Every finding on record at Parham Health Care & Rehab Center

Based on resident interviews, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment remained free of accident hazards and to provide adequate supervision and safety measures to protect residents from the likelihood of accidents and hazards from permitting smoking in an undesignated courtyard that did not have a means to extinguish a fire. This resulted in the identification of immediate jeopardy and substandard quality of care and had the potential to affect residents on three of three units within the facility. The facility staff also failed to ensure that the fire extinguisher in the designated smoking area was an approved and inspected extinguisher. The findings included:The facility staff permitted unsafe smoking practices by allowing residents to smoke in a non-designated area without appropriate supervision or having the required safety controls, which reflected a breakdown in systemic controls governing smoking safety, lack of enforcement of designated smoking areas, failure to implement safe disposal practices, and failure to mitigate known fire risks associated with combustible materials, all of which created a high probability of fire ignition and had the likelihood of causing serious injury, serious harm, or death to residents, staff, and visitors throughout the entire facility.On 3/17/2026 at approximately 1:24PM, Resident #10 was observed smoking in the non-designated courtyard area, extinguished a cigarette on the ground, and discarded it into a trash receptacle. Observations of the trash receptacle revealed a mixture of general trash that contained combustible materials, including paper cardboard, and plastic liners. At the time of observation: No Ashtrays or fire-safe disposal containers were present, no fire extinguisher or fire blanket was available, the trash receptacle contained combustible waste, and environmental conditions included high winds, which increased the fire ignition risk.A review of the clinical record revealed that Resident #10 was admitted to the facility on [DATE] for post-surgical rehabilitation. The MDS (Minimum Data Set) dated 1/8/26 revealed that Resident #10 had BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. Resident #10 had a smoking assessment conducted on admission to the facility which scored him as an Independent Smoker.On 3/17/26 approximately 2:00 p.m. an interview was conducted with LPN #1who stated that the courtyard off the parlor area is not a designated smoking area, but Residents do smoke out there sometimes. She further stated that the staff try to redirect them when they see them do it.On 3/18/26 at 10:15 a.m., the corporate maintenance technician stated that there has been no Director of Maintenance at the facility since [DATE]. He stated that he has been coming to the building to help since then. He stated that the responsibility for fire safety usually falls under maintenance and the Administrator. He stated that there is a checklist for what is supposed to be in the smoking courtyard.On 3/18/26 at approximately 10 :46 am, an interview was conducted with CNA #1who stated that she was assigned to supervise the designated smoking area. CNA #1 stated that residents can come out at any time while the staff member is working to smoke. CNA #1 identified the courtyard located across from room [ROOM NUMBER] [not the courtyard Resident #10 was seen smoking in] is the only designated smoking area. CNA #1 was asked how she knew who needed assistance and what type of assistance was needed. CNA #1 presented the logbook with resident photos and type of assistance needed. When asked what specific type of supplies are needed for assisting residents with smoking safety, she stated that they have a fireproof metal can for disposal of cigarette butts, a fire extinguisher, and smoking blanket. Observation of the fire extinguisher revealed there was no inspection tag or date on it.On 3/18/26 at approximately 11:00 am, an interview was conducted with the Corporate Maintenance Technician who stated that all fire extinguishers should be labeled and dated. When asked about the one located in the smoking courtyard, he stated that it appears to be store bought and was not ordered through their vendor. He also confirmed there was no evidence that the fire extinguisher had been inspected.A review of the smoking policy revealed the following: Policy #1019: . 2. The Administrator will designate areas outside of the building for any smoking activities. 3. The designated area on the grounds must: a. be well ventilated, b. not allow passive smoke to re-circulate into the building, c. strictly prohibit the use and or storage of oxygen, d. have access to ashtrays of noncombustible material and safe design. 5 Based on the Smoking Safety Assessment a patient may smoke in the designated area either independently or with supervision,.6. If supervision is required, the patient will be supervised by staff or other appropriate person (i.e., family member). 7. The center will maintain all smoking paraphernalia for patients who require supervision with smoking. Patients who do not require supervision with smoking may maintain possession of their own smoking paraphernalia.On 3/18/26 at 3:00 p.m., the survey team met with the facility administrator and director of nursing and notified them that the survey team had identified immediate jeopardy for accident hazards as the non-compliance created a high probability of fire ignition which had the potential and likelihood of serious injury, serious harm, or death to residents, staff, and visitors. The immediate jeopardy began on 3/17/26.The facility submitted the initial IJ removal plan on 3/18/26 at 5:40 p.m. The removal plan read, Plan Corrective Action for those residents found to be affected by the deficient practice:Resident #10 was placed on 1:1 observation on 3/17/26 for safety reasons due to smoking in an unauthorized area. Resident #10 was re-educated on the smoking policy and procedure, to include smoking location, cigarette disposal, on 3/17/26. Locks were ordered 3/17/26 to be installed to the courtyard doors on 3/18/26 to prevent unauthorized smoking. Lock installation on the non-designated courtyard began at 1:00 pm on 3/18/26.Corrective Actions taken for residents with potential to be affected by deficient practice. All residents have the potential to be affected by the deficient practice. The Facility Administrator will conduct a town hall meeting on 3/18/26 at 7 p.m. with the residents that smoke and review facility smoking policy to include locations, cigarette disposal and consequences for non -compliance could lead to suspension of smoking privileges or potential discharge. All residents that smoke will have a new smoking policy acknowledgement obtained.Systemic Changes put into place to ensure the deficient practice does not recur:The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Dietary Manager, Business Office Manager, Human Resources, Rehab Director, and Unit Managers) will be educated by the [NAME] President of Operations on smoking policy and designated smoking areas. The Facility Staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas. No employee will be allowed to work until educated.Monitoring of corrective action to ensure the deficient practice does not recur.The Administrator or designee will conduct weekly environmental safety rounds three times a week for (4) weeks, then monthly audits for (2) months to ensure no resident is smoking in a non-designated smoking area.The facility will be complete with plan for removal of the Immediate Jeopardy 3/19/26 at 12:00 p.m.The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 3/18/26 at 4:10 p.m. On 3/19/26, the survey team conducted interviews with various facility staff from all departments. The staff were able to answer questions regarding the smoking policy and were able to properly identify the designated smoking areas, materials that should be available in those areas fireproof disposal container, fire blanket, fire extinguisher, and book with resident photos and type of assistance required if any. On 3/19/26, interviews were conducted with the residents of the facility that smoke and they were able to identify the correct smoking courtyard and that smoking was allowed 7 am - 7 pm. The independent smokers were aware that they are allowed to maintain their smoking implements per the facility's smoking policy. They were able to smoke within the hours provided and in the designated areas. The residents who require assistance were aware they should only be supervised in the designated smoking area with staff. On 3/19/26, the survey team reviewed the in-service records, town hall meeting minutes, reviewed the Patient Smoking Acknowledgement forms, and checked the designated smoking area for proper equipment and supplies for smoking safety. Immediate Jeopardy was removed at 3:00 pm on 3/19/26, at which time the scope and severity was lowered to a level two isolated.The facility provided no additional information prior to the conclusion of the survey.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for fifteen occurrences affecting one resident (Resident #201-R201) in a survey sample of 14 residents.The findings included: For R201 the facility staff failed to obtain blood pressure prior to administering his blood pressure medication as ordered by the physician on 15 occasions, which put the resident at risk for a hypotensive event(s) [event where the blood pressur drops too low]. R201was admitted to the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension. R201's most recent MDS (Minimum Data Set) with anARD (Assessment Reference Date) of 2/18/26 coded R201 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible score of 15, indicating the resident has no cognitive impairment. The MDS section gg coded the resident as 1 dependent on staff for all aspects of ADL care to include feeding, bathing, dressing, grooming and toileting. R201 requires the use of a mechanical lift for transfers and uses an electric wheelchair for ambulation. On 4/14/26 at 10:00 am a review of the clinical record for R201 revealed that R201 had an order that read: Nifedipine ER Extended Release 24-hour 30 mg Give 1 tablet by mouth one time a day for hypertension hold if sys BP less than 120 order date 6/2/25. A review of the MAR (Medication Administration Record) revealed that from 3/31/26 through 4/14/26 there were no recorded blood pressures prior to the administration of the medication Nifedipine. On 4/14/26 at approximately 1:00 pm an interview was conducted with LPN 3 who stated that blood pressures are not automatically taken when administering blood pressure medications. She stated that if there is an order for blood pressure to be obtained prior to administering the blood pressure medication it would be recorded on the MAR. LPN 3 also stated that they document blood pressures in the electronic health record (EHR). LPN 3 looked in her computer and could not find any recorded blood pressures prior to administration of Nifedipine. LPN 3 stated that nurses should read the orders prior to the administration of any medication. LPN 3 stated that the danger of not checking the blood pressure prior to the administration of the medication is that if the pressure is too low and the medication needs to be held you would not know it and the resident's blood pressure could bottom out. On 4/14/26 at approximately 2:45 pm the DON and Administrator were made aware of the concern and the DON stated that the blood pressure was checked and the medication was discontinued due to the resident no longer needing the medication. According to the American Heart Association, .Symptoms of low blood pressure: Constantly low blood pressure can be dangerous if it causes signs and symptoms such as: Confusion, Dizziness, Nausea, Fainting, Fatigue, Neck or back pain, Headache, Blurred vision, Heart palpitations, or feelings that your heart is skipping a beat, fluttering or beating too hard or too fast . Accessed online at: https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low

