulder pain lasting approximately one week, exhibited tearfulness and avoidance behaviors, and remained in her room due to fear of encountering Resident #2. Resident #2 continued to be present in common areas for approximately three weeks after Resident #1 expressed fear and concern. An Immediate Jeopardy (IJ) situation was identified on 3/14/2026. While the IJ was removed on 3/15/2026, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for injury, emotional harm, unsafe conditions, and compromised dignity and safety.Findings include: 1.Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: osteoarthritis (a degenerative joint disease caused by the breakdown of cartilage covering the ends of bones), depression (mood disorder causing persistent sadness, loss of interest, and physical symptoms like fatigue or pain that disrupt daily life), anxiety disorder (mental health conditions involving excessive, persistent, and uncontrollable worry or fear that interferes with daily life), Alzheimer's disease (a progressive neurological disorder causing brain shrinkage and cognitive decline), abnormalities of gait and mobility, and age related physical debility . Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. Resident #1 reported feeling down, depressed, or hopeless for several days and exhibited no behavioral symptoms. Resident #1 used a wheelchair for mobility and received a scheduled pain medication regimen with no reported pain. Record review of Resident #1's Care Plan, last revised on 10/24/2025, revealed a care area which addressed increased pain/discomfort and risk for injury related to diagnoses of chronic pain and osteoarthritis. Interventions included encouraging the resident to verbalize feelings of pain/discomfort; assisting with ADLs and providing comfort measures as indicated; encouraging socialization and participation in activities as tolerated; monitoring the effectiveness of pain medications and other interventions and reporting to the MD if ineffective; monitoring for side effects of pain medications and reporting any noted to the MD; observing for signs and symptoms of increased pain/discomfort and assessing for possible causes, implementing interventions such as administering pain medications, treatments, and relaxation modalities, and evaluating for relief; and utilizing a 0-10 numeric pain scale to assess pain level. Further record review of Resident #1 care plan, last revised on 10/24/2025, revealed a focus area which addressed the potential for decline in psychosocial well-being and social isolation, as evidenced by the mood interview. Interventions included encouraging family involvement to support a positive psychosocial outlook; encouraging family to bring familiar items during visits; encouraging the resident to attend activities of choice and facilitating pairing with peers who share similar interests; engaging the resident in reminiscing about past experiences and life prior to residency; and introducing the resident to others to promote social interaction and relationship building. Record review of another care plan area for Resident #1, last revised on 10/25/2025, revealed a focus on the use of psychotropic medications and the resident's risk for adverse reactions and episodes of depressive and anxiety-driven behaviors, as evidenced by a diagnosis of depression with anxiety and the use of antidepressant medications. Interventions included encouraging the resident to verbalize feelings during behavioral episodes; monitoring for signs of depressive behaviors such as spontaneous crying, sad mood/affect, self-imposed isolation, and mood not easily altered; reporting any noted changes to the MD/RP; and documenting findings in the clinical record. Record review of Resident #1's physician order, dated 9/30/2025, revealed an order for cyclobenzaprine HCl oral tablet 10MG to be given by mouth every 8 hours as needed for neck and muscle pain related to other chronic pain. Record review of Resident #1's February and March 2026 MAR revealed order for cyclobenzaprine HCl oral tablet 10MG to be given by mouth every 8 hours as needed for neck and muscle pain was administered once on 2/17/2026 at 11:58 PM with a pain rating of 5/10. Record review of Resident #1's physician order, dated 10/1/2025, revealed an order to monitor resident every shift for Target Behaviors of confusion and depressive features. Record review of Resident #1's February and March 2026 TAR revealed according to order to monitor for target behaviors of confusion and depressive features every shift, no behaviors were noted. Record review of Resident #1's physician order, dated 10/1/2025, revealed an order to observe for pain every shift. Record review of Resident #1's February and March 2026 TAR revealed according to order to monitor for pain every shift, no complaints of pain were noted. Record review of Resident #1's physician order, dated 1/8/2026 and discontinued on 2/23/2026, revealed an order for Acetaminophen Extra Strength Tablet 500 MG to give 2 tablet by mouth two times a day for Arthritis. Record review of Resident #1's physician order, dated 2/23/2026, revealed an order for Acetaminophen Extra Strength Tablet 500 MG to give 2 tablet by mouth two times a day related to unspecified osteoarthritis, unspecified site. Record review of Resident #1's February and March 2026 MAR revealed order for Acetaminophen Extra Strength Tablet 500 MG, 2 tablets by mouth two times a day was administered 2/1/2026 - 3/15/2026 as ordered with a pain level of 0/10. Record review of Concern Report, dated 2/22/2026, revealed concern was received by LVN A from Resident #1 regarding Resident #2. The description of concern was, Several residents complaining that above resident cleans DR (dining room) and takes their plates and cups away before they are finished. Investigation details noted, Spoke with resident and was instructed not to clean the DR anymore. Leave it for the kitchen staff. Resident also arguing with other residents about their plates and drinks. Further review of the report revealed the concern was reported to the social worker . Bottom of the concern report regarding Findings of investigation/resolution was blank as well as whom the investigation results were reported to was blank. Investigator signature and Administrator review signatures were also blank on the report. Record review of Resident #1's Psychological Services progress note, dated 2/23/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with no new stressors noted. The progress note revealed her progress and plan included in part, .Client appeared stable, relaxed and comfortable throughout the visit . continue routine supportive visit to reinforce emotional well-being. Encourage participation in day room activities and peer interaction. monitor for changes in affect and behavior. Record review of Resident #1's progress note, dated 2/24/2026 at 12:42 PM, revealed a physiatry progress note by NP, noted in part, .Resident #1 reports right shoulder/arm pain today. She states another resident ran into her with a wheelchair accidentally a few days ago. She reports the pain is subsiding. Right shoulder pain: patient states another resident accidentally backed into her with her wheelchair. Patient states pain in right arm is subsiding. She did not want to roll sleeves all the way up to exam skin; likely a contusion as there is tenderness with palpation over right upper arm area; range of motion (ROM ) is intact. Can abduct shoulder to about 60 degrees. Pain is improving per patient. If it persists, will get xray. Record review of Resident #1's Quarterly Care Plan Meeting note, provided by the facility after exit on 3/16/2026 at 12:02 PM, documented an effective date of 2/24/2026 at 1:30 PM. Care Plan meeting note reflected Resident #1's RP attended the meeting in person and had a summary noting in part, .The family was able to express their concerns regarding the resident having a verbal disagreement with a peer. Their concerns were addressed by IDT members. Record review of Resident #1's psychiatric subsequent assessment, dated 2/27/2026, noted reason for referral was depression and anxiety and chief complaint noted was, I hear voices sometimes. Resident #1's History of Presenting Illness noted in part, .Depression: Staff reports current symptoms of loss of interest. severity level 4 (moderate). Symptoms occurring for 8 months. Anxiety: Staff reports current symptoms of impaired concentration. symptoms have been occurring for 7 months. Cognitive Impairment: staff reports current symptoms of confusion and reports no current symptoms of forgetfulness.symptoms have been occurring for 11 months. collateral information: Staff denies any complaints/concerns at this time. Further review of progress note revealed Resident #1's psychiatric review of systems noted anxiety symptoms, depressive symptoms and insomnia and her Mental Status Examination noted she had an anxious depressed mood. Record review of Resident #1's Psychological Services progress note, dated 3/2/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with no new stressors noted. The progress note revealed her progress and plan included in part, .Client presented with a calm and stable demeanor. continue regular supportive check-ins to sustain emotional stability. Encourage involvement in day room programming and peer interactions. Record review of Resident #1's Psychological Services progress note, dated 3/10/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with a new stressor of recent illness noted. The progress note revealed her progress and plan included in part, .Discussed recent illness involving diarrhea and assessed clients physical status. Reinforced positive shift toward increased social interaction as symptoms improved. client appeared more comfortable and reported feeling better physically. She engaged in conversation and expressed enjoyment in socializing again. The plan also included to encourage continued social engagement and monitor physical recovery . Observation and interview on 3/13/2026 at 5:00 PM, the Administrator identified Resident #1 sitting in the dining room at a table with another resident. Resident #1 said things had generally been going okay at the facility, but she reported having a serious issue with one resident. Resident #1 stated there was another female resident who was always in the dining room messing with everyone. Resident #1 stated she did not know the resident's name but identified her as being present in the dining room at that time, sitting a few tables away. It was noted Resident #2 was seated in the dining room approximately two tables away from Resident #1. Resident #1 stated Resident #2 did not like her, and she did not know why. Resident #1 stated Resident #2 was rude to her and other residents and would say nasty hateful things to everyone. Resident #1 stated she had never done anything to Resident #2 to cause this behavior and said she was terrified of Resident #2 because Resident #2 had hit me with her wheelchair a few weeks earlier. Resident #1 pointed out an area in the dining room, beside a nearby table, and stated that was where she was sitting when she felt a hard crash from behind. Resident #1 stated she could hear Resident #2 talking but could not make out what she was saying. Resident #1 stated she was so scared when it happened, she could not remember who else was around and was in shock from the incident. Resident #1 stated Resident #2 eventually wheeled away, while she remained scared and concerned Resident #2 might return. Resident #1 recalled seeing her RP later that same day and told her what happened. Resident #1 stated she and her RP then spoke to the facility staff about the incident involving Resident #2. Resident #1 stated after the incident of being hit by the wheelchair, if she saw Resident #2 in the hallway or dining room, she would go back to her room because she was afraid to be around her and did not know what Resident #2 might do next. Resident #1 stated the way Resident #2 treated her and the other residents was very upsetting. Resident #1 stated her RP and staff tried to tell her that was just how Resident #2 acted because she had issues, but Resident #1 stated she did not feel it was fair that she and the other residents had to tolerate being harassed by Resident #2. Resident #1 stated she did not think Resident #2 should be at the facility. Resident #1 stated she was still scared of Resident #2 but felt somewhat safer now because she made friends at the facility who she felt had her back. Resident #1 stated she was just beginning to return to the dining room while Resident #2 was present due to encouragement from her RP and other residents, but she would rather not have to be around Resident #2. Resident #1 stated after being hit by Resident #2's wheelchair, she experienced severe shoulder pain. Resident #1 stated the wheelchair strike was really hard and hurt really bad. Resident #1 pointed to her right shoulder as the area affected and stated it felt better at the time of the interview; however, after the incident she had pain in her right shoulder for about one week. Resident #1 stated her RP was aware of the shoulder pain and recalled telling her PE teacher (NP) about the incident and her shoulder pain as well. During the interview, another resident sat at a nearby table sneezed loudly. Resident #1 was visibly startled and jumped in her chair. The state surveyor reassured Resident #1 the noise was another resident sneezing. Resident #1 grabbed her chest and stated the noise startled her and she felt more cautious of her surroundings since the incident with Resident #2. 2. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: dementia with other behavioral disturbances, COPD (progressive lung disease that restricts airflow, causing chronic breathing difficulties, cough, and fatigue), Type II diabetes, lack of coordination, depression, psychotic disorder with hallucinations due to known physiological condition (severe mental health conditions causing a loss of contact with reality, characterized by hallucinations, delusions, and disorganized thinking), insomnia, and muscle weakness . Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 7/15, which indicated severe cognitive impairment. The resident exhibited no behavioral symptoms, utilized a wheelchair or walker for mobility, and was able to independently self-propel her wheelchair. Record review of Resident #2's care plan, initiated on 11/2/2023 and last revised on 3/13/2026, revealed a focus area addressing episodes of inappropriate behaviors and the risk for increased behavioral episodes and related injury. This was evidenced by the resident storing soiled clothing in boxes in her room, collecting and storing facility linens in boxes which resulted in odors in the room, placing paper towels and toilet paper in her pull-up briefs, and moving/dragging and rearranging dining room chairs (added to the care plan on 3/13/2026). Interventions included educating the resident to avoid using paper products as padding in her briefs each shift; explaining that the facility will complete her laundry and discouraging the storage of soiled laundry in her room; reminding and encouraging the resident to allow staff to collect her laundry and linens daily; monitoring and documenting behaviors as they occurred and reporting progress or decline to the MD; observing for early warning signs of behaviors and approaching the resident calmly, calling her by name, and providing reassurance as needed; and providing a psychiatric consult as ordered. Record review of Resident #2's physician order, dated 3/18/2024, revealed to monitor target behavior of confusion or aggression at the end of each shift. Record review of Resident #2's February and March 2026 TAR revealed no behaviors were observed. Record review of Resident #2's progress notes revealed no entries from 2/16/2026 - 3/13/2026. Record review of Resident #2's Psychological Services Progress notes, dated 2/23/2026, 3/1/2026 and 3/9/2026 revealed she had diagnoses which included major depressive disorder and generalized anxiety and her symptoms focused on during the sessions, in part, included anxiety and agitation, and her functional behavioral challenges that were focused on, in part, included verbal or physical aggression. Summary of the notes included no concerns, or distress was noted and to continue to monitor residents mood, responsiveness and emotional stability. Observation and interview conducted on 3/13/2026 at 12:41 PM revealed approximately seven residents seated at tables in the dining room, all of whom appeared to have finished their meals. Resident #2 was observed in the dining room, ambulating in her wheelchair by propelling herself with both feet. She was observed moving from table to table, picking up items from tables and the floor while also pulling on chairs and tables. Resident #2 was then observed wheeling over to Resident #3 and attempting to pull on Resident #3's wheelchair. Resident #2 bent over, unlocked the left wheel brake of Resident #3's wheelchair, and pulled the wheelchair backward away from the table. Resident #2 was heard mumbling; however, her statements could not be understood. Resident #3 did not respond verbally during this interaction. No staff were present in the dining room at the time; however, staff were observed passing by in the hallway in front of the dining room and in adjacent office areas. The state surveyor approached Resident #2 while she was leaning on the left side of Resident #3's wheelchair. After introduction, Resident #2 asked the state surveyor what she wanted. Resident #2 was able to state her name and indicated she was cleaning, showing the state surveyor trash in her hand. Resident #2 then instructed the state surveyor to leave so she could continue cleaning. She subsequently wheeled away from Resident #3 and the state surveyor and continued moving around to other tables. 3. Record review of Resident #3's facesheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Type II diabetes, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing it of oxygen), chronic kidney disease (long-term, progressive loss of kidney function), congestive heart failure (a chronic, progressive condition where the heart inefficiently pumps blood, causing fluid buildup in the body). Observation and interview conducted on 3/13/2026 at 12:41 PM revealed during the state surveyor's interview with Resident #2, Resident #3 remained silent. After Resident #2 wheeled away, Resident #3 was able to state her name and reported she was doing okay. Resident #3 stated she did not know what Resident #2 wanted or why her wheelchair had been moved and reported having no complaints. Resident #3 was unable to state whether she knew Resident #2. 4. Record review of Resident #4's facesheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Type II diabetes, hypertension , mononeuropathy (damage or dysfunction of a single peripheral nerve, resulting in localized pain, numbness, tingling, and muscle weakness), anxiety disorder, obsessive compulsive disorder (chronic mental health condition characterized by uncontrollable, recurring thoughts and repetitive behaviors performed to reduce anxiety), and age-related cataracts (progressive clouding of the eye's natural lens). Record review of Resident #4's Annual MDS, dated [DATE], revealed a BIMS score of 13/15, which indicated her cognition was intact. Resident #4 had no behaviors, and she could ambulate with a walker. Interview conducted on 3/13/2026 at 12:00 PM revealed Resident #4 stated there was a resident who moved around the facility taking items, whom she identified as Resident #2. Resident #4 reported approximately one month ago, she was in the dining room near the kitchen door waiting for an item she had requested when Resident #2 approached her in a wheelchair and told her to move out of the way. Resident #4 stated she informed Resident #2 she was waiting for something, however, Resident #2 continued yelling at her to move. Resident #4 reported when she did not move, Resident #2 struck her on the arm with her hand. Resident #4 stated the Director of Nursing (DON) was nearby and believed the DON witnessed the incident. Resident #4 further stated the DON told her Resident #2 was confused and this explained her behavior, which indicated it was part of Resident #2's baseline behaviors. Resident #4 reported she began avoiding Resident #2 whenever she saw her because she felt Resident #2 did not like her and was consistently rude to others. Resident #4 stated it was not fair that other residents had to tolerate Resident #2's behavior due to her confusion. Resident #4 added there was another unit designated for residents with cognitive impairment and suggested Resident #2 should be transferred there and stated she did not understand why this had not occurred. Interview conducted on 3/13/2026 at 4:33 PM, CNA A stated she was familiar with Resident #2 and was aware of behaviors involving physical and verbal aggression toward residents and staff. CNA A reported Resident #1 told her Resident #2 previously hit her. CNA A stated she did not witness the incident; however, she recalled an occasion when she was escorting Resident #1 to the dining room and, upon seeing Resident #2, Resident #1 became tearful and stated she did not want to enter the dining room due to fear of Resident #2. CNA A reported she asked Resident #1 why she was avoiding Resident #2, and Resident #1 stated Resident #2 had hit her. CNA A was re-interviewed on 3/13/2026 at 5:20 PM and stated Resident #1 first reported the incident to her a few weeks ago. CNA A stated Resident #1 continued to express concerns about Resident #2 whenever she encountered her, became visibly upset at the sight of Resident #2, and preferred to remain in her room to avoid contact. CNA A reported she had received multiple in-services on abuse and neglect and understood all allegations of abuse should be reported to the Administrator, who served as the Abuse Coordinator. CNA A stated she did not report Resident #1's allegations because Resident #1 indicated the nurse and social worker were already aware, and she assumed the issue was being addressed. CNA A further stated, in response to Resident #2's behaviors, staff attempted to monitor her in the dining room to prevent her from disturbing other residents; however, Resident #2 did not respond well to redirection. Interview conducted on 3/13/2026 at 4:50 PM, the Administrator stated no concerns had been reported to her regarding Resident #2 exhibiting aggressive behaviors. The Administrator reported she was aware Resident #2 frequently attempted to clean the dining room and would take trays from residents before they had finished eating; however, she had not received any reports of aggressive behavior during these incidents. The Administrator stated she spoke with Resident #4 almost daily and Resident #4 had not reported any altercations involving Resident #2. The Administrator further stated she was not aware of any incidents involving Resident #1 and Resident #2 and indicated staff were trained to report all abuse concerns directly to her so an investigation could be conducted. The Administrator stated staff received in-service training multiple times per month on abuse and neglect, which included her role as the Abuse Coordinator, identification of different types of abuse, and the requirement to report all abuse concerns to her. Phone interview conducted on 3/13/2026 at 5:11 PM revealed the Director of Nursing (DON) stated she had neither witnessed nor received any reports of Resident #2 exhibiting aggressive behavior toward any resident, which included Resident #1 and Resident #4. The DON denied speaking with Resident #4 regarding Resident #2 and stated Resident #4 had not reported any concerns to her. The DON further stated if any allegations of abuse, whether verbal or physical, were reported to her, she would notify the Administrator to initiate an investigation and ensure appropriate reporting . The DON added the staff were trained to report any allegation or witness of abuse to her or the Administrator so it could be promptly addressed and investigated. Phone interview conducted on 3/13/2026 at 6:06 PM, Resident #1's responsible party (RP) stated there was a significant concern involving Resident #2 and reported Resident #1 was fearful of Resident #2. The RP stated she visited the facility on either 2/21/2026 or 2/22/2026, at which time Resident #1 reported, just minutes prior to her arrival, Resident #2 had rammed her with a wheelchair in the dining room. The RP stated Resident #1 was upset and crying following the incident. The RP reported this caused her to become upset and tearful as well due to concerns for Resident #1's safety, and she made staff aware of the situation. The RP stated several CNAs were present and appeared aware of the incident. She reported speaking with LVN A regarding Resident #2's aggressive behavior and asked what actions would be taken to ensure Resident #1's safety. The RP stated she did not recall any staff assessing Resident #1 at that time. She reported observing a bruise developing on Resident #1's elbow . The RP stated she was later informed staff assessed Resident #1's shoulder due to complaints of pain; however, she was told there was no bruising noted to the shoulder and was not informed of any assessment of the elbow. The RP stated she believed the elbow was the point of impact and the pain radiated to the shoulder. The RP further reported Resident #1's right shoulder bothered her for about a week after the incident. The RP reported a care plan meeting was held on 2/24/2026 with approximately three staff members, which included a social worker. She stated she asked what actions were being taken regarding Resident #2 to ensure Resident #1's safety and was informed the situation was being handled and the behaviors described were typical for Resident #2 due to her diagnoses. The RP further stated Resident #1 continued to express fear of Resident #2 during phone calls and avoided leaving her room due to concern Resident #2 would approach or interfere with her. The RP reported she had to encourage Resident #1 to resume normal activities and reassured her she should not allow Resident #2's behavior to limit her daily routine. The RP stated she continued to observe Resident #2 in the dining room during visits and reported Resident #2 exhibited similar behaviors toward other residents. The RP added prior to the wheelchair incident, Resident #1 reported Resident #2 made inappropriate and hateful remarks toward her and other residents. The RP recalled an incident Resident #1 reported in which Resident #2 approached her table, spoke negatively to another resident, and told both residents to go back to where the hell they came from. The RP was unable to identify who the other resident was but stated she was cognitively impaired and not able to defend herself which was why Resident #1 attempted to defend them by telling Resident #2 to leave them alone. The RP stated she felt Resident #1 trying to defend the other resident sparked Resident #2's rage towards Resident #1. The RP also reported observing Resident #2 staring at Resident #1 in the dining room during visits and described the behavior as appearing hostile and caused her to be concerned. Interview conducted on 3/13/2026 at 6:38 PM, the Administrator stated she had just come back from speaking with Resident #1, and she did tell her an incident occurred involving Resident #2 and her being bumped by Resident #2's wheelchair. The Administrator stated Resident #1 reported feeling safe in the facility; however, Resident #1 expressed she believed the contact with the wheelchair was intentional. Interview conducted on 3/13/2026 at 7:00 PM, the Social Worker stated during the care plan meeting on 2/24/2026, the RP asked about Resident #2 and what actions were being taken to address her behaviors. The Social Worker reported she was only aware of a verbal altercation between Resident #1 and Resident #2 and had not received any reports indicating Resident #1 had been struck or rammed with a wheelchair. The Social Worker stated she explained to the RP, Resident #2 was cognitively impaired, and the actions described were consistent with her behavior. She further indicated to the RP interventions were in place to attempt to prevent Resident #2 from disturbing other residents. The Social Worker explained Resident #2 exhibited behaviors such as attempting to clean the dining room and frequently tried to take other residents' plates while they were still eating, which caused disruptions. She stated, in response, staff should monitor Resident #2 and intervene prior to interaction with other residents. The Social Worker stated redirection was often ineffective, as Resident #2 would resume the behavior shortly after being redirected. The Social Worker further stated Resident #2 could become verbally aggressive when she did not get her way; however, she denied any knowledge of physical aggression. The social worker stated if she was aware of any concerns of abuse, she would have immediately reported it to the Administrator. Interview conducted on 3/13/2026 at 7:13 PM revealed LVN A stated she recalled Resident #1 and the RP approaching her while upset about an altercation with Resident #2 a few weeks ago. LVN A stated she did not witness the incident; however, she was informed Resident #2 attempted to take Resident #1's plate and cup while she was still eating and continued to do so while making hateful remarks. LVN A denied being told Resident #1 was struck by Resident #2 but stated Resident #1 reported Resident #2 bumped her with her wheelchair. LVN A stated she did not read the situation as an allegation of abuse. LVN A reported she spoke with Resident #1 and the RP and explained the behavior was consistent with Resident #2's known behaviors and she would address the situation. LVN A stated she subsequently spoke with Resident #2 and redirected her and instructed her not to take items from residents while they were eating. She reported Resident #2 did not respond well to redirection and wheeled away appearing upset following the intervention. LVN A stated she was aware allegations of abuse were required to be reported to the Abuse Coordinator, identified as the Administrator. LVN A identified some types of abuse to include verbal, physical, and sexual. However, LVN A stated she did not report the incident to the Administrator because she did not believe it was a repeated occurrence or that Resident #2 was specifically targeting Resident #1 and it was just part of Resident #2's behaviors. LVN A believed the situation was resolved through her redirection of Resident #2. LVN A

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that to prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 8 residents (Resident #1 and #2) reviewed for implementation of the abuse policy. The facility failed to implement its abuse policy by not investigating or reporting allegations of verbal and physical abuse to the facility's Abuse Coordinator after Resident #1 and her RP reported concerns of abuse by Resident #2 to LVN A and CNA A on the weekend of 2/21/2026. The facility failed to assess Resident #1 following the allegation of abuse in accordance with its abuse/neglect policy. Resident #1 subsequently reported shoulder/arm pain and exhibited signs of psychological distress related to the alleged abuse. An Immediate Jeopardy (IJ) situation was identified on 3/14/2026. While the IJ was removed on 3/15/2026, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse to go undetected and unreported, allowing potential continuation of abuse and increasing the risk for serious psychological and physical harm.Findings include: 1.Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: osteoarthritis (a degenerative joint disease caused by the breakdown of cartilage covering the ends of bones), depression (mood disorder causing persistent sadness, loss of interest, and physical symptoms like fatigue or pain that disrupt daily life), anxiety disorder (mental health conditions involving excessive, persistent, and uncontrollable worry or fear that interferes with daily life), Alzheimer's disease (a progressive neurological disorder causing brain shrinkage and cognitive decline), abnormalities of gait and mobility, and age related physical debility . Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. Resident #1 reported feeling down, depressed, or hopeless for several days and exhibited no behavioral symptoms. Resident #1 used a wheelchair for mobility and received a scheduled pain medication regimen with no reported pain. Record review of Resident #1's Care Plan, last revised on 10/24/2025, revealed a care area which addressed increased pain/discomfort and risk for injury related to diagnoses of chronic pain and osteoarthritis. Interventions included encouraging the resident to verbalize feelings of pain/discomfort; assisting with ADLs and providing comfort measures as indicated; encouraging socialization and participation in activities as tolerated; monitoring the effectiveness of pain medications and other interventions and reporting to the MD if ineffective; monitoring for side effects of pain medications and reporting any noted to the MD; observing for signs and symptoms of increased pain/discomfort and assessing for possible causes, implementing interventions such as administering pain medications, treatments, and relaxation modalities, and evaluating for relief; and utilizing a 0-10 numeric pain scale to assess pain level. Further record review of Resident #1 care plan, last revised on 10/24/2025, revealed a focus area which addressed the potential for decline in psychosocial well-being and social isolation, as evidenced by the mood interview. Interventions included encouraging family involvement to support a positive psychosocial outlook; encouraging family to bring familiar items during visits; encouraging the resident to attend activities of choice and facilitating pairing with peers who share similar interests; engaging the resident in reminiscing about past experiences and life prior to residency; and introducing the resident to others to promote social interaction and relationship building. Record review of another care plan area for Resident #1, last revised on 10/25/2025, revealed a focus on the use of psychotropic medications and the resident's risk for adverse reactions and episodes of depressive and anxiety-driven behaviors, as evidenced by a diagnosis of depression with anxiety and the use of antidepressant medications. Interventions included encouraging the resident to verbalize feelings during behavioral episodes; monitoring for signs of depressive behaviors such as spontaneous crying, sad mood/affect, self-imposed isolation, and mood not easily altered; reporting any noted changes to the MD/RP; and documenting findings in the clinical record. Record review of Resident #1's physician order, dated 9/30/2025, revealed an order for cyclobenzaprine HCl oral tablet 10MG to be given by mouth every 8 hours as needed for neck and muscle pain related to other chronic pain. Record review of Resident #1's February and March 2026 MAR revealed order for cyclobenzaprine HCl oral tablet 10MG to be given by mouth every 8 hours as needed for neck and muscle pain was administered once on 2/17/2026 at 11:58 PM with a pain rating of 5/10. Record review of Resident #1's physician order, dated 10/1/2025, revealed an order to monitor resident every shift for Target Behaviors of confusion and depressive features. Record review of Resident #1's February and March 2026 TAR revealed according to order to monitor for target behaviors of confusion and depressive features every shift, no behaviors were noted. Record review of Resident #1's physician order, dated 10/1/2025, revealed an order to observe for pain every shift. Record review of Resident #1's February and March 2026 TAR revealed according to order to monitor for pain every shift, no complaints of pain were noted. Record review of Resident #1's physician order, dated 1/8/2026 and discontinued on 2/23/2026, revealed an order for Acetaminophen Extra Strength Tablet 500 MG to give 2 tablet by mouth two times a day for Arthritis. Record review of Resident #1's physician order, dated 2/23/2026, revealed an order for Acetaminophen Extra Strength Tablet 500 MG to give 2 tablet by mouth two times a day related to unspecified osteoarthritis, unspecified site. Record review of Resident #1's February and March 2026 MAR revealed order for Acetaminophen Extra Strength Tablet 500 MG, 2 tablets by mouth two times a day was administered 2/1/2026 - 3/15/2026 as ordered with a pain level of 0/10. Record review of Concern Report, dated 2/22/2026, revealed concern was received by LVN A from Resident #1 regarding Resident #2. The description of concern was, Several residents complaining that above resident cleans DR (dining room) and takes their plates and cups away before they are finished. Investigation details noted, Spoke with resident and was instructed not to clean the DR anymore. Leave it for the kitchen staff. Resident also arguing with other residents about their plates and drinks. Further review of the report revealed the concern was reported to the social worker . Bottom of the concern report regarding Findings of investigation/resolution was blank as well as whom the investigation results were reported to was blank. Investigator signature and Administrator review signatures were also blank on the report. Record review of Resident #1's Psychological Services progress note, dated 2/23/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with no new stressors noted. The progress note revealed her progress and plan included in part, .Client appeared stable, relaxed and comfortable throughout the visit . continue routine supportive visit to reinforce emotional well-being. Encourage participation in day room activities and peer interaction. monitor for changes in affect and behavior. Record review of Resident #1's progress note, dated 2/24/2026 at 12:42 PM, revealed a physiatry progress note by NP, noted in part, .Resident #1 reports right shoulder/arm pain today. She states another resident ran into her with a wheelchair accidentally a few days ago. She reports the pain is subsiding. Right shoulder pain: patient states another resident accidentally backed into her with her wheelchair. Patient states pain in right arm is subsiding. She did not want to roll sleeves all the way up to exam skin; likely a contusion as there is tenderness with palpation over right upper arm area; range of motion (ROM ) is intact. Can abduct shoulder to about 60 degrees. Pain is improving per patient. If it persists, will get xray. Record review of Resident #1's Quarterly Care Plan Meeting note, provided by the facility after exit on 3/16/2026 at 12:02 PM, documented an effective date of 2/24/2026 at 1:30 PM. Care Plan meeting note reflected Resident #1's RP attended the meeting in person and had a summary noting in part, .The family was able to express their concerns regarding the resident having a verbal disagreement with a peer. Their concerns were addressed by IDT members. Record review of Resident #1's psychiatric subsequent assessment, dated 2/27/2026, noted reason for referral was depression and anxiety and chief complaint noted was, I hear voices sometimes. Resident #1's History of Presenting Illness noted in part, .Depression: Staff reports current symptoms of loss of interest. severity level 4 (moderate). Symptoms occurring for 8 months. Anxiety: Staff reports current symptoms of impaired concentration. symptoms have been occurring for 7 months. Cognitive Impairment: staff reports current symptoms of confusion and reports no current symptoms of forgetfulness.symptoms have been occurring for 11 months. collateral information: Staff denies any complaints/concerns at this time. Further review of progress note revealed Resident #1's psychiatric review of systems noted anxiety symptoms, depressive symptoms and insomnia and her Mental Status Examination noted she had an anxious depressed mood. Record review of Resident #1's Psychological Services progress note, dated 3/2/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with no new stressors noted. The progress note revealed her progress and plan included in part, .Client presented with a calm and stable demeanor. continue regular supportive check-ins to sustain emotional stability. Encourage involvement in day room programming and peer interactions. Record review of Resident #1's Psychological Services progress note, dated 3/10/2026, revealed Resident #1 had a diagnosis of major depressive disorder, her functional and behavioral challenges that were focused on during the session was adjustment difficulty with a new stressor of recent illness noted. The progress note revealed her progress and plan included in part, .Discussed recent illness involving diarrhea and assessed clients physical status. Reinforced positive shift toward increased social interaction as symptoms improved. client appeared more comfortable and reported feeling better physically. She engaged in conversation and expressed enjoyment in socializing again. The plan also included to encourage continued social engagement and monitor physical recovery . Observation and interview on 3/13/2026 at 5:00 PM, the Administrator identified Resident #1 sitting in the dining room at a table with another resident. Resident #1 said things had generally been going okay at the facility, but she reported having a serious issue with one resident. Resident #1 stated there was another female resident who was always in the dining room messing with everyone. Resident #1 stated she did not know the resident's name but identified her as being present in the dining room at that time, sitting a few tables away. It was noted Resident #2 was seated in the dining room approximately two tables away from Resident #1. Resident #1 stated Resident #2 did not like her, and she did not know why. Resident #1 stated Resident #2 was rude to her and other residents and would say nasty hateful things to everyone. Resident #1 stated she had never done anything to Resident #2 to cause this behavior and said she was terrified of Resident #2 because Resident #2 had hit me with her wheelchair a few weeks earlier. Resident #1 pointed out an area in the dining room, beside a nearby table, and stated that was where she was sitting when she felt a hard crash from behind. Resident #1 stated she could hear Resident #2 talking but could not make out what she was saying. Resident #1 stated she was so scared when it happened, she could not remember who else was around and was in shock from the incident. Resident #1 stated Resident #2 eventually wheeled away, while she remained scared and concerned Resident #2 might return. Resident #1 recalled seeing her RP later that same day and told her what happened. Resident #1 stated she and her RP then spoke to the facility staff about the incident involving Resident #2. Resident #1 stated after the incident of being hit by the wheelchair, if she saw Resident #2 in the hallway or dining room, she would go back to her room because she was afraid to be around her and did not know what Resident #2 might do next. Resident #1 stated the way Resident #2 treated her and the other residents was very upsetting. Resident #1 stated her RP and staff tried to tell her that was just how Resident #2 acted because she had issues, but Resident #1 stated she did not feel it was fair that she and the other residents had to tolerate being harassed by Resident #2. Resident #1 stated she did not think Resident #2 should be at the facility. Resident #1 stated she was still scared of Resident #2 but felt somewhat safer now because she made friends at the facility who she felt had her back. Resident #1 stated she was just beginning to return to the dining room while Resident #2 was present due to encouragement from her RP and other residents, but she would rather not have to be around Resident #2. Resident #1 stated after being hit by Resident #2's wheelchair, she experienced severe shoulder pain. Resident #1 stated the wheelchair strike was really hard and hurt really bad. Resident #1 pointed to her right shoulder as the area affected and stated it felt better at the time of the interview; however, after the incident she had pain in her right shoulder for about one week. Resident #1 stated her RP was aware of the shoulder pain and recalled telling her PE teacher (NP) about the incident and her shoulder pain as well. During the interview, another resident sat at a nearby table sneezed loudly. Resident #1 was visibly startled and jumped in her chair. The state surveyor reassured Resident #1 the noise was another resident sneezing. Resident #1 grabbed her chest and stated the noise startled her and she felt more cautious of her surroundings since the incident with Resident #2. 2. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: dementia with other behavioral disturbances, COPD (progressive lung disease that restricts airflow, causing chronic breathing difficulties, cough, and fatigue), Type II diabetes, lack of coordination, depression, psychotic disorder with hallucinations due to known physiological condition (severe mental health conditions causing a loss of contact with reality, characterized by hallucinations, delusions, and disorganized thinking), insomnia, and muscle weakness . Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 7/15, which indicated severe cognitive impairment. The resident exhibited no behavioral symptoms, utilized a wheelchair or walker for mobility, and was able to independently self-propel her wheelchair. Record review of Resident #2's care plan, initiated on 11/2/2023 and last revised on 3/13/2026, revealed a focus area addressing episodes of inappropriate behaviors and the risk for increased behavioral episodes and related injury. This was evidenced by the resident storing soiled clothing in boxes in her room, collecting and storing facility linens in boxes which resulted in odors in the room, placing paper towels and toilet paper in her pull-up briefs, and moving/dragging and rearranging dining room chairs (added to the care plan on 3/13/2026). Interventions included educating the resident to avoid using paper products as padding in her briefs each shift; explaining that the facility will complete her laundry and discouraging the storage of soiled laundry in her room; reminding and encouraging the resident to allow staff to collect her laundry and linens daily; monitoring and documenting behaviors as they occurred and reporting progress or decline to the MD; observing for early warning signs of behaviors and approaching the resident calmly, calling her by name, and providing reassurance as needed; and providing a psychiatric consult as ordered. Record review of Resident #2's physician order, dated 3/18/2024, revealed to monitor target behavior of confusion or aggression at the end of each shift. Record review of Resident #2's February and March 2026 TAR revealed no behaviors were observed. Record review of Resident #2's progress notes revealed no entries from 2/16/2026 - 3/13/2026. Record review of Resident #2's Psychological Services Progress notes, dated 2/23/2026, 3/1/2026 and 3/9/2026 revealed she had diagnoses which included major depressive disorder and generalized anxiety and her symptoms focused on during the sessions, in part, included anxiety and agitation, and her functional behavioral challenges that were focused on, in part, included verbal or physical aggression. Summary of the notes included no concerns, or distress was noted and to continue to monitor residents mood, responsiveness and emotional stability. Observation and interview conducted on 3/13/2026 at 12:41 PM revealed approximately seven residents seated at tables in the dining room, all of whom appeared to have finished their meals. Resident #2 was observed in the dining room, ambulating in her wheelchair by propelling herself with both feet. She was observed moving from table to table, picking up items from tables and the floor while also pulling on chairs and tables. Resident #2 was then observed wheeling over to Resident #3 and attempting to pull on Resident #3's wheelchair. Resident #2 bent over, unlocked the left wheel brake of Resident #3's wheelchair, and pulled the wheelchair backward away from the table. Resident #2 was heard mumbling; however, her statements could not be understood. Resident #3 did not respond verbally during this interaction. No staff were present in the dining room at the time; however, staff were observed passing by in the hallway in front of the dining room and in adjacent office areas. The state surveyor approached Resident #2 while she was leaning on the left side of Resident #3's wheelchair. After introduction, Resident #2 asked the state surveyor what she wanted. Resident #2 was able to state her name and indicated she was cleaning, showing the state surveyor trash in her hand. Resident #2 then instructed the state surveyor to leave so she could continue cleaning. She subsequently wheeled away from Resident #3 and the state surveyor and continued moving around to other tables. Interview conducted on 3/13/2026 at 4:33 PM, CNA A stated she was familiar with Resident #2 and was aware of behaviors involving physical and verbal aggression toward residents and staff. CNA A reported that Resident #1 had told her that Resident #2 had previously hit her. CNA A stated she did not witness the incident; however, she recalled an occasion when she was escorting Resident #1 to the dining room and, upon seeing Resident #2, Resident #1 became tearful and stated she did not want to enter the dining room due to fear of Resident #2. CNA A reported she asked Resident #1 why she was avoiding Resident #2, and Resident #1 stated that Resident #2 had hit her. CNA A was re-interviewed on 3/13/2026 at 5:20 PM and stated that Resident #1 first reported the incident to her a few weeks ago. CNA A further stated that Resident #1 continued to express concerns about Resident #2 whenever she encountered her, became visibly upset at the sight of Resident #2, and preferred to remain in her room to avoid contact. CNA A reported she had received multiple in-services on abuse and neglect and understood that all allegations of abuse should be reported to the Administrator, who serves as the Abuse Coordinator. CNA A stated she did not report Resident #1's allegations because Resident #1 indicated that the nurse and social worker were already aware, and she assumed the issue was being addressed. CNA A further stated that, in response to Resident #2's behaviors, staff attempted to monitor her in the dining room to prevent her from disturbing other residents; however, Resident #2 does not respond well to redirection. Interview conducted on 3/13/2026 at 4:50 PM, the Administrator stated no concerns had been reported to her regarding Resident #2 exhibiting aggressive behaviors. The Administrator reported she was aware that Resident #2 frequently attempted to clean the dining room and would take trays from residents before they had finished eating; however, she had not received any reports of aggressive behavior during these incidents. The Administrator further stated she was not aware of any incidents involving Resident #1 and Resident #2 and indicated staff were trained to report all abuse concerns directly to her so an investigation could be conducted and if she was not available for them to report to the DON. The Administrator stated staff received in-service training multiple times per month on abuse and neglect, which included her role as the Abuse Coordinator, identification of different types of abuse, and the requirement to report all abuse concerns to her. Phone interview conducted on 3/13/2026 at 5:11 PM revealed that the Director of Nursing (DON) stated she had not received any reports of Resident #2 exhibiting aggressive behavior toward any resident. The DON further stated if any allegations of abuse, whether verbal or physical, were reported to her, she would notify the Administrator to initiate an investigation and ensure appropriate reporting. The DON added the staff were trained to report any allegation or witness of abuse to her or the Administrator so it could be promptly addressed and investigated. The DON said the priority in abuse and neglect allegations is to ensure resident safety first which included assessing residents for injuries and reporting immediately after ensuring residents involved are okay and safe. Phone interview conducted on 3/13/2026 at 6:06 PM, Resident #1's responsible party (RP) stated there was a significant concern involving Resident #2 and reported that Resident #1 was fearful of Resident #2. The RP stated she visited the facility on either 2/21/2026 or 2/22/2026, at which time Resident #1 reported that, just minutes prior to her arrival, Resident #2 had rammed her with a wheelchair in the dining room. The RP stated Resident #1 was upset and crying following the incident. The RP reported that this caused her to become upset and tearful as well due to concerns for Resident #1's safety, and she made staff aware of the situation. The RP stated that several CNAs were present and appeared aware of the incident. She reported speaking with LVN A regarding Resident #2's aggressive behavior and asked what actions would be taken to ensure Resident #1's safety. The RP stated she did not recall any staff assessing Resident #1 at that time. She reported observing a bruise developing on Resident #1's elbow. The RP stated she was later informed that staff assessed Resident #1's shoulder due to complaints of pain; however, she was told there was no bruising noted to the shoulder and was not informed of any assessment of the elbow. The RP stated she believed the elbow was the point of impact and that the pain radiated to the shoulder. The RP further reported Resident #1's right shoulder bothered her for about a week after the incident. The RP reported that a care plan meeting was held on 2/24/2026 with approximately three staff members, including a social worker. She stated she asked what actions were being taken regarding Resident #2 to ensure Resident #1's safety and was informed that the situation was being handled and that the behaviors described were typical for Resident #2 due to her diagnoses. The RP further stated that Resident #1 continued to express fear of Resident #2 during phone calls and avoided leaving her room due to concern that Resident #2 would approach or interfere with her. The RP reported she had to encourage Resident #1 to resume normal activities and reassured her that she should not allow Resident #2's behavior to limit her daily routine. The RP stated she continued to observe Resident #2 in the dining room during visits and reported that Resident #2 exhibited similar behaviors toward other residents. The RP added that prior to the wheelchair incident, Resident #1 had reported that Resident #2 made inappropriate and hateful remarks toward her and other residents. The RP recalled an incident Resident #1 reported in which Resident #2 approached her table, spoke negatively to another resident, and told both residents to go back to where the hell they came from. The RP was unable to identify the other resident involved. The RP also reported observing Resident #2 staring at Resident #1 in the dining room during visits and described the behavior as appearing hostile and caused her to be concerned. Interview conducted on 3/13/2026 at 6:38 PM revealed that the Administrator stated she spoke with Resident #1, who reported that an incident had occurred involving Resident #2 and that she was bumped by Resident #2's wheelchair. The Administrator stated that Resident #1 reported feeling safe in the facility; however, Resident #1 expressed that she believed the contact with the wheelchair was intentional. Interview conducted on 3/13/2026 at 7:00 PM, the Social Worker stated during the care plan meeting on 2/24/2026, the RP asked about Resident #2 and what actions were being taken to address her behaviors. The Social Worker reported she was only aware of a verbal altercation between Resident #1 and Resident #2 and had not received any reports indicating Resident #1 had been struck or rammed with a wheelchair. The Social Worker stated she explained to the RP, Resident #2 was cognitively impaired, and the actions described were consistent with her behavior. She further indicated to the RP interventions were in place to attempt to prevent Resident #2 from disturbing other residents. The Social Worker explained Resident #2 exhibited behaviors such as attempting to clean the dining room and frequently tried to take other residents' plates while they were still eating, which caused disruptions. She stated, in response, staff should monitor Resident #2 and intervene prior to interaction with other residents. The Social Worker stated redirection was often ineffective, as Resident #2 would resume the behavior shortly after being redirected. The Social Worker further stated Resident #2 could become verbally aggressive when she did not get her way; however, she denied any knowledge of physical aggression. The social worker stated she had been in-serviced on abuse and neglect and if she was aware of any concerns of abuse, she would have immediately reported it to the Administrator. Interview conducted on 3/13/2026 at 7:13 PM revealed LVN A stated she recalled Resident #1 and the RP approaching her while upset about an altercation with Resident #2 a few weeks ago. LVN A stated she did not witness the incident; however, she was informed Resident #2 attempted to take Resident #1's plate and cup while she was still eating and continued to do so while making hateful remarks. LVN A denied being told Resident #1 was struck by Resident #2 but stated Resident #1 reported Resident #2 bumped her with her wheelchair. LVN A stated she did not read the situation as an allegation of abuse. LVN A reported she spoke with Resident #1 and the RP and explained the behavior was consistent with Resident #2's known behaviors and she would address the situation. LVN A stated she subsequently spoke with Resident #2 and redirected her and instructed her not to take items from residents while they were eating. She reported Resident #2 did not respond well to redirection and wheeled away appearing upset following the intervention. LVN A stated she was aware allegations of abuse were required to be reported to the Abuse Coordinator, identified as the Administrator. LVN A identified some types of abuse to include verbal, physical, and sexual. However, LVN A stated she did not report the incident to the Administrator because she did not believe it was a repeated occurrence or that Resident #2 was specifically targeting Resident #1 and it was just part of Resident #2's behaviors. LVN A believed the situation was resolved through her redirection of Resident #2. LVN A denied completing an assessment of Resident #1 following the allegation due to her not seeing a concern for abuse and stated she was not informed Resident #1 experienced pain related to the incident otherwise she would of assessed her. LVN A reported, in response to Resident #2's behaviors, staff monitored her during meals to prevent her from taking items from other residents. She further stated recently Resident #2 had not been observed taking items from residents' plates but developed a fixation on a bookcase in the hallway and did not want other residents to touch it. LVN A stated she also redirected Resident #2 regarding this behavior, and Resident #2 responded with signs of frustration when redirected. LVN A stated she was aware that all allegations of abuse are required to be reported to the Abuse Coordinator, identified as the Administrator. However, LVN A stated she did not report the incident because she did not believe it was a repeated occurrence or that Resident #2 was specifically targeting Resident #1, and she believed the situation had been resolved through redirection. LVN A denied completing an assessment of Resident #1 following the allegation and stated she was not informed that Resident #1 experienced pain related to the incident. LVN A reported that, in response to Resident #2's behaviors, staff monitor her during meals to prevent her from taking items from other residents. She further stated that recently Resident #2 had not been observed taking items from residents' plates but had developed a fixation on a bookcase in the hallway and did not want other residents to touch it. LVN A stated she also redirected Resident #2 regarding this behavior, and Resident #2 responded with signs of frustration when redirected. Interview on 3/23/2026 at 1:28 PM, the NP stated he authored Resident #1's physiatry progress note, dated 2/24/2026, and recalled Resident #1 reporting right shoulder pain. The NP stated he had a brief discussion with Resident #1 regarding the pain and recalled her reporting another resident had run into her with a wheelchair that may have initiated the pain. The NP stated Resident #1 did not indicate whether she believed the incident was intentional and he interpreted the event as accidental. The NP further stated he did not explore the incident in detail, as Resident #1 reported the pain was subsiding and not severe. He did attempt to assess Resident #1's shoulder but she did not want him to visualize the skin area, so he was just able to palpate the area in which she expressed minor pain when he did. NP stated no orders for x-rays were ordered at that time because Resident #1 expressed the pain was already getting better and made no further complaints about it that he was aware of. Record review of the facility Abuse, Neglect, and Exploitation (ANE) Prohibition policy revised 10/2024 revealed in part, .The facility administrator serves as the Abuse Prevention Coordinator. In the temporary absence of Administrator, appointed designee may temporarily serve as the Abuse Prevention Coordinator. Abuse - the willful infliction of injury, unreasonable confinement, intimi

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #3, Resident #4, Resident #5, Resident #13, and Resident #14) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3, Resident #4, Resident #5, Resident #13 and Resident #14's rooms was in a position that was accessible to the resident on 11/17/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #3 Record review of Resident #3's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #3's Comprehensive MDS Assessment, dated 08/28/2025, reflected the resident had a severe impairment (the resident required significant assistance and support in daily life) in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident was dependent on staff for transfers and bed mobility. Record review of Resident #3's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls and one of the interventions was to ensure the call light was within reach. Observation and interview on 11/17/2025 at 9:05 AM revealed Resident #3 was in her bed, awake. It was observed that the resident's call light was on top of the resident's side table and was not within reach. When asked about what she used when she needed to call the staff, the resident did not answer. During an interview and observation on 11/17/2025 at 9:10 AM, LVN C stated call lights should always be within reach of the resident so the residents would be able to call the staff if they needed assistance. She went inside Resident #3's room and saw the call light on top of the side table. She took the call light from the side table and placed it where the resident could reach it. She said she would tell the CNA assigned to the hall to make sure that residents' call lights were within reach. She called CNA H and talked to her regarding the call light. She said the call lights were for all the residents and all the staff were responsible in making sure they were within reach. In an interview on 11/18/2025 at 1:03 PM, CNA H stated that the call lights should always be with the residents. She said she must have forgotten to put the call light at the side of the resident when she went to check on Resident #3 during her morning round. Resident #4 Review of Resident #4's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and atrophy. Review of Resident #4's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident required assistance for bed mobility and transfer. Review of Resident #4's Comprehensive Care Plan, dated 09/26/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 11/17/2025 at 9:20 AM revealed Resident #4 was in her bed with eyes closed. It was observed that the resident's call light was in the trash can and the cord of the call light was between the frame of the bed and the mattress. The cord was not visible. Observation and interview on 11/17/2025 at 9:41 AM, RN B stated the call lights were used by the resident to call the staff if they needed something or if they needed assistance. She said without the call lights, the residents might fall if they tried to do things by themselves. She said the call lights were for all the residents, whether independent or dependent residents. She went inside Resident's #4's room and saw the call light was not within reach of the resident. She took the call light, cleaned it, and placed it where the resident could reach it. In an interview on 11/17/2025 at 9:46 AM, CNA I stated she did not notice Resident #4's call light was not with the resident. She said the call lights were there so the resident could use them to call the staff. She said it did not matter if the residents were using them or not, but the important thing was it was within reach of the residents. Resident #5 Review of Resident #5's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and repeated falls. Review of Resident #5's Quarterly MDS Assessment, dated 08/26/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated that the resident required maximal assistance for toileting, bed mobility, and transfer. Review of Resident #5's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 11/17/2025 at 9:52 AM revealed Resident #5 was in her bed, awake. It was observed that the resident's call light was inside the resident's drawer. The resident said she could not reach it and she did not know who put it inside the drawer of her side table. In an interview on 11/17/2025 at 11:12 AM, CNA G stated she did not notice that Resident #5's call light was inside her drawer. She said call lights should be with the residents in case they needed the staff. She said she would go the resident's room and would check if the call light was within reach of the resident. Resident #13 Record review of Resident #13s Face Sheet, dated 11/18/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #13 had diagnoses which included Alzheimer's disease (progressive cognitive decline, memory loss, and behavioral changes) and muscle wasting and atrophy. Record review of Resident #13's Quarterly MDS Assessment, dated 10/16/2025, reflected severe cognitive impairment with a BIMS score of 05. Section I (active diagnoses) reflected hemiplegia (paralysis on one side of the body) following a stroke. Section GG (functional abilities) indicated the resident required assistance with self-care and mobility needs. Record review of Resident #13's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls and injuries related to impaired cognition, incontinence, and impaired mobility. One intervention was to ensure the call light was within reach and answer it promptly. During an observation and interview on 11/17/25 at 9:20 AM, Resident #13 was lying in bed awake. Her call light was on the floor between the head of the bed and the nightstand. When asked about her call light, Resident #13 did not reply. CNA J came in the room and stated she was going to change Resident #13. When asked about the call light, CNA J stated it should have been within reach. She stated it was important for Resident #13 to be able to reach the call light in case of an emergency or if the resident needed something. She placed the call light on the bed and secured it where Resident #13 could reach it. During an interview on 11/17/2025 at 9:56 AM, ADON K stated Resident #13's call light should have been placed within reach. She stated it was important to ensure Resident #13's call light was within reach in case she needed assistance. Resident #14 Record review of Resident #14's Face Sheet, dated 11/18/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #14 had diagnoses which included Type 2 diabetes mellitus (the body does not use insulin properly which leads to elevated blood glucose levels), dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), and rheumatoid arthritis (autoimmune disorder that causes pain and swelling of the joints). Record review of Resident #14's Quarterly MDS Assessment, dated 08/27/2025, reflected a BIMS score of 99 which indicated the resident was unable to complete the assessment. Section C (cognitive patterns) reflected Resident #14 was severely impaired with decision making regarding tasks of daily life. Section GG (functional abilities) reflected Resident #14 required assistance with self-care and mobility needs. Record review of Resident #14's Comprehensive Care Plan, dated 11/05/2025, reflected the resident was at risk for falls and injuries. One intervention was to ensure the call light was within reach and answer it promptly. During an observation and interview on 11/17/2025 at 10:47 AM, Resident #14 was lying in bed awake. The call light was on the floor at the head of the bed. An attempt to interview Resident #14 revealed she was unable to answer questions appropriately related to her cognitive status. CNA J was in the hall and came to Resident #14's room. She picked up the call light and clipped it to the resident's pillow to ensure she could reach it. CNA J stated it was important for Resident #14's call light to be within reach in case she needed to call for help. In an interview on 11/18/2025 at 8:40 AM, the DON stated call lights were safety measures wherein the residents could call the staff if they needed something or needed to do something that needed assistance. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries. The DON said all the staff were responsible for the call lights, including her. The DON said the expectation was for the staff to scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said an in-service was already initiated but she would monitor the staffs' compliance about call lights. In an interview on 11/18/2025 at 10:31 AM, ADON A stated call lights should be with the residents at all times when the residents where inside the room because the call lights were the only way they could reach out to the staff if they were in distress or just needed water. She said the call light were for all residents, whether independent or dependent. She said an independent resident might be having a heart attack and could not call anybody because the call light was not with the resident. She said she was also responsible in checking if the call lights were with the residents. She said an in-service had been going around and that she would coordinate with the DON to randomly check if the call lights were with the residents. During an interview on 11/18/2025 at 12:27 PM, LVN L stated the residents' call lights should have been within reach. She stated it was important to ensure residents were able to reach staff if they needed assistance. She stated the facility had begun in-services. During an interview on 11/18/2025 at 12:40 PM, ADON K stated call lights should have been on the residents' beds. She stated all the call light cords had a clip to secure to the bed. She stated it was important to ensure the residents' call lights were in their reach in case they needed help. In an interview on 11/18/2025 at 1:20 PM, the Administrator stated the staff should make sure that the call lights were with the residents before they leave the room. She said for some residents, the call lights were their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights. Record review of the facility's policy Call Lights, revised December 2023, reflected The facility will provide a call light system that is accessible, functional, and responsive to meet the needs of the residents.Call lights will be placed within reach of the resident's bed or sitting area in the resident's room.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #5, Resident #8, Resident #12, and Resident #13) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA F and CNA G performed hand hygiene and changed their gloves during Resident #5's incontinent care on 11/17/2025.2. The facility failed to ensure LVN C wore a gown while administering Resident #8's medication via g-tube, who had an order for enhanced barrier protection, on 11/17/2025. 3. The facility failed to ensure CNA I performed hand hygiene during Resident #12's incontinent care on 11/17/2025.4. The facility failed to ensure CNA J changed gloves and washed her hands while providing incontinent care for Resident #13 on 11/17/2025.These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1. Review of Resident #5's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with overactive bladder (a bladder control problem which leads to a sudden urge to urinate). Review of Resident #5's Quarterly MDS Assessment, dated 08/26/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated that the resident had urinary and bowel incontinence. Review of Resident #5's Comprehensive Care Plan, dated 09/29/2025, reflected the resident had bowel and bladder incontinence and one of the interventions was to change promptly. Observation on 11/17/2025 at 9:45 AM revealed CNA F and CNA G were about to do Resident #5's incontinent care. Both CNAs put on a pair of gloves, but did not wash their hands before putting on the pairs of gloves. CNA G was observed taking the gloves that she wore from her pocket. CNA F took a brief and placed it on the resident's side. CNA G unfastened the brief and pushed it in the middle of the resident's legs. She then cleaned the resident's perineal area using the front to back technique. After cleaning the perineal area, she assisted the resident to turn towards the wall and cleaned the resident's bottom. After cleaning the resident's bottom, she took the brief from the side of the resident and placed it under the resident. CNA G then rolled back the resident and fixed the brief. She did not change her gloves throughout the process of incontinent care. In an interview on 11/17/2025 at 10:01 AM, CNA F stated their hands should be washed before incontinent care to make sure their hands were clean before touching the gloves that would be used for incontinent care. She said washing hands before any care was done to prevent infection. In an interview on 11/17/2025 at 10:04 AM, CNA G stated she washed her hands after taking care of a resident before going to Resident #5's room. She said she should have washed her hands again before performing the resident incontinent care, because she touched a lot of thing on her way to Resident #5's room. She said she did have some gloves in the pocket of her scrub pants, and she should not be doing that because her pockets might be dirty rendering the gloves used for incontinent care dirty. She said she should have changed her gloves after cleaning the resident's bottom and before touching the new briefs to prevent using dirty gloves. She said using soiled gloves could cause transfer of germs to the new brief. She said her hands should also be sanitized if she changed her gloves. She said she would be mindful the next time she did incontinent care. 2. Record review of Resident #8's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status. Record review of Resident #8's Comprehensive MDS Assessment, dated 10/24/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #8's Quarterly Care Plan, dated 09/28/2025, reflected the resident required enhanced barrier protection and one of the interventions was to monitor the resident for signs and symptoms of infection. Record review of Resident #8's Physician Order, dated 04/01/2024, reflected Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities. every shift. Observation on 11/17/2025 at 2:15 PM revealed LVN C was about to administer Resident #8's medication via g-tube. She prepared her medications and went inside the resident's room. She washed her hands and then closed the door. She did not wear a gown before giving the resident's medication via g-tube. It was observed that there was sign outside the door that EBP was required because the resident had a g-tube. In an interview on 11/17/2025 at 2:47 PM, LVN C stated Resident #8 had a g-tube and EBP was required. She said she did not know why she forgot to wear a gown when she administered the resident's medication. She said the gown was needed basically to prevent transmission of microorganisms from one resident to another. She said she would wear a gown the next time she cared for residents with g-tube. 3. Record review of Resident #12's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertensive encephalopathy (a brain dysfunction due to a rapid increase in blood pressure). Record review of Resident #12's Comprehensive MDS Assessment, dated 10/15/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #12's Comprehensive Care Plan, dated 10/08/2025, reflected that the resident was incontinent for bladder and bowel, and one of the interventions was to perform routine rounding to include incontinence care and brief changes. An observation on 11/17/2025 at 11:11 AM revealed CNA I was about to do Resident #12's incontinent care. She washed her hands and put on a pair of gloves. She pulled the gloves that she wore from her pocket. She unfastened the brief and pushed it between the resident's legs. She cleaned the perineal area using a front to back technique. She rolled the resident to her side and cleaned the resident's bottom. Before cleaning the resident's bottom, she took off her gloves, pulled a pair form her pocket, and put on the gloves. She did not sanitize her hands. After cleaning the bottom, she took off her gloves, pulled a pair from her pocket, and put I on. She did not sanitize her hands before putting on the new pair of gloves. She took the brief and placed it under the resident. She rolled back the resident and fixed the brief. In an interview on 11/17/2025 at 11:29 AM, CNA I stated she should have sanitized her hands when she changed her gloves to make sure her hands were clean before touching the new pair of gloves. She said she needed to sanitize her hands in between changing of gloves to prevent cross contamination, and eventually infection. She said she did put some gloves in her pockets to have easy access to them. She said she was not sure if her pocket was clean. She said because she would put her keys and cell phone in her pocket, she would not put gloves inside her pocket again, and would just get them from the box to make sure she was using clean gloves. In an interview on 11/18/2025 at 8:40 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom and before touching the new brief. She said the hands should be sanitized in between changing of gloves. She said staff should not be put gloves inside staff pockets because they put their cell phones and keys in their pockets rendering the pockets not clean. She said the staff would also put their hands in their pocket and nobody would know what they touched before putting their hands in the pockets. She said if a resident had a g-tube, the staff should wear a gown every time the staff had contact with the resident. She said the procedures mentioned should be in place to prevent cross contamination and to prevent the spread of infection. She said every resident that needed EBP had a sign outside to remind the staff that they needed to wear gowns and gloves every time they had contact with the resident. She said she already initiated an in-service about infection control and would closely monitor staffs' adherence to the policy of infection control. In an interview on 11/18/2025 at 10:31 AM, ADON A stated the staff should be mindful that they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, during, and after any care. She said the staff should also change their gloves after touching a soiled brief or after cleaning the resident's bottom. She said the staff should sanitize their hands when they were changing their gloves. She said the staff should not put their gloves inside their pockets because they put their car keys, money, snacks, and dirty hands in their pockets. She said another way to prevent the spread of infection was to practice EBP when needed. She said residents with a g-tube required gown to protect the resident and also the staff if the resident had any microorganism that could cling to them. She said she would coordinate with the DON to do an in-service again about infection control. She said the staff would be re-trained and would spot check them. In an interview on 11/18/2025 at 1:20 PM, the Administrator stated the staff should be mindful of what they were doing to ensure that there was no cross contamination or spread of infection. She said after touching something soiled, the staff should change their gloves and sanitize the hands in between changing of gloves. She said she was not a clinician, but she knew that if there was a sign for EBP, then the staff should wear a gown in addition to the gloves. She said the gloves should not be in the pockets. She said the concerns discussed would all contribute to the development and spread of infection. She said she would coordinate with the DON about the issue. 4. Record review of Resident #13's Face Sheet, dated 11/18/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #13 had diagnoses which included Alzheimer's disease (progressive cognitive decline, memory loss, and behavioral changes) and muscle wasting and atrophy. Record review of Resident #13's Quarterly MDS Assessment, dated 10/16/2025, reflected severe cognitive impairment with a BIMS score of 05. Section GG (functional abilities) reflected Resident #13 required assistance with self-care needs. Section H (bowel and bladder) indicated she was frequently incontinent of bowel and bladder. Record review of Resident #13's Comprehensive Care Plan, dated 09/29/2025, reflected the resident had bowel and bladder incontinence and was at risk for skin breakdown and infection. One intervention was to provide incontinent care after each incontinent episode and as needed. During an observation and interview on 11/17/2025 at 9:31 AM, CNA J provided incontinence care for Resident #13. CNA J had supplies on the bedside table. She pulled the curtain around the bed to provide privacy. CNA J put on clean gloves and helped the resident roll to her right side. CNA J removed the brief revealing loose stool on the resident's bottom and brief. CNA J dropped the soiled brief into the waste basket. She removed the package of wipes from the bedside table and placed it on the bed near her. CNA J cleaned the resident's bottom and dropped the wipes into the waste basket. CNA J did not remove the gloves. She removed the linens and dropped them into a plastic bag. She secured the fitted sheet on each end on her side of the bed. CNA J moved to the other side of the bed and assisted the resident to roll to her left side. CNA J secured the fitted sheet on each end and placed a clean brief under Resident #13 and the resident rolled to her back. CNA J used her gloved hands to push the end of the bed against the wall and moved to the other side of the bed. CNA J pulled more wipes from the package and cleaned the front of the resident, pulled up the front of the brief, and secured the tabs. She pulled the resident's gown down to cover her, placed the pillow under the resident's head, and covered her with a clean sheet. CNA J did not remove her gloves before carrying the bag of soiled linen and the package of wipes to the shower room in the hall. CNA J came out of the shower room and used hand sanitizer from a pump on the wall to clean her hands. When asked about the package of wipes, she stated she put them in the shower room so could find them quickly when she needed them. CNA J stated she should have changed her gloves and washed her hands or used hand sanitizer while providing incontinent care. She stated she should have removed her gloves and used hand sanitizer or washed her hands before leaving the resident's room. CNA J stated she should not have used the same package of wipes in different residents' rooms. She stated hand hygiene was important for infection control and to prevent spreading germs. During an interview on 11/17/2025 at 9:56 AM, ADON K stated CNA J should have used hand hygiene and changed gloves for infection control and to prevent spreading infection to other residents. She stated CNA J should not take the same package of wipes into different residents' rooms. During an interview on 11/18/25 at 12:16 PM, the DON stated she spoke with CNA J about changing gloves and using hand hygiene when providing incontinent care. The DON stated she reminded CNA J packages of wipes could not be carried in and out of a resident's room. She stated CNA J should have washed her hands or used hand sanitizer before putting on gloves and after removing gloves. The DON stated it was important to use proper hand hygiene with incontinence care. She stated the risk to residents was the spread of germs and infection. She stated the facility had started in-servicing staff members. During an interview on 11/18/25 at 12:27 PM, LVN L stated CNA J should have changed her gloves and used hand sanitizer or washed her hands when providing incontinence care. She stated CNA J should not have taken the package of wipes in and out of Resident #13's room. She stated it was important to prevent cross contamination and the spread of infection. She stated the facility was already in-servicing staff. Review of the facility's policy Hand Hygiene, revised December 2024, reflected It is the policy of The Facility to prioritize hand hygiene as a fundamental practice in preventing the spread of infections. All staff must perform hand hygiene.When to Utilize Hand Hygiene . Before/after resident contact . After removing gloves or PPE . After contact with bodily fluids, surface, or contaminated equipment Record review of the facility's policy entitled Enhanced Barrier Precautions Policies and Procedures revised March 2024 reflected Policy: Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms and employs targeted gown and glove use during high-contact resident care activities for targeted residents . EBP are indicated for residents with any of the following . indwelling medical devices . feeding tubes. Policy and procedure for infection control was requested via email to the DON and Administrator on 11/18/2025 at 10:30 AM but was not provided prior to exit.