Based on observation, family interview, staff interviews, and clinical record review, the facility staff failed to provide a provider ordered mechanically altered diet for one of forty-three sampled residents (R)119 resulting in harm. R119 developed pneumonia and required antibiotic treatment.The findings included:R119's diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction.R119's hospital Discharge summary dated [DATE] included dietary orders for a pureed diet.Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate the resident was on a mechanically altered diet.R119's comprehensive care plan (CCP) included the focus area at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, requiring assistance to eat and dysphagia requiring puree diet. Date initiated 12/22/25.R119's clinical record included a provider order dated 12/19/25 for a Regular diet, Dysphagia Advanced texture, Thin Liquids consistency. On 12/22/25 this diet order was changed to include downgrade to puree per recommendations from hospital.On 02/11/26 at 1:10 p.m., the surveyor observed R119 eating lunch. Certified Nursing Assistant (C.N.A.) #4 was standing beside R119 and stated she was not allowing R119 to eat their chicken as she had a question about the consistency. Per request of the surveyor the Dietician and Speech Language Pathologist (SLP) observed the meal tray. The dietician stated the chicken could use more liquid and the SLP stated the chicken was a mixture of mechanically altered and pureed. When asked if it would be safe for R119 to consume the chicken the SLP stated that knowing this resident it would not be safe for them to eat. The tray ticket that accompanied this meal listed puree crispy chicken thigh as an entree.During a family interview on 02/11/26 at 1:20 p.m., this family member expressed concerns over R119 not receiving their correct diet and stated that on super bowl Sunday (02/08/26) R119 was provided with a milkshake that contained Oreo cookies and Reese's Pieces and on three occasions the facility staff had provided R119 with the wrong meal trays. On 02/11/26 the administrative staff terminated C.N.A. #5 for providing R119 the wrong texture milkshake on 02/08/26. This milkshake was described as a milkshake with Oreo's. The facility administrative staff provided the surveyor with emails regarding this incident. In the first email C.N.A. #5 stated she apologized for the mistake involving providing a milkshake with Oreos to a resident who is on a puree diet. The second email stated they would like to clarify that there was a mistake and misunderstanding regarding the milkshake. The milkshake the patient received was safe and appropriate for him to consume on his puree diet. The Oreo milkshake was not given to the patient.R119 was seen by the provider at the facility on 02/11/26 this provider documented .seen today for SNF [skilled nursing facility] follow-up. Chest radiograph obtained today revealed infiltrate consistent with recurrent aspiration pneumonia. It was reported that he recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Given this represents his second pneumonia treatment course in recent weeks, he has been initiated on Augmentin and doxycycline antibiotic therapy. Following discussion with son, prednisone dosage has been increased to 10 mg daily for a seven-day course, after which it will be reduced back to his baseline dose of 5 mg daily. Additionally, a probiotic has been ordered to prevent Clostridioides difficile infection given the recurrent antibiotic exposure.On 02/11/26 at 4:23 p.m., during an interview with R130 this resident confirmed he had door dashed on super bowl Sunday and obtained a cookies and cream milkshake for R119. R130 stated he had told the person who was taking his order to grind up the pieces because the resident was on a puree diet. When asked if he was sure R119 had consumed the item R130 stated Oh yeah I saw him later he said it was good and his son was picky about what he ate. The above issues were reviewed with the Administrator, Director of Nursing (DON), and Regional Nurse on 02/12/26 at 3:01 p.m. and again on 02/13/26 at 12:00 p.m.In addition to R119 being served the milkshake with candy pieces on 02/08/26 and non-pureed chicken on 02/11/26, the DON provided documentation which indicated R119 also received the wrong diet during the weekend of 12/20/25-12/21/25 and provided the survey team with an AD HOC (as needed) quality assurance and performance improvement plan (QAPI) for R119 dated 12/22/25 with a date of compliance of 01/26/26. The plan addressed The resident had the wrong diet served to him which the resident did eat, over the weekend. A chest X ray was ordered and obtained on 12/23/25 with the findings reading Patchy densities are noted involving the perihilar regions.Bilateral perihilar atelectasis/infiltrate. On 12/24/15 the provider ordered the antibiotic Avelox 1 tablet by mouth one time a day for pneumonia. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain resident clinical records in a manner to ensure privacy and confidentiality of records, on two of three nursing units (Central and [NAME] wings). The findings included:The facility staff failed to maintain resident's clinical record access in a manner to safeguard and protect the content of information from authorized disclosure by allowing facility staff to use personal computers for daily tasks on two nursing units. On 2/12/26 at 9:30 AM, observations were conducted on each of the units. Observations revealed that six of the facility nurses working on the central and west wings, were utilizing their own personal laptop computers to access resident clinical records and documents. On 2/12/26 at 9:30- 10 AM, interviews were conducted with the facility staff about the use of their personal computers. The staff reported, They don't have enough computers, there is only one on this unit and there is no charger for it. They are missing chargers, so I bring my own computer. They aren't charged and it makes me late on passing medications, so I bring my own. The employees/nurses reported that they cannot access the clinical records of residents when they are offsite using their personal computers. On 2/12/26 at 2:46 PM, during a meeting with the facility administrator, director of nursing and regional director of clinical services (RDCS), the above concerns were shared. The RDCS stated that facility staff were not to use their personal computers. The RDCS stated that the staff were not able to access the electronic health record of residents when they are not on the facility's network. The discussion was held that there was no system to ensure that facility staff did not save residents' personal medical information or personal identifying information on personal computers for later use. The RDCS went on to state that the management staff could provide the nursing staff with their facility issued laptop computers to use versus staff utilizing their personal computers. During the above meeting, the facility administrator stated that she had sent nine computers back recently and had ordered nine more. When asked what the turnaround time on that was and when the replacement computers would be received, the administrator stated she did not know. According to a facility document titled, Technology & Information Systems Acknowledgement which was updated 09/2023, it read in part, . Employees should use company computers and information systems primarily for company business only. No additional information was provided.

Based on observation, resident interviews, staff interviews and facility documentation review, the facility staff failed to provide a functional, sanitary and comfortable environment for residents on 3 of 3 units.The findings included:1.On all three units, the facility failed to provide enough linen, including wash cloths, towels, and bed linens to care for residents. On 2/10/2026 at 2:45 p.m., an interview was conducted with Resident # 122 who resided on the East Wing. Resident # 122 was alert and oriented with a BIMS score of 15/15 indicating no cognitive impairment. Resident # 122 stated she often had to wait long periods of time for the staff to provide incontinence care because they do not have enough linen. Resident # 122 stated she sometimes had to wait hours until linen was available so that incontinence care could be provided On 2/10/2026 at approximately 2:55 p.m., observations were made on all Resident care units. The linen carts on all three units/halls contained a scarce amount of linen. On 2/12/2026 at 3:10 p.m., an observation was made on the East Wing, revealing a scarce amount of linen available. The linen cart on the East Unit contained only 4 blankets, 8 gowns, wash cloths, 4 towels and 2 fitted sheet, 1 blue incontinence pad, two light weight blankets, and 2 pillow cases. Staff interviews with CNAs (certified nursing assistants) 1,2 and 6 all revealed that frequently they do not have enough linen. When asked what they do if a Resident has an incontinence episode, each of the CNAs reported they must go to other units to see if they can find linen. One of the CNAs, who asked to remain anonymous, stated that the facility just doesn't have adequate linens to provide for Resident care needs. That CNA also said that the linen carts would be stocked for the night shift but the day or evening shift might need linens prior to the start of the night shift to clean Residents. She stated, it's like that all the time. On 2/11/2026 at 2:45 p.m., an interview was conducted with the Housekeeping Director who stated there were issues with the linen. He stated he did not have staff to launder them. Stated he was going to check the Par levels- pull the information On 2/12/2026 at 2:03 p.m., the Housekeeping Director provided the survey team with a copy of the Monthly Linen Inventory Sheet evidence of linen being ordered. The Housekeeping Director stated the facility was going to place their monthly order. He stated we already placed a supplementary order for 600 towels on 2/7/2026 after review of the back-up linen supply. On 2/12/2026 during the end of day debriefing, the Administrator, Director of Nursing and Regional Director of Clinical Services were informed of the findings. They stated that it was important to have sufficient linen to provide care to meet the needs of the Residents. On 2/12/2026 during the end of day debriefing, the Administrator, Director of Nursing and Regional Director of Clinical Services were informed of the findings. They stated that it was important to have sufficient linen to provide care to meet the needs of the Residents. No further information was provided. 