Based on observation, interview and record review the facility failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for fourteen (Resident #4, #12, #15 #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26) of twenty-six residents reviewed for resident call system. 1. The facility failed to ensure the call light system in Resident #4's restroom was functioning on 11/17/2025. 2. The facility failed to ensure the call light system in Resident #15 and Resident #16's restroom was functioning on 11/17/2025. 3. The facility failed to ensure the call light system in Resident #17 and Resident #18's restroom was functioning on 11/17/2025. 4. The facility failed to ensure the call light system in Resident #19 and Resident #20's restroom was functioning on 11/17/2025. 5. The facility failed to ensure the call light system in Resident #12 and Resident #21's restroom was functioning on 11/17/2025. 6. The facility failed to ensure the call light system in Resident #22 and Resident #23's restroom was functioning on 11/17/2025. 7. The facility failed to ensure the call light system in Resident #24 and Resident #25's restroom was functioning on 11/17/2025. 8. The facility failed to ensure the call light system in Resident #26's restroom was functioning on 11/17/2025. This failure could place the residents at the memory care unit at risk of not having a means of directly contacting the staff to obtain assistance for activities of daily living or help in the event of an emergency.Findings included: 1. Resident #4 Review of Resident #4's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with unsteadiness of feet and difficulty in walking. Review of Resident #4's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident used a walker, required assistance for bed mobility, transfer, hygiene, shower, and dressing. Review of Resident #4's Comprehensive Care Plan, dated 09/26/2025, reflected the resident was at risk for falls and incontinent for bladder and bowel. The interventions were to be sure the resident's call light was within reach and assist the resident to use the toilet regularly. 2. Resident # 15 Review of Resident #15's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with cerebrovascular disease (blood supply to the brain was interrupted). Review of Resident #15's Comprehensive MDS Assessment, dated 10/08/2025, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident used a cane, was independent for eating, bed mobility, transfers, and walking 10 feet. Review of Resident #15's Comprehensive Care Plan, dated 10/24/2025, reflected the resident was at risk for falls, had ADL self-care deficits, and was incontinent for bladder and bladder. The interventions were to be sure the resident's call light was within reach, assist the resident to use the toilet, and provide limited assistance for toileting. Resident #16 Review of Resident #16's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture to right patella (knee bone) and frequency of micturition (refers to the need to urinate many times during the day or night). Review of Resident #16's Comprehensive MDS Assessment, dated 10/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident used a walker, needed supervision for toileting and dressing. The resident was independent for bed mobility, and walking for 10 feet. Review of Resident #16's Comprehensive Care Plan, dated 10/20/2025, reflected the resident was at risk for falls, was incontinent, and had ADL self-care deficits. The interventions were to be sure the resident's call light was within reach, encourage independent function, and assist the resident to the toilet. 3. Resident #17 Review of Resident #17's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertensive retinopathy (eye condition caused by high blood pressure) and visual loss. Review of Resident #17's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was not using any adaptive device and was independent for bed mobility, toilet transfer, and could walk for 150 feet. Review of Resident #17's Comprehensive Care Plan, dated 09/26/2025, reflected the resident was at risk for falls and had an ADL self-care deficit. The interventions were to be sure the resident's call light was within reach and to provide assistance for toileting. Resident #18 Review of Resident #18's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with syncope (fainting) and collapse. Review of Resident #18's Comprehensive MDS Assessment, dated 09/01/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated that the resident was using a walker, required supervision for bed mobility, hygiene, dressing, transfer, and was able to walk for 10 feet. Review of Resident #18's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls, had an ADL self-care deficit, and had urinary and bowel incontinence. The interventions were to be sure the resident's call light was within reach, assist to use the toilet regularly, and encourage independent function. 4. Resident #19 Review of Resident #19's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dizziness and abnormalities of gait and mobility. Review of Resident #19's Comprehensive MDS Assessment, dated 09/19/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated that the resident was using a walker, required supervision for toileting hygiene, dressing, bed mobility and toilet transfer. Review of Resident #19's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls and had a self-care deficit. The interventions were to be sure the resident's call light was within reach and provide supervision for toileting. Resident #20 Review of Resident #20's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and visual loss. Review of Resident #20's Comprehensive MDS Assessment, dated 10/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated that the resident used a walker, required supervision for dressing, and transfer. The resident had the ability to walk at least 150 feet. Review of Resident #20's Comprehensive Care Plan, dated 10/23/2025, reflected the resident was at risk for falls, had ADL self-care deficits, and urinary incontinence. The interventions were to be sure the resident's call light was within reach and to assist the resident to use the toilet. 5. Resident #12 Record review of Resident #12's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and lack of coordination. Record review of Resident #12's Comprehensive MDS Assessment, dated 10/15/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was independent for bed mobility and needed assistance for transfer. Record review of Resident #12's Comprehensive Care Plan, dated 10/08/2025, reflected that the resident was at risk for falls, incontinent for bladder and bowel, and had self-care deficits. The interventions were ensure call lights were within reach, assist the resident to the toilet frequently. Resident #21 Review of Resident #21's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with parkinsonism (brain condition that caused slow movements, rigidity, and tremors). Review of Resident #21's Comprehensive MDS Assessment, dated 11/02/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident was independent for hygiene, dressing, but required assistance for bed mobility and transfer. Review of Resident #21's Comprehensive Care Plan, dated 09/26/2025, reflected the resident was at risk for falls and self-care deficits and one of the interventions was to be sure the resident's call light was within reach. 6. Resident #22 Review of Resident #22's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and atrophy. Review of Resident #22's Comprehensive MDS Assessment, dated 09/21/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was independent for toileting, dressing, shower, bed mobility and transfer. Review of Resident #22's Comprehensive Care Plan, dated 09/29/2025, reflected the resident was at risk for falls and self-care deficits. The interventions were to be sure the resident's call light was within reach and to remind the resident to use the toilet regularly. Resident #23 Review of Resident #23's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #23's Comprehensive MDS Assessment, dated 08/30/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated that the resident required assistance for toilet hygiene, bed mobility and transfer. Review of Resident #23's Comprehensive Care Plan, dated 09/26/2025, reflected the resident was at risk for falls, incontinent for bladder and bowel, and had a self-care deficit. The interventions were to be sure the resident's call light was within reach and remind the resident to use the toilet regularly. 7. Resident #24 Review of Resident #24's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pain to thoracic spine (central part of the spine). Review of Resident #24's Comprehensive MDS Assessment, dated 10/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated that the resident required assistance for toilet hygiene, dressing, bed mobility and transfer. Review of Resident #24's Comprehensive Care Plan, dated 10/19/2025, reflected the resident was at risk for falls, had urinary and bowel incontinence, ADL self-care deficits. The interventions were to be sure the resident's call light was within reach and remind the resident to use the toilet regularly. Resident #25 Review of Resident #25's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pain and lack of coordination. Review of Resident #25's Comprehensive MDS Assessment, dated 08/22/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated that the resident required assistance for toileting, dressing, bed mobility and transfer. Review of Resident #25's Comprehensive Care Plan, dated 08/28/2025, reflected the resident was at risk for falls, had urinary and bowel incontinence, and ADL self-care deficits. The interventions were to be sure the resident's call light was within reach and remind the resident to use the toilet regularly. 8. Review of Resident #26's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with syncope and repeated falls. Review of Resident #26's Comprehensive MDS Assessment, dated 09/02/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated that the resident required assistance for toileting, hygiene, bed mobility and transfer. Review of Resident #26's Comprehensive Care Plan, dated 09/12/2025, reflected the resident was at risk for falls, had urinary and bowel incontinence, and ADL self-care deficits. The interventions were to be sure the resident's call light was within reach and remind the resident to use the toilet regularly. During an observation in the Memory Care Unit on 11/17/2025 starting at 9:30 AM the call light systems inside Resident #4, #12, #15 #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26's restrooms were not functioning. It was observed that when the call light switches inside the restrooms were activated, there were no lights outside the residents' rooms to signal that somebody triggered the call lights. During interview and observation on 11/17/2025 starting at 9:41 AM, RN B stated the resident's restrooms were supposed to have call lights so the residents could call the staff in case they were done with whatever they were doing inside the restroom. She said she knew the restrooms had call lights but was not sure if the call lights were working. She went inside Residents #21, #19, and #20's restroom and activated the call light. She then went outside the room to check if the call light was working and said the call light was not working because the light outside the resident's room was not flashing. She then went to Residents #22, #23, #24, and #25's restroom and checked the call light and said the call light was also not working. She then went to Residents #15, #16, #17, and #18's restroom and said the call light was also not working. She then went to Residents #4 and #26's restroom and said the call lights were also not working. She said she did not know that the call lights in the memory unit were not working. She said she was responsible in checking if the call lights were working or not. She said the issue was not whether the residents were using it or not, but that the resident did not have a way to call the staff if assistance was needed. She said some of the resident were ambulatory and would go to the restroom by themselves so it would be important that the call lights were working. She said the staff should not assume that the residents in the memory care unit would not know how to use the call lights. She said she would let maintenance know that the call lights in the memory care unit were not functioning. In an interview on 11/17/2025 at 9:45 AM, CNA I stated she was not aware the call lights in the restrooms were not working. She said it would be important that the call lights were working so the residents would be able to call the staff if they were done with bowel movement or if they needed to be changed. She said the staff could also use the call light to call another staff if they needed assistance in case a resident had a fall in the restroom. In an interview on 11/18/2025 at 8:40 AM, the DON stated she was not aware that the call lights inside the restrooms in the memory care unit were not working. She said she did not get a report about the call lights. She said the staff were responsible in checking if the call lights were working or not. She said the head of maintenance should be making their rounds to check the call lights. She said it was important that the call lights were working in case the residents needed help when they were inside the restroom. In an interview on 11/18/2025 at 10:31 AM, ADON A stated call lights should be checked to see if they were working or not. There should be routine checking of the call lights in all the residents' rooms. She said the call lights should all be functioning so that the residents would have something to use to call the staff if they needed help. In an interview on 11/17/2025 at 11:40 AM, the Director of Supplies stated he was also the maintenance manager and that he was just informed that all the call lights in the memory care unit were not functioning. He said he was new in the facility but was still responsible in checking all the call lights in the facility. He said he was not aware that the call lights in the memory care unit were not working because the call lights outside the memory care unit were working. He said he should have checked the call lights personally and not assume that they were working. He said he would include the call lights on his daily walk through to make sure they were working. In an interview on 11/18/2025 at 1:20 PM, the Administrator stated somebody should have noticed that the call lights inside the memory care unit were not operating. She said it was important that the call lights were working, not just inside the memory care unit, but in all residents' rooms so that they would have a way to call the staff when needed. Record review of the facility's policy Call Lights Policies and Procedures revised December 2023, reflected The facility will provide a call light system that is accessible, functional, and responsive to meet the needs of the residents . Functionality . Call lights will be in working order . Call lights will be monitored routinely to assess functionality

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #1 and Resident #2) of fifteen residents reviewed for dignity. 1. The facility failed to ensure CNA H did not stand while assisting Resident #1 with lunch on 11/17/2025. 2. The facility failed to provide a privacy bag for Resident #2s catheter bag (collects urine from the urinary bladder) on 11/17/2025. These failures could place the residents at risk of not having their right to a dignified existence maintained.Findings included: 1. Record review of Resident #1's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of a body part). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 10/11/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 14. The Comprehensive MDS Assessment indicated that the resident was dependent on staff for eating. Record review of Resident #1's Comprehensive Care Plan, dated 10/09/2025, reflected the resident had ADL self-care deficits and one of the interventions was to provide assistance for eating. Observation on 11/17/2025 at 12:04 PM revealed Resident #1 was sitting in his wheelchair in-front of the nurse's station. It was observed that CNA H was pushing a food cart along with CNA G. Both of them stopped in front of the nurse's station and then CNA G grabbed a tray from the food cart and went inside a resident's room. While waiting for CNA G, CNA H started feeding Resident #1 while he was still sitting in front of the nurse's station. She was standing up while feeding the resident. CNA G then told her to usher the resident to the dining area to continue feeding the resident. In an interview on 11/17/2025 at 12:09 PM, LVN C stated she did not notice that CNA H started feeding Resident #1 while he was still in the hallway and was standing up while feeding the resident. She said she should have pushed the resident's wheelchair in the dining area and fed the resident in the dining area instead of feeding the resident in the hallway. She said when assisting a resident during meals, the staff should also be sitting down to provide dignity to the resident. In an interview on 11/17/2025 at 1:03 PM, CNA H stated she should be sitting down when assisting with residents' meals. She said she started feeding Resident #1 in the hallway while waiting for CNA G. She said she was standing up while she was assisting the resident with lunch in the hallway. She said, when assisting somebody during meal times, she should sit down so she would be face to face with the resident. She said standing up in front of the resident was not a way of showing respect and dignity and as if she was in a hurry. She said she did not know what she was thinking. She said CNA G stopped her and told her to bring the resident to the dining area and that she should be sitting down when feeding the resident. In an interview on 11/17/2025 at 1:44 PM, Resident #1 did not reply when asked if it was okay for him that the staff was standing up while assisting him during lunchtime. 2. Record review of Resident #2's Face Sheet, dated 11/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease. Record review of Resident #2's Comprehensive MDS Assessment, dated 11/13/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Review of Resident #2's Comprehensive Care Plan, dated 11/14/2025, reflected that the resident had a Foley catheter (device used to help drain urine from bladder) and one of the interventions was to provide a catheter bag. Review of Resident #2's Physician Order, dated 11/08/2025, reflected (Specify type . indwelling urinary catheter (device used to help drain urine from bladder): 16 Fr (French: unit of measurement for catheter sizes) with . cc normal saline balloon using a closed drainage system. Change monthly and as needed. every night shift starting on the 10th and ending on the 11th every month. In an observation and interview on 11/17/2025 at 10:39 AM Resident #2 was in her wheelchair at her doorway. She said she was waiting for somebody to push her wheelchair to the activity area. It was observed that the resident had a catheter hooked beneath her wheelchair. The catheter bag, with urine inside, did not have a privacy bag. The resident stated she had a catheter because she had a kidney problem. She said she was transferred by an aide to her wheelchair but did not notice if her catheter was inside a privacy bag. She said she was about to go out of her room and it would be nice if her urine bag was not exposed. In an interview on 11/17/2025 at 10:42 AM, CNA F stated she was the one who transferred Resident #2 to her wheelchair. She said she was aware that the resident's catheter bag did not have a privacy bag. She said she should have asked for a privacy bag before transferring the resident to be sure that the catheter bag was not exposed. She said it would be embarrassing if the resident would be in the hallway and everybody could see her urine. She said she would look for a privacy bag. In an interview on 11/18/2025 at 8:40 AM, the DON stated the staff should sit down next to the resident when assisting them during mealtimes. She said sitting beside the resident also allowed close observation of the resident's eating habits like if the residents were swallowing the food, if there was a problem in swallowing, if the resident was pocketing the food, if the residents were choking. She said standing up while assisting during meals would give an impression that the staff was in a hurry. The DON also stated that catheter bags should be inside a privacy bag to maintain the resident's dignity. She said the facility was using catheter bags that had flaps on them and the flaps served as the cover. She said if the resident was using a catheter bag that did not have a flap, it should be in a privacy bag to prevent embarrassment but provide privacy and dignity. She said the expectation was for all the staff to ensure that the residents were provided dignity by sitting down while assisting during meals and ensuring that the catheter bag was not exposed. She said she already started an in-service pertaining to providing dignity as soon as CNA H told them about the dignity issue. In an interview on 11/18/2025 at 10:31 AM, ADON A stated a privacy bag should be provided if a resident had a catheter to avoid incidents that could lead to embarrassment. The purpose of the privacy bag was to provide dignity for residents with urinary catheters. ADON A said the staff assisting a resident during mealtime should be sitting alongside the residents to also provide dignity. She said sitting beside the residents would allow better observation of the residents' needs during mealtime. She also said sitting beside the resident encouraged interaction and promoted safety when eating. She said the expectation was for the staff to provide dignity in all aspects of the resident's care. She said the DON already started an in-service about dignity. In an interview on 11/18/2025 at 1:20 PM, the Administrator stated a catheter bag without a privacy bag was a dignity issue because the content of the catheter bag could be seen from the hall way. She said the staff assisting a resident to eat should be sitting down and within eye level of the resident also to provide dignity. She said all the staff, even her, were responsible in providing dignity to all residents. He said staff must do their due diligence in ensuring that the residents had a dignified existence while in the facility. The Administrator said she would coordinate with the DON to make sure that the staff were aware of the meaning of providing dignity. Record review of the facility's policy entitled, Resident Rights, Dignity and Privacy Handout undated, reflected Resident Dignity: Treating residents with the utmost respect, recognizing their inherent worth and value as individuals. It involves honoring their autonomy, privacy, and personal preferences, while also ensuring their physical and emotional well-being is maintained. Record review of the facility's policy entitled Catheter Care Policies and Procedures revised 02/2024 reflected Catheter Management . Privacy: Store the catheter bag in a privacy bag to maintain dignity.

Based on observations, interviews, and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for two (Resident #6 and Resident #7) of residents reviewed for privacy and confidentiality. 1. The facility failed to ensure MA D did not leave Resident #6's medical information at the side of the medication cart unattended on 11/17/2025. 2. The facility failed to ensure MA E did not leave Resident #7's medical information on top of the medication cart unattended on 11/17/2025.Findings included: 1. Record review of Resident #6's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #6's Comprehensive MDS Assessment, dated 09/30/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #6's Comprehensive Care Plan, dated 09/27/2025, reflected the resident had asthma (lung disorder caused by narrowing of the airways) and one of the interventions was to give medications as ordered. Record review of Resident #6's Physician Order, dated 05/06/2025, reflected Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Observation on 11/17/2025 at 8:57 AM revealed MA D was passing medications down the hall. It was observed that a blister pack was at the side of the medication cart where the plastic cups and small paper cups were stored. The blister pack was facing the hallway and Resident #6's medical information was visible to passers-by. On the blister pack was Resident #6's name, the name of the medication, the prescription number of the medication, the dose and the frequency of the medication, the physician's order, the diagnosis indicating why the medication was being administered, and the name of the pharmacy. Observation on 11/17/2025 at 9:01 AM revealed MA D went inside a resident's room to administer medications. She left the medication cart outside the resident's room with the blister pack still at the side of the medication cart and Resident #6's information still visible. Observation on 11/17/2025 at 9:12 AM revealed MA D took resident #6's blister pack and put them inside the drawer of the medication cart when asked about the blister packs. In an interview on 11/17/2025 at 12:40 PM, MA D stated she should have secured Resident #6's empty blister pack until she got a chance to re-order it or she should have just flipped it so the back of the blister pack would be the one showing. She said since the blister pack had the resident's medical information, then it could be considered as a HIPAA violation because that information was confidential. 2. Record review of Resident #7's Face Sheet, dated 11/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypothyroidism (a condition wherein the thyroid gland did not produce enough thyroid hormones). Record review of Resident #7's Comprehensive MDS Assessment, dated 10/16/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had hypothyroidism. Record review of Resident #7's Comprehensive Care Plan, dated 10/07/2025, reflected the resident had hypothyroidism and one of the interventions was to observe for edema (swelling caused by fluid trapped in the tissues of the body). Record review of Resident #7's Physician Order, dated 10/08/2019, reflected Lasix Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema. Observation on 11/17/2025 at 9:23 AM revealed a cart was parked on a hallway going to the memory care unit. On top of the cart was a blister pack and on the blister pack was Resident #7's name, the name of the medication, the prescription number of the medication, the dose, the frequency, the physician's order, the diagnosis indicating why the medication was being administered, and the name of the pharmacy. It was observed that nobody was attending the cart and the cart was facing the hallway. During an interview on 11/17/2025 at 9:25 AM, MA E stated she was not with her medication cart because she was administering a resident's medication. She said she should have put the blister pack inside the medications cart before leaving her cart because Resident #7's medical medication was on the blister pack. She said she would be mindful that no information about the resident would be left on top of the cart because it was a HIPAA violation. In an interview on 11/18/2025 at 8:40 AM, the DON stated personal and medical information about a resident should not be exposed for everybody to see because it was confidential. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full confidentiality and secure any information for all residents. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on 11/18/2025 at 10:31 AM, ADON A stated the staff should make sure that no information about any resident was left on top of the cart before leaving the cart unattended. She said the resident's information was confidential and should not be seen by unauthorized individuals. She said that was a HIPAA violation. She said the expectation was for the staff not to leave any personal or medical information about a resident. She said she would coordinate with the DON to do an in-service about privacy and confidentiality. In an interview on 11/18/2025 at 1:20 PM, the Administrator stated the staff must make sure the residents' information was not exposed and protected because it was a violation of the resident's privacy and confidentiality of the care/treatment they were receiving. She said the expectation was for all the staff to make sure the personal and medical information of a resident was not visible to unauthorized individuals. She said she would collaborate with the DON to do an in-service about privacy and confidentiality. Record review of the facility's policy entitled, Resident Rights, Dignity and Privacy Handout undated, reflected Resident Privacy . confidentiality . 4. Right to Privacy and Confidentiality . Confidential handling of medical, personal, and financial information.

Based on interview and record review the facility failed to ensure residents were free from abuse for one (Resident # 1) of 6 residents reviewed for abuse. The Administrator emotionally and verbally abused Resident # 1 when she yelled at the resident and pointed her finger in Resident #1's face bringing Resident #1 to tears. The failure place residents at risk of further abuse and diminished self worth.Findings included:Record review of Resident # 1's face sheet, dated 6/26/2025, revealed a [AGE] year-old male initial admission date, 3/3/2023. Resident # 1 had diagnoses including Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery ( a stroke caused by a blood clot (thrombosis) in an artery supplying the brain), Alzheimer Disease (a progressive brain disorder that gradually impairs memory, thinking skills, and eventually, the ability to carry out the simplest tasks), Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side (common consequences of cerebral infarction, or stroke, affecting one side of the body), Diabetes Mellitus (a group of metabolic diseases characterized by high blood sugar levels), Mood Disorder (a group of mental health conditions characterized by significant and persistent disturbances in a person's emotional state, impacting their ability to function in daily life, Dementia (a general term for a decline in mental ability severe enough to interfere with daily life), Major Depressive Disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life) and Transient Ischemic Attack (TIA) and Cerebral Infarction (A TIA involves a temporary blockage, with symptoms resolving within minutes or hours, while a cerebral infarction (stroke) involves a longer-lasting blockage, leading to tissue damage and potentially permanent disability). Record review of Resident # 1's quarterly MDS assessment, dated 3/1/2025 indicated Resident # 1 had minimal difficulty hearing. Resident # 1 had unclear speech. Resident # 1 was usually understood and usually understood others. Resident # 1's BIMS was a 09 (moderate cognitive impairment). Resident # 1 used a wheelchair. Resident # 1 was independent with toileting hygiene, sit to lying, sit to stand, toilet transfer. Resident # 1 required setup or clean-up assistance with eating, oral hygiene, putting on/taking off footwear. Resident # 1 required supervision or touching assistance with shower/bathe self, upper body dressing, and personal hygiene. Resident # 1 was occasionally incontinent with urinary and bowel.Record review of Resident # 1's Care Plan, revision date 8/9/2023, indicated Resident # 1 had communication impairment; Goal: staff will anticipate and meet needs that Resident # 1 is not able to effectively communicate; Interventions: allow resident time to verbalize his thoughts/needs. Do not rush. Ask him to repeat as needed. Use writing materials if resident is having trouble relaying his thoughts/needs; allow time for resident to digest information-do not rush; approach in a calm manner using eye contact- call resident by name. Resident # 1 had cognitive impairment; Goal- Resident # 1's needs will be met, and dignity maintained; Interventions- allow time for tasks and responses, anticipate and assist with ADL's q shift, and explain all procedures using terms gestures the resident can understand. Resident # 1 had episodes of behaviors and was at risk for further increased episodes and injury; Goal-Resident # 1 will decrease behavioral episodes through behavioral monitoring and interventions; Interventions- encourage to attend social activities of preference, give medication as ordered, monitor and chart behaviors as they occur and report progress /declines to MD; observe for early warning signs of behavior-approach in a calm manner, call by name remove from unwanted stimuli.During an interview and observation with Resident # 1 on 6/26/2025 at 11:10 a.m., Resident # 1 stated he wanted to move into an apartment. He stated that he was at the nurse's station talking to staff when the Administrator approached him and yelled in his face. He stated the Administrator pissed him off when she yelled at him. He stated he told the Administrator to stay away from him. Resident # 1 stated two days ago he was drawing and the Administrator came by his door and he stated that upset him because he told the Administrator to stay away from him. Resident # 1 stated he wanted to leave the facility because the Administrator was rude. Resident # 1 had a stroked, therefore, he had limited verbal skill. Resident # 1 was able to verbally express his frustration.During an interview with MA A on 6/26/2025 at 2:10 p.m., MA A stated a couple of days ago (she could not remember the date) she heard a verbal altercation. She stated that the verbal altercation was extremely loud, and she thought it was two residents. She stated that when she arrived at the nurse's station, she observed Resident # 1 and the Administrator in a verbal altercation. She stated that she did not know what Resident # 1 and the Administrator were arguing about. She stated that the Administrator was loud and disrespectful towards Resident # 1. She stated that Resident # 1 was loud as well, and the Administrator should have de-escalated the situation by leaving. She stated that another staff member had to ask the Administrator to leave the area. She stated that Resident # 1 was so upset he was standing up and hitting the desk. She stated that another CNA (name unknown) was at the desk and that CNA (name unknown) was able to de-escalate the situation and calm Resident # 1 down.During an interview with Social Worker A on 6/26/2025 at 2:30 p.m., with Social Worker A , she stated that on 6/16/2025 Resident # 1 was sitting next to the nurses' station in his wheelchair. She stated that Resident # 1 had a hard time speaking and expressing himself as he had a stroke. She stated that if someone listened to Resident # 1 they could understand him. She stated that Resident # 1 was expressing his needs to direct care staff. She stated that Resident # 1 was upset, and he started yelling as he could not express himself with words. She stated that the Administrator came from around the corner, and she got in Resident # 1's face and began yelling at him and pointing her finger in his face. She stated that the Administrator told Resident # 1 to shut up. She stated that Resident # 1 was so upset that he stood up and he began to hit the desk with his hands, and he was crying. She stated that the Administrator continued to speak rudely to Resident # 1. She stated that a direct care staff asked the Administrator to leave the area as the situation needed to be de-escalated and the resident was upset. Other A stated that she was concerned that Resident # 1 was going to fall or could possibly had another stroke. She stated that another direct care staff calmed Resident # 1 down and she took him to his room. She stated that the Administrator's approach and the way she spoke to Resident # 1 was unprofessional.During an interview with CNA A on 6/27/2025 at 12:46 p.m., CNA A stated Resident # 1 had a stroke and he has problems verbally expressing himself. She stated that Resident # 1 can communicate his needs, but it is hard to understand hm. She stated that did not remember the date of the verbal altercation between Resident # 1 and the Administrator. She stated that Resident # 1 was at station 2 and he wanted to go out for the day or go home permanently. She stated that Resident # 1 was speaking to the staff at station 2 about leaving. She stated that Resident # 1 was upset, and he began to yell and talk loudly. She stated that the Administrator approached Resident # 1, and she introduced herself to him. She stated that Resident # 1 started cursing at the Administrator. She stated that the Administrator told Resident # 1 you will not talk to me like that. She stated that upset Resident # 1 as he was trying to get his words out. She stated that Resident # 1 started crying. She stated that Resident # 1 does have behavior issues and most direct care staff know how to help him calm down. She stated that the Administrator met Resident # 1 for the first time, and she was yelling at him. She stated with Resident # 1 that was not going to work because when he is upset, he will hit things and people. She stated that she and CNA B were able to calm him down as they took him to his room and fixed him coffee. She stated that the Administrator made the situation worse. She stated that the Administrator should approach Resident # 1 differently. She stated that the Administrator approached Resident # 1 yelling at him, and that escalated the situation. She stated that Resident # 1 was sitting in his wheelchair and when he got upset with the Administrator he stood up. She stated that she was concerned because she did not want Resident to fall. She stated that the DON told the Administrator to walkway, and she walked away mumbling. CNA A stated that the Administrators approach towards Resident # 1 was unprofessional.During an interview with CNA B on 6/27/2025 at 1:12 p.m., CNA B stated she did not now the date and time of the incident. She stated that it happened last week. She stated a direct care staff came and got her. She stated that when Resident # 1 is upset she can calm him down. She stated that when she arrived at the nurses' station Resident # 1 was hysterical and cursing. She stated that she observed the Administrator leaned over in Resident # 1's face and she told Resident # 1 that he was not going anywhere. She stated that Resident # 1 wanted to leave the facility. She stated that she doesn't know what was said prior to her arriving at the nurses' station. She stated that the Administrator told Resident # 1 I am the Administrator, and you will not curse at me. She stated that Resident # 1 continued to curse. She stated that she was concerned for Resident # 1 as he was upset, and he recently had a stroke. She stated that she did not want Resident # 1 to fall or have stroke or a heart attack; she stated he was just that mad. The situation was de-escalated as CNA B told the DON to get the Administrator away and the DON walked the Administrator down the hall. She stated that she and CNA A took Resident # 1 to his room. She stated it took a while for him to calm down as he was still cursing. She stated that Resident # 1 was mentally abused by the Administrator. CNA B stated that the DON, CNA A, LVN A and the Social Worker were present.During an interview with LVN A on 6/27/2025 at 2:00 p.m., LVN A stated that Resident # 1 had been talking to the NP about going home and he told the NP he wanted to go home in 2 months. She stated that the NP told Resident # 1 that everything needed to be in place before he discharged home. Resident # 1 had been speaking with the Social Worker about going home. She stated that she thinks the Social Worker was working on Resident # 1's paperwork. She stated that last week (date unknown) Resident # 1 was at the nurses' station and he was inquiring about going home. She stated that she told Resident # 1 that everything must be in place before he can move. She stated that Resident # 1 wants to go to an apartment. LVN A stated that Resident # 1 got upset because he wanted an answer as to when he could move, and she did not have that answer. She stated that the Social Worker would make those arrangements; however, she stated that Social Worker was terminated on 6/25/2025 (two days ago). She stated that Resident # 1 was upset, and he began yelling and cursing. She stated that the new Administrator came from around the corner, and she got in Resident # 1's face and she said, I'm the new Administrator and my name is [Administrator] and you will not curse at me like that. LVN A stated that Resident # 1 was not cursing at the Administrator because she was not around, and he was cursing in general. She stated that the Administrator asked Resident # 1 Where do you think you are going? She stated that made Resident # 1 upset. She stated that she did not understand why the Administrator would say that to Resident # 1 as he was already upset, and he did not know her. She stated that she asked Resident # 1 to calm down. She stated that he did not calm down. She stated that CNA A and CNA B usually can calm him down. She said CNA B told Resident # 1 that she would call his friend for him. She stated that Resident # 1 agreed to go to the room with CNA A and CNA B. She stated that the Administrator should have approached Resident # 1 differently. She stated that if the Administrator would have left Resident # 1 alone and let the staff deal with him he would have calmed down. She stated that both Resident # 1 and the Administrator were yelling. She stated that she wanted Resident # 1 to calm down because she did not want him to have another stroke. She stated that he was also standing, and she did not want him to fall. She stated that the Administrator was yelling back and forward with Resident # 1. She stated that the Administrator's approach was unprofessional.During an interview with the Administrator on 6/27/2025 at 3:05 p.m., the Administrator stated last week (date unknown) Resident # 1 was at the nurse's station. She stated that overheard Resident # 1 screaming. She stated that she was on another hallway. She stated that she went to the nurse's station and Resident # 1 was sitting in his wheelchair. She stated that Resident # 1 was yelling because he wanted to go home. She stated that she approached Resident # 1 and introduced herself to him. She stated that Resident # 1 said I want to get the F out of here. She stated at this point Resident # 1 stood up and came towards her. She stated that attempted to calm Resident # 1 down; however, Resident # 1 continued to scream and curse. She stated that staff (name unknown) went to get the CNA (name unknown) as this CNA was able to calm Resident # 1. The Administrator stated that she did know how the situation was de-escalated as she walked away. The Administrator stated that she did not yell at Resident # 1. The Administrator stated that she did not point her finger at Resident # 1. The Administrator stated that she patted Resident # 1 on his arm when she introduced herself to him.During an interview with ADON A on 6/27/2025 at 3:47 p.m., ADON A stated she was present when the verbal altercation occurred between Resident # 1 and the Administrator. She stated that she thinks the incident happened last Thursday (6/19/2025). She stated she was doing rounds when she heard Resident # 1 being loud. She stated that Resident # 1 is hard to understand because of his stroke and his verbiage is hard to understand and he gets frustrated. She stated that Resident # 1 wanted to leave, and he wanted to go to an apartment where can stay by himself. She stated that the Administrator heard Resident # 1. She stated that Resident # 1 was sitting in his wheelchair when the Administrator walked up to him. She stated that the Administrator patted Resident #1 and he stood up and started cursing at her. She stated that the Administrator was talking with Resident # 1 but she was not speaking to him in an aggressive tone. She stated that the DON told her to go and get CNA B as she can calm Resident # 1 down. She stated that when she left to go get CNA B the Administrator was still standing there talking to Resident # 1. She stated that CNA B was able to calm Resident # 1 down.During an interview the DON on 6/27/2025 at 4:37 p.m., the DON stated she was in her office, and she heard someone with a loud voice. She stated that when she came down the hallway it was Resident # 1 who was loud. She stated that Resident # 1 was voicing that he wanted to leave and go to an apartment. She stated that Resident # 1 was cursing and being very aggressive to staff and pounding on things. She stated that she attempted to calm him down. She stated that the Administrator came from around the hall and the Administrator was speaking to Resident # 1. She stated that the Administrator told Resident # 1 to hold on because it is a process, and the facility needed to make sure Resident # 1 was going somewhere safe. She stated that the Administrator did not say anything wrong to Resident # 1. She stated that Resident # 1 wanted to leave the facility, and he was upset because he could not leave. She stated that Resident # 1 stood up at the nurses' stations as he was upset. She stated that she asked ADON A to go and get CNA B as she can calm Resident # 1 down. She stated that CNA A was able to calm Resident # 1 down.Record review of the facility's policy on Resident Rights, Dignity and Privacy Handout, not dated indicated 1) Right to dignity, respect and freedom a) treated with dignity and respect, b) freedom from abuse , neglect and exploitation, and corporal punishment, c)right to make personal choices about care and daily life.

Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 5 residents (CR# 1) reviewed for quality of care. The facility failed to immediately contact emergency services and transfer CR #1 to the hospital when she complained of pain to the head, and was on a prescribed anticoagulant medication, after an unwitnessed fall on 11/21/2023 at 9:25 pm. CR#1 was life flighted to the hospital after vomiting three times after the fall. An IJ was identified on 11/30/2023. The IJ template was provided to the facility on [DATE] at 1:59pm. While the IJ was removed on 12/1/2023 at 3:40pm, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility needs to measure the effectiveness of their plan. The failure placed residents who are at risk for falls and on anti-coagulant medication at risk of delayed treatment that could lead to decline in health and death. Findings Included Record review of CR #1's face sheet dated 7/3/2023, revealed an [AGE] year-old female who was admitted to the NF on 07/03/2023. Her diagnoses included the following: chronic respiratory failure with hypoxia (occurs when the respiratory system cannot adequately remove carbon dioxide), chronic obstructive pulmonary disease (a group of lung disease that makes it difficult to breathe), urinary tract infection ( infection of the urinary system), acute embolism and thrombosis of deep vein of left lower extremities (blockage of the artery), hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), hypotension (low blood pressure), peripheral vascular disease (poor circulation of blood flow to the limbs), congestive heart failure (a chronic condition that prevent the heart from pumping blood as well as it should) depression (a medical illness that effect the mood), and chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood). Record review of CR#1's quarterly MDS dated [DATE] BIMS summary score coded her as 07 indicating she was moderately impaired for cognition for decision making. She was coded as having no behaviors. Record review of CR#1's physician's order revealed an order for Apixaban (oral blood thinner used to prevent blood clotting and stroke) oral 5 mg two times a day. Record review of November 2023 MAR revealed documentation that Hydrocodone -Acetaminophen tablet5-325 was given at 8:00 pm, Apixaban 5mg was given at 5:00pm on 11/21/2023. Record review of the Nurse's investigation report dated 11/21/2023 revealed at 9:40 p.m. CR#1 was observed lying on the floor on her left side next to her bed with a blanket. The resident stated that she fell when she was going to the bathroom. She was noted with a small bruise to the lateral aspect of right hand, a small abrasion to her lower back and no bleeding noted. Complain of head pain no bruising, redness or swelling noted. Two staff members assisted the resident back to bed and she was cleaned up. The resident was assessed for injuries, neuro checks were initiated, and pain medications were given. Blood pressure readings for CR #1 were not identified as a concern. ?9:40PM: 159/84 ?10:10PM: 144/80 ?10:40PM: 102/87 Record review of nurses for CR#1 dated 11/21/2023 at 11:40 p.m. reflected in part, family came to visited patient at 10:40 pm after she was notified that patient had a fall and family requested that an x ray be done and resident to be sent to the hospital. EMS was called and arrived. Patient had 3 emesis from 10:40 pm till she left by EMS at 11:34pm. Emesis was greenish yellow and moderate amount. Patient, awake and alert during this time. While EMS was in room doing assessment, patient right side of face become droop and she could not talk back. They stated that patient will go life flight to hospital downtown. EMS left at 11:34 pm. Guardian and family in room and aware of situation. Record review of EMS records revealed EMS was called at 11:17 p.m. by RN H. In an interview on 11/28/2023 at 11:46 a.m. CNA F she said she was doing her rounds on 11/21/2023 and around 9:30 p.m. she went to CR#1's room and she found the resident on the floor. She said she asked CR#1 what happened, and she told her she was going to the restroom and fell . She said she did not move her, but quickly went to get the nurse. She said RN G went to the room assessed the resident and on completion of the assessment RN G asked CR#1 some questions, took her vitals, and she assisted RN G with putting the resident back to bed. CNA F said CR#1 then pointed at her head in a gesture to indicate that her head was hurting. CNA F said the nurse then brought CR#1 a clear cup with a pill, believed to be Tylenol and gave it to the resident. In an interview with on 11/28/2023 at 2:30p.m. RN G said she was called by CNA F to come CR#1's room because the resident was on the floor. She said she went to the resident's room, and she was lying on her left side on the floor next to her bed. She said she assessed the resident and did not see any redness or swelling. She said there was a small bruise to the hand and an abrasion to the lower back with no bleeding. She said after her assessment CNA F assisted her in putting the resident back to bed. She said the resident pointed to her head and said in Spanish that her head hurt. She said she called the family and NP. She said the NP told her to monitor the resident and give her pain medication and she said she gave her Tylenol. She said she did not remember if she asked the resident if she hit her head when she fell . Further interview with RN G revealed she followed the fall protocol by assessing the resident, calling the NP and doing neuro checks. In an interview with the DON on 11/28/2023 at 3:58 p.m. regarding CR#1's fall, she said RN G assessed CR#1, called the doctor, the family and did neuro checks. She said RN G followed the physician's order to only monitor resident and not sending the resident to the hospital. She admitted that she did not see any orders for Tylenol to be given and no documentation that Tylenol was given. In an interview with RN H on 11/28/2023 at 4:43 p.m. she said she was working the night shift and was on Station 2 taking report at the start of the shift. She said she did not assess CR#1 because when she got to Station 1; EMS was in CR#1's room assessing her. She said when she was talking to the family they told her CR#1 had vomited and they were requesting an x-ray to be done. She said the resident vomited twice when she was in the room and her face became droopy and then she became unresponsive, at that point EMS was in the room, and they decided to life flight her to the hospital because they thought she was having a stroke. She said CR#1 left for the hospital around 11:30 p.m. on 11/21/2022. In an interview with the NP on 11/29/2023 at 9:14 a.m. he said he was called on 11/21/2023 at 9:45 p.m. regarding CR#1's fall. He said he gave orders for the nurse to give the resident pain medication. At 11/21/2023 at 9:53pm he received a text from the facility stating the family of CR#1 wanted an x-ray to be done and he gave orders for x-ray and CT scan of the head to be done. He said he told the nurse she was to call the on-call nurse as he was not on call. I an interview with FM A on 11/29/2023 at 1:43pm she stated she arrived at the facility on 11/21/2023 at 10:30pm. She said she observed CR#1 lying in bed with a dry green (bio) type of vomit on her clothing. It appeared dry making her think no one had checked on the resident for a while. She stated FM#B arrived at 10:40pm. and told the 10-6 shift nurse that there was a bump on the side of CR#1's face and x rays were needed. She stated the nurse replied, Why? There's nothing wrong with her. FM A said they demanded that 911 should be called. FM A said RN H responded that they needed permission. FM A said 911 was eventually called and arrived sometime after 11:00pm. In an interview with FM B on 11/29/2023 at 1:50pm she stated she visited CR#1 on 11/21/2023 and left the facility at 8:10pm. She said at 10:10pm she received a called from the facility about her CR#1's fall. In an interview with RN H on 11/29/2023 at 2:55pm she said she knew CR#1 was on an anti-coagulant. She said she called the NP and told him about CR#1 complaining about her head hurting after her assessment and neuro checks. The NP told her to administer medications for pain. RN H said she administered Tylenol because CR#1 had already had her hydrocodone and it was too soon to administer another tablet; therefore, she gave her Tylenol. She said she did not ask the NP what pain medication she should give. She said she should have asked the NP for an order since there was no order for the Tylenol. Further interview with RN H regarding fall policies of a resident that had an unwitnessed fall and was currently taking ant-coagulants. She responded, I don't know. She said she would need to look at the policy to make sure she gave the correct answer. In an interview with the DON on 11/29/2023 at 3:23pm. she confirmed the fall policies for a resident with an unwitnessed fall and taking ant-coagulant medication was they should always be assessed (head to toe), and neuro checks conducted, then notify NP. If there was an emergency, they should send the resident out immediately. The DON stated RN H requested x-rays and CR#1 was sent to the hospital after the family's request. The DON stated the resident began to vomit prior to EMS being called. The DON stated there was no order for Tylenol but stated RN H received verbal authorization from the NP to administer Tylenol. The DON was then asked why it took the facility almost 2 hours to call EMS, and she responded, I don't know. Record review of the undated facility policy and procedure on Fall Management reflected in part, 2. the resident will be checked for any abnormalities i.e. a. deformed, discolored or painful body parts. B. Bumps, C. Bruises, D. Cuts, E. Abrasions, F. Scrapes, G. Confusion and H. Level of consciousness. PLAN OF REMOVAL CR #1 was transferred to the hospital on 11/ 21/ 23. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/30/23 to review the IJ template and Plan of Removal. On 12/1/23 the Administrator and Director of Nursing completed a route cause analysis using the 5 whys and added to the ADHOC QAPI information. On 11/30/23 the Director of Nursing and Assistant Director of Nursing assessed residents who had an unwitnessed fall in the last 10 days for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings. The Director of Nursing initiated an in-service on 11/30/23 with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head). 911 should be activated upon identification of the abnormal findings. Licensed Nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 12/1/23. The Director of Nursing initiated an in-service on 11/30/23 with licensed nurses. Topics included: completing thorough assessments post-fall with considerations for residents on anticoagulants. Licensed Nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 12/1/23. The Director of Nursing initiated an in-service on 11/30/23 with the certified nursing assistants. Topics included: CNAs should report to their charge nurse any changes in condition from the resident's normal behavior including changes after a fall and emergencies. Certified nursing assistants will be educated before starting their next shift. Education will be included in orientation on Education will be completed 12/1/ 23. The Director of Nursing provided 1:1 education with RN H and RN G on (1 2/ 1/ 2023). Education included Fall procedures and activating the emergency response system (911) for any resident on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head); 911 should be activated upon identification of the abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. The Regional Nurse Consultant provided 1:1 education with the DON and ADON on (12/1/2023). Education included Fall procedures and activating the emergency response system (911) for any resident on anti-coagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head); 911 should be activated upon identification of the abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. The Administrator and DON reviewed the policy on Fall Management, Changes of Condition, and Residents on Anticoagulant medications with no changes required. Monitoring the POR on 12/1/2023: During the survey monitoring, the Administrator was interviewed regarding what she believed was the root cause of the IJ. Administrator believed a delay in sending CR#1 to the hospital, via, 911 was an unclear communication response between the registered nurse and nurse practitioner. There is a plan in place to monitor this issue, which the medical staff should meet at lease 2-3 per week and create a monitoring log to avoid this issue occurring again. The Administrator expects the Director of Nursing to monitor all the systems daily as it relates to the IJ tags, physician notification and ensuring thorough and immediate documentation in the system. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed CR#1 should have immediately been sent out of the facility, via, 911 because she was taking anticoagulant, and the medical doctor should have been called instead of the nurse practitioner. The DON said the registered nurses notified the nurse practitioner because the medical director works at a clinic, which closes at 5pm so the next point of contact was the nurse practitioner as it was after 5pm. The DON plans to monitor this issue by following up daily on residents who are prescribed anticoagulants and to be proactive in ensuring clear instructions are given to the nursing staff by the doctor. The DON expectations of the RN's are to follow protocols when getting orders from the doctor. The RN must paraphrase back to the doctor what they understand so that the order is clear. The DON indicated she personally evaluated each resident, who are administered anticoagulants, for neurological deficiencies. Record review of the facility POR Binder revealed: revealed an Ad HOC QAPI meeting on 11/30/23 to review the IJ template and Plan of Removal. On 11/30/23 In-Service trainings initiated by the DON to licensed nurses on Fall Procedures, activating the emergency response system (911) for any residents on anticoagulants who fall and present with signs or symptoms of head injury (acute headache, vomiting, or abnormal findings to the scalp/head, and changes in condition. The Regional Nurse consultant completed a 1:1 education with DON and ADON on 12/1/2023 on Fall procedures, activating response system (911) should be activated upon identification of the abnormal findings; and completing abnormal findings; and completing thorough assessments post-fall with considerations for residents on anticoagulants. On 12/1/23 between 8:30am - 3:30pm, the POR monitoring was conducted. The following CNAs were interviewed CNA G, CNA H, CNA I, CNA J CNA K. CNA L, CNA M, CNA N and CNA O were asked what training they had received. Each CNA indicated they had received In-Service training on change of condition (identifying a change in the norm for the resident, like the resident isn't talking or responding, unable to wake up, and a resident who is experiencing depression).They also stated thy were also in-service on falls, immediate notification to the charge nurse and dialing 911 themselves if unable to locate a nurse in an emergency (life or death) situation. Each CNA stated they received their training at the beginning of their shift on 11/30/23 and on 12/1/23. Each stated they understood their responsibilities of Certified Nursing Assistant. The CNAs were able to demonstrate understanding of the in-service training received. On 12/1/23 between 8:30am - 3:30pm, the POR monitoring was conducted. The following RN's and LVN's were interviewed, RN I, RN J, LVN A, LVN B, LVN C, and LVN D. All were asked what training they had received. Each stated they had received In-Service training on change of condition, falls, immediate notification and dialing 911 and the importance in speaking with a MD or calling the on-call MD. Record review of the POR revealed in-service signatures of all medical personnel on fall, change of condition and initiating emergency response through 911. The Administrator was informed the Immediate Jeopardy was removed on 12/01/2023 at 3:40 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision for 3 (Resident #1, Resident #2, CR#3) of 9 residents reviewed for accident and incidents. The facility did not provide adequate supervision for Resident #2 who had a history of wandering and sexual inappropriate behaviors. Resident #2 was found in Resident #1's room sexually abusing Resident #1 The facility did not provide adequate supervision for CR#3 who had a history of sexual inappropriate behaviors. CR#3 was found sexually abusing Resident #1. The facility did not provide adequate supervision for Resident #1 who had a history of wandering. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/04/21 at 11:35 AM. While the Immediate Jeopardy was removed on 08/07/21, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope of isolation due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems These failures could place residents on the secure unit at risk of, a diminished quality of life, abuse, neglect, and serious injury. Findings Included: Record review of Resident #2's face sheet revealed Resident #2 was a [AGE] year old male that was admitted to the facility on [DATE] with a diagnoses of [CONDITION(S)], [CONDITION(S)], muscle wasting atrophy, anxiety disorder, vitamin D deficiency, muscle weakness, abnormality of gain and mobility, lack of coordination, hallucinations, pain, benign prostate [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], vitamin B deficiency, depressive disorders, irritable bowel syndrome, and constipation. Record review of Resident #2's Physician Progress Note dated 07/02/21 revealed .Review of Systems .Psychiatric: Staff reports agitation, some sexual behavior Record review of Resident #2's MDS dated [DATE] revealed Resident #2 had a BIMS of 11 of 15 which meant he had moderate cognitive impairment. Record review of Resident #2's Care Plan dated 04/15/21 revealed Resident #2 experienced wandering, moved with no rational purpose, seemingly oblivious to needs or safety, and goes into other resident rooms. The interventions indicated staff are to remove resident from other resident's rooms and unsafe situations and staff are to provide comfort measures for basic needs. The resident care plan indicated Resident #2 had episodes of adverse behavior verbally aggressive-cursing, racial slurs, yelling/screaming, fabricate facts, unreliable history, manipulates staff, had inappropriate behavior of disrobing in common areas, urinates in public, masturbates in public, and verbally entices other conflicts related to [CONDITION(S)]. Interventions were for staff to anticipate the resident's behavior and re-direct the resident when in close proximity to others that might invoke aggression, asses for triggers that may contribute / prompt behaviors, and attempt to redirect resident to safe area when increased behavior noted. Record review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease, wandering, abnormalities of gait, lack of coordination, and muscle weakness. Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS of 99 which meant she was unable to complete the interview. Record review of Resident #1's Care Plan dated 10/20/20 revealed Resident #1 experienced wandering, moved with no rational purpose, and was seemingly oblivious to her needs or safety. The interventions are for staff to remove the resident from other resident's rooms and unsafe situations, when resident begins to wander, provide comfort measures for basic needs. Record review of Resident #1's progress notes dated 01/26/2021 written by DON revealed at around 11am the resident and another resident were found in the same room together with the door open. The two residents were immediately separated, and she was assisted to her room. She was noted with bm on self and was taken to shower by CNA. Head to toe skin assessment was done and no skin break down noted. RP was notified. 