2. During the initial tour of the East Wing, the floors of the hallways were observed to be dirty. There was debris and build-up of dirt noted in the corners. During tour of the East Wing, there were several observations of the facility being unclean The observations included: dirty floors, dirty towels under bins in one resident's room (Resident # 143) and gnats in the dirty water fountain. There were floors in the corridors that were dirty with debris in the corners. Three hand sanitizing dispensers outside of resident rooms were observed to be dirty with white debris caked on the bottom dish. Some dispensers were empty but with dirty casings. On 2/10/2026 at 11:45 a.m. during the initial tour of Resident # 143's room, observed wet towels with dark orangish-brown stains on the floor under bins by the window. On 2/10/2026 at 2:07 p.m., the stains appeared to be getting bigger on the towels. On 2/11/2026 at 10:45 a.m., the situation was noted to be the same. On 2/11/2026 at 11:00 a.m., an interview was conducted with the housekeeping Director. He stated that the housekeeping staff were expected to clean the residents' rooms, clean the floors and spills but they do not move the personal belongings of the residents. On 2/12/2026 during an afternoon tour of the unit, observed the Water fountain located near the East Wing nurses station -soiled near the drain- approximately 5-inch brownish stain noted around the drain-gnats came out of the drain when the button was pressed to have water flow. Water did flow from the spigot, and several gnats came out of the drain. The Unit Manager for East Wing and the Regional Director of Clinical Services were standing in the hallway directly in front of the nurses station approximately 4 feet from the surveyor. They both saw the gnats and came over to the water fountain. The Unit Manager stated the stain looked like the Med Pass Nutritional supplement that nurses administer during medication pass and pour. She pointed to the container of Med Pass located on top of the medication cart that was located in the hallway near the nurse's station. When asked if the nurses pour the medication or supplement down the drain, the Unit Manager stated no but it's the residents. The Unit Manager was asked if nurses were expected to ensure residents consume medications and/or supplements during the medication administration pass. She stated yes. The Activities Coordinator immediately came over with cleaner and started cleaning the water fountain drain. Gnats were flying over the water fountain and landing on the walls. There were no Housekeeping staff noted in the area. There were residents in the corridor near the nurses station. The Regional Director of Clinical Services asked the staff to put a plastic bag over the water fountain. A staff member was observed placing a large clear plastic bag over the water fountain. During the end of day debriefings on 2/12/2026 and 2/13/2026, the Administrator, Regional Director of Clinical Services and the Director of Nursing were informed of the findings. They stated residents should have a clean, safe and comfortable environment. They also stated nurses should ensure that residents swallow the medication or supplement and do not pour down the water fountain drain. No further information was provided. 3. For R125, the residents' room was observed by the surveyor to have clothes piled up on the floor, dirty dishes on the over the bed table, debris scattered throughout the floor, and a brown substance on the floor in the bathroom and inside the resident's doorway. R125 diagnoses included metabolic encephalopathy, aphasia, hemiplegia and hemiparesis. Section C (cognitive patterns) of R125's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/04/26 included a brief interview for mental status (BIMS) score of 6 of a possible 15 points, indicating R125 was severely impaired in cognitive skills for daily decision making. R125's comprehensive care plan included the focus area requires assistance with activities of daily living and resident has behaviors interventions included 1:1 until seen by provider. This resident did not have a roommate at the time of the survey. During initial tour on 02/10/26 R125's room was observed by the surveyor to have clothes on the floor piled up in a corner, debris on the floor, dirty dishes on the over the bed table, and a brown substance on the floor at the doorway and on the bathroom floor. Resident #125 was not in their room. On 02/12/26 at 1:40 p.m., during an interview with the Bench Manager, this staff stated the personal items and dishes should have been cleaned and removed by nursing and housekeeping should have cleaned whatever the brown substance was on the floor. This staff stated housekeeping work from 7:00 a.m. to 4:30 p.m. daily. On 02/13/26 at 12:00 p.m., during a meeting with the Administrator, Director of Nursing (DON), and Regional Nurse #1 and #2 the issues with R125's room were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Residents #126 and #127, who shared a room on the west wing, the facility staff failed to maintain a sanitary and comfortable environment. On 2/10/26 at 11:41 AM, during a tour of the west wing, Resident #126 and #127's room was observed from the hallway. The room was in disarray with refuse throughout the floor and a pile of paper trash on the floor in front of the bedside tables. The floors were soiled. In the resident's bathroom was debris. On 2/10/26 at 11:42 AM, the surveyor entered the room and interviewed both residents. Resident #126 reported it had been four days since someone came in the clean. Resident #127 stated, They don't clean every day, maybe every other day, but it depends on who is working. 5. In the window across from the therapy gym, the window had an abundance of cobwebs present for the duration of the survey. Throughout each day of the survey, the window across from the therapy gym that looked into an enclosed courtyard had cobwebs in the window. Just below that was a spider web that had also been present throughout the survey. On 2/10/26 an interview was conducted with one of the housekeepers, (housekeeper #1). Housekeeper #1 reported that there are three housekeepers per day for the entire facility and said, it used to be four but it got cut back. Housekeeper #1 went on to explain that each room is to be cleaned daily which included, sweeping and mopping the floor, wiping high touch surfaces, cleaning the bathroom, etc. When asked if the housekeepers are able to get to each room daily, housekeeper #1 said, I am able to get to every room, because sometimes I work until 9:30 PM to get it done. Housekeeper #1 went on to say that when she returns from being off on the weekend, it looks like a bomb went off. On 2/12/26 at 1:21 PM, an interview was conducted with the housekeeping bench manager/regional housekeeping director (RHD). When asked about the duties of the housekeepers, the RHD said, housekeepers know their assigned halls and it is color coded for common areas too. They have a binder on their cart with a map and layout of the facility that has rooms assigned with a list of what to do. When asked about the number of housekeepers, the RDH said, lately they have only had 3 housekeepers per day. It is difficult to get staffing; we are using a temporary staffing agency. When asked if he was aware that some residents and staff report cleaning is not occurring on weekends, the RHD said, This weekend there will be a manager covering weekends. I was not aware and not informed of things were not being done. The RHD explained, they [the housekeepers] do general housekeeping in the morning of all the rooms, sweep, mop, dusting, wipe surfaces and after lunch they tidy up and look for spills. The above areas of concern were discussed and the RHD agreed that it was not sanitary or comfortable and said, Absolutely not acceptable. On 2/12/26 at 2:13 PM, an interview was conducted with two additional housekeepers, (housekeepers #4 & #5). Both reported they used to have 5-6 housekeepers per day and now only have three. They reported it changed about six months ago and now only have three to four per day and they team up to get the work accomplished. The facility policy titled, Daily Resident/Patient Room Cleaning was received and reviewed. The policy read in part, .The room cleaning tasks should be performed in the following order: 1. Straighten up the resident's room; 2. Dust all flat surfaces with a cloth disinfectant, clean the air vent covers, and spot clean all necessary areas; 3. Dust mop the floor and sweep all trash and debris to the door and pick it up with the dustpan. 4. Empty and clean the trashcans and put in a new liner if necessary. 5. Wet mop the room using disinfectant, ensuring a CAUTION floor sign is in use. On 2/12/26, during an end of day meeting the above findings were discussed with the facility Administrator, director of nursing and regional director of clinical services (RDCS). Following the end of day meeting, the facility administrator and RDCS accompanied a surveyor to the hallway at the therapy gym, some of the resident rooms identified above and was shown some of the findings. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to follow infection control standards during medication administration on one of three units (west wing), involving four residents. The findings included:On the west wing licensed practical nurse #3 (LPN #3) failed to follow infection control standards during medication administration to prevent the spread of infection. Continuous observations revealed in a 42-minute period and following administration of medications to four residents, LPN #3 failed to perform any hand hygiene and failed to perform any cleaning/disinfecting of a glucometer. On 2/12/26 at 10:40 AM, observations of medication administration were conducted with a licensed practical nurse (LPN #3). The surveyor notified the nurse that the surveyor wanted to do a narc count when she was at a stopping point. LPN #3 was observed to have long artificial nails. Resident #132 (R132) came out of his room and the nurse (LPN #3) said she wanted to give him his medication and check his blood sugar before he left the unit. The nurse pulled two OTC medications out of a bottle by inserting her finger into the bottle and using her fingernail to scoop the pill out of the bottle. LPN #3 removed packages of medications that were pre-packaged by the pharmacy, LPN #3 then proceeded to remove the medication from the card into her bare hand then placed the pills into the medication cup. During this process, one of the pills fell onto the top of medication cart, LPN #3 then proceeded to pick up the pill with her barehand and place the pill into the medication cup. LPN #3 entered R132's room, put on gloves and checked the resident's blood sugar using a glucometer and provided the medication. LPN #3 returned to the medication cart, disposed of the lancet, medication cup, and gloves and placed the glucometer onto the top of the medication cart and began documenting on the computer, without performing any hand hygiene. On 2/12/26 at 10:52 AM, Resident #133 (R133) exited her room and approached LPN #3 at the medication cart in the hall and said that she had an appointment, her ride was waiting and she needed her medication. LPN #3 then proceeded to retrieve R133's medications. LPN #3 removed medications from the packages by putting them into the palm of her bare hand, before placing them into the medication cup. LPN #3 then placed the glucometer into the medication cart drawer, without any disinfecting of it and entered R133's room to administer medications. LPN #3 then exited the room and returned to the medication cart without performing any hand hygiene. On 2/12/26 at 10:57 AM, LPN #3 and the surveyor conducted a narcotic count and no concerns were noted. LPN #3 had still not performed any hand hygiene. On 2/12/26 at 11:03 AM, LPN #3 began medication pass for Resident #134 (R134). LPN #3 again putting medications into the palm of her hand before placing them into the medication cup. LPN #3 again removed medications from the bottle by putting her finger into the bottle and scooping the medication out with her fingernail then placed into the medication cup. While in R134's room to provide medication, while talking to the resident, LPN #3 was observed touching the footboard of the bed with her hands while talking to the resident. LPN #3 then exited the room and returned to the medication cart and started documenting via the computer, without performing hand hygiene. On 2/16/26 at 11:12 AM, LPN #3 began pulling medications for R134's roommate, resident #106 (R106). LPN #3 again placed the medications into the palm of her hand when removing them from the medication card before putting them into the medication cup. LPN #3 entered the room of R106, provided the medications and exited the room. On 2/16/26 at 11:14 AM, LPN #3 pushed the medication cart to the nursing station, removed her laptop computer from the medication cart, and placed it on the nursing station desk and sat down behind the nursing station and began working on the computer. On 2/16/26 at 11:17 AM, LPN #3 returned to the medication cart, prepared a dose of MiraLAX and then took it to R134, who remained in their room. LPN #3 exited the room and returned to the nursing station without performing any hand hygiene. LPN #3 then approached the treatment cart and began opening each drawer, moving around the contents before retrieving some wound supplies. LPN #3 took the wound care supplies to R134's room and left them with the resident. Upon leaving the room at 11:22 AM, LPN #3 was asked when she was going to perform hand hygiene. LPN #3 said, Normally I keep sanitizer in my pocket, but it was in my bag. I was going to wash them now. When asked why it was important to perform hand hygiene, LPN #3 said, So you don't spread germs between residents. On 2/16/26 at 11:30 AM, the director of nursing and regional director of clinical services were made aware of the above concerns. According to the facility policy titled, Handwashing Requirements with an effective date of 2/6/2020, it read in part, . Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections. The policy went on to read, 1. Hand hygiene can consist of handwashing with soap and water or use of an alcohol based hand rub (ABHR), ABHR should be used instead of soap and water in all clinical situations except when hands are visibly soiled. 1. The following is a list of some situations that require hand hygiene:. c. Before and after performing any invasive procedure (e.g. fingerstick blood sampling). E. Fingernails and Artificial Nails: 1. Keep fingernails short, neat, and trimmed. 2. A majority of bacterial growth occurs along the proximal 1 mm of the nail adjacent to the subungual skin. Chipped nail polish also harbors high levels of bacteria; therefore remove any chipped nail polish prior to performing direct patient care. The facility policy titled, General Guidelines for Medication Administration, with an effective date of 09-2018, was reviewed. The policy read in part, I. Preparation. 1. Medications are prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to prepare and administer medications. 2. Handwashing and Hand Sanitization: a. The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: i. Before beginning a medication pass. ii. Prior to handling any medication. iii. After coming into direct contact with a resident. c. Hand sanitization is done with a facility approved sanitizer. i. Between handwashing when returning to the medication cart or preparation area, ii. At regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. On 2/12/26, during an end of day meeting, the above findings were again reviewed with the facility administrator, director of nursing and regional director of clinical services. No additional information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for one resident (Resident #201- R201) in a survey sample of 14 residents.The findings included: For R201 the facility staff failed to obtain blood pressure prior to administering his blood pressure medication as ordered by the physician on 15 occasions, which put the resident at risk for hypotensive events (event where the blood pressure drops too low). R201was admitted to the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension. R201's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/18/26 coded R201 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible score of 15, indicating the resident has no cognitive impairment. The MDS section gg coded the resident as 1 dependent on staff for all aspects of ADL care to include feeding, bathing, dressing, grooming and toileting. R201 requires the use of a mechanical lift for transfers and uses an electric wheelchair for ambulation. On 4/14/26 at 10:00 am a review of the clinical record for R201 revealed that R201 had an order that read: Nifedipine ER Extended Release 24-hour 30 mg Give 1 tablet by mouth one time a day for hypertension hold if sys BP less than 120 order date 6/2/25. A review of the MAR (Medication Administration Record) revealed that from 3/31/26 through 4/14/26 there were no recorded blood pressures prior to the administration of the medication Nifedipine. On 4/14/26 at approximately 1:00 pm an interview was conducted with LPN 3 who stated that blood pressures are not automatically taken when administering blood pressure medications. She stated that if there is an order for blood pressure to be obtained prior to administering the blood pressure medication it would be recorded on the MAR. LPN 3 also stated that they document blood pressures in the electronic health record (EHR). LPN 3 looked in her computer and could not find any recorded blood pressures prior to administration of Nifedipine. LPN 3 stated that nurses should read the orders prior to the administration of any medication. LPN 3 stated that the danger of not checking the blood pressure prior to the administration of the medication is that if the pressure is too low and the medication needs to be held, the nurse would not know it and if the medication is given, the resident's blood pressure could bottom out. On 4/14/26 at approximately 2:45 pm the DON and Administrator were made aware of the concern and the DON stated that the blood pressure was checked and the medication was discontinued due to the resident no longer needing the medication. No further information was provided. According to the American Heart Association, .Symptoms of low blood pressure: Constantly low blood pressure can be dangerous if it causes signs and symptoms such as: Confusion, Dizziness, Nausea, Fainting, Fatigue, Neck or back pain, Headache, Blurred vision, Heart palpitations, or feelings that your heart is skipping a beat, fluttering or beating too hard or too fast . Accessed online at: https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respect resident's right to be free from misappropriation of property for one resident (Resident #121-R121) in a survey sample of 43 residents. The findings included:For R121, the facility staff failed to protect the residents' right to be free from misappropriation of property when clothes were delivered to the facility and the resident never received the items. On 2/10/26, a clinical record review was conducted of R121's chart. Review of the progress notes and care plan revealed no documentation regarding a request for R121's family to provide clothing or that clothing was received. On 2/10/26 at 3 PM, an interview was conducted with R121. R121 reported he recalled getting some new clothes a few months ago but couldn't recall what he received, who gave them to him, and said his memory wasn't perfect. On 2/12/26 the facility was asked to provide any grievances they had on file regarding R121. On 2/13/26, the facility provided a grievance that was filed by R121's family member dated 9/26/25. According to the grievance form it read, RP sent clothes to facility they were left at front desk, resident never received the clothes. The summary of investigation read, Facility searched but unable to locate. Resident sister will be reimbursed $119.34. Summary of Actions taken: Facility to reimburse missing items and spoke with family on labeling clothes. Attached was a receipt of delivery to the facility and a receipt for the clothes purchased. On 2/13/26 at 10:54 AM, during a phone call with R121's family member, they reported they had never received the reimbursement despite speaking with the facility leadership on several occasions. On 2/13/26 at 12:02 PM, the facility administrator confirmed that the reimbursement had not been sent to the family member despite the grievance indicating it had been and the administrator said, it [the reimbursement] was pending approval with the business office. The administrator stated she had requested it to be expedited and sent out that day. On 2/13/26 at 12:15 PM, during an end of day meeting with the facility administrator, director of nursing and regional director of clinical services the above concerns were discussed. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to respond to grievances for one resident (Resident #121-R121) in a survey sample of 43 residents. The findings included:On 2/10/26, a clinical record review was conducted of R121's chart. Review of the progress notes and care plan revealed no documentation regarding a request for R121's family to provide clothing. On 2/10/26 at 3 PM, an interview was conducted with R121. R121 reported he recalled getting some new clothes a few months ago but couldn't recall what he received and said his memory wasn't perfect. On 2/10/26, attempts were made to reach R121's family, designated representative, but were not successful. On 2/12/26 the facility was asked to provide any grievances they had on file regarding R121. On 2/13/26, the facility provided a grievance that was filed by R121's family member dated 9/26/25. According to the grievance form it read, RP sent clothes to facility they were left at front desk, resident never received the clothes. The summary of investigation read, Facility searched but unable to locate. Resident sister will be reimbursed $119.34. Summary of Actions taken: Facility to reimburse missing items and spoke with family on labeling clothes. Attached was a receipt of delivery to the facility and a receipt for the clothes purchased. On 2/13/26 at 10:54 AM, during a phone call with R121's family member, they reported they had never received the reimbursement. On 2/13/26 at 12:02 PM, the facility administrator confirmed that the reimbursement was pending approval with the business office. The administrator stated she had requested it to be expedited and sent out that day. On 2/13/26 at 12:15 PM, during an end of day meeting with the facility administrator, director of nursing and regional director of clinical services the above concerns were discussed regarding that lack of responding to a grievance filed on behalf of R121. No further information was provided.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the responsible party (RP) of a change in condition for one of forty-three residents (R) 119. The findings included:The facility staff failed to notify the RP of a fall that resulted in R119 being sent to the emergency room (ER). R119's diagnoses included vascular dementia, stridor, cerebral infarction, and dysphagia.Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making.R119's face sheet listed a family member as being the RP and emergency contact #1. R119's clinical record included a progress note documented by the nursing staff on 01/12/26 at 4:39 a.m. indicating R119 was .on the floor in his room.sustained a small bruise to his orbital area.On 01/12/26 at 1:29 p.m., the nursing staff documented R119 was sent to the ER.During the clinical record review, the surveyor was unable to locate any documentation that the RP had been notified of the fall or transfer to the ER.On 02/11/26 at approximately 4:20 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services the surveyor requested evidence that the RP had been notified of the fall and transfer to the ER on [DATE]. On 02/11/26 the facility staff provided the survey team with a copy of their policy titled, Significant Change of Condition effective date 01/29/24. This policy read in part, Procedure.Responsible party will be notified of a change of condition.On 02/12/26 at 2:35 p.m., the DON stated they were unable to find any notification to the RP of R119's fall. The DON stated the RP should have been notified when the resident fell and was stabilized. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement a person-centered comprehensive care plan (CCP) for one of forty -three residents, Resident (R) 119.The findings included:The facility staff failed to consistently implement R119's CCP regarding their puree diet and weekly weights. R119's diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction.Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate the resident was on a mechanically altered diet. R119's CCP included the focus area at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, requiring assistance to eat and dysphagia requiring puree diet. Interventions included weekly weights (date initiated 12/22/25).R119's clinical record included a provider order dated 12/19/25 for a Regular diet, Dysphagia Advanced texture, Thin Liquids consistency. On 12/22/25 this diet order was changed to include downgrade to puree per recommendations from hospital.During the clinical record review, the surveyor was only able to locate two documented weights the first being obtained on12/31/25 (158 pounds) and the second weight on 01/30/26 (157.3 pounds).On 02/11/26 at 1:10 p.m., the surveyor observed R119 eating lunch. Certified Nursing Assistant (C.N.A.) #4 was standing beside R119 and stated she was not allowing R119 to eat their chicken as she had a question about the consistency. Per request of the surveyor the Dietician and Speech Language Pathologist (SLP) observed the meal tray. The dietician stated the chicken could use more liquid and the SLP stated the chicken was a mixture of mechanically altered and pureed. When asked if it would be safe for R119 to consume the chicken the SLP stated that knowing this resident it would not be safe for them to eat. During a family interview on 02/11/26 at 1:20 p.m., this family member expressed concerns over R119 not receiving their correct diet and stated that on Super Bowl Sunday (02/08/26) R119 was provided with a milkshake that contained Oreo cookies and Reese's Pieces and on three occasions the facility staff had provided R119 with the wrong meal trays. On 02/11/26 the administrative staff terminated C.N.A. #5 for providing R119 the wrong texture milkshake.The issues with R119's person-centered CCP not being consistently implemented were reviewed with the Administrator, Director of Nursing (DON), and Regional Nurse on 02/12/26 at 3:01 p.m. and again on 02/13/26 at 12:00 p.m.The facility policy titled, Care Planning with an effective date of 11/01/19 read in part, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.No further information regarding these issues was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to protect the residents' right to be free from physical abuse by other residents for 11 of 48 residents in the survey sample, Residents #43, #12, #37, #40, #39, and #41, resulting in the identification of immediate jeopardy; and for Residents #48, #38, #24, #42, and #10. The findings include: 1. For Resident #43 (R43), the facility staff failed to protect the resident's right to be free from physical abuse on 7/30/25, resulting in harm to R43. On 7/30/25, Resident #43 was punched in the face by Resident #32, resulting in Resident #43 being transferred to the hospital for a trauma evaluation for bruising and facial lacerations. A review of a facility synopsis of events dated 7/30/25 revealed, in part: Resident [#32] brought Resident [#43] to Nurse.[R32] reported that [R43] was bleeding on his bed. [R43] reported 'Why do y'all let him keep beating me?' Residents were separated due to being roommates and [R32] moved and placed on 1:1.[R43 was assessed with noted injuries to face and general discomfort was expressed. Resident was sent out to hospital for eval (evaluation) and treat.[R43] only resident noted with injuries and discomfort.911 called. A review of R43's clinical record revealed the following progress notes dated 7/30/25: 10:30 p.m. Resident was being assisted out in the hallway by [Resident #32]. Upon assisting [R43] back in room, resident stated, 'Why do you keep letting him hit me like that?' Writer asked resident who he stated 'him.' Writer assisted resident to his wheelchair and assisted him to the desk. During assessment resident stated, 'My face and chest hurts.' Writer assessed resident, noted to (sic) bilateral eyes were both dark bluish like around his eyes, and laceration to left eye brow. Previous area to upper eye also bleeding noted. Writer made sure resident was safe.Resident seems to be slightly lethargic but responds to his baseline. 11:12 p.m. All disciplines made aware resident sent out to [name of local hospital] trauma unit for evaluation.11:48 p.m. Writer was informed by resident charge nurse that resident roommate had brought him out of the room by the arms when she noticed bruising to resident's face. Residents separated.Writer observed scratches to resident's forehead with bilateral orbital bruising. A review of R43's visit summary from the local hospital dated 7/31/25 revealed, in part: You were seen today for alleged assault, contusion of face. 2. For Resident #12 (R12), the facility staff failed to protect the resident's right to be free from physical abuse on 9/24/25. On 9/25/25, Resident #12 was punched in the face twice by Resident #32, resulting in five small abrasions on Resident #12's cheek bone. A review of a facility synopsis of events dated 9/24/25 revealed, in part: [Resident #12] reported to Activities Director that [R32] punched him in the face. [R12] asked the resident to 'come on by and move' so that he could pass through. [R32] stated that he felt he was being 'offended and didn't like it and he swung on him and didn't miss.' Residents were separated upon initial report and [R32] placed on 1:1. [R12] was assessed for further injuries with 5 small abrasions noted around the left cheek bone and left orbital (sic) of the eye. Neurochecks initiated. A review of R12's clinical record failed to reveal any note describing the altercation between R12 and R32. 3. For Resident #37 (R37), the facility staff failed to protect the resident's right to be free from physical abuse on 12/8/25, resulting in harm to R37. On 12/8/25, Resident #37 was punched in the head and face by Resident #32, who had orders for 1:1 supervision. This resulted in Resident #37's injuries requiring a provider's order for treatment. A review of a facility synopsis of events dated 12/8/25 revealed, in part: Staff reported that while in the Dining room [Resident #32] got up and struck [R37] in the face related to saying something to him that he couldn't recall when questioned by staff. Residents separated.First aide (sic) provided to [R37] and [R32] will continue with 1:1 services. A review of R37's clinical record revealed the following progress note dated 12/8/25: Brought to writer's attention that resident was being hit in the head repeatedly by another resident. Residents were separated. Injuries, small cut to right eye and some redness noted. A review of R37's revealed a new order dated 12/8/25 for cleansing of the R37's right eye and the application of triple antibiotic ointment to treat an injury sustained in the altercation with R32. 4. For Resident #40 (R40), the facility staff failed to protect the resident from being physically abused and assaulted by another resident (Resident #26-R26), who was known for having aggressive behaviors and was to have supervision while smoking, which is where/when the incident occurred. R40 sustained injuries which resulted in new physician orders for R40's injuries and orders for the resident to be evaluated at the hospital, which constituted harm. On 10/18/25, Resident #26 and #40 were in the designated smoking area. Both Residents #26 and #40 had been assessed to require supervision while smoking. Resident #26, who was known to have behaviors, pulled Resident #40 to the ground out of his wheelchair and began hitting Resident #40 in the face and head. The provider gave an order for Resident #40 to be transferred to the hospital for evaluation of his injuries. On 12/12/25 during a clinical record review of R26's chart, it was noted that he had an altercation with another resident. According to a nursing progress note dated 10/19/25 it read, Resident remains on 1:1 for physical assault. No behaviors observed or reported. In the week prior there was no documentation regarding details of an assault. On 12/12/25, the facility's director of nursing (DON) was asked to provide any information regarding an incident involving R26 in October. According to a facility incident summary dated 10/18/25, it noted R26 and R40 and read, CAN [sic] (certified nursing assistant) observed resident [name redacted] punch resident [R40's name redacted] in the face. Residents were immediately separated. Non-emergency services called treatment initiated. Resident [name redacted of another resident listed whose name was inaccurately noted in report] placed on 1:1. RP [responsible party], provider and police notified. Skin assessments and pain assessments were conducted for both residents. Resident [R40 name redacted] noted with abrasion to head. Investigation initiated. On 12/12/25, upon receipt of the facility documentation regarding the incident involving R26 and R40, the DON was asked about another resident identified in the incident summary. The DON acknowledged that the wrong resident had been noted in the report, and it should have been R26, who was the aggressor. The DON was asked about the incident and reported that it took place out front and stated it was in front of the facility. The DON could not give any further details about the incident. The facility provided in their documents a statement written by Resident #44 (R44). The statement read, I was sitting smoking when I heard [R26 name redacted] shouting profanity at another resident, next he wheeled over to him, grabbed him in the collar, and pulled him to the ground and proceeded to hit him with both fist about the head and face. I yelled several times for him to stop. He finally stopped after punching him four or five times. At this point the nurse [registered nurse #1- RN #1 name redacted] arrived. On 12/15/25, during a clinical record review of R26's chart it was noted that a Smoking Safety Screen was most recently conducted 8/27/25, prior to the incident. According to that safety screen, R26 was to have supervision while smoking. R26's care plan with a revision date of 10/27/25, read, Physical aggression towards staff/other residents- not easily redirected. interventions included, 1:1 related [sic], assure the resident they are safe if they become distressed, constant redirection with inappropriate behaviors or verbiage, monitor behaviors/concerns, psych referral PRN [as needed], provide medication list to resident and have him sign, psych eval [evaluation], psych services referral as needed, redirect resident to subjects that matter to them when behaviors occur, send out for psych eval. R26's clinical record also noted that the resident smoked cigarettes and had an intervention dated 5/21/25 that read, Supervise with smoking. On 12/15/25, during a clinical record review of R40's chart, a nursing progress note dated 10/18/25 read, EMS/ [emergency medical services] [locality redacted] Fire at facility to transport resident to ED [emergency department] d/t [due to] allegedly being pulled out of chair and hit in head multiple times by another resident. Resident noted with abrasion to top of scalp. Despite education and encouragement, resident refused to be taken to hospital. RP [responsible party] contacted x2 but unsuccessful, unable to leave message as voicemail was full. NP [nurse practitioner] notified, no new orders. On 10/18/25, a change in condition note was entered into R40's chart that noted, . Skin status evaluation: abrasion, pain status evaluation: Does the resident/patient have pain? Yes. R40 also had a new physician order dated 10/18/25 that read, wound care: Cleanse area to top right side of head with wound cleaner. Apply xeroform gauze and cover with band aid. Change daily as needed. According to R40's most recent smoking safety evaluation conducted prior to the incident, on 10/3/25, R40 required supervise with smoking. On 12/12/25 at 10:30 AM, an interview was conducted with R44. When asked about the incident R44 stated that they [multiple residents] were