2pm NP here to see resident and noted redness to peri area with discharge ordered lab and medication for [MEDICATION(S)]. NP notified RP of findings . Record review of Resident #2's Progress Notes dated 03/06/2021 11:20 written by RN C revealed . Patient sitting next to resident in dining room on station 2. Patient was talking with resident. Patient started to rub on other resident's leg. Patient and resident separated, patient educated on personal space and not touching other residents (especially without their permission). CNA and RN asked patient to go back down to station 3, patient non-compliant, continues to wheel back and forth down the hallway on station 2 . Record review of Resident #2's Progress Notes dated 03/11/2021 written by RN C revealed Patient sitting in dining room on station 2 with another resident. Patient attempted to hold resident's hand under dining room table, resident pulled hand away from resident and told him no, she had a boyfriend. Patient told resident he didn't care. Patient sat very close to resident and ate his soup. RN redirected and educated patient on not making other residents feel uncomfortable. Asked patient to return to station 3 to eat soup/lunch. Patient wheeled himself to station 3 but continues to wheel up and down the hallway on station 1 and 2 . Record review of Resident #2's Hospital Progress Note dated 03/12/21 revealed . Patient arrived on unit via wheelchair from ED after medical clearance at 8:15PM .He was nervous and slightly irritable .Per nursing home report, he was swinging at staff and cursing them and residents. He was intrusive, going into other residents' rooms and being difficult to redirect. He has been hallucinating that he sees or hears people who are not there and is paranoid someone may be after him or that staff has stolen his cell phone which he lost or misplaced .He is inappropriate at times with female residents trying to hold their hand or making them feel uncomfortable. He refuses nursing care and assessment at times . Record review of Resident #2's Progress Notes dated 06/18/21 written by RN A revealed . CNA reported this resident entered a female resident's room while she was lying in bed and kissed her on the head at 9:45 pm. When CNA asked res to leave female residents room, he showed her his middle finger, nurse went to resident and requested he go to his room and remain in bed and not get up to go into female res. rooms . In an interview on 07/20/21 at 1:26 PM, CNA A stated on 07/17/21 she was on station #2 when a resident on her station wanted some ice so she went to the memory care unit to get the ice. She stated when she walked by Resident #1's room she saw the back of Resident #2 while he sat on the side of Resident #1s bed with his pants down. She said Resident #1 was in her bed with her brief off and her pants down. She stated Resident #2's hands were on Resident #1's thighs. She stated she told Resident #2 to leave Resident #1's room. CNA A stated she reported what she saw to RN A who was behind the desk outside the memory care unit. She stated CNA B was the only aide on duty in the memory care unit. In an interview on 07/20/21 at 2:13 PM, CNA B stated on 07/17/21 she was in the dining room watching the other residents when she heard a CNA A say, what are you doing. CNA B stated when she got up Resident #2 was already walking toward his room. She stated Resident #2 did touch residents on shoulder, but other residents did that as well. She stated she was on the memory care unit by herself at the time of the incident. She stated RN A went back and forth to the unit periodically. In an interview on 07/20/21 at 3:00 PM, CNA B stated on 07/17/21 the incident between Resident #1 and Resident #2 happened after supper somewhere between 6PM to 7:30 PM. She said usually she had Resident #1 with her but there was another resident that was more confused that day, so she needed to supervise that resident a little more. She stated the incident between Resident #1 and Resident #2 happened quickly because both residents were sitting with her in the day room before the incident occurred. She could not remember the last time she saw them. In an interview on 07/20/21 at 12:28 PM, RN A stated on 07/17/21 CNA A from Station #2, came to the Memory Care Unit to get some ice for a resident on her station. When she passed Resident #1's room she saw Resident #2 standing next to Resident #1's bed, his pants were down around his ankles. Resident #1 was laying on the bed her pants were down below her knees with her brief on and had some feces on her buttocks. CNA A reported Resident #2 was touching Resident #1 on her right hip/thigh area and CNA A told him to stop and redirected him out the room. CNA A got RN A and she went and assessed Resident #1. Resident #1 had no injuries, no secretions or blood in vaginal area. She was cleaned up and brought into the dinner room. Resident #2 went into his room and the DON was notified. RN A stated Resident #1 was ambulatory, and she could use her hands and legs. She stated she was not sure how Resident #1's pants were removed. She stated Resident #1 had no previous incidents like this before. RN A said Resident #2 did approach women and rub them on shoulder and kiss them on the forehead. She said it was reported to her that he kissed Resident #1 on the mouth before, but she did not witness this. Record review of Resident #2's Progress Notes dated 07/19/21 written by DON revealed .Resident was noted in another resident's room. The residents were immediately separated and redirected. Resident was moved to 45A and psych service was started. New order to increase [MEDICATION(S)] due to behaviors. NP and RP notified of changed . Record review of Resident #1's Progress Notes dated 07/19/21 written by DON revealed . spoke to RP about another resident that was found in resident's room while she laid in bed, residents were immediately separated. Head to toe skin assessment was done, no discoloration or skin break down was noted. NP was notified of incident. Resident is noted laughing, walking with no problems . Observation and interview on 07/20/21 at 10:07 AM revealed Resident #1 was sitting in a chair in dayroom. Resident #1 did not respond to questions, just laughed when questioned. Observation and interview on 07/20/21 at 10:09 AM revealed Resident #2 laid down in bed. Resident #2 stated he did not have any concerns with abuse at the facility. He stated some of the older men would come and lay down in his bed. He stated he remembered being moved to a new room recently but did not know why. He did not remember going into a female's room or any sexual activity with a female. In an interview on 07/20/21 at 10:55 AM the DON stated, it was reported to her by the RN A that Resident #2 was found in Resident #1's bedroom on 07/17/21. Resident #1's sheets were down to her ankles and she was in her gown. The resident had feces in her brief. The DON stated she was not sure if Resident #1's brief was off. The DON stated Resident #2's pants were down; she was not sure if his penis was erect. The DON stated the nurse aide redirected the residents. RN A completed a head to toe assessment and no redness, bruising or discoloration was noted. Resident #2 was sent to his room and the NP was notified as well as the responsible party. The DON stated Resident #1 and Resident #2's rooms were across from each other so Resident #2 was moved to a different room . The DON stated Resident #2 had a history of wandering into other residents' rooms . She stated she did not have an incident investigation report for either incident because nothing happened between the residents. In an interview on 08/02/21 at 11:20 the DON stated Resident #1 had a [MEDICATION(S)] infection which caused the redness and was not related to the incident between her and CR#3. In an interview on 07/20/21 at 12:02 PM the Administrator stated it was reported to her that Resident #2 wandered into Resident #1's room and his pants were down. The staff immediately separated them, and Resident #2 was moved to a different room away from her, nothing physical occurred. The physician was notified but there was not a justification to send the resident to the psych hospital. Resident #2 was sent to the psych hospital a while back for a different situation . The Administrator stated Resident #2 was her family member, but she does not treat him any differently from the other residents, she is harder on him and expects more from him. In an interview on 07/20/21 at 12:37 PM, the DON stated the NP could not justify sending Resident #2 to the behavioral hospital. The DON stated Resident #2's [MEDICATION(S)] was increased due to his increased behaviors. The DON stated Resident #2 would be seen by the local behavioral services next week and they are more familiar with his needs. The DON said the facility typically had two staff assigned to the memory care area. The nurse was usually in the hallway during the evening and the aide was in the dayroom or helping residents. In an interview on 07/20/21 at 12:38 PM, the Administrator stated she was not sure what to do and wanted to know the state agency's recommendation for this situation. She stated the best case was to have Resident #2 transferred to another facility, she was his dual power of attorney. She could have him transferred to a different facility quickly. In an interview on 07/20/21 at 1:35 PM, the Administrator stated she was not aware of the other sexual behaviors by Resident #2, she did not read the hospital notes or physician notes. She was having Resident #2 moved to an all-male facility. In an interview on 07/20/21 at 1:41 PM, the DON stated Resident #2 was being sent to the behavioral hospital and he will not be returning. In an interview on 07/20/21 at 2:27 PM, CNA C stated Resident #2 had a history of touching other female residents. Staff would redirect him and report him to administration, but he would curse out staff and keep doing the same things. Staff had to redirect him before he could go too far with touching other residents. Staff were scared to say something because he was the Administrators family member. In an interview on 07/20/21 at 2:29 PM, MA A stated she worked on the secure unit at times and Resident #2 had a history of touching other female residents. In an interview on 07/20/21 at 2:45 PM, RN A stated there was one nurse aide assigned to the memory care unit. MA B was assigned to that unit but was scheduled to come in at 8 PM. MA B passed the 8 PM medications and she passed the 4PM medications on the memory care unit. RN A said the memory care unit was part of station #3 but the nurse aide for station #3 did not work on the memory care unit. Staff on the memory care unit had to get staff from station #3 to help with transfers when needed. In an interview on 07/20/21 at 3:34 PM, the DON stated the facility usually had two people assigned to the memory care unit. The nurse had a camera at the desk of station #3 so she could see what was going on the memory care unit. Today Resident #2 was sent to the behavioral hospital and was accepted to another facility. In an interview on 08/02/21 at 11:10 AM the NP stated the Resident #2 had sexual behaviors and they were discussed with the facility. There were discussions regarding proper placement, moving to another facility closer to family, or a higher level of care. Resident#2 mentioned he wanted to have a girlfriend and that was not possible in this type of environment. Resident #2 was a younger resident, so he was given a sex toy. The nurses trained him to use the toy, he was doing pretty good with that. Resident #2 did not have any issues up until he was found in another resident's room. No sexual activity was reported between Resident #2 and Resident #1 during that incident. Behavioral Services had increased his [MEDICATION(S)], but she was not sure when that occurred. 2. Record review of CR#3's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnosis of [CONDITION(S)], fever, pain, neuromuscular dysfunction of bladder, constipation, [CONDITION(S)] disorder, Alzheimer's disease, and repeated falls. Record review of CR#3's MDS dated [DATE] revealed he had a BIMS of 3 which meant he had severe cognitive impairment. Record review of CR#3's care plan dated 05/04/21 revealed CR#3 resided on the secure unit due to risk of exit seeking and risk for injury from wandering related to dementia as evidence by impaired cognition and safety awareness. CR#3 was at risk for injury from others while residing in secure unit due to altered cognition. Staff approaches are to monitor and discuss activity preference, allow resident to choose activity inside and outside that do not pose a safety risk, call resident by name when giving care, involve in care as much as possible, explain procedures using terms/gestures resident can understand, and keep environment free from possible hazards. Record review of CR#3's baseline care plan dated 01/18/21 revealed CR#3 had inappropriate sexual behavior of attempts to touch staff and other residents inappropriately. Staff approaches were to monitor resident frequently for any attempts to make inappropriate sexual advances, attempt to redirect resident if any hypersexual behaviors were noted, separate from other residents temporarily if any inappropriate behaviors are noted, call MD and family, and medicate as ordered . Record review of CR#3's progress notes dated 01/17/2021 written by RN B revealed .Pt up ambulating ad lib in secure unit with no c/o pain or discomfort voiced or noted. Pt noted with very inappropriate sexual behaviors-towards staff and female residents. Pt informed of inappropriateness of acts and redirected. Np made aware of behaviors . Record review of CR#3's progress notes dated 01/18/2021 written by LVN A revealed . CNA to room to do vitals, was sexually inappropriate, rubbing on her leg, asked her if he could put something in there, when she asked .he told her his little penis. She told him no, he told her to come back later . Record review of CR#3's progress notes dated 01/26/2021 written by DON revealed . 11am resident was noted in a room with another resident with door open and were immediately separated by CNA. Resident was noted with hypersexual tendency. NP was notified of situation and ordered for resident to be sent to senior care at [hospital]for med adjustment. RP was notified of situation and ordered. 12pm resident was transferred to senior care via van driver. In an interview on 08/03/21 at 10:37 AM CNA D stated she was on the secure unit by herself when the incident occurred between Resident #1 and CR#3.on 01/26/21. She was back there by herself at the time. It was the 6am-2pm shift. She remembers hitting the glass to get RN C's attention to come into the secure unit to assist. It is hard when you work the secure unit by yourself. In an interview on 08/05/21 at 12:50 PM RN B stated CR#3 would always make sexual comments about doing dirty sexual stuff. CR#3 would not touch but he would tell staff to come and get into the bed with him while giving medicine. Staff tried to keep an eye on the resident, when he would speak like that staff would redirect him. None of the touch incidents occurred when she was on duty. In an interview on 08/05/21 at 1:53 PM LVN A stated CR#3 was trying to get the nurse aide to get into the bed with him. CR#3 told her he wanted to put something inside of her. He did this several times when he first came to the facility. CR#3 had sexually inappropriate behaviors. He would ask to touch and feel female residents and staff. LVN A was not sure which nurse aide that was but this was during the 10p-06a shift. LVN A said Resident #1 had a history of wandering in other resident's rooms. Resident #1 did not understand what she was doing and she has to be watched. She had seen her walk into other male resident's rooms before. Resident #1 just laughs when spoken to and does not know what was going on. Record review of Resident #3's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] and [CONDITION(S)], muscle wasting atrophy, [CONDITION(S)] disorder, transient ischemic attach, cerebral infarction, [CONDITION(S)], heart failure, [CONDITION(S)] and hypertensive chronic kidney disease. Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 8 which meant she had mild cognitive impairment. Observation and interview on 08/04/21 at 11:58 AM revealed Resident #3 was sitting in a wheelchair, resident was in a pleasant mood. Resident #3 stated she did not recall being touched by a male resident at the facility, but she remembered by touched by a family friend at [AGE] years old. Record review of Resident #4's face sheet revealed she was an [AGE] year-old female she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, dementia, urinary tract infection, [CONDITION(S)], muscle wasting atrophy, [CONDITION(S)], and [CONDITION(S)]. Record review of Resident #4's MDS dated [DATE] revealed she did not have a BIMS score. Observation and interview on 08/04/21 at 12:02 PM revealed Resident #4 was sitting in wheelchair, resident in a pleasant mood. Resident could not communicate and answer questions clearly. In an interview on 08/02/21 at 12:35 PM RN C stated CNA D told her it was an incident between Resident #1 and CR#3. CR#3 was standing over Resident #1. Resident #1 had BM in brief which was down, CR#3 had no fecal matter on his penis. Resident #1 was lying in CR#3's bed. RN C asked CR#3 what happened but he could not answer. She contacted the DON and NP. Residents were separated. CR#3's briefs was on and he did not have an erection. It was reported to her by a resident that Resident #2 came up to a female resident in dining room and touched her on the hand, she separated the residents and spoke with Resident #2 about the behaviors. She said Resident #2 had another incident, he came in the dining room and touched a female resident on the leg. The residents were separated. She was not sure which incident involved Resident #3 or Resident #4 . One of the incidents occurred on 3/6/21, the other incident occurred on 3/11/21. Resident #4 has dementia and cannot communicate. Resident #3 may not be here anymore. Resident #2 would come from Station #3 and wheel himself to Station #2. He was placed on the secure unit sometime in March or April of 2021. In an interview on 08/07/21 at 7:05 AM the DON stated its important monitor residents with sexual inappropriate behaviors because residents that cannot consent to sexual encounters can become abused, especially in the dementia unit. The facility does not want residents taking advantage of other residents. It made other residents feel uncomfortable. Record review of the facility policy Safety and Supervision of Residents dated December 2007 revealed Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities Facility-Oriented Approach to Safety .1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization .Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition . An Immediate Jeopardy was identified on 08/04/21 11:35 AM and the DON was informed of IJ in the area of accidents/supervision and the IJ template was provided to him via email at 11:51 AM and a plan of removal was requested. The plan of removal was accepted on 08/06/21 at 8:32 AM and included: .PLAN OF REMOVAL Name of facility: [facility name] Date: August 4, 2021 Immediate action: Resident #2 was discharged from the facility on 7/20/21 at 5:00 PM. Resident #1 was assessed at the time of the incident without any concerns. Resident #1 was re-assessed on 8/4/21 by the Director of Nursing and found to be without distress with good food intakes and hydration per normal for the resident. Resident #1s care plan was reviewed and revised to show supervision and monitoring and communicate any changes in the plan of care prior to staff starting their shift through direct report. The C.N.A. profile will be update appropriately to reflect any changes in care. On 8/4/21 at 12:45, The nursing administrative team assessed the residents who reside on the secured unit by completing wandering assessments and supervision needs as well as changes in their usual activities of daily living. Behavior tracking logs and care plans were reviewed and revised as needed. No concerns were revealed. On 8/4/21 the Director of Nursing re-evaluated the staffing for the secured unit so that there would always be two (2) staff assigned on the schedule for the day and evening shift to give care appropriate within their scope of practice. The facility secured a contract with a nursing agency on 1/7/2021 to fulfill any needs resulting in not being able to staff the facility. If agency staff is required on the secured unit, they will receive the same training as regular facility staff, prior to working on the secured unit. There are currently no residents residing on the secured unit who require the assist of two (2) staff however if a resident becomes a two (2) person assist, they will be re-assessed by the Director of Nursing/designee for continued residency on the unit. If a resident required two (2) person assist because of illness or other situation, the staff will be instructed to ask staff outside the unit for assistance so that residents are always monitored by a staff. On 8/4/21 the Director of Nursing began a direct-staff in-service regarding the monitoring and safety of residents including sexual behaviors and re-direction of residents with aggressive behaviors using crisis prevention intervention (CPI) training utilizing a power point. The regional nurse consultant educated the Director of Nursing regarding this training. Also included in this training is the procedure for relieving staff for breaks so that the two (2) staff criteria are not broken as well as seeking assistance should a resident require a two (2) person assist. Direction was given to staff to monitor for residents wandering into another resident's room's and to re-direct following CPI training strategies. Staff will routinely round the secured unit to identify concerns and huddle at change of shift to give report on shift occurrences. If any concerns with resident behavior are identified, sexual or otherwise, the staff will separate residents and keep on 1:1 monitoring of any resident with sexual inappropriate behavior or otherwise until a sufficient intervention implemented under the direction of the Director of Nursing. The charge nurse will notify the administrator and Director of Nursing immediately for any concerns with any resident with sexual inappropriate behavior or otherwise. Any concerns with any resident with sexual inappropriate behavior or otherwise will be reviewed in the morning Clinical Meeting, behavior tracking will be updated, and plan of care reviewed and revised as needed. Nursing administration will communicate any findings to the staff on the secured unit and the Resident Profile (C.N.A. plan of care) will be updated. This training will be completed by end of day 8/5/21. Any staff not receiving this education by end of day 8/4/21 will be required to receive it before beginning their next assigned shift. Facilities Plan to ensure compliance quickly The Director of Nursing will be responsible for monitoring the daily staffing schedules to validate there are two (2) staff scheduled for the day and evening shift for the secured unit. Staffing agency will be utilized if needed to staff this unit. If staffing agency is not available, then administrative staff will assist in staffing the secured unit. The administrator/designee will bring all concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team (IDT) review . Surveyor Verification of Plan of Removal was as follows: Observation on 08/04/21 at 12:50 PM on the memory care unit revealed the facility had 2 staff on unit. Observation on 08/05/21 at 1:40 PM on the memory care unit revealed the facility had 2 staff on unit. Observation on 08/06/21 at 12:45 PM on the memory care unit revealed the facility had 3 staff on unit. Observation on 08/07/21 at 6:00 AM on the memory care unit revealed the facility had 2 staff on unit. Interviews were started on 08/06/21 at 1:07 PM and continued through 08/07/21 at 7:05 AM with 31 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff were interviewed regarding the plan of removal: MA D, CNA E, CNA F, Medical Records, LVN A, RN C, CNA G, ADON A, MDS Coordinator A, MDS Coordinator B, ADON B, CNA C, CNA H, RN A, Maintenance Director, Social Worker, CNA J, Activity Aide, RN D, Dietary Cook, Floor Tech, CNA J, DON, CNA K, Laundry Aide, PTA, CNA L, CNA M, MA D, CNA D, and Transportation. Staff were able to verbalize the plan of removal. Record review of the behavior tracking logs for memory care residents revealed no concerns with behavior monitoring. Record review of the care plans for 11 of 11 memory care residents revealed no concerns with care plan updates. Record review of the facility contracts revealed the facility had contracts with 2 staffing agencies dated 5/27/20 and 6/22/21. Record review of the facility C.N.A. profile revealed the facility updated care plans were in the kiosk for memory care residents with wandering behaviors. Record review of the facility staffing sheets dated 08/04/21, 08/05/21, 08/06/21 and 08/07/21 revealed the facility had 2 staff members assigned to the 6a-2p and 2p-10p shifts. Record review of the facility in-service sheets dated 08/04/21 revealed staff on from multiple department including (Nursing Department, Housekeeping, Activities, Dietary, Maintenance, Transportation, Business Office, Social Services, Laundry) were in-serviced on sexual inappropriate behaviors, sexual triggers, de-escalation, reporting incidents to administration immediately, 2 staff on the memory care unit, supervision on the secure unit, swapping out staff for breaks and lunch, and calling out from work on the secure unit. While the DON was informed that the Immediate Jeopardy was removed on 08/07/21 at 7:05 AM, the facility remained out of compliance at severity of no actual harm with potential for more than minimal harm with a scope of isolation due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective s [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse and neglect for three of Nine residents (Resident #1, Resident #2, and CR#3) reviewed for abuse and neglect. The facility failed to provide adequate supervision for Resident #2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide adequate supervision for CR#3 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to adequately supervise Resident #1 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/04/21 at 11:35 AM. While the Immediate Jeopardy was removed on 08/07/21, the facility remained out of compliance at the scope of a pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to train staff and evaluate the effectiveness of their plan. These failures placed residents on the secure unit at risk of diminished abuse and neglect. Findings Included: Record review of Resident #2's face sheet revealed Resident #2 was a [AGE] year old male that was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Review of Systems .Psychiatric: Staff reports agitation, some sexual behavior Record review of Resident #2's MDS dated [DATE] revealed Resident #2 had a BIMS of 11 of 15 which meant he had moderate cognitive impairment. Record review of Resident #2's Care Plan dated 04/15/21 revealed Resident #2 experienced wandering, moved with no rational purpose, seemingly oblivious to needs or safety, and goes into other resident rooms. The interventions indicated staff are to remove resident from other resident's rooms and unsafe situations and staff are to provide comfort measures for basic needs. The resident care plan indicated Resident #2 had episodes of adverse behavior verbally aggressive-cursing, racial slurs, yelling/screaming, fabricate facts, unreliable history, manipulates staff, had inappropriate behavior of disrobing in common areas, urinates in public, masturbates in public, and verbally entices other conflicts related to [CONDITION(S)]. Interventions were for staff to anticipate the resident's behavior and re-direct the resident when in close proximity to others that might invoke aggression, asses for triggers that may contribute / prompt behaviors, and attempt to redirect resident to safe area when increased behavior noted. Record review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS of 99 which meant she was unable to complete the interview. Record review of Resident #1's Care Plan dated 10/20/20 revealed Resident #1 experienced wandering, moved with no rational purpose, and was seemingly oblivious to her needs or safety. The interventions are for staff to remove the resident from other resident's rooms and unsafe situations, when resident begins to wander, provide comfort measures for basic needs. Record review of Resident #1's progress notes dated 01/26/2021 written by DON revealed at around 11am the resident and another resident were found in the same room together with the door open. The two residents were immediately separated, and she was assisted to her room. She was noted with bm on self and was taken to shower by CNA. Head to toe skin assessment was done and no skin break down noted. RP was notified. 2pm NP here to see resident and noted redness to peri area with discharge ordered lab and medication for [MEDICATION(S)]. NP notified RP of findings . Record review of Resident #2's Progress Notes dated 03/06/2021 11:20 written by RN C revealed . Patient sitting next to resident in dining room on station 2. Patient was talking with resident. Patient started to rub on other resident's leg. Patient and resident separated, patient educated on personal space and not touching other residents (especially without their permission). CNA and RN asked patient to go back down to station 3, patient non-compliant, continues to wheel back and forth down the hallway on station 2 . Record review of Resident #2's Progress Notes dated 03/11/2021 written by RN C revealed Patient sitting in dining room on station 2 with another resident. Patient attempted to hold resident's hand under dining room table, resident pulled hand away from resident and told him no, she had a boyfriend. Patient told resident he didn't care. Patient sat very close to resident and ate his soup. RN redirected and educated patient on not making other residents feel uncomfortable. Asked patient to return to station 3 to eat soup/lunch. Patient wheeled himself to station 3 but continues to wheel up and down the hallway on station 1 and 2 . Record review of Resident #2's Hospital Progress Note dated 03/12/21 revealed . Patient arrived on unit via wheelchair from ED after medical clearance at 8:15PM .He was nervous and slightly irritable .Per nursing home report, he was swinging at staff and cursing them and residents. He was intrusive, going into other residents' rooms and being difficult to redirect. He has been hallucinating that he sees or hears people who are not there and is paranoid someone may be after him or that staff has stolen his cell phone which he lost or misplaced .He is inappropriate at times with female residents trying to hold their hand or making them feel uncomfortable. He refuses nursing care and assessment at times . Record review of Resident #2's Progress Notes dated 06/18/21 written by RN A revealed . CNA reported this resident entered a female resident's room while she was lying in bed and kissed her on the head at 9:45 pm. When CNA asked res to leave female residents room, he showed her his middle finger, nurse went to resident and requested he go to his room and remain in bed and not get up to go into female res. rooms . In an interview on 07/20/21 at 1:26 PM, CNA A stated on 07/17/21 she was on station #2 when a resident on her station wanted some ice so she went to the memory care unit to get the ice. She stated when she walked by Resident #1's room she saw the back of Resident #2 while he sat on the side of Resident #1s bed with his pants down. She said Resident #1 was in her bed with her brief off and her pants down. She stated Resident #2's hands were on Resident #1's thighs. She stated she told Resident #2 to leave Resident #1's room. CNA A stated she reported what she saw to RN A who was behind the desk outside the memory care unit. She stated CNA B was the only aide on duty in the memory care unit. In an interview on 07/20/21 at 2:13 PM, CNA B stated on 07/17/21 she was in the dining room watching the other residents when she heard a CNA A say, what are you doing. CNA B stated when she got up Resident #2 was already walking toward his room. She stated Resident #2 did touch residents on shoulder, but other residents did that as well. She stated she was on the memory care unit by herself at the time of the incident. She stated RN A went back and forth to the unit periodically. In an interview on 07/20/21 at 3:00 PM, CNA B stated on 07/17/21 the incident between Resident #1 and Resident #2 happened after supper somewhere between 6PM to 7:30 PM. She said usually she had Resident #1 with her but there was another resident that was more confused that day, so she needed to supervise that resident a little more. She stated the incident between Resident #1 and Resident #2 happened quickly because both residents were sitting with her in the day room before the incident occurred. She could not remember the last time she saw them. In an interview on 07/20/21 at 12:28 PM, RN A stated on 07/17/21 CNA A from Station #2, came to the Memory Care Unit to get some ice for a resident on her station. When she passed Resident #1's room she saw Resident #2 standing next to Resident #1's bed, his pants were down around his ankles. Resident #1 was laying on the bed her pants were down below her knees with her brief on and had some feces on her buttocks. CNA A reported Resident #2 was touching Resident #1 on her right hip/thigh area and CNA A told him to stop and redirected him out the room. CNA A got RN A and she went and assessed Resident #1. Resident #1 had no injuries, no secretions or blood in vaginal area. She was cleaned up and brought into the dinner room. Resident #2 went into his room and the DON was notified. RN A stated Resident #1 was ambulatory, and she could use her hands and legs. She stated she was not sure how Resident #1's pants were removed. She stated Resident #1 had no previous incidents like this before. RN A said Resident #2 did approach women and rub them on shoulder and kiss them on the forehead. She said it was reported to her that he kissed Resident #1 on the mouth before, but she did not witness this. Record review of Resident #2's Progress Notes dated 07/19/21 written by DON revealed .Resident was noted in another resident's room. The residents were immediately separated and redirected. Resident was moved to 45A and psych service was started. New order to increase [MEDICATION(S)] due to behaviors. NP and RP notified of changed . Record review of Resident #1's Progress Notes dated 07/19/21 written by DON revealed . spoke to RP about another resident that was found in resident's room while she laid in bed, residents were immediately separated. Head to toe skin assessment was done, no discoloration or skin break down was noted. NP was notified of incident. Resident is noted laughing, walking with no problems . Observation and interview on 07/20/21 at 10:07 AM revealed Resident #1 was sitting in a chair in dayroom. Resident #1 did not respond to questions, just laughed when questioned. Observation and interview on 07/20/21 at 10:09 AM revealed Resident #2 laid down in bed. Resident #2 stated he did not have any concerns with abuse at the facility. He stated some of the older men would come and lay down in his bed. He stated he remembered being moved to a new room recently but did not know why. He did not remember going into a female's room or any sexual activity with a female. In an interview on 07/20/21 at 10:55 AM the DON stated, it was reported to her by the RN A that Resident #2 was found in Resident #1's bedroom on 07/17/21. Resident #1's sheets were down to her ankles and she was in her gown. The resident had feces in her brief. The DON stated she was not sure if Resident #1's brief was off. The DON stated Resident #2's pants were down; she was not sure if his penis was erect. The DON stated the nurse aide redirected the residents. RN A completed a head to toe assessment and no redness, bruising or discoloration was noted. Resident #2 was sent to his room and the NP was notified as well as the responsible party. The DON stated Resident #1 and Resident #2's rooms were across from each other so Resident #2 was moved to a different room . The DON stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not have an incident investigation report for either incident because nothing happened between the residents. In an interview on 08/02/21 at 11:20 the DON stated Resident #1 had a [MEDICATION(S)] infection which caused the redness and was not related to the incident between her and CR#3. In an interview on 07/20/21 at 12:02 PM the Administrator stated it was reported to her that Resident #2 wandered into Resident #1's room and his pants were down. The staff immediately separated them, and Resident #2 was moved to a different room away from her, nothing physical occurred. The physician was notified but there was not a justification to send the resident to the psych hospital. Resident #2 was sent to the psych hospital a while back for a different situation . The Administrator stated Resident #2 was her family member, but she does not treat him any differently from the other residents, she is harder on him and expects more from him. In an interview on 07/20/21 at 12:37 PM, the DON stated the NP could not justify sending Resident #2 to the behavioral hospital. The DON stated Resident #2's [MEDICATION(S)] was increased due to his increased behaviors. The DON stated Resident #2 would be seen by the local behavioral services next week and they are more familiar with his needs. The DON said the facility typically had two staff assigned to the memory care area. The nurse was usually in the hallway during the evening and the aide was in the dayroom or helping residents. In an interview on 07/20/21 at 12:38 PM, the Administrator stated she was not sure what to do and wanted to know the state agency's recommendation for this situation. She stated the best case was to have Resident #2 transferred to another facility, she was his dual power of attorney. She could have him transferred to a different facility quickly. In an interview on 07/20/21 at 1:35 PM, the Administrator stated she was not aware of the other sexual behaviors by Resident #2, she did not read the hospital notes or physician notes. She was having Resident #2 moved to an all-male facility. In an interview on 07/20/21 at 1:41 PM, the DON stated Resident #2 was being sent to the behavioral hospital and he will not be returning. In an interview on 07/20/21 at 2:27 PM, CNA C stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff had to redirect him before he could go too far with touching other residents. Staff were scared to say something because he was the Administrators family member. In an interview on 07/20/21 at 2:29 PM, MA A stated she worked on the secure unit at times and Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 07/20/21 at 2:45 PM, RN A stated there was one nurse aide assigned to the memory care unit. MA B was assigned to that unit but was scheduled to come in at 8 PM. MA B passed the 8 PM medications and she passed the 4PM medications on the memory care unit. RN A said the memory care unit was part of station #3 but the nurse aide for station #3 did not work on the memory care unit. Staff on the memory care unit had to get staff from station #3 to help with transfers when needed. In an interview on 07/20/21 at 3:34 PM, the DON stated the facility usually had two people assigned to the memory care unit. The nurse had a camera at the desk of station #3 so she could see what was going on the memory care unit. Today Resident #2 was sent to the behavioral hospital and was accepted to another facility. In an interview on 08/02/21 at 11:10 AM the NP stated the Resident #2 had sexual behaviors and they were discussed with the facility. There were discussions regarding proper placement, moving to another facility closer to family, or a higher level of care. Resident#2 mentioned he wanted to have a girlfriend and that was not possible in this type of environment. Resident #2 was a younger resident, so he was given a sex toy. The nurses trained him to use the toy, he was doing pretty good with that. Resident #2 did not have any issues up until he was found in another resident's room. No sexual activity was reported between Resident #2 and Resident #1 during that incident. Behavioral Services had increased his [MEDICATION(S)], but she was not sure when that occurred. 2. Record review of CR#3's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#3's MDS dated [DATE] revealed he had a BIMS of 3 which meant he had severe cognitive impairment. Record review of CR#3's care plan dated 05/04/21 revealed CR#3 resided on the secure unit due to risk of exit seeking and risk for injury from wandering related to dementia as evidence by impaired cognition and safety awareness. CR#3 was at risk for injury from others while residing in secure unit due to altered cognition. Staff approaches are to monitor and discuss activity preference, allow resident to choose activity inside and outside that do not pose a safety risk, call resident by name when giving care, involve in care as much as possible, explain procedures using terms/gestures resident can understand, and keep environment free from possible hazards. Record review of CR#3's baseline care plan dated 01/18/21 revealed CR#3 had inappropriate sexual behavior of attempts to touch staff and other residents inappropriately. Staff approaches were to monitor resident frequently for any attempts to make inappropriate sexual advances, attempt to redirect resident if any hypersexual behaviors were noted, separate from other residents temporarily if any inappropriate behaviors are noted, call MD and family, and medicate as ordered . Record review of CR#3's progress notes dated 01/17/2021 written by RN B revealed .Pt up ambulating ad lib in secure unit with no c/o pain or discomfort voiced or noted. Pt noted with very inappropriate sexual behaviors-towards staff and female residents. Pt informed of inappropriateness of acts and redirected. Np made aware of behaviors . Record review of CR#3's progress notes dated 01/18/2021 written by LVN A revealed . CNA to room to do vitals, was sexually inappropriate, rubbing on her leg, asked her if he could put something in there, when she asked .he told her his little penis. She told him no, he told her to come back later . Record review of CR#3's progress notes dated 01/26/2021 written by DON revealed . 11am resident was noted in a room with another resident with door open and were immediately separated by CNA. Resident was noted with hypersexual tendency. NP was notified of situation and ordered for resident to be sent to senior care at [hospital]for med adjustment. RP was notified of situation and ordered. 12pm resident was transferred to senior care via van driver. In an interview on 08/03/21 at 10:37 AM CNA D stated she was on the secure unit by herself when the incident occurred between Resident #1 and CR#3.on 01/26/21. She was back there by herself at the time. It was the 6am-2pm shift. She remembers hitting the glass to get RN C's attention to come into the secure unit to assist. It is hard when you work the secure unit by yourself. In an interview on 08/05/21 at 12:50 PM RN B stated CR#3 would always make sexual comments about doing dirty sexual stuff. CR#3 would not touch but he would tell staff to come and get into the bed with him while giving medicine. Staff tried to keep an eye on the resident, when he would speak like that staff would redirect him. None of the touch incidents occurred when she was on duty. In an interview on 08/05/21 at 1:53 PM LVN A stated CR#3 was trying to get the nurse aide to get into the bed with him. CR#3 told her he wanted to put something inside of her. He did this several times when he first came to the facility. CR#3 had sexually inappropriate behaviors. He would ask to touch and feel female residents and staff. LVN A was not sure which nurse aide that was but this was during the 10p-06a shift. LVN A said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not understand what she was doing and she has to be watched. She had seen her walk into other male resident's rooms before. Resident #1 just laughs when spoken to and does not know what was going on. Record review of Resident #3's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 8 which meant she had mild cognitive impairment. Observation and interview on 08/04/21 at 11:58 AM revealed Resident #3 was sitting in a wheelchair, resident was in a pleasant mood. Resident #3 stated she did not recall being touched by a male resident at the facility, but she remembered by touched by a family friend at [AGE] years old. Record review of Resident #4's face sheet revealed she was an [AGE] year-old female she was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] revealed she did not have a BIMS score. Observation and interview on 08/04/21 at 12:02 PM revealed Resident #4 was sitting in wheelchair, resident in a pleasant mood. Resident could not communicate and answer questions clearly. In an interview on 08/02/21 at 12:35 PM RN C stated CNA D told her it was an incident between Resident #1 and CR#3. CR#3 was standing over Resident #1. Resident #1 had BM in brief which was down, CR#3 had no fecal matter on his penis. Resident #1 was lying in CR#3's bed. RN C asked CR#3 what happened but he could not answer. She contacted the DON and NP. Residents were separated. CR#3's briefs was on and he did not have an erection. It was reported to her by a resident that Resident #2 came up to a female resident in dining room and touched her on the hand, she separated the residents and spoke with Resident #2 about the behaviors. She said Resident #2 had another incident, he came in the dining room and touched a female resident on the leg. The residents were separated. She was not sure which incident involved Resident #3 or Resident #4 . One of the incidents occurred on 3/6/21, the other incident occurred on 3/11/21. Resident #4 has dementia and cannot communicate. Resident #3 may not be here anymore. Resident #2 would come from Station #3 and wheel himself to Station #2. He was placed on the secure unit sometime in March or April of 2021. In an interview on 08/07/21 at 7:05 AM the DON stated its important monitor residents with sexual inappropriate behaviors because residents that cannot consent to sexual encounters can become abused, especially in the dementia unit. The facility does not want residents taking advantage of other residents. It made other residents feel uncomfortable. Record review of the facility policy Safety and Supervision of Residents dated December 2007 revealed Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities Facility-Oriented Approach to Safety .1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization .Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition . An Immediate Jeopardy was identified on 08/04/21 11:35 AM and the DON was informed of IJ in the area of accidents/supervision and the IJ template was provided to him via email at 11:51 AM and a plan of removal was requested. The plan of removal was accepted on 08/06/21 at 8:32 AM and included: .PLAN OF REMOVAL Name of facility: [facility name] Date: August 4, 2021 Immediate action: Resident #2 was discharged from the facility on 7/20/21 at 5:00 PM. Resident #1 was assessed at the time of the incident without any concerns. Resident #1 was re-assessed on 8/4/21 by the Director of Nursing and found to be without distress with good food intakes and hydration per normal for the resident. Resident #1s care plan was reviewed and revised to show supervision and monitoring and communicate any changes in the plan of care prior to staff starting their shift through direct report. The C.N.A. profile will be update appropriately to reflect any changes in care. On 8/4/21 at 12:45, The nursing administrative team assessed the residents who reside on the secured unit by completing wandering assessments and supervision needs as well as changes in their usual activities of daily living. Behavior tracking logs and care plans were reviewed and revised as needed. No concerns were revealed. On 8/4/21 the Director of Nursing re-evaluated the staffing for the secured unit so that there would always be two (2) staff assigned on the schedule for the day and evening shift to give care appropriate within their scope of practice. The facility secured a contract with a nursing agency on 1/7/2021 to fulfill any needs resulting in not being able to staff the facility. If agency staff is required on the secured unit, they will receive the same training as regular facility staff, prior to working on the secured unit. There are currently no residents residing on the secured unit who require the assist of two (2) staff however if a resident becomes a two (2) person assist, they will be re-assessed by the Director of Nursing/designee for continued residency on the unit. If a resident required two (2) person assist because of illness or other situation, the staff will be instructed to ask staff outside the unit for assistance so that residents are always monitored by a staff. On 8/4/21 the Director of Nursing began a direct-staff in-service regarding the monitoring and safety of residents including sexual behaviors and re-direction of residents with aggressive behaviors using crisis prevention intervention (CPI) training utilizing a power point. The regional nurse consultant educated the Director of Nursing regarding this training. Also included in this training is the procedure for relieving staff for breaks so that the two (2) staff criteria are not broken as well as seeking assistance should a resident require a two (2) person assist. Direction was given to staff to monitor for residents wandering into another resident's room's and to re-direct following CPI training strategies. Staff will routinely round the secured unit to identify concerns and huddle at change of shift to give report on shift occurrences. If any concerns with resident behavior are identified, sexual or otherwise, the staff will separate residents and keep on 1:1 monitoring of any resident with sexual inappropriate behavior or otherwise until a sufficient intervention implemented under the direction of the Director of Nursing. The charge nurse will notify the administrator and Director of Nursing immediately for any concerns with any resident with sexual inappropriate behavior or otherwise. Any concerns with any resident with sexual inappropriate behavior or otherwise will be reviewed in the morning Clinical Meeting, behavior tracking will be updated, and plan of care reviewed and revised as needed. Nursing administration will communicate any findings to the staff on the secured unit and the Resident Profile (C.N.A. plan of care) will be updated. This training will be completed by end of day 8/5/21. Any staff not receiving this education by end of day 8/4/21 will be required to receive it before beginning their next assigned shift. Facilities Plan to ensure compliance quickly The Director of Nursing will be responsible for monitoring the daily staffing schedules to validate there are two (2) staff scheduled for the day and evening shift for the secured unit. Staffing agency will be utilized if needed to staff this unit. If staffing agency is not available, then administrative staff will assist in staffing the secured unit. The administrator/designee will bring all concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team (IDT) review . Surveyor Verification of Plan of Removal was as follows: Observation on 08/04/21 at 12:50 PM on the memory care unit revealed the facility had 2 staff on unit. Observation on 08/05/21 at 1:40 PM on the memory care unit revealed the facility had 2 staff on unit. Observation on 08/06/21 at 12:45 PM on the memory care unit revealed the facility had 3 staff on unit. Observation on 08/07/21 at 6:00 AM on the memory care unit revealed the facility had 2 staff on unit. Interviews were started on 08/06/21 at 1:07 PM and continued through 08/07/21 at 7:05 AM with 31 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff were interviewed regarding the plan of removal: MA D, CNA E, CNA F, Medical Records, LVN A, RN C, CNA G, ADON A, MDS Coordinator A, MDS Coordinator B, ADON B, CNA C, CNA H, RN A, Maintenance Director, Social Worker, CNA J, Activity Aide, RN D, Dietary Cook, Floor Tech, CNA J, DON, CNA K, Laundry Aide, PTA, CNA L, CNA M, MA D, CNA D, and Transportation. Staff were able to verbalize the plan of removal. Record review of the behavior tracking logs for memory care residents revealed no concerns with behavior monitoring. Record review of the care plans for 11 of 11 memory care residents revealed no concerns with care plan updates. Record review of the facility contracts revealed the facility had contracts with 2 staffing agencies dated 5/27/20 and 6/22/21. Record review of the facility C.N.A. profile revealed the facility updated care plans were in the kiosk for memory care residents with wandering behaviors. Record review of the facility staffing sheets dated 08/04/21, 08/05/21, 08/06/21 and 08/07/21 revealed the facility had 2 staff members assigned to the 6a-2p and 2p-10p shifts. Record review of the facility in-service sheets dated 08/04/21 revealed staff on from multiple department including (Nursing Department, Housekeeping, Activities, Dietary, Maintenance, Transportation, Business Office, Social Services, Laundry) were in-serviced on sexual inappropriate behaviors, sexual triggers, de-escalation, reporting incidents to administration immediately, 2 staff on the memory care unit, supervision on the secure unit, swapping out staff for breaks and lunch, and calling out from work on the secure unit. While the DON was informed that the Immediate Jeopardy was removed on 08/07/21 at 7:05 AM, the facility remained out of compliance at the scope of a pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to trai [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse for 5 of 10 residents (Resident #8, #9, #5,#10, #2) reviewed for abuse: The facility failed to address Resident #7's physical behaviors towards other residents, including Residents #8, #9, #5, #10. Residents #2 and #5 verbalized fear of Resident #7 due to her behaviors. These failures could place all residents at risk for abuse and mental anguish. The findings were: Resident #7 Record review of Resident #7's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] revealed she had a BIMS of 99 which meant she was unable to complete the interview. The section regarding mood revealed she had symptoms of being short-tempered, easily annoyed. The section regarding behaviors revealed she had exhibited physical and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. Resident #7 put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or living environment. Record review of Resident #7's Care Plan dated 11/06/20 revealed Resident #7 had behaviors related to [MEDICAL CONDITION] disorder, dementia with behaviors as evidenced by hitting another resident. Staff were to intervene as needed to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to another location as needed. Resident #7 exhibited purposeful overt verbal and physical aggression/combativeness in resident-to-resident settings i.e kicking other residents, verbal outbursts and threats towards staff and residents. Staff were to notify NP of concerns, administer psychiatric medications and engage resident in activities to attempt reduction of behaviors. She was previously referred to psychological and psychiatric care. Resident #7 had episodes of verbally aggressing-cursing, yelling/screaming, physically aggressive: hitting, pinching, kicking, throwing objects. Staff were to anticipate behaviors and re-direct when in close proximity of others that might invoke aggression, assess for triggers that may contribute/prompt behaviors, assess for pain, attempt to redirect resident to safe areas when increased behavior noted, administer psych medications and maintain calm environment. Record review of Resident #7's progress noted dated 10/30/20 revealed .Patient arrived to facility via transportation van at (1:00pm). Patient arrived in wheelchair. Patient yelled at staff, combative and aggressive. Patient called staff [***] es. Patient wheeled into bedroom. Patient ambulating with walker in bedroom, throwing things around bedroom, patient threw raised toilet seat into other resident's bedroom. Patient continues to yell and be combative with staff. NP here, reports to administer PRN IM [MEDICATION NAME] to patient. [MEDICATION NAME] administered to patient. Patient currently in bedroom asleep on bed . Record review of Resident #7's progress noted dated 11/01/20 revealed . (7:00am) Resident refused to stay in room. Was ambulating through hallways. Redirected with little to no success, was combative during times. (7:30am) Resident ended up on station 2 while staff doing rounds. She was then witnessed to hit another resident in the face. Resident cursing and swinging at staff. Resident taken to room . explained that behavior was unacceptable. PRN [MEDICATION NAME] administered with no effect on behavior. NP notified, no new orders, stated to call DON and ask for transfer. DON called. Will monitor until placement can be arranged do to behaviors. During 6-2 shift resident threw out all items from room. Cursed at staff anytime someone approached her. Continues to call staff [***] es Redirection unsuccessful. Resident was kicking window with feet, no injuries noted. Will continue to monitor . Record review of Resident #7's progress noted dated 11/10/20 at 9:40 PM revealed .Patient verbally aggressive and throwing things at staff attempted to redirect with no improvement. Did not take medications this evening. Patient was redirected to room and was administered [MEDICATION NAME] injection patient then remained in room and began throwing things into hallway Record review of Resident #7's progress noted dated 11/10/20 at 2:16 PM revealed . Resident aggressive and verbally abuse towards staff and residents. Redirected several times without success. PRN [MEDICATION NAME] administered. Will continue to monitor . Record review of witness statement dated 11/10/20 revealed I had just returned from lunch and was approaching Station I nursing station when Resident #7 rammed her rollator walker into Resident #10's walker causing her coffee to spill on her walker and on the floor. Resident #11 was walking behind when this occurred it caused her to lose her balance and I caught her stumble. I spoke to Resident #10 and told her she needed to wait for other residents to pass and clear the walk way . Record review of Resident #7's progress noted dated 11/11/20 revealed .Resident visibly agitated and aggressive this shift throwing items in hallway, knocking over plants, tables and chairs. Shouting at staff and another resident in hallway. Multiple attempts to calm resident were unsuccessful. NP and DON agreed sending resident to geri psych unit for evaluation may be helpful. Nurse called for EMS transfer, resident refused to go to hospital, EMS personnel stated they could not take her against her will . Record review of Resident #7's progress noted dated 11/12/20 revealed .Resident sitting in (dining room) on station 2, hollering at staff and cursing and called staff names. Resident threw a pitcher of ice water at staff. DON aware . Record review of Resident #7's progress noted dated 11/15/20 revealed .resident at station 2 dining room throwing her walker across the room, yelling, continues moving furniture, resident attempted to go out exit door of dining room, when asked to come back in, screamed then get out of the way Record review of Resident #7's progress noted dated 11/17/20 revealed . Staff was assisting another patient in a w/c when this patient walked by with a walker and rammed the walker into the other patient's knees and stated Get out of the way. Patient then walked to her room and grabbed a trash can lid and threw it into an empty room. Staff attempted to redirect this patient with no success. ADON notified . Observation and attempted interview on 11/19/20 at 1:25 PM revealed Resident #7 was sitting in the dining room. Resident did not answer questions but blankly starred into space. Resident started yelling at nursing staff and other residents sitting at another table in dining room playing games. Resident #7 was yelling and cursing sit down [***] . Observation on 11/19/20 at 1:33 PM revealed Resident #7 was sitting in the dining room cursing and yelling at residents. Observation on 11/19/20 at 1:49 PM revealed Resident #7 was walking down the hallway with her walker. Facility staff were asking Resident to sit in her wheelchair. She was yelling and cursing at staff. Record review of Resident #7's progress noted dated 11/19/20 revealed .Resident had been verbally abuse (sic) to staff and residents today, cursing, calling racial slurs to staff members and residents. She had been physically abuse (sic) as well, throwing tables, her breakfast and lunch tray on the floor. She did mention she was hungry, offered her another grilled cheese sandwich or a ham and cheese sandwich she refused stated I don't care for grilled cheese and the ham and cheese is dry. Several staff members attempted to calm her down but attempts were unsuccessful, any residents that were in the vicinity were moved elsewhere for their safety . Resident #8 Record review of Resident #8's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS dated [DATE] revealed she had a BIMS of 5, indicating severe cognitive impairment. Record review of Resident #8's progress notes dated 11/01/20 at 9:30 AM revealed This morning at (7:30am) patient was hit in the face by another resident, the event was witnessed. RN assessed patient, patient had redness and a small amount of inflammation to face, no bruising noted. Patient reports she has pain all over face, not able to point to a specific area on face. RN administered PRN Tylenol to patient. Patient reports glasses are crooked, not fitting her properly. Doctor notified .2 view x-ray to right and left facial bones portable due to wheel chair bound .Filled out appointment sheet for transportation director for patient to have an eye doctor appointment this week. RN started 72 hour neuro V/S sheet. Patient's RP has been notified . Record review of Resident #8's Incident Report dated 11/01/20 revealed . patient was hit in the face by another resident .No injuries noted, patient complains of pain to whole face .RN completed head to toe skin assessment on patient, redness to face/no bruises/injuries noted. Resident was taken to Station 1, Quarantine Hallway . Staff is not letting patient come out of room Observation and interview on 11/19/20 at 1:17 PM revealed Resident #8 was lying in bed, resident stated she was slapped by Resident #7 and it broke her glasses. She said the facility stated they were going to get her some new glasses. She said the slap really hurt her, she was in the dining room at the time and everyone saw her get slapped. Resident #7 just walked up and slapped her for no reason. Resident #9 Record review of Resident #9's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's MDS dated [DATE] revealed she had a BIMS of 10, indicating moderate cognitive impairment. In an interview on 11/19/20 at 2:13 PM LVN #2 stated Resident #9 was going to have a visitor so she was sitting in the hallway. She said Resident #7 was coming around and rammed into her with the walker and said get out the way. She tried to redirect Resident #7 but she is hard to redirect. Resident #7 then picked up a lid on a trash can and threw it into one of the empty rooms. Resident #9 did not have any injuries and did not complain of pain. Observation and interview on 11/19/20 at 2:24 PM revealed Resident #9 was lying in bed, resident showed no signs of distress, resident did not remember incident and could not explain the incident involving Resident #7. Resident #10 Record review of Resident #10's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #10's MDS dated [DATE] revealed she had a BIMS of 11, indicating moderate cognitive impairment. Observation and interview on 11/19/20 at 2:00 PM revealed Resident #10 was sitting in a wheelchair in the dining room playing dominoes. Resident #10 stated Resident #7 was dangerous and the facility had to rearrange the dining room area. She said Resident #7 threw books, hit and yelled at other people and it was pretty bad. In an interview on 11/19/20 at 2:27 PM the PTA stated she was coming from lunch, when she saw Resident #7 rammed Resident #10's walker with her walker on 11/10/20. Resident #10 had her coffee on the walker, Resident #10 lost her balance and bumped into Resident #11. She grabbed Resident #11 to prevent her from falling. Resident #7 was insisting to get by all the residents. She was trying to redirect Resident #7 to wait. The PTA got the residents moved out of the way, got towels to clean up the coffee on the floor. She made sure residents were okay, they were headed down to a physician's appointment. She said the other residents were scared and Resident #7 was a danger to some of the residents because they could not protect themselves. She said the facility could not find a place for her to go. Resident #5 Record review of Resident #5's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed she had a BIMS of 13, indicating moderate cognitive impairment. Observation and interview on 11/19/20 at 11:47 AM revealed Resident #5 was sitting in a wheelchair. She stated Resident #7 had a room down the hallway from her and she was mean. Resident #7 would curse at residents, throw things at residents and would yell and scream. She would also throw books. Resident stated she was scared of Resident #7. Resident #7 told her she was a long haired [***] . She was concerned about what the Resident #7 could do at night. Resident #2 Record review of Resident #2's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed she had a BIMS of 11, indicating moderate cognitive impairment. Observation and interview on 11/19/20 at 11:38 AM revealed Resident #2 was sitting in recliner chair. She said Resident #7's room was down the hallway. She said Resident #7 and was crazy. Resident #7 would throw things and curse at people. She was unpredictable. She was scared of Resident #7 and did not want her near her room. In an interview on 11/19/20 at 12:30 PM CNA #1 stated Resident #7, hit a resident. She said today, Resident #7 took her meal tray and flipped it over in the dining room. The residents were scared of Resident #7. She said she stood in the hallway to protect the other residents from Resident #7. She said Resident #7 was mean and called Resident #5 a long haired [***] . In an interview on 11/19/20 at 1:19 PM, Housekeeper #1 stated Resident #7 was a danger to the other residents. She said she was aggressive, Resident #7 threw her tray today and turned over the table. She said she has hit other residents and she had to get in between her and other residents in the past. She said the facility just wanted them to let her do what she wanted. Resident #7 slapped Resident #8 in the face before and broke her glasses. She had hit other residents in the past. In an interview on 11/19/20 at 1:20 PM the Maintenance Director stated Resident #7 was a danger to the other residents at the facility, and she was not fit for this type of facility. In an interview on 11/19/20 at 1:26 PM the MDS Nurse stated Resident #7 had episodes of agitation. She said facility staff try not to agitate her more. Resident #7 got more agitated when staff try to calm her down. Staff try to get residents out of the way for safety purposes and let her cool down and try and reengage with her. In an interview on 11/19/20 at 1:30 PM LVN #1 stated Resident #7 was partial blind in one eye and was hard of hearing. She would type a message on her phone and let her read it to see if she needed anything. She was not here when Resident #7 slapped Resident #8 and hit another resident with the walker, but she heard about the incidents. In an interview on 11/19/20 at 2:13 PM LVN #2 stated Resident #9 was going to have a visitor so she was sitting in the hallway. She said Resident #7 was coming around and rammed into her with the walker and said get out the way. She tried to redirect Resident #7 but she was hard to redirect. Resident #7 then picked up a lid on a trash can and threw it into one of the empty rooms. Resident #9 did not have any injuries and did not complain of pain. In an interview on 11/19/20 at 2:20 PM ADON #1 stated Resident #7 hit Resident #9 with a walker on 11/10/20 but Resident #7 did not hit the resident she just hit the resident's walker. ADON#1 was not aware of the incident on 11/17/20 when she hit Resident #9 with a walker. Resident #7 was sent to the psychiatric hospital before but she came back the same way when she left. Psychiatric Services was coming to see Resident #7 at the facility. All she had was a witness statement by the staff on the incident for 11/10/20. No incident report for the incident on 11/17/20. At this time, surveyor requested Resident #7's psychiatric services notes, but they were not provided by the time of exit. In an interview on 11/19/20 at 2:45 PM ADON #2 stated the facility sent Resident #7 to the psychiatric hospital for a while and she had a fall there which fracture her hip. She was sent to another facility and then they sent her back. Since being back, Resident #7 had been very aggressive, the facility already sent out paperwork to multiple facilities. The facility tried to get her to different places, but no one would accept her, she had been denied. The facility called the police to see if they could do anything, but they could not do anything for the facility. Resident #7 did not have family around here. Some days she was fine other days she was not, like today. She said Resident #7 was hard of hearing, so she was very loud. The resident was being seen by psychiatric services. She said when a resident hit another resident, the staff were supposed to do a head to toe assessment, ask the patient's what happened, then do a follow up on the incident, notify the physician, notify the family, and complete incident report. She was not here when Resident #7 slapped Resident #8 and broke her glasses. She was not here when Resident #7 hit Resident #9 with a walker. Resident #7 had PRN [MEDICATION NAME] that they use at times, try to get her to calm down. She said Resident #7 did not like crowds. She starts cursing more, try to tell aides that work to limit crowds, pull everyone away from her. She will knock over tables and chairs. Sometimes the DON can calm her down a bit, she likes her a lot, sometimes she will take snacks, she will eat snack and be fine, other times they give her [MEDICATION NAME] sometimes it works sometimes it does not. In an interview on 11/19/20 at 3:07 PM LVN #2 stated she got busy and did not do the incident report on 11/17/20, she will make sure a report gets completed today. In an interview on 12/04/20 at 11:15 AM the NP stated Resident #7 was being seen by psychiatric services and she had multiple adjustments to her medications. Resident #7 was very suspicions and does not take her medications. She said Resident #7 was finally being transferred because she needed better placement, she was admitted to the psychiatric hospital several times. She had an order for [REDACTED].>In an interview on 12/04/20 at 11:35 AM the Social Worker stated Resident #7 was being transferred today. Not sure the time but sometime after lunch. She was being moved to an Assisted Living Facility . Resident #7 was admitted to the facility in March. Before she was admitted the facility was not informed of her behaviors. The facility was told Resident#7 had moments of bad behavior. She was admitted to the facility from the psychiatric hospital. Initially she was placed in the secure unit. Because of the amount of residents in the secure unit at the time she was moved to the regular unit. The facility was concerned and wanted her to be around residents that could verbalize any issues. The residents on the secure unit would trigger her behaviors and could not verbalized if she hit them or what was going on. Resident #7 was transferred to the psychiatric hospital multiple times. Sometimes she would be gone for a month before returning. The facility had to call the policy and get a detainment order to have her sent to the psych hospital due to her behaviors. Resident #7's Medicare days ran out and it was hard to get her into the psychiatric hospital. The Social Worker tried to get the local mental health authority involved but she did not have any luck. They said the nursing home was not equipped to deal with these things. She tried to get Resident #7 admitted to a mental health hospital, state hospital, state supported living center but was denied due to her [DIAGNOSES REDACTED]. Yesterday they finally got an acceptance from a personal care home. In an interview on 12/04/20 at 12:55PM the Administrator and ADON #2 stated the facility was trying to find placement for Resident #7, they had documentation of all the facilities they attempted to refer her to in her chart. The DON, Social Worker, and Administrator called 40 places and sent clinicals but denied. The facility would call the police for help, she exhausted all her Medicare days, and the facility could not send her to the psychiatric hospital. She never had this much trouble trying to get a resident transferred out of the building. The facility sent a 30-day discharge notice as well to her responsible party. That was a couple of weeks ago. When Resident #7 would start having behaviors staff kept her away from others, watched her constantly, monitoring her, contact the NP, and keep the residents away from her. In an interview on 12/04/20 at 2:30 PM ADON #2 stated Resident#7 was transported to her new facility. Record review of clinical records revealed Resident #7 did not have an incident report for the dates of 11/17/20 and 11/10/20. Record review of the facility policy Abuse and Neglect - Clinical Protocol dated 04/2013 revealed Cause Identification 1. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes .Treatment/Management .1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 12 Residents (Resident #7) reviewed for infection control in that: -The facility failed to inform LVN F of her positive COVID test results resulting in her coming to work and going to the negative unit to work. -The facility failed to ensure COVID positive staff worked only with COVID positive residents and had no exposure to negative residents or staff. -LVN F administered insulin to Resident #7 inside the Resident's room on 7/8/2020 wearing only an N95 mask and no additional PPE. -The facility failed to ensure staff donned all PPE. Staff were obeserved not wearing eye protection. An immediate jeopardy was identified on 7/11/20. While the IJ was lowered on 7/14/20, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all Residents at risk for exposure to an infectious disease. Findings include: Record review of Resident #7's clinical record revealed a 79- year -old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 7's MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 10 out of 15 indicating moderately impaired cognition. She was extensively dependent for bed mobility, transfer, dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident # 7's undated comprehensive care plan read in part: .Resident #7 is at risk for frequent infections . related to diabetes mellitus . Interventions included but were not limited to, .obtain and monitor lab/ diagnostic work as ordered . Record review of Resident #7's Physician orders [REDACTED]. Observation on 6/30/2020 at 9:35 a.m. revealed the VPRT Testing task force conducting blanket testing for all Residents and facility staff. LVN F and Resident were both included in testing on 6/30/2020. Record review of the testing results with the Administrator and Interim DON on 7/9/2020 revealed Resident #7's negative test results were provided on 7/7/2020. Further review of the testing results revealed LVN F's positive result was provided on 7/7/2020. Record review of electronic surveillance snapshots of Resident #7's room revealed on 7/8/2020 at 6:49 a.m. LVN F was observed approaching Resident #7 with what appeared to be a syringe in her right hand. Further review of the electronic surveillance snapshots of Resident #7's room on 7/8/2020 at 6:49 a.m. revealed LVN F at Resident#7's bedside performing care. LVN F was wearing an N95 respirator and no other PPE. During a telephone interview with LVN F on 7/9/20 at 1:07 p.m. she confirmed she last worked at the facility on 7/8/2020. She said she was assigned to Station 1. When asked did she work on Station 2, she initially said she, .answered the call light. When asked did she give insulin to Resident #7, she said she did give insulin to Resident #7, then was moved from Station 2 over to Station 1. She said she was not initially assigned to Station 1 but was moved there because she tested positive for COVID-19 on 7/7/2020. She said after she was moved the facility in-serviced her on infection control procedures regarding COVID-19. She said she usually worked on Station 2 and normally she viewed her unit assignment when she arrived for her shift. She said when she arrived for her shift on 7/8/2020 her usual assignment was posted which indicated she was to remain on Station 2. She said she was informed of her positive result the day she arrived for her shift. Record review of CDC.gov website June 2020 read in part, .Contingency capacity strategies for healthcare facilities include: Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities. Developing plans to allow asymptomatic HCP who have had an unprotected exposure to [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19) but are not known to be infected to continue to work. -These HCP should still report temperature and absence of symptoms each day before starting work. These HCP should wear a facemask (for source control) while at work for 14 days (this is the time period during which exposed HCP might develop symptoms, i.e., the current incubation period for [MEDICAL CONDITION]) after the exposure event. A facemask instead of a cloth face covering should be used by these HCP for source control during this time period while in the facility. After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic . .If HCP are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria Prioritizing HCP with suspected COVID-19 for testing, as testing results will impact when they may return to work and for which patients they might be permitted to provide care. Developing criteria to determine which HCP with suspected or confirmed COVID-19 (who are well enough to work) could return to work in a healthcare setting before meeting all Return to Work Criteria-if shortages continue despite other mitigation strategies. -Considerations include: The type of HCP shortages that need to be addressed. Where HCP are in the course of their illness (e.g., [MEDICAL CONDITION] shedding appears to be higher earlier in the course of illness). The types of symptoms they are experiencing (e.g., persistent fever). Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment? The type of patients they care for (e.g., immunocompromised patients). -As part of planning, healthcare facilities (in collaboration with risk management) should create messaging for patients and HCP about actions that will be taken to protect them from exposure to [DIAGNOSES REDACTED]-CoV-2 if HCP with suspected or confirmed COVID-19 are allowed to work. .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: · Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. ?If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. .· Eye Protection-Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. ·Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. .· Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. During an interview with the Administrator and Interim DON on 7/9/2020 at 10:10 a.m. the Administrator confirmed LVN F was tested for COVID-19 on 6/30/20 and the results from 7/7/2020 revealed she was positive. She said yesterday she was not sure what occurred but according to reports the nurse looked at somebody. When asked to explain, she said LVN F entered the room of Resident #7 to check on her and we (indicating the facility) saw and immediately conducted an in-service. the Administrator said staff could view their schedule via phone or they could view a paper copy that was posted daily by the DON's office. The Interim DON said LVN F was on the schedule for Station 1 but, she entered the room to check on Resident # 7 and facility management saw her when she exited and immediately conducted an in-service. The Interim DON said she had called LVN F on 7/8/20, after becoming aware LVN F was working with negative residents, to inform LVN F she could not be on Station 2 (the negative Station). The Administrator said LVN F should have known not to go and work with a non-COVID patient. The Administrator said she was not sure sure if LVN F was instructed to do so but she should not have worked with Resident #7. The Administrator said she assigned MA B to notify staff of positive results and said she should have followed up with MA B on whether she was able to reach the staff. During an interview with LVN A on 7/9/20 at 10:28 a.m., when asked if she knew of any COVID positive staff who had worked with COVID negative residents at the facility, she said she knows one. She said LVN F was working with a negative resident on 7/8/20. She said the facility reportedly explained a positive staff with no symptoms could work with a negative resident. Record review of Resident #7's Treatment Administration Record for July 2020 revealed the medication Humalog U-100 (insulin [MEDICATION NAME]) 100 unit/ml, 15 units subcutaneous three times per day was given on 07/08/20 at 8:00 a.m. by LVN F. Further review of the TAR revealed LVN F documented Resident #7's oxygen saturation as 93% and completed a pain evaluation documenting a pain level of 0 out of 10. In a later interview on 7/9/2020 at 11:20 a.m. the Administrator said she did not know LVN F gave insulin to Resident #7. She said after speaking with the Interim DON she was informed that LVN F went to Station 2, which was classified as a general care unit or non-COVID /non-quarantine unit. When asked did the Department of State Health Services approve COVID Positive staff to work with COVID negative residents she said, No. She said DSHS informed her that staff who tested positive for COVID-19 and were asymptomatic were approved to work with positive COVID residents. Record review of the DSHS On Site visit report, dated 7/9/2020 read in part: .It was agreed that all staff in the building would be in-serviced and would wear N95 mask and face protection at all times within the facility. As it was observed that some staff were not wearing their face mask correctly . During a phone interview with the Administrator on 7/10/2020 at 9:43 a.m. she said she assigned the van driver (MA B) to contact positive staff members to inform them of their results of their COVID positive tests on 7/7/20. She said the NF was unable to contact LVN F because the phone number provided was disconnected. When asked did she attempt to use the alternative phone number provided, the Administrator said, she would have to check on that. During a follow-up telephone interview with LVN F on 7/10/2020 at 10:06 AM she said she was informed the van driver was calling positive staff on the evening of July 7, 2020. She said she called the facility on Tuesday to check if she was scheduled to work on Tuesday. She said she was informed she was not on the schedule. She said no one from the facility contacted her on July 7, 2020 to inform her she was positive for COVID-19. During an interview with MA B on 7/14/2020 at 11:45 a.m. she said she was instructed by the Administrator to contact positive staff and inform them of their positive results on 7/7/2020. She said when she called LVN F, she did not get an answer. She said she was able to contact LVN F via the alternative phone number provided. She said she reported LVN F's positive test result and LVN F said, Ok. Interview with the Interim DON on 7/12/2020 at 12:25 p.m. revealed on 7/11/2020 Resident #7 began running a temp. She said the NF collected a sample and sent the sample through Fed Ex and the result should be available approximately on Wednesday or Thursday. She said since exposure to the positive staff the NF had been monitoring her through the nurse's progress notes but not utilizing the NF COVID- 19 observation form. She said the NF would begin using the COVID- 19 observation form. During interview with the Interim DON on 7/9/2020 at 11:53 a.m. she said nursing staff, including the charge nurses or unit managers should be monitoring if staff are wearing PPE properly. She said staff had been trained on 7/8/2020 on how to properly don and doff PPE. She said all staff should be wearing N95 mask and goggles or face shields. Observation on 7/11/2020 at 11:38 am revealed Dietary Aide D on Station 3 without goggles or face shield on. She said she left them in her work area. She said she was supposed to have them on secondary to the NF instructing her to wear mask, goggles and disposable gown at all times while inside the NF. Observation on 7/11/2020 at 11:45 am revealed MA P on Station 2, the COVID positive station, did not have a face shield or goggles on. She said her face shield was located in the trash can because it broke and the goggles were in her locker. She was able to verbalize the purpose of PPE which was to prevent cross contamination. She confirmed the NF had instructed her to wear appropriate PPE, N95, goggles/face shield, and gown, at all times while in the NF. Record review of the NF policy on COVID Infection Control, undated, read in part, .Positive workers can only work with positive residents until management tells you otherwise. You must enter in through C hall . The above failures resulted in an Immediate Jeopardy (IJ). The Interim DON, Vice President of the South Region, and Regional Nurse Consultant were notified of the IJ on 7/11/20 and a plan of removal (POR) was requested at that time. The IJ template was emailed to the Regional Nurse Consultant and Interim DON. After revisions, the POR was accepted on 7/12/2020 at 11:11 a.m. The POR read in part: Immediate Action o On 7/11/20, the Interim Director of Nursing re-educated Nurse F on the facility policy allowing only positive asymptomatic employees to care for positive residents. Also included in the in-service was the re-education regarding appropriate PPE to be worn when caring for residents residing in the facility, and that residents need to be wearing a mask when an employee enters their room and/or assisting the resident to put their mask on. Staff will wear goggles and face shield when a resident is unable to tolerate wearing a face mask or refuses. o On 7/11/20, the Interim Director of Nursing re-educated the facility nursing staff on only positive staff caring for positive Residents only. Also included was education regarding appropriate PPE to be worn when caring for residents residing in the facility, and the residents needing to wear a mask when an employee enters their room. o Resident #7 was swabbed for Covid-19 on 7/11/20 and the sample sent to the contracted laboratory for testing. The resident had normal vitals and the facility completes a temperature check every shift. The resident at this time is showing no signs or symptoms of Covid-19 or any other change in condition. o All residents are monitored every shift for temperature changes and/or significant change of condition. No new symptomatic residents have been identified since 7/8/2020. o Nursing staff were re-educated on 7/8/20 by the Director of Nursing. Staff not receiving this education will receive it before starting their next assigned shift. o The facility has a contract with Provenir Temporary Staffing and they are solicited for staff whenever needs arise and one staff (C.N.A.) is starting on 7/13/20. Other requests for staffing agency have not been filled. The facility has requested State assistance but have not heard back regarding this request. Asymptomatic positive employees are used as a last resort only and will only work with positive residents. This model is a short-term solution and the facility regularly runs ads for long-term permanent staff including sign-on bonus'. o Covid and Quarantine units are identified by a sign stating Isolation for Covid. Continued Compliance 1. The Director of Nursing/Designee will monitor the facility for compliance with staffing and positive employee placement within the facility (only on positive halls) and to validate that staff are always donning appropriate PPE as well as residents wearing masks when employees enter their room. Monitoring will occur daily for the next seven (7) days and randomly thereafter. Any concerns will be corrected immediately and reported to the administrator. 2. Every day until there are no more positive employees, the Director of Nursing/Designee, will call the positive employee to remind them that they are only working on the Covid unit and are not to help or go onto any other unit. They will enter and exit through a back door exit off the Covid unit. Following acceptance of the facility's Plan of Removal, the facility was monitored from 7/12/2020 to 7/14/2020. Observation of Station 3 on 7/12/2020 at 11:43 a.m. revealed staff wearing PPE appropriately. Observation of the designated COVID room on Station 3 revealed the facility had implemented their plan of removal. Interview with CNA T on 7/12/2020, at 11:48 am with CNA T revealed this was her first day back from some time off. She said she had been trained on the different units and how to manage care. She was able to describe the proper PPE application and removal. She was knowledgeable in monitoring for signs and symptoms of COVID and how to report any changes. She said COVID positive staff are restricted from working with COVID negative Residents. Observation of Station 2 on 7/12/2020 at 11:52 a.m. revealed MA P had all required PPE applied correctly. Record review of the staffing assignment for all stations revealed the NF the components of the POR related to positive staff caring for positive Residents only, were in place. Observation and interview of Resident #7 on 7/13/2020 at 3:30 p.m. revealed a PPE station located outside the room. A sign was noted on the door which revealed Resident #7's room was now identified as a quarantine room. The Interim DON was present during the observation and informed this surveyor Resident #7 started to have a temperature on 7/12/2020. She said the roommate was moved to another room and was being monitored but had not had a temperature. The Interim DON said Resident #7 was tested but the results would not be available until approximately Thursday, 7/16/2020. Observation on 7/14/2020 at 9:59 a.m. revealed staff had PPE applied appropriately. Interview with LVN G on 7/14/2020 at 10:08 a.m. revealed nursing staff had received updated training. She said since the revised training nurses were required to apply new PPE between residents and doff between residents. She said she had only been working on station 2 or, the negative unit. She said she was tested for COVID on 6/30/20 and her results were negative. Interview with MA Z on 7/14/2020 at 10:04 am she staff were no longer allowed to work multiple areas of the facility. She said wherever the staff was assigned they were to remain. She said she was tested both times on 5/21/2020 and 6/30/2020 via the blanket testing and her results were negative. She said if staff test positive and do not have symptoms they are only allowed to work with COVID positive residents. In an interview on 7/14/2020 at 10:13 a.m. with the Interim DON and the Regional Nurse, they said all of the components of the POR were in place. During interview with the Interim DON, Regional Nurse Consultant, and the Administrator, on 7/13/2020 at 3:54 p.m. this surveyor asked how they thought the IJ occurred. The Administrator said LVN F was positive and the NF allowed the nurse to work with Resident identified as negative for COVID. The Interim DON said, We dropped the ball, the nurse should have been informed of her test results prior to beginning her shift. The Regional Nurse Consultant said LVN F knew she was positive. She said since the IJ, the NF had called staff to remind them of the NF policy. A more definitive answer was not provided. The COO, Interim DON, and Regional Nurse Consultant were informed on 7/14/2020 at 10:48 a.m. that the IJ was lowered; however, the facility remained out of compliance at a scope of pattern level and a severity of actual harm due to the facility needing more time to monitor their plan of removal.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment including the use of PPE and following CDC guidelines for COVID-19 for 7 of 8 residents (Resident #1, #2, #3, #4, #5, #6 and #7) reviewed for infection control. -The facility failed to ensure staff providing care to both quarantined and non-quarantined residents used appropriate PPE. -The facility failed to ensure staff caring for readmitted residents on the quarantined skilled unit wore appropriate PPE while caring for a resident who required suctioning. -The facility failed to issue N95s respirators, face shields or goggles to staff caring for quarantined residents. -The facility failed to place Residents #4 and #7 that refused the COVID-19 testing on quarantine. The residents were on the Memory Care Unit. -The facility did not implement interventions to prevent the potential spread of COVID 19. An Immediate Jeopardy (IJ) was identified on 5/28/2020. While the IJ was removed on 5/31/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern while they continued to monitor their plan of removal. These failures placed all residents at risk of contracting an infectious disease resulting in possible serious illness. Findings Include: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year old female admitted to the NF on 05/20/20 and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Record review of Resident # 1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 1 out of 15 indicating severely impaired cognition. Further review revealed that Resident #1 required extensive assistance with bed mobility, transfer, eating, toilet use, personal hygiene, and total assistance with dressing. Resident #1's range of motion was impaired on one side of the upper extremity and both sides of the lower extremities. Resident #1 was always incontinent of bowel and bladder. Record review of Resident #1's Physician orders [REDACTED]. Further review of physician orders [REDACTED]. Record review of Resident #1's TAR for May 2020 revealed Resident #1 was suctioned as needed orally twice on 05/25/20. Record review of Resident #1's nursing progress notes dated 04/29/20 at 2:54 p.m. documented by LVN-A read in part: .at approximately 12:45 p.m. CNA yelled out in hallway for help for nurse .resident eyes watering, red face and seemed to be attempting to cough. CNA stated resident took a bite of food and started choking on it. [MEDICATION NAME] maneuver and suction resident. Resident turning blue in color. Multiple thrust performed and suctioning. Resident started coughing and talking .Resident normal color returned .approximately at 1:30 pm called the NP new orders for CXR 2 vie stat, CT of head without contrast, labs, if any changes in baseline send to ER, oxygen at 2 liters as needed .at 3:26 p.m. resident transfer to hospital for stat procedures . Record review of Resident #1's nursing progress notes dated 04/29/20 at 6:47 p.m. documented by RN-P revealed the following: .Called NP to report that nurse was slowly feeding resident, but resident was frequently coughing/being suctioned after each bite .resident on oxygen at 2 liters nasal cannula .oxygen saturation between 88-91%. NP reported to send resident to ER for irregular lab work .resident was taken to hospital by EMS at 6:40 p.m. Record review of Resident #1's nursing progress notes dated 05/22/20 at 4:35 pm documented by RN-M read in part: .Patient returned to facility by ambulance via stretcher by two attendants. V/S 98.8, 20, 98% O2 at 3 liter via nasal cannula .awake, alert, oriented to self, unable to make needs known . Record review of Resident #1's nursing notes dated 05/24/20 documented at 1:37 p.m. by LVN-A read in part: .at 10:50 a.m. nurse went into room resident gargling, skin pale grayish color and clammy. Nurse began to suction resident noted to be in respiratory distress v/s 101.6, [PHONE NUMBER]/101-24-SPO2 at 78% 4 liters nasal cannula oxygen non-rebreather mask at 10 liter and continued to suction intermittently .EMS called at approximately 11 a.m .continues to suction intermittently .MD notified of condition .resident left facility at 11:20 a.m . Record review of Resident #1's care plan dated 05/26/20 revealed Resident #1 required quarantine/isolation due to entry from outside facility to reduce the risk of possible spread of COVID-19. Interview on 05/26/20 at 9:45 a.m. the DON said Resident #1 went to the hospital over the weekend due to low SPO2 and increase in temperature. The DON said Resident #1 came back to the NF the same day. The DON said Resident #1 had pneumonia. Observation on 05/26/20 at 10:43 a.m. revealed Resident #1 resting in bed quietly with eyes closed wearing oxygen nasal cannula. Further observation was made of a suction canister set-up on the left side of resident bed with clear secretions inside. Further observation was made of the PPE bin and there were no N95s or face shields or goggles. Interview on 05/26/20 at 10:43 a.m. with LVN-A said the nursing staff was using cloth hospital gowns in case the NF had a positive COVID-19, so they were not using disposable isolation gowns. Observation on 05/26/20 at 11:45 a.m. revealed a staff member was wheeling Resident #1 down hallway and the resident was wearing a mask. The staff member said they were taking Resident #1 to be weighed on another hall. Further observation was made of CNA-T placing on gloves , hospital gown, and wearing a cloth facemask entering Resident #1's room without sanitizing hands. Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: · Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. *When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program. · Eye Protection *Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Gloves -Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. · Gowns -Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: *aerosol generating procedures *care activities where splashes and sprays are anticipated *high-contact patient care activities that provide opportunities for transfer of pathogens to the *hands and clothing of HCP. Examples include: *dressing *bathing/showering *transferring *providing hygiene *changing linens *changing briefs or assisting with toileting *device care or use *wound care Additional strategies for optimizing supply of gowns are available. · Facilities should work with their health department and healthcare coalition to address shortages of PPE. 3. Patient Placement · For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization . If hospitalization is not medically necessary, home care is preferable if the individual ' s situation allows. · If admitted , place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section) · As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Interview on 05/26/20 at 11:55 a.m. with CNA-T said she had been working at the NF since February of 2020 and had been in-serviced on isolation precautions, donning and removing of PPE, hand hygiene. CNA-T said she wears a cloth mask that she got outside of the facility whom a lady made for her. CNA-T said she was working with the residents on station 1 that were in quarantine and had never been issued an N-95 mask. CNA-T said she did not have a designated hall that she worked on. Record review of CDC.gov webstie read in part: .HCP use of homemade masks: In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Interview on 05/26/20 at 12:25 p.m. with the DON said she was against accepting new admissions because the NF did not know their true status for COVID-19 and the NF had a shortage of PPE (N-95s and face shields). The DON said staff who were taking care of residents on quarantine should be wearing the N-95 mask and face shield. She was aware the staff were wearing cloth masks but was instructed by Corporate that they were not to use N95s until they had a positive case. The DON said Resident #1 missed the test for COVID-19 due to being at the hospital. The DON said she had asked the hospital to test Resident #1 for the COVID-19 before discharging resident back to the NF, the hospital declined. Telephone Interview on 05/26/20 at 3:10 p.m. with (CN) Corporate Nurse said her role in assisting the NF in relation to COVID-19 was to guide and monitor the NF by staying abreast with the guidelines given by various agencies such as HHSC, DSHS, CMS, etc. The Corporate Nurse said she instructed the NF to use the following PPE, disposable gowns, gloves, surgical mask when caring for residents on isolation or quarantine. The Corporate Nurse said she instructed the NF staff to only use the N-95 mask if the NF had a known positive COVID-19 resident. The Corporate Nurse said the staff should be wearing the N-95 mask, goggles, and face shield for residents with a cough, requiring aerosol treatments that could produce a cough, and suctioning. The Corporte Nurse said the NF staff were instructed to conserve PPE for positive cases of COVID-19. The Corporate Nurse said she did not know how much PPE the NF had. The Corporate Nurse said she would have to call the NF to get their inventory on PPE. Record review of CDC website cdc.gov read in part, .PRIORITIES FOR COVID-19 TESTING (Nucleic Acid or [MEDICATION NAME]) High Priority hospitalized patients with symptoms Healthcare facility workers, workers in congregate living settings, and first responders with symptoms Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms Priority Persons with symptoms of potential COVID-19 infection, including: fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat. Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans. Resident #2 Record review of Resident #2's face sheet revealed an [AGE] year old female admitted to the NF on 05/18/20 with the following diagnoses; [MEDICAL CONDITION], muscle weakness and atrophy, right humerus fracture, and intestinal obstruction. Interview on 05/26/20 at 9:55 a.m. with LVN-A on station 1 said there were five residents on station 1 that were on quarantine (in private rooms). LVN-A said four of the residents on quarantine were readmits from the hospital, and the other resident that was on quarantine refused to be tested for COVID-19 on the day of testing. LVN-A said the NF did not have designated staff for each station or hall, (indicating the facility used the same staff to care for both those on quarantine and those not on quarantine). LVN-A said the type of PPE being used in the NF to care for residents on quarantine were the following; gloves, surgical mask, and hospital gowns. LVN-A said the NF said they would give the nursing staff an N-95 mask if the NF had a positive COVID-19. Observation on 05/26/20 at 10:47 a.m. revealed Resident #2 on station 1 who was a new admit was sitting up in her wheelchair in her room dressed in street clothing with eyes closed wearing a surgical mask. A hospital gown was hanging on the outside of resident door. Record review of Resident #2 MDS assessment dated [DATE] revealed a BIMS score of 12 out 15 (cognition level intact). Further record review of Resident #2 functional status revealed that resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision with eating. resident # 2 had impairment on one side of the upper extremity. Further review revealed that Resident #2 was frequently incontinent of bowel and bladder. Record review of Resident # 2 Comprehensive Care Plan revised 05/20/20 revealed that resident was being care planned for at risk for COVID-19 infection due to non-compliance with wearing a facemask when out of room and/or hand washing or using alcohol-based hand rub. Interview on 05/26/20 at 12:00 p.m. with RN-Z said she was in-serviced to don the following PPE when providing care for residents on quarantine; surgical or cloth mask, gloves. RN-Z said residents on quarantine that needed to be weighed, take residents out of their rooms to another hall to be weighed with the resident wearing a surgical mask. RN-Z said she had been in-serviced to practice hand hygiene before entering a resident room, during care, and before exiting resident room to prevent cross contamination. Interview on 05/26/20 at 12:25 p.m. with the DON said station 2 had been the designated station to place COVID-19 positive residents. The DON said the NF did not have designated staffing. The DON said the NF had been instructed by Corporate Office to conserve PPE on hand for a positive case of COVID-19. The DON said staff should have not hung hospital gown on door due to cross contamination. The DON said residents on quarantine should not be leaving their room to go and be weighed due to cross contamination. The DON said she would look to see if the NF had a policy on quarantine. The DON said Corporate had instructed staff to wear a cloth face mask and to wash the mask at the end of day in 160 degree temperature. In an interview on 05/26/20 at 12:10 pm with the Maintenance Director, he said he used a number system/grid to guide him on the settings on how to clean certain linen. For example, #7 referred to personal linen. He did not specify if this setting was an appropriate setting to kill any bacteria/germs in relation to COVID-19. Interview on 05/26/20 at 10:08 a.m. with Administrator said she had PPE in stock and it was kept in her office and storage room. The Administrator said she received PPE from SETRAC as well as Corporate Office. The Administrator said the NF designated station for a COVID-19 positive was station 2 in private rooms. The Administrator said she did not have designated staffing to care for the residents that were on quarantine or a resident (s) that may test positive for the COVID-19 at this time. The Administrator said she had never heard of designated staffing and that herself and the DON would further discuss designated staffing in case the NF had a positive COVID-19 resident(s). Further interview with the Administrator said she did have some staff members working at other NF and communicated with those NF in monitoring for any outbreaks of COVID-19. The Administrator said the staff had been instructed to use a surgical mask or a cloth mask, gloves, and hospital gown to care for residents in quarantine to preserve PPE in case the NF had a positive COVID-19. The Administrator said new admissions and readmits were placed in quarantine for 14 days to monitor for signs and symptoms of COVID such as cough, fever, shortness of breath, decrease in taste and smell. The Administrator said she thought the staff only needed to wear the N-95 mask if the resident was symptomatic. The Administrator said all the residents in the NF had been asymptomatic. Further interview with the Administrator at that time said she had on hand the following PPE: *N-95: 730 *Shoe Covers: 50 *isolation gowns: overall-23 and regular disposable-274 *Face Shields: 98 *Goggles: 96 *Procedure Mask: 4100 *Gloves: 21 cases Resident #3 Record review of the admission sheet for Resident #3 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's comprehensive MDS assessment dated [DATE] revealed a BIMS of 03 out of 15 indicating severely impaired cognition. He required extensive assistance from two staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #5 was always incontinent of bowel and had a indwelling urinary catheter. Record review of Resident #3's Care Plan dated as initiated 05/21/20 and revised on 5/28/20 revealed the following care plan: Problem: Resident requires quarantine/isolation due to entry from outside facility Goal: reduction in risk of possible spread of Covid 19. Interventions: Educate resident of need for quarantine/isolation in room per recommendations x 2 weeks, encourage and remind resident to follow set quarantine/isolation that is in place, remind resident to wear face mask when staff is in room giving care, remind/encourage resident to wear a face mask if out of room for any reason necessary. Record review of Resident #3's nurses notes dated 05/21/2020 read in part: .received call from ER that pt would be returning with DX UTI and Hematuria. 1 gram [MEDICATION NAME] given in ER . Record review of Resident #3's nurses notes dated 05/21/2020 read in part: .10:05 pm returned form ER with new order for Keflex 500 mg po tid x 5 days DX uti . Record review of Resident #3's facility's COVID-19 Observation Form dated 5/22/20 read in part: .Treatments: isolation, Quarantine. Interventions: initiate Quarantine/isolation (specify why)-s/p ER visit, other (specify)-abt for uti . Record review of Resident #3's Hospital to Post-Acute Care Facility Transfer-COVID -19 assessment dated [DATE] read in part: .has patient been laboratory tested for COVID-19? NO, test not performed because patient did not meet the CDC testing criteria. May transfer . Record review of Resident #3's facility's Resident Readmit Tracker COVID-19 presented by the DON on 5/26/20 at 9:36 am revealed Resident was D/C on 5/21/20 and returned on 5/21/20 Resident was not tested . Observation on 5/26/2020 at 9:55 am revealed Resident #3's door was open to the hallway with an isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was a sign posted on the resident's room door which read, See nurse before entering. Further observation revealed Housekeeper A was inside the resident's room with a hospital gown, cloth mask and gloves on. Resident #3 was lying in his bed watching TV. The resident did not have a mask on while the housekeeper was in the room. In an interview on 5/26/2020 at 10:20 am with Housekeeper A, she said she worked full time at this facility. She said the See the nurse signs on the residents room doors meant the resident had come from the hospital. She said for precaution from the [MEDICAL CONDITION], staff had to wear a cloth mask, hospital gown, and gloves. She said she used one cart to clean all of the rooms on her assigned hall. In an interview and observation on 5/26/20 at 10:26 am with LVN C, she had a cloth mask on. She said Resident # 3 had come from the hospital. He was quarantined for 14 days. She said he was diagnosed with [REDACTED]. She said today was his day 5 of 14. She said the staff were to wear a cloth mask, hospital gown, and gloves while caring for the resident. She said the isolation station consisted of gloves and hospital gowns. She said the facility had been providing homemade masks to the staff and residents. The surveyor asked if N95 masks were provided to the staff to care for the quarantined residents. LVN C said the facility was conserving PPE in the event of positive COVID cases. In an interview and observation on 5/26/2020 at 10:37 am with CNA B, she said she worked full time during the 6-2 pm shift at this facility. She had a surgical mask on. She said residents with a See the nurse sign on their doors were the residents that had come from the hospital. She said they were in quarantine for 14 days as precaution for COVID signs and symptoms. She said the staff were to wear a mask, hospital gown, and gloves while caring for these residents. She said staff could wear homemade masks or facility provided cloth masks to care for the quarantined residents. She said the facility has been providing homemade masks that had been donated to the facility. These masks were being washed after each use by the laundry department and re-issued back out to them. She said she did not feel comfortable wearing a cloth mask, therefore she had bought a box of surgical masks for herself. In an interview and observation on 5/26/20 on 10:45 am with CNA C, he said he worked full time during the 6-2 pm shift at this facility. He had a cloth mask on. He said the facility has been providing homemade masks that had been donated to the facility. He said residents with a See the nurse sign on their doors were the residents that had come from the hospital. He said the staff were to wear a cloth mask, hospital gown and gloves while caring for these residents. In an interview and observation on 5/26/20 at 11:37 am with the Wound Care Nurse, she said she worked full time at this facility. She said her responsibility was to assist the DON with infection logging, tracking and trending. She said she provided wound care for Resident #3's heels and sacrum area. She said the resident was quarantined for 14 days. She said she wore a cloth mask, hospital gown, and gloves while providing wound care for the resident. She said the facility was conserving PPE in the event of positive COVID cases. The WCN had a cloth mask on. She said the facility has been providing homemade masks that had been donated to the facility. She said these masks were being washed after each use by the laundry department and re-issued back out to them. Resident #4 Record review of the admission sheet for Resident #4 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's comprehensive MDS assessment dated [DATE] revealed a BIMS of 99 indicating the BIMS assessment was not done. Resident #4 had a short term memory problem, long term memory problem, and cognitive skills for daily decision making were assesed by staff as severely impaired and she never/rarely made decisions. She required supervision from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #4 was always incontinent of bowel and bladder. Record review of Resident #4's Care Plan dated as initiated 05/22/20 and revised on 5/26/20 revealed the following care plan: Problem: Resident refused covid 19 testing, requires 14 day isolation. Goal: resident will remain in room in isolation daily x 14 days. Interventions: explain to resident the need for ongoing isolation due to refusal of covid 19 testing, monitor resident for any s/s of covid 19, provide meals care and activities in room while resident is in isolation, reassure resident and allow her to express her feelings daily, remind resident to not leave her room and remind resident to wear a mask when staff is in room. Record review of Resident #4's nurses notes dated 05/21/2020 (recorded as late entry on 05/26/2020 at 04:04 PM) written by the DON read in part: .pt refused testing for covid 19 by national guard. Placed on 14 days isolation . Record review of Resident #4's nurses notes dated 05/27/2020 read in part: .Resident up 'cleaning' the dining room. Spoke with NP informed her of behavior yesterday and refusal of V/S or temp. Also informed her that we had to place her on isolation (sic) d/t refusal of Covid 19 test for 14 days . Record review of Resident #4's facility's COVID-19 Observation Form initiated on 5/26/20 and completed on 5/27/20 read in part: .Treatments: isolation, Quarantine. Interventions: initiate Quarantine/isolation (specify why)-refused covid test . Record review of Resident #4's facility's Resident Readmit Tracker COVID-19 presented by the DON revealed Resident was a new admit on 3/27/20 Resident was not tested . Observation on 5/26/2020 at 11:01 am reveled Resident #4's door was open to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the resident's room door which indicated that the resident was on isolation precautions. Further observation revealed there were no covered isolation bins in the room for trash or dirty linens to allow for disposal of contaminated items in a controlled manner. Observation and attempted interview on 5/26/2020 at 11:03 am revealed Resident #4 was sitting on the chair in the common/dining area. She was alert and well groomed. The resident mumbled for 5 minutes while being interviewed. She was hard to understand and did not respond appropriately to questions asked about her stay at the facility. In an interview on 5/26/20 at 2:24 pm with the DON, she said Resident #4 in the MCU should be placed on isolation because the resident refused testing for COVID 19 by the National Guard. She said the resident's status was unknown. She said the resident should be treated as a suspected/positive COVID resident. At this time, the surveyors requested a list of all residents who refused/missed the COVID-19 testing by the National Guard. In an interview on 5/26/20 at 3:23 pm with the Administrator, she said the DON went ahead and in serviced the nurses that the residents who refused testing should be placed on 14 days quarantine. She said there was some miscommunication between the nurses. She said Resident #4 was admitted sometime in April and had completed her 14 days, but the resident should have been on isolation (sic) again since she refused COVID testing when the National Guard conducted COVID testing of all staff and residents. She said the facility was still pending test results. In an interview on 5/26/2020 at 10:12 am with LVN B, she said she was the Charge Nurse for Station 3 and the MCU. She said Resident #6 was placed on quarantine/isolation for 14 days because she refused the COVID testing due to impaired cognition. She said the resident was to wear a mask, and the staff were to wear a mask and gloves. She said she felt they did not have enough PPE on hand if residents began to test positive for COVID. She said the facility has been providing homemade masks that had been donated to the facility. She said the facility was conserving PPE in the event of positive COVID cases. LVN B said Resident #4 and # 7 also refused COVID-19 testing due to impaired cognition on the MCU. LVN B said she did not know why those residents were not placed on quarantine. Resident #5 Record review of the admission sheet for Resident #5 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's comprehensive MDS assessment dated [DATE] revealed a BIMS of 06 out of 15 indicating severely impaired cognition. He required extensive assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #5 was always incontinent of bowel and bladder. Record review of Resident #5's Care Plan dated (initiated) 05/23/20 and revised on 5/27/20 revealed the following care plan: Problem: Resident requires quarantine/isolation due to entr (TRUNCATED)

Based on interview and record review the facility failed to provide care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 24 residents (CR #1) reviewed for quality of care. -The facility failed to assess, intervene and monitor CR #1 when she complained of abdominal pain, constipation, and had a hard, distended, and painful abdomen. - The facility failed to follow up with the physician when several and different types of medication to relieve constipation were ineffective. On [DATE] CR #1 was found non-responsive and was sent to the hospital where she died . An IJ was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected 1 discharged resident and could place 23 residents identified by the facility as having constipation at risk of increased pain, complications related to constipation, decline in their health, hospitalization and death. Findings Include: CR #1: Record review of CR #1's face sheet revealed a [AGE] year old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was discharged to the hospital on [DATE] and later died . Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed CR #1 had a BIMS score of 12 indicating she had moderately impaired decision making skills. She was able to be understood and understand others and had no memory problems. Record review of her functional status (ADL) revealed she was independent with no help from staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She was occasionally incontinent of bowel and bladder. Record review of CR #1's revised care plan dated [DATE] and revised on [DATE] read in part, Resident has history of constipation. Toileting - independent [MEDICATION NAME] and [MEDICATION NAME] as directed. Further review of the care plan section revealed a care plan dated [DATE] and revised on [DATE] and [DATE] for alteration in elimination as exhibited by occasional incontinence and continence of bowel due to decreased mobility and [DIAGNOSES REDACTED].approaches included: promote adequate nutrition, meds/labs as ordered, notify MD of changes as needed. Additional approaches were handwritten on [DATE] for [MEDICATION NAME] suppository 10 mg as needed for constipation, [DATE] [MEDICATION NAME] 17grams mix in ,[DATE] ounces of beverage of choice, [DATE] [MEDICATION NAME] , [DATE] KUB ordered . Record review of the Physician ' s note dated [DATE] read in part, [MEDICATION NAME] suppository 10 mg 1 PRN once a day for constipation. On [DATE] [MEDICATION NAME] as needed was discontinued and [MEDICATION NAME] 17 grams by mouth once a day was ordered. Record review of the MAR for CR #1 revealed that the resident was taking [MEDICATION NAME] 325 mg every day since [DATE]. Record review of the Nurses notes for CR #1 revealed: [DATE] At 5:05 a.m. Completed by RN A.- The note read in part-Resident abdomen hard and swollen and painful. Checked for impaction, noted very small rectal opening with large firm BM inside. Attempted to break up, however caused much discomfort for resident. Give [MEDICATION NAME] suppository with some success during the night. Abdomen remains hard and tender. Resident states if she could have the [MEDICATION NAME] every day, she would not get so constipated. Faxed MD for QD [MEDICATION NAME]. There was no documentation that the [MEDICATION NAME] once a day was effective. Further review of the nurses ' notes revealed no documentation of CR #1 ' s constipation, abdominal pain and discomfort between [DATE] to [DATE]. Further review of nurses ' notes revealed: [DATE] at 1:58 a.m. - Milk of Magnesia Suspension 30 cc p.o. daily PRN. PRN administered - constipation. [DATE] at 4:25 a.m. Completed by LVN A.- Medication follow-up- (Milk of Magnesia Susp 30cc PO daily PRN) Medication was not effective. There was no other documentation to indicate the resident received further assessment or if the MD was consulted. [DATE] at 7:53 a.m. RN B called MD on call about Abdominal distention new orders received. Completed by RN B. Record review of SBAR communication form dated [DATE] at 7:15 am revealed in part: Situation- Abdomen distention Changes in last week- [MEDICATION NAME] Resident evaluation (changes compared to baseline): decreased mobility, weakness, needs more ADL assistance, abdominal tenderness, decreased/absent of bowel sounds, distended abdomen, decreased appetite/fluid intake. Record review of the physician's order [REDACTED]. KUB/abd x-ray DX. Pain/constipation. Portable d/t pain and increased weakness. Record review of the x-ray KUB IV dated [DATE] at 11: 11 a.m. at faxed on [DATE] at 3:06 a.m. revealed: Findings: No pathologically dilated loops of bowel are seen. There is an increased amount of fecal matter present. No portal venous air or free air is noted. The bones are osteopenia. Degenerated changes are noted. There are surgical clips in the right upper quadrant. Impression: Increased fecal matter, compatible with prior cholecystectomy. signed by MD A. Record review of the Nurses notes for CR#1 revealed that there was no mention that the physician was informed of the X-ray results. There was a second reading of the same KUB X-ray faxed to the facility on [DATE] at 13:22 p.m. Done by a different doctor, MD B Record review of the second reading x-ray KUB dated [DATE] at 11: 11 a.m. at faxed on [DATE] at 13:22 p.m. revealed: Findings: There is moderate nonspecific stool within the rectum. The amount of stool is otherwise unremarkable. No evidence of bowel obstruction or pneumoperitoneum. [MEDICAL CONDITION] changes are noted in the spine. Cholecystectomy clips are present. Impression: Moderate nonspecific stool within the rectum. Otherwise unremarkable exam. Signed by MD B. Further record review of nurse's notes revealed in part: - [DATE] 11:35 a.m. revealed in part that the resident continued to have Abdominal distention. The abdominal X-ray shows stool, checked for impaction unable to reach any stool per rectum. - [DATE] at 6:55 p.m. [MEDICATION NAME] 10 mg suppository 1 PR daily PRN constipation. Resident very distended, constipated. - [DATE] at 11:12 p.m. [DATE] Milk of Magnesia susp 30 cc PO daily PRN, administered for constipation. -[DATE] at 1:13 a.m. Medication follow-up- (Milk of Magnesia Suspension 30cc PO daily PRN) Medication was not effective. There was no documentation that the physician was consulted. -[DATE] at 5:02 a.m. -Resident found unresponsive by CNA P at 4:00 a.m. EMS was called and CPR started. EMS arrived at 4:15 a.m. and took over compressions, IV started with fluids. Family member notified that resident was going to be transported to the local hospital. EMS called .pulse found doctor ordered resident to be transferred to the hospital. Resident being transported from facility at 4:50 a.m. Completed by LVN A. Record review of the hospital nurse 's notes dated [DATE] documented: 0540 - Abd distended and hard like a basketball. blink reflex as response to painful stimuli. 0600 - Fingers left hand becoming cyanotic. Family member stated CR#1 was DNR. No further life support measures to be done. PT pronounces dead at 0622 am. Record review of labs completed in the hospital and dated [DATE] revealed in part: .hematology- RBC 3.09 low (normal range 3XXX,[DATE].40 ul), HGB 8.3 low (normal range 11XXX,[DATE].4 ul), HCT 26.5 low (normal range 34XXX,[DATE].0 %), MCHC 31.4 low (normal range 32XXX,[DATE].0 g/dl Record review of the ER physician ' s documentation dated [DATE]: CPR in progress >40 prior to arrival in the ER. CR#1 ABD: Distended and hard as a board. She was placed on vent and shortly thereafter she lost her pulse again. Differential Diagnosis: [REDACTED]. In an interview with the Director of Nursing on [DATE] at 1:30 p.m. revealed she did not work the weekend of [DATE] but there was a nurse on call. She said she was not notified of CR#1's change of condition by the staff until Monday. She said that the doctor should have been called and CR#1 should have been sent to the emergency room earlier. In interviews conducted on [DATE] between 11:00 a.m. and 4:00 p.m. with two alert and oriented residents that wished to remain anonymous they said they knew CR#1 and she should not have died . They said she had been complaining of constipation and pain for about three weeks and the facility did nothing. They said she was always up and down the hallway in her wheelchair and she was not sick except that she started to complain of not being able go to bathroom to do #2. During an interview on [DATE] at 3:30 p.m. with LVN B, who worked the 6 am to 2 pm shift, she said she worked on [DATE]. She said that CR#1 ' s abdomen was distended and it was still distended on Sunday. She said she asked CR#1 if she was alright and CR#1 told her that she was fine just that she was Full of[***] while laughing. She said that she and another nurse called the MD and they suggested a KUB. The MD ordered a KUB on [DATE] but there was no result at the end of her shift. During an interview on [DATE] at 3:45 p.m. with CNA L, who worked the 2 pm to 10 pm shift, she said she worked with CR#1 on [DATE] and that the resident had a BM and she cleaned her up. She said when she went to flush the toilet it was medium size BM and it was soft. CNA L said CR#1 would touch her stomach and said it was painful. She said sometimes CR #1 would complain of not having a BM and she would let the nurse know. Interview on [DATE] at 4:14 p.m. with CNA J, who worked the 2 pm to 10 pm shift, said that CR#1 always complained of her stomach hurting and always had issues going to the bathroom. She said on [DATE] she went to the room at about 9:30 a.m. and she saw brown color smear of BM on the toilet and on the floor and that was how she knew CR#1 had gone to the bathroom. She said she did not know what size it was or if it was hard or soft because there was no BM in the toilet bowl. During interviews between [DATE] and [DATE] with three family members of other residents that wished to remain anonymous, they said they heard CR#1 complaining of not being able to go the bathroom. They said CR#1 complained that if she could go to the bathroom she would not be so constipated. They said they feel CR#1 should have gone to the hospital two weeks ago. They said maybe she would not have died if the facility had sent her to the hospital. During an interview on [DATE] at 11:45 a.m. with RN A, who is the weekend supervisor, she said she was working on [DATE] when LVN B said CR#1's abdomen was still hard. She said they started thinking what test could be done to find out what was wrong. She said they suggested the KUB test and the physician said it was OK with him. She said she was not sure if the result came back during her shift as she was not working directly with CR#1. RN A said she did not do an actual assessment on the resident, but LVN B told her about the issues. During an interview on [DATE] at 1:10 p.m. with CNA E she said she did not work with CR#1 the week before she died . She said however, the resident always complained of constipation and said she was backed up. She said sometimes she would give CR #1 prune juice and she would go. Record review of CR #1 ' s the CNA ' s ADL tracking form for [DATE] on all three shifts revealed the following: 10:00 p.m. to 6:00 am on [DATE] : 1 bowel movement was documented 6:00 a.m. to 2:00 pm On [DATE], [DATE]-[DATE], [DATE] and [DATE] 0 [DATE] one BM on those days ON ,[DATE] and [DATE] documentation of 2 BM on that shift 2:00 to 10:00 p.m. There was no documentation of any BM between [DATE] and [DATE] On [DATE] and [DATE] documentation of 1 meaning that she had 1 BM In interview conducted with the DON on [DATE] at 1:20 pm she said they CNA ' s were only documenting the number of times residents had a bowel movement. She said they never usually document the size. During an interview with CNA P via telephone on [DATE] at 1:50 p.m. she said the number on the ADL sheets indicate how many times the resident has a bowel movement. She said they never document the size or description of the BM. She said if the resident was continent she would ask them if they had a bowel movement. During an Interview on [DATE] at 4:00 p.m. with CNA L she said they always document the number of times the resident had a bowel movement but they never document the size or if it was runny, hard or soft. She said CR#1 she would tell you if she had a bowel movement. During a telephone interview on [DATE] at 10:45 a.m. with LVN A, she worked the 10 pm to 6 am shift, she said on [DATE] she worked the 10:00 p.m. - 6:00 a.m. shift. She said she was taking report from the 2:00 p.m. -10:00 p.m. nurse when CNA P came and told her that CR#1 wanted to see her. She said she went to CR#1 ' s room and she told her she was constipated and her stomach was hurting and she wanted something to make her fart. She said her stomach was distended and her bowel had little sound, not very active. She said she gave her some Milk of Magnesia and left her in her room. She said she went back to the 2:00 p.m. -10:00 p.m. (LVN B) who was giving her end of shift report and she told her that CR#1 was complaining of abdominal pain and ask if she should send her out. She said the LVN B said no because she had order for [MEDICATION NAME] three times a day and they did a KUB and the doctor knew about CR #1. LVN A said at about 1:00 a.m. she went back to check on the resident and she was still in pain and the resident said she did not use the bathroom. She said about 3:45 a.m. and 4:00 a.m. CNA P told her that CR#1 was non-responsive. She said when she went to the room the resident stomach had gotten bigger and CR#1 was not breathing. She said called 911 and the other staff and initiated CPR. She said 911 came and took over they got a pulse and transported her to the hospital. When asked why she did not called the physician LVN A said that she didn ' t because the previous nurse told her she had already called him. In an interview with Doctor J on [DATE] at 11:30 a.m. he said he was CR#1 ' s doctor but he was not on call on the weekend of [DATE] it was another doctor. However he was not notified of any changes in CR#1 ' s condition prior to [DATE] after her death. He said on [DATE] he was asked to look at a report concerning CR#1. During an interview on [DATE] at 1:50 p.m. with CNA P, who worked the 10 pm to 6 am shift she said she was the Aide for CR#1 and at around 10:45 p.m. she had just started her shift when she went into CR#1 ' s room and she was complaining of have pain in her stomach. She said CR#1 asked her if she could assist her to use the bathroom. She said she assisted her but she did not use the bathroom. She said she asked her to call the nurse and she did. She said at about 1:10 a.m. she went back to CR#1 ' s room and she was still complaining of pain to her stomach and said her skin was itching and burning her she called the nurse and the nurse went and checked on the resident. She said at about 3:45 a.m. she checked on CR #1 again and she was non-responsive and she called the nurse and the nurse call the other staff and 911. She said the initiate CPR until the EMS came. In an interview with the weekend on call Doctor K on [DATE] at 2:05 p.m. he said he did not know who CR#1 was because CR#1 was not his patient. He refused to confirm or deny if he was contacted by the facility concerning treatment for [REDACTED].#1 was not his patient. Record review of Resident Assessment policy and Procedures dated ,[DATE] reads in part . Policy It is the policy of the facility that all residents are assessed to determine their needs. The facility will provide care and treatment to promote the resident ' s highest practicable physical, psychological and social needs. Procedure 5. When the resident ' s condition is declining vs. maintaining or improving due to the progression of their medical condition , and its apparent the resident is approaching the end of life, the physician and family/legal representative will be contacted. Change of Condition Process dated ,[DATE] reads in part . Purpose A change in condition should target many areas of the interdisciplinary team (IDT) function. Skill, assessment and intervention to any change in condition will vary depending on that change with the IDT when necessary. To ensure the optimal outcome for the resident, nursing process of assessment, plan intervention and evaluation will be used. Physician involvement is always required following the interact process without exclusion of the Licensed Professional ' s judgment, as is follow up assessment per federal Regulatory Guidelines. The resident care plan is to be updated as interventions are implemented . , The Administrator and the DON were informed that an IJ was identified on [DATE] at 1:55 pm and a plan of removal (POR) was requested. A Plan of Removal was received on [DATE] at 4:00p.m. After two revisions were made the Plan of Removal was accepted on [DATE] at 2:00 pm. The Plan of Removal reads in part IMMEDIATE ACTION: 100% review of all residents listed on the 24 Report Sheet for Change of Condition in the past 7 days, all SBARs completed for changes of condition in the past 7 days and all Physician order [REDACTED]. TRAINING The Director of Nursing, Assistant Director of Nursing, MDS Coordinator and the Care Plan Registered Nurse will start in-services with all licensed nurses on the basic protocol related to changes of condition, assessments and clinical documentation immediately on [DATE] and continuing until all current in-house staff have been trained to be 100% in-serviced by no later than [DATE]. In addition, all new hire nurses will be educated on the following and this will be added to the-hire orientation material. Specific education presented consists of the following and will be presented quarterly to all nursing staff. Basic Protocol on Prompt Assessment, Changes of Condition and Clinical Documentation reads in parts . To ensure the optimal outcome for the resident, nursing process of Assessment, Plan, Intervention and Evaluation will be used. Process: The INTERACTIVE 4.0 system is to be followed. All forms are to be completed in their entirety, signed and dated as needed, and kept per medical records retention or QA committee as indicated. All new nursing staff shall have this included in their new hire orientation. Protocol: Stop and Watch- early detection tool shall be used by Certified Nurse Assistants (CNA) and other staff as needed. Changes in Condition Assessment Guidelines (File Cards)- will be followed by the licensed nurse for the initial and when necessary the follow up assessment to detect change of condition by symptoms and categories. CARE PATHWAYS-to be used as needed when [DIAGNOSES REDACTED]. SBAR- Situation-Background-Assessment/Appearance - Request form is to be used for documentation prior to notifying physician/Nurse Practitioner or Physician Assistant. In addition, all residents with a change in condition will be added to the 24 hour report sheet and their attending physician and responsible party notified . .In services on new policy were initiated on [DATE] and were completed on [DATE]. DON, ADON, Staffing coordinator, MDS nurses, and CNAs were in-serviced on new procedure . The resident that triggered the IJ is deceased . All resident who had changes in condition and complain of constipation were reviewed and documented on the 24 hour report sheet. The residents who were alert and oriented were interview for recurrent constipation and pain . The facility was monitored on [DATE] and on [DATE] with the following results: Observations were made from [DATE]-[DATE]/16 to ensure adequate supervision was provided and constipation issues were being addressed by staff. Interviews were conducted from [DATE]-[DATE] with CNAs, Nurses, administration and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services related to changes in condition, issues related to constipation, abdominal pain, documentation, etc. Record review of in-services conducted from [DATE] to [DATE] revealed that staff had been trained onn changes in condition, assessments, documentation, etc. Record review also revealed that the facility assessed the facility residents between [DATE] and [DATE] to ensure no changes in condition were missed. In an interview with the DON on [DATE] at 12:53pm, when asked how the IJ came about she said that it was poor documentation and communication. She said that they would not have had the IJ if CR#1 was sent to the hospital in a timely manner. In an interview with the Administrator on [DATE] at 1:05 pm, he said that it was lack of communication between the staff. He said his staffs worked hard but the issue with CR#1 was a lack of communication. The Administrator and DON were informed on [DATE] at 7:10 p.m. am that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at an pattern level due to facility needing more time to monitor the plan of removal for effectiveness. The facility DON reported there were 23 residents with [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 24 residents reviewed for clinical files. (CR#1) - The facility failed to maintain complete records of CR#1 ' s bowel condition and bowel function from [DATE] through [DATE]. - The facility failed to create and maintain a systematically organized Charting by Exception record. - The facility ' s record for CR#1 ' s bowel condition and bowel function did not contain a record of the resident ' s assessments. An IJ was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected one resident and placed place 23 residents identified by the facility as having constipation at risk of receiving inappropriate nursing and/or medical care due to incomplete or inaccurate clinical records. Findings include: CR #1: Record review of CR #1's face sheet revealed a [AGE] year old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was discharged to the hospital on [DATE] and later died . Record review of the Physician ' s note dated [DATE] read in part, [MEDICATION NAME] suppository 10 mg 1 PRN once a day for constipation. On [DATE] [MEDICATION NAME] as needed was discontinued and [MEDICATION NAME] 17 grams by mouth once a day was ordered. Record review of the MAR for CR #1 revealed that the resident was taking [MEDICATION NAME] 325 mg every day since [DATE]. Record review of the Nurses notes for CR #1 revealed: [DATE] at 5:05 a.m. Completed by RN A. - The note read in part-Resident abdomen hard and swollen and painful. Checked for impaction, noted very small rectal opening with large firm BM inside. Attempted to break up, however caused much discomfort for resident. Give [MEDICATION NAME] suppository with some success during the night. Abdomen remains hard and tender. Resident states if she could have the [MEDICATION NAME] every day, she would not get so constipated. Faxed MD for QD [MEDICATION NAME]. There was no documentation that the [MEDICATION NAME] once a day was effective. Further review of the nurses ' notes revealed no documentation of CR #1 ' s constipation, abdominal pain, discomfort or nursing assessment of the residents bowel function or condition between [DATE] to [DATE]. Further review of nurses ' notes revealed: [DATE] at 1:58 a.m. - Milk of Magnesia Suspension 30 cc p.o. daily PRN. PRN administered - constipation. [DATE] at 4:25 a.m. Completed by LVN A.- Medication follow-up- (Milk of Magnesia Susp 30cc PO daily PRN) Medication was not effective. There was no other documentation to indicate the resident received further follow up or assessment of bowel function, bowel condition or, if the MD was consulted. [DATE] at 7:53 a.m. RN B called MD on call about abdominal distention new orders received. Completed by RN B. Record review of SBAR communication form dated [DATE] at 7:15 am revealed in part: Situation- Abdomen distention Changes in last week- [MEDICATION NAME] Resident evaluation (changes compared to baseline): decreased mobility, weakness, needs more ADL assistance, abdominal tenderness, decreased/absent of bowel sounds, distended abdomen, and decreased appetite/fluid intake. Record review of the physician 's order dated [DATE] at 7:45 a.m. revealed [MEDICATION NAME] 17 grams by mouth QID mix with ,[DATE] ounces with beverage of choice times for three days or until resolve then return to qd. KUB/abd x-ray DX. Pain/constipation. Portable d/t pain and increased weakness. Further record review of nurse's notes revealed in part: - [DATE] 11:35 a.m. the resident continued to have abdominal distention. The abdominal X-ray shows stool, checked for impaction unable to reach any stool per rectum. There was no documentation to indicate if an assessment was completed. - [DATE] at 6:55 p.m. [MEDICATION NAME] 10 mg suppository 1 PR daily PRN constipation. Resident very distended, constipated. There was no documentation to indicate if an assessment was completed to check for pain, bowel function or condition. - [DATE] at 11:12 p.m. [DATE] Milk of Magnesia susp 30 cc PO daily PRN, administered for constipation. -[DATE] at 1:13 a.m. Medication follow-up- (Milk of Magnesia Suspension 30cc PO daily PRN) Medication was not effective. There was no documentation that the physician was consulted or that the resident was assessed. -[DATE] at 5:02 a.m. -Resident found unresponsive by CNA P at 4:00 a.m. EMS was called and CPR started. EMS arrived at 4:15 a.m. and took over compressions, IV started with fluids. Family member notified that resident was going to be transported to the local hospital. EMS called .pulse found doctor ordered resident to be transferred to the hospital. Resident being transported from facility at 4:50 a.m. Completed by LVN A. Record review of the hospital nurse ' s notes dated [DATE] documented: 0540 - Abd distended and hard like a basketball. blink reflex as response to painful stimuli. 0600 - Fingers left hand becoming cyanotic. Family member stated CR#1 was DNR. No further life support measures to be done. PT pronounced dead at 0622 am. Record review of the ER physician ' s documentation dated [DATE]: CPR in progress >40 prior to arrival in the ER. CR#1 ABD: Distended and hard as a board. She was placed on vent and shortly thereafter she lost her pulse again. Differential Diagnosis: [REDACTED]. Record review of the CAN ' s ADL tracking form for CR #1 ' s for [DATE] on all three shifts revealed the following: 10:00 p.m. to 6:00 am on [DATE] : 1 bowel movement was documented 6:00 a.m. to 2:00 pm On [DATE], [DATE]-[DATE], [DATE] and [DATE]- one BM on those days ON ,[DATE] and [DATE] documentation of 2 BM. [DATE]- documented one BM. (This is at least one hour after CR #1 was found unresponsive and was transported to the ER at 4:50 am.) 2:00 to 10:00 p.m. shift There was no documentation of any BM between [DATE] and [DATE] On [DATE] and [DATE] documentation of 1 meaning that she had 1 BM The bowel movement recorded on [DATE] between 6:00 am and 2:00 pm , after CR #1 left the facility at 4:05 am, indicate that the CAN records were not reliable. In interview conducted with the DON on [DATE] at 1:20 pm she said the CNA ' s were only documenting the number of times residents had a bowel movement. She said they never usually document the size. During an interview with CNA P via telephone on [DATE] at 1:50 p.m. she said the number on the ADL sheets indicate how many times the resident has a bowel movement. She said they never document the size or description of the BM. She said if the resident was continent she would ask her if they had a bowel movement. During an interview on [DATE] at 3:45 p.m. with CNA L, who worked the 2 pm to 10 pm shift, she said she worked with CR#1 on [DATE] and that the resident had a BM and she cleaned her up. She said when she went to flush the toilet it was medium size BM and it was soft. CNA L said CR#1 would touch her stomach and said it was painful. She said sometimes CR #1 would complain of not having a BM and she would let the nurse know. In an interview on [DATE] at 4:14 p.m. with CNA J, who worked the 2 pm to 10 pm shift, she said that CR#1 always complained of her stomach hurting and always had issues going to the bathroom. She said on [DATE] she went to the room at about 9:30 a.m. and she saw brown color smear of BM on the toilet and on the floor and that was how she knew CR#1 had gone to the bathroom. She said she did not know what size it was or if it was hard or soft because there was no BM in the toilet bowl. During an interview on [DATE] at 11:45 a.m. with RN A, weekend supervisor, she said she was working on [DATE] when LVN B said CR#1's abdomen was still hard. She said they started thinking what test could be done to find out what was wrong. She said they suggested the KUB test and the physician said it was OK with him. She said she was not sure if the result came back during her shift as she was not working directly with CR#1. RN A said she did not do an actual assessment on the resident, but LVN B told her about the issues. During a telephone interview on [DATE] at 10:45 a.m. with LVN A, she worked the 10 pm to 6 am shift, she said on [DATE] she worked the 10:00 p.m. - 6:00 a.m. shift. She said she was taking report from the 2:00 p.m. -10:00 p.m. nurse when CNA P came and told her that CR#1 wanted to see her. She said she went to CR#1 ' s room and she told her she was constipated and her stomach was hurting and she wanted something to make her fart. She said her stomach was distended and her bowel had little sound, not very active. She said she gave her some Milk of Magnesia and left her in her room. She said she went back to the 2:00 p.m. -10:00 p.m. (LVN B) who was giving her end of shift report and she told her that CR#1 was complaining of abdominal pain and asked if she should send her out. She said LVN B said no because she had an order for [REDACTED]. She said about 3:45 a.m. and 4:00 a.m. CNA P told her that CR#1 was non-responsive. She said when she went to the room the resident stomach had gotten bigger and CR#1 was not breathing. She said called 911 and the other staff and initiated CPR. She said 911 came and took over they got a pulse and transported her to the hospital. When asked why she did not call the physician LVN A said that she did ' t because the previous nurse told her she had already called him. In an interview with Doctor J on [DATE] at 11:30 a.m. he said he was CR#1 ' s doctor but he was not on call the weekend of [DATE], another doctor. However he said he was not notified of any changes in CR#1 ' s condition prior to [DATE] after her death. He said on [DATE] he was asked to look at a report concerning CR#1. Change of Condition Process dated ,[DATE] reads in part . Purpose A change in condition should target many areas of the interdisciplinary team (IDT) function. Skill, assessment and intervention to any change in condition will vary depending on that change with the IDT when necessary. To ensure the optimal outcome for the resident, nursing process of assessment, plan intervention and evaluation will be used. Physician involvement is always required following the interact process without exclusion of the Licensed Professional ' s judgment, as is follow up assessment per federal Regulatory Guidelines. The resident care plan is to be updated as interventions are implemented . , Record review of the Administrative Code TITLE 22 EXAMINING BOARDS PART 11 TEXAS BOARD OF NURSING CHAPTER 217 LICENSURE, PEER ASSISTANCE AND PRACTICE RULE §217.11 Standards of Nursing Practice read in part: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; The Administrator and the DON were informed that an IJ was identified on [DATE] at 1:55 pm and a plan of removal (POR) was requested. A Plan of Removal was received on [DATE] at 4:00p.m. After two revisions were made the Plan of Removal was accepted on [DATE] at 2:00 pm. The Plan of Removal reads in part . IMMEDIATE ACTION: 100% review of all residents listed on the 24 Report Sheet for Change of Condition in the past 7 days, all SBARs completed for changes of condition in the past 7 days and all Physician order [REDACTED]. TRAINING The Director of Nursing, Assistant Director of Nursing, MDS Coordinator and the Care Plan Registered Nurse will start in-services with all licensed nurses on the basic protocol related to changes of condition, assessments and clinical documentation immediately on [DATE] and continuing until all current in-house staff have been trained to be 100% in-serviced by no later than [DATE]. In addition, all new hire nurses will be educated on the following and this will be added to the-hire orientation material. Specific education presented consists of the following and will be presented quarterly to all nursing staff. Basic Protocol on Prompt Assessment, Changes of Condition and Clinical Documentation reads in part . To ensure the optimal outcome for the resident, nursing process of Assessment, Plan, Intervention and Evaluation will be used. Process: The INTERACTIVE 4.0 system is to be followed. All forms are to be completed in their entirety, signed and dated as needed, and kept per medical records retention or QA committee as indicated. All new nursing staff shall have this included in their new hire orientation. Protocol: Stop and Watch- early detection tool shall be used by Certified Nurse Assistants (CNA) and other staff as needed. Changes in Condition Assessment Guidelines (File Cards)- will be followed by the licensed nurse for the initial and when necessary the follow up assessment to detect change of condition by symptoms and categories. CARE PATHWAYS-to be used as needed when [DIAGNOSES REDACTED]. SBAR- Situation-Background-Assessment/Appearance - Request form is to be used for documentation prior to notifying physician/Nurse Practitioner or Physician Assistant. In addition, all residents with a change in condition will be added to the 24 hour report sheet and their attending physician and responsible party notified . .In services on new policy were initiated on [DATE] and were completed on [DATE]. DON, ADON, Staffing coordinator, MDS nurses, and CNAs were in-serviced on new procedure . The resident that triggered the IJ is deceased . All resident who had changes in condition and complain of constipation were reviewed and documented on the 24 hour report sheet. The residents who were alert and oriented were interview for recurrent constipation and pain . The facility was monitored on [DATE] and on [DATE] with the following results: Observations were made from [DATE]-[DATE]/16 to ensure adequate supervision was provided and constipation issues were being addressed by staff. Interviews were conducted from [DATE]-[DATE] with CNAs, Nurses, administration and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services related to changes in condition, issues related to constipation, abdominal pain, documentation, etc. Record review of in-services conducted from [DATE] to [DATE] revealed that staff had been trained on changes in condition, assessments, documentation, etc. Record review also revealed that the facility assessed the facility residents between [DATE] and [DATE] to ensure no changes in condition were missed. In an interview with the DON on [DATE] at 12:53pm, when asked how the IJ came about she said that it was poor documentation and communication. She said that they would not have had the IJ if CR#1 was sent to the hospital in a timely manner. In an interview with the Administrator on [DATE] at 1:05 pm, he said that it was lack of communication between the staff. He said his staffs worked hard but the issue with CR#1 was a lack of communication. The Administrator and DON were informed on [DATE] at 7:10 p.m. that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at a pattern level due to facility needing more time to monitor the plan of removal for effectiveness. The facility DON reported there were 23 residents with [DIAGNOSES REDACTED].