all in the smoking area. R44 identified that resident #41 (R41) and R40 were at a table talking. Resident #26 thought [R40's name redacted] said something to R41, but R40 had not opened his mouth. R26 then went over to R40 cursing at him. Everyone keep saying stop. R44 then stated that R26 grabbed R40 by the collar, pulled him to the ground and started punching him in the face. I rolled up and yelled at [R26's name redacted] to stop it! R44 went on to state that R40 sustained a cut on his head. R44 reported that no staff were present, and another resident came inside the facility to get help and [RN #1's name redacted] came. R44 explained that normally a staff member is present but I think the lady [employee scheduled to supervise smoking] was sick. R44 recalled there were about seven or eight residents in the smoking area but couldn't recall who the other residents were. When asked if R44 had seen R26 with behavior before, R44 said, Constantly. He is always cursing and fighting. When asked if R44 was afraid of R26, the resident said, I'm not, but a lot of people are. On 12/12/25 at 10:45 AM, an attempt was made to interview R41, but the resident was not available. On 12/12/25 at 11:52 AM, an interview was conducted with RN #1. RN #1 reported that the incident occurred a little before 4:30 PM. RN #1 said, One resident said a resident needed help. When I got out there, we got [R40's name redacted] back in the chair and blood was coming from the top of the scalp. They said [R26's name redacted] pulled him out of the chair and was hitting him. They were in the smoking area [enclosed courtyard] at the table and chairs designated for smokers. We brought [R40's name redacted] inside, cleaned the wound and called the nursing supervisor. When asked about R26's behaviors, RN #1 reported, he has a TBI [traumatic brain injury] and starts yelling and getting angry over nothing. RN #1 went on to report that the doctor wanted to send R40 to the hospital, but the resident refused. 5. For Resident #39 (R39), the facility staff failed to protect the resident's right to be free from physical abuse on 10/5/25. On 11/12/25, Resident #41 was punched in the chest by R7, who had a history of requiring additional supervision related to her behaviors A review of a facility synopsis of events dated 10/5/25 revealed, in part: [Resident #39] was trying to go into Family Parlor while [R7] was sitting in the entrance. When trying to pass by[R7] struck [R39] in the chest. Staff was informed of incident.Staff immediately separated both residents. [R7] was placed on 1:1. A review of R39's clinical record revealed the following progress note dated 10/5/25: Resident informed this nurse that another resident hit her with a closed fist in her chest for no apparent reason as she was attempting to wheel herself into the family pallor (sic) room. The other resident was positioned at the entrance of the family pallor (sic) room sitting in her wheelchair.Residents immediately separated for safety, aggressor placed on 1:1. 6. For Resident #41 (R41), the facility staff failed to protect the resident's right to be free from abuse on 11/12/25. A review of a facility synopsis of events dated 11/12/25 revealed, in part: [Resident #41] was sitting in her wheelchair being assisted down the hall by another resident going outside to courtyard when they came up to the double doors near the nurses desk.[R7] was blocking the hall, they asked her [to] 'please move.' She responded with 'No your mama.' [R41] asked her to repeat, 'what did you say, I can't hear you,' and [R7] fanned her hand toward [R41's] face and [R41] started yelling, 'She hit me right in the mouth.' LPN (licensed practical nurse) intervened and separated residents. [R7] placed on 1:1, skin, pain, and trauma assessment completed on residents with no abnormalities. A review of R41's clinical record revealed the following progress note dated 11/12/25: Resident was sitting in her wheelchair being assisted down the hall by another resident going outside to courtyard when they came up to the double doors near the nurses' desk.[Resident #7] was blocking the hall, they asked [R7] to please move and she responded with, 'No your [NAME].' [R39] asked her to repeat.and [R7] swung her hand near the face of [R39], and [R39] started yelling [R7] had hit her in the mouth. A review of R38's clinical record revealed the following progress note dated 10/13/25: [Resident #7] entered R38's room and was asked to leave several times. [R38] then adamantly told [R7] to leave room. [R7] then struck [R38] on her lower left back side. Residents separated. On 12/10/25 at 2:48 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated that physical abuse is when one resident intentionally hurts another resident. She added that abuse is one person doing something with the intent to harm another resident. She explained that it is the facility's responsibility to protect residents from abuse of any kind, whether from another resident, staff member, or visitor. On 12/16/25 at 10:16 a.m., OSM (other staff member) #5, the social services assistant, was interviewed. She stated that physical abuse is defined as someone hitting someone else or doing something that affects another person in a negative physical way. She added that all facility staff are responsible for protecting all residents from abuse. On 12/16/25 at 1:26 p.m., LPN (licensed practical nurse) #3, a unit manager was interviewed. She stated physical abuse is when someone hits, strikes, wounds, or injures a resident in an intentional manner. She stated that the facility staff is responsible for preventing any kind of abuse for all residents. On 12/17/25 at 10:02 a.m., OSM #8, the social services director, was interviewed. She stated that all residents should be free of physical abuse. She explained that any resident to resident altercation that resulted in one resident striking, hitting, injuring, or wounding another resident is considered physical abuse. On 12/10/25 at 2:48 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated that physical abuse is when one resident intentionally hurts another resident. She added that abuse is one person doing something with the intent to harm another resident. She explained that it is the facility's responsibility to protect residents from abuse of any kind, whether from another resident, staff member, or visitor. On 12/16/25 at 10:16 a.m., OSM (other staff member) #5, the social services assistant, was interviewed. She stated that physical abuse is defined as someone hitting someone else or doing something that affects another person in a negative physical way. She added that all facility staff are responsible for protecting all residents from abuse. On 12/16/25 at 1:26 p.m., LPN (licensed practical nurse) #3, a unit manager was interviewed. She stated physical abuse is when someone hits, strikes, wounds, or injures a resident in an intentional manner. She stated that the facility staff is responsible for preventing any kind of abuse for all residents. On 12/17/25 at 10:02 a.m., OSM #8, the social services director, was interviewed. She stated that all residents should be free of physical abuse. She explained that any resident to resident altercation that resulted in one resident striking, hitting, injuring, or wounding another resident is considered physical abuse. A review of the facility policy, Patient Protection, revealed, in part: There is zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center.Patients of the Center have the legal right to be free from verbal, sexual, mental, and physical abuse. The facility's deficient practice placed all facility residents at risk of being abused. This resulted in a determination of Immediate Jeopardy (IJ), cited at level four widespread. On 12/15/25 at 3:45 p.m., ASM #2 and ASM #3, the regional director of clinical services, were informed of these concerns and that the facility was in immediate jeopardy (IJ). On 12/15/25 at 8:00 p.m., the facility's IJ Removal Plan was accepted by the SA (state agency) supervisor. Facility Removal Plan Immediate Supervision. Resident #32, # 7, #26 is now under 1:1 supervision 24/7 being close proximities of resident to ensure that staff member can deescalate or intervene with any possible altercationsResident #40 will not be allowed to smoke unsupervised. Resident #26 will not be allowed to smoke unsupervised.A dedicated staff member has been assigned to always monitor residents 40 and #26 during smoking breaks. The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.Resident #37, #41, and #39 will have trauma screens performed on all resident that were abused by other residents. Resident #12 and #43 no longer resides in facility Corrective Actions taken for residents with potential to be affected by deficient practice All residents have the potential to be affected by this deficient practice. The Facility will educate all staff on the abuse policy. The DON or designee will educate on abuse and 1:1 ensuring that staff doing 1:1 being close proximities of resident to ensure that staff member is able to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door. The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient. Nursing staff on all shifts will document any unusual, increased, or change in behaviors will be reported and documented in the medical records. Then during clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.All residents that require supervised smoking have the potential to be affected by this deficient practice. Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision. Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required. The facility will schedule staff member to be in the courtyard while smoking occurs Systemic changes put into place to ensure the deficient practice does not reoccur:The Interdisciplinary Team( Director of Nursing, Assistant Director of Nursing, Social Services, Activities Director, Dietary Manager, Business Office Manager, Maintenance, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse. IDT will be educated on what a 1:1 entails which will includes maintaining arms length while inside and outside of the room. Nursing staff on all shifts will document any unusual, increased , or change in behaviors will be reported and documented in the medical records. Anyone providing 1:1 care will be scheduled by staffing that will have their relief person for break noted on schedule. Resident on 1:1 will be documented on daily by assigned staff that will be collected daily by charge nurse. Staff will be educated that you may not leave the resident until you have a relief person, you have to remain in close proximities of resident to ensure that staff member is able to deescalate or intervene with any possible altercations while on one to one inside and outside of room. The Regional Director of Clinical Services will also educate the IDT team on the need for supervision for residents identified as supervision while smoking on ensuring all residents requiring supervision are supervised while smoking. The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present. This education will be provided to all staff, and no employee will be allowed to work after 11:59 pm until they are educated to include agency staff. Monitoring for corrective actions to ensure deficient practice does not recur:While the resident remains in the facility, a monthly review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments .The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximities of resident to ensure that staff member is able to deescalate or intervene with any possible altercations. five times a week times 4 weeks then 3 times a week times 4 weeks. Facility will monitor all residents who have been identified as supervised smokers. All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds. If supervision is deemed necessary, the resident will be supervised by a designated staff.The DON or designee will audit residents who are supervised smokers five times a weeks for 4 weeks then 3 times a week times 4 weeks to ensure they are supervised while smoking. The facility alleges removal of the Immediate Jeopardy on 12/16/25 at 1900 (7:00 p.m.). On 12/17/25 at 9:08 a.m., the survey team began verification of the facility's removal plan. This verification process included observation of residents on 1:1 supervision, observation of residents in the smoking area, staff interviews on all elements of the plan, and review of all smoking safety assessments and trauma screens completed as part of the abatement plan. The survey team was able to verify that the facility completed the abatement plan on 12/16/25 at 10:22 p.m. After Immediate Jeopardy was removed, the scope and severity were lowered to level three pattern. 7. For Resident #48 (R48), the facility staff failed to protect the resident's right to be free from physical abuse by another resident (Resident #26- R26). On 12/15/25-12/16/25, during a clinical record review of R26's chart, it was noted that on 10/18/25, R26 assaulted another resident and was placed on one-to-one observations. There was almost daily entries in R26's progress notes of behaviors from 10/18/25-10/25/25. According to a nursing note entry dated 10/25/25 at 1 AM, which read, Writer was called to the unit by the charge nurse to assess Resident [R26's name redacted] who hit another resident also threaten and accuse the charge nurse of not given him his medication and loud verbalization causing peers to be alarmed/frighten. Resident was not able to be deescalated for some time frame for at least 30 to 45 minutes so 911, DON [director of nursing] and Provider was called. 911 team responded, felt that he should go to the hospital because if he was to have a repeat episode other resident or staff may be harmed since he could not be restrained. Resident [R26's name redacted] R/P (responsible party) was called no answer message left for her to call the facility Resident was sent out to hospital to be evaluated since this was the second incident within last 12 hours Resident [R26's name redacted] have a DX. [diagnosis] TTAUMATIC [sic] brain injury which could be worsening [sic]. There was an additional progress note in R26's chart dated 10/25/25 at 1 AM, that read, Nurses was checking in the room since he is a 1 on 1 on the other patient and the resident stated he never got his medication. Both nurses informed him that he did in fact receive his medication and that he cannot get any more at the time. The resident then stated that he would know if he got his medication and that we were liars. Nurses attempted to deescalate the situation, and he got even more agitated. Resident got up and cursed out the nurse and stated he was going to kill her if he got his hands on her. He then chased her around the facility and punch another resident in the face in the process. Non-pharmacological Intervention: Staffed reassured him that he got his medication and attempted to deescalate the situation. Outcome: Resident has been sent to hospital for reevaluation. According to R26's physician orders, there was an order for Resident on 1:1 supervision initiated on 10/18/25 which was discontinued on 10/25/25 at 12:16 PM, following the resident being sent to the hospital for evaluation. Another progress note entry dated 10/25/25, indicated that the facility staff had spoken to hospital staff who were . looking for a BHU (behavioral health unit) bed for the resident. According to progress notes, the census tab, and physician orders, R26 returned to the facility on [DATE], at which time the one-to-one observation resumed. According to a progress note in R26's chart dated 10/28/25 at 11:01 PM, it read, Writer was at nurses station talking with resident [Resident #48's room number redacted] who was in front of nurse station near soiled utility room. As we where [sic] talking this resident [R26] could be heard coming down the main hallway (connecting all units)yelling out and cursing. Writer immediately came from behind nurses station due to [Resident #48's room number redacted] also going around nurses station to see who was yelling. When writer observed that it was this resident [R26] I stepped in between both parties as this resident was attempting to lunge toward resident [Resident #48's room number redacted] and fell onto his buttocks out the w/c [wheel chair] in front ice machine room. Resident was yelling I didn't forget you stupid mother fucker, you wanna pick on somebody in a w/c, I'll kill you I have killed all the people that needed to be killed, You bitch ass ni**** come on I'm ready to die, come on mother ***** hit me what you go do I'm a cripple but I still will beat you're a$$. Resident continued with behaviors and threats. Other staff members ran to assist resident in calming down and to assist resident back in w/c after assessing that he did not have any injuries and writer continued to stay in between both residents. Resident in [Resident #48's room number redacted] kept telling resident to leave him alone, this not what you want I'm telling you. informed him not to say any thing d/t [due to] it further increased this resident's agitation. This resident was removed from the unit and taken back to his unit, had calmed down shortly after redirection and change of subject. Stated he was tired and wanted to go to bed. His nurse and supervisor made aware of incident and that no physical contact was made between resident's. On 12/16/25, the director of nursing (DON) was asked to provide any information she had regarding R26's incident with another resident on 10/25/25, to identify who the other resident was. On 12/16/25, the DON provided the surveyor with an incident summary that identified Resident #48. The facility's incident summary noted, Staff reported that resident [R26's name redacted] was arguing with staff and when resident [R48's name redacted] walked out the room to see what was going on resident [R26's name redacted] punched him [R48] in the face. Residents separated. On 12/16/25, a clinical record review of R48's chart was performed. A nursing note entry dated 10/25/25 read, Resident was standing in the hall while another resident was being aggressive and got struck in the face. There was another progress note in R48's chart dated 10/28/25 at 21:15 that read, Writer prevented resident from altercation with another resident: As resident was talking with writer at nurses station resident room [Resident #26's room number redacted] came down hallway yelling and cursing. Writer stepped in between residents as [Resident #26's room number redacted] lunged at this resident. [Resident #26's room number redacted] fell onto floor out of w/c [wheelchair] because of this action. This resident kept telling [Resident #26's room number redacted] to go ahead and leave him alone, this is not what he want. Writer informed resident that it was best if he did not say anything d/t [due to] increased agitation of [Resident #26's room number redacted]. Residents was kept separated and resident [Resident #26's room number redacted] was removed from the unit no physical contact between residents was made. Supervisor made aware of incident. Resident is own RP [responsible party]. 8. For Resident #38 (R38), the facility staff failed to protect the resident's right to be free from physical abuse on 10/13/25. A review of a facility synopsis of events dated 10/13/25 revealed, in part: [R7] was noted sitting in the doorway of [Resident #38's] door. When [R38] attempted to move her wheelchair, she was swatted at her (sic) leg striking her leg wi

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care, services, and supervision for resident safety for six of 48 residents in the survey sample, Residents #32, #7, #40, and #26, resulting in the identification of immediate jeopardy; and for Residents #48, and #45. The findings include:1. For Resident #32 (R32), on three occasions in 2025, the resident physically assaulted other residents, despite being known to have had previous aggressive behaviors, and, in one instance, being under a provider's orders for 1:1 supervision. The lack of supervision of R32 resulted in harm to two victims, Residents #43 and #37. On 7/30/25, Resident #32 punched Resident #43 in the face, resulting in Resident #43 being transferred to the hospital for a trauma evaluation for bruising and facial lacerations. On 9/25/25, Resident #32 punched Resident #12 in the face twice, which resulted in five small abrasions on the cheek bone. On 12/8/25, Resident #32, who had orders for 1:1 supervision, punched Resident #37 in the head and face, requiring a provider's order for treatment of R#37's injuries. On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/21/25, R32 was coded as being moderately cognitively impaired, having scored nine out of 15 on the BIMS (brief interview for mental status). His diagnoses include TBI (traumatic brain injury) and intellectual disability. A review of R32's clinical record revealed facility concerns regarding his aggressive behaviors and orders for close supervision dating back to 5/24/25. This review revealed orders for 1:1 supervision on 5/4/25 and 6/3/25, as well as supervision sight checks every 30 minutes on multiple days in June 2025.A review of a facility synopsis of events dated 7/30/25 revealed, in part: Resident [#32] brought Resident [#43] to Nurse.[R32] reported that [R43] was bleeding on his bed. [R43] reported 'Why do y'all let him keep beating me?' Residents were separated due to being roommates and [R32] moved and placed on 1:1.[R43 was assessed with noted injuries to face and general discomfort was expressed. Resident was sent out to hospital for eval (evaluation) and treat.[R43] only resident noted with injuries and discomfort.911 called.R32's progress notes revealed no documentation regarding the description of this incident.A review of R32's care plan, initiated 3/14/23 and updated 5/27/25 revealed, in part: [R32 has behaviors r/t (related to) TBI with cognition impairment.physical aggression with a peer.verbal and physical aggression towards staff/other residents.physically aggressive with another resident.Continue to redirect from other residents when restless, agitated, aggressive to prevent altercations (5/27/25). R32's care plan revealed no evidence of review or revision of current interventions following the altercation on 7/30/25 with R43.A review of a facility synopsis of events dated 9/24/25 revealed, in part: [Resident #12] reported to Activities Director that [R32] punched him in the face. [R12] asked the resident to 'come on by and move' so that he could pass through. [R32] stated that he felt he was being 'offended and didn't like it and he swung on him and didn't miss.' Residents were separated upon initial report and [R32] placed on 1:1. [R12] was assessed for further injuries with 5 small abrasions noted around the left cheek bone and left orbital (sic) of the eye. Neurochecks initiated.Further review of R32's clinical record revealed the following progress note dated 9/25/25: Per nurse aide ran to nursing station to report that resident had punched another resident [Resident #12] in the face twice. Residents were separated and assessed for injuries. [R32] was questioned regarding the reason for the incident and what upset him to cause him to hit the other resident.[R32] was placed on 1:1 supervision. There was no evidence in the record that R12 required a provider's assessment or new orders immediately following this altercation.A review of R32's care plan initiated 3/114/23 revealed, in part: [R32] has behaviors r/t (related to) TBI (traumatic brain injury) with cognition impairment, restlessness, agitation, mood d/o (disorder), physical aggression with a peer.verbal and physical aggression towards staff/other residents. R32's care plan revealed no evidence of review or revision of current interventions following the altercation on 9/25/25 with R12.A review of R32's provider's orders revealed the following order dated 11/11/25 with no end date: 1:1 observation (during wake [sic] hours).A review of a facility synopsis of events dated 12/8/25 revealed, in part: Staff reported that while in the Dining room [R32] got up and struck [Resident #37] in the face related to saying something to him that he couldn't recall when questioned by staff. Residents separated.First aide (sic) provided to [R37] and [R32] will continue with 1:1 services.Further review of R32's clinical record revealed the following progress note dated 12/8/25: Behavior Note.Resident was sitting in dining room. While 1:1 sitter and another staff member was (sic) passing dinner trays, [R32] thought another resident said something to him. [R32] started punching the other resident on the head and face. Residents were immediately separated. When asked, [R32] could only say, 'He said something to me.' Witnesses present state that nothing was said to [R32]. 2. For Resident #7 (R7), on three occasions in 2025, the resident physically assaulted other residents, despite being known to have had previous aggressive behaviors.On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/10/26, R7 was coded as being severely cognitively impaired, having scored three out of 15 on the BIMS (brief interview for mental status). Her diagnoses include dementia with behaviors and psychosis.A review of a facility synopsis of events dated 10/5/25 revealed, in part: [Resident #39] was trying to go into Family Parlor while [R7] was sitting in the entrance. When trying to pass by[R7] struck [R39] in the chest. Staff was informed of incident.Staff immediately separated both residents. [R7] was placed on 1:1.A review of R7's clinical record revealed the following progress note dated 10/5/25: Resident who received physical aggression informed this nurse that this resident hit her with a closed fist in her chest for no apparent reason as she was attempting to wheel herself into the family pallor (sic) room. This resident was positioned at the entrance of the family pallor (sic) room sitting in her wheelchair. Two residents present at time of incident. Residents immediately separated for safety, aggressor placed on 1:1.A review of R7's care plan initiated 11/9/23 revealed, in part: The resident has behaviors related to dementia, hoards, aggressive hitting other residents.physically aggressive toward others.striking out at residents. R7's care plan revealed no evidence of review or revision of current interventions following the altercation on 10/5/25 with R39.A review of a facility synopsis of events dated 10/13/25 revealed, in part: [R7] was noted sitting in the doorway of [Resident #38's] door. When [R38] attempted to move her wheelchair, she was swatted at her (sic) leg striking her leg with open hand. Residents were separated. Skin and pain assessment conducted. No concerns. [R38]fully dressed reported no discomfort. No marks noted and stated [R7] didn't phase her.[R7] continues on 15 [minute] checks. [R38] made aware to inform staff to remove patients sitting in the doorway.Further review of R7's clinical record revealed the following progress notes: 10/12/25 Resident is on 1:1 monitoring for assaulting another resident. Resident has periods of times when she is very pleasant and then she can have behaviors. She does need close monitoring when she is outside of her room. 10/13/25 [R7] struck [R38] on the left lower back side.A review of R7's care plan revealed no evidence of review or revision of current interventions following the altercation on 10/13/25 with R38.A review of a facility synopsis of events dated 11/12/25 revealed, in part: [Resident #41] was sitting in her wheelchair being assisted down the hall by another resident going outside to courtyard when they came up to the double doors near the nurses desk.[R7] was blocking the hall, they asked her [to] 'please move.' She responded with 'No your mama.' [R41] asked her to repeat, 'what did you say, I can't hear you,' and [R7] fanned her hand toward [R41's] face and [R41] started yelling, 'She hit me right in the mouth.' LPN (licensed practical nurse) intervened and separated residents. [R7] placed on 1:1, skin, pain, and trauma assessment completed on residents with no abnormalities.Further review of R7's clinical record revealed the following progress note dated 11/12/25: Reported to writer by another staff member that resident was observed swinging her hand towards another resident's facial area [NAME] they were attempting to wheel by in wheelchair. Witness states she didn't exactly see what part of her face this resident's hand came in contact with except that it was towards her face.Residents separated from each other and placed on 1:1 supervision.3. For Residents#40 (R40) and #26 (R26), the facility staff failed to provide supervision in the smoking area to maintain a safe environment and protect the resident from being assaulted by R26. R40 sustained injuries which resulted in new physician orders for treatment of R40's injuries and orders for the resident to be evaluated at the hospital, which constituted harm. On 10/18/25, while Resident #26 and #40 were in the designated smoking area, Resident #26, who was known to have behaviors, pulled Resident #40 to the ground out of his wheelchair and began hitting Resident #40 in the face and head. The provider gave an order for Resident #40 to be transferred to the hospital for evaluation of his injuries. Both residents had been assessed to require supervision while smoking. On 12/12/25 during a clinical record review of R26's chart, it was noted that he had an altercation with another resident. According to a nursing progress note dated 10/19/25 it read, Resident remains on 1:1 for physical assault. No behaviors observed or reported. In the week prior there was no documentation regarding details of an assault. On 12/12/25, the facility's director of nursing (DON) was asked to provide any information regarding an incident involving R26 in October. According to the facility's incident summary dated 10/18/25, it noted R26 and R40 had an altercation, and it read, CAN [sic] (certified nursing assistant) observed resident [name redacted] punch resident [R40's name redacted] in the face. Residents were immediately separated. Non-emergency services called treatment initiated. Resident [name redacted of another resident listed whose name was inaccurately noted in report] placed on 1:1. RP [responsible party], provider and police notified. Skin assessments and pain assessments were conducted for both residents. Resident [R40 name redacted] noted with abrasion to head. Investigation initiated. On 12/12/25, upon receipt of the facility documentation regarding the incident involving R26 and R40, the DON was asked about another resident identified in the incident summary. The DON acknowledged that the wrong resident had been noted in the report, and it should have been R26 noted as the aggressor. The facility provided in their documentation a statement written by Resident #44 (R44). The statement read, I was sitting smoking when I heard [R26 name redacted] shouting profanity at another resident, next he wheeled over to him, grabbed him in the collar, and pulled him to the ground and proceeded to hit him with both fist about the head and face. I yelled several times for him to stop. He finally stopped after punching him four or five times. At this point the nurse [registered nurse #1- RN #1 name redacted] arrived. On 12/12/25 at 10:30 AM, an interview was conducted with R44. When asked about the incident R44 stated that they [multiple residents] were all in the smoking area. R44 identified that resident #41 (R41) and R40 were at a table talking. Resident #26 thought [R40's name redacted] said something to R41, but R40 had not opened his mouth. R26 then went over to R40 cursing at him. Everyone keep saying stop. R44 then stated that R26 grabbed R40 by the collar, pulled him to the ground and started punching him in the face. I rolled up and yelled at [R26's name redacted] to stop it! R44 went on to state that R40 sustained a cut on his head. R44 reported that no staff were present, and another resident came inside the facility to get help and [RN #1's name redacted] came. R44 explained that normally a staff member is present but I think the lady [employee scheduled to supervise smoking] was sick. R44 recalled there were about seven or eight residents in the smoking area but couldn't recall who the other residents were. When asked if R44 had seen R26 with behavior before, R44 said, Constantly. He is always cursing and fighting. When asked if R44 was afraid of R26, the resident said, I'm not, but a lot of people are. On 12/12/25 at 10:45 AM, an attempt was made to interview R41, but the resident was not available. On 12/12/25 at 11:52 AM, an interview was conducted with RN #1. RN #1 reported that the incident occurred a little before 4:30 PM. RN #1 said, One resident said a resident needed help. When I got out there, we got [R40's name redacted] back in the chair and blood was coming from the top of the scalp. They said [R26's name redacted] pulled him out of the chair and was hitting him. They were in the smoking area [enclosed courtyard] at the table and chairs designated for smokers. We brought [R40's name redacted] inside, cleaned the wound and called the nursing supervisor. When asked about R26's behaviors, RN #1 reported, he has a TBI [traumatic brain injury] and starts yelling and getting angry over nothing. RN #1 went on to report that the doctor wanted to send R40 to the hospital, but the resident refused. RN #1 confirmed that staff were not present in the courtyard, smoking area at the time of the incident because a resident came and got him to assist. On 12/15/25, during a clinical record review of R26 and R40's charts it was noted that both residents had Smoking Safety Screen forms that indicated both residents required supervision with smoking. Details of the incident were recorded in R40's chart in a nursing progress note dated 10/18/25. The note read, EMS/ [emergency medical services] [locality redacted] Fire at facility to transport resident to ED [emergency department] d/t [due to] allegedly being pulled out of chair and hit in head multiple times by another resident. Resident noted with abrasion to top of scalp. Despite education and encouragement, resident refused to be taken to hospital. RP [responsible party] contacted x2 but unsuccessful, unable to leave message as voicemail was full. NP [nurse practitioner] notified, no new orders.On 10/18/25, a change in condition note was entered into R40's chart that noted, . Skin status evaluation: abrasion, pain status evaluation: Does the resident/patient have pain? Yes. R40 also had a new physician order dated 10/18/25 that read, wound care: Cleanse area to top right side of head with wound cleaner. Apply xeroform gauze and cover with band aid. Change daily as needed. According to R40's most recent smoking safety evaluation conducted prior to the incident, on 10/3/25, R40 required supervise with smoking. On 12/16/25 at 12:40 PM, an interview was conducted with R40. When asked about incident in smoking courtyard where another resident hit him, he said, I don't remember anything about it.On 12/10/25 at 2:28 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated abuse occurs when someone is hurt with an intention of harming another person. She stated residents are able to abuse other residents. She agreed that some residents require more intense supervision in order to prevent them from abusing other residents. She stated close supervision can be as infrequent as 15 or 30 minute checks, or it can be as intense as a 1:1 staff member always with a resident requiring this type of close monitoring. She stated the increased supervision can be a nursing intervention or the provider may write an order for it. She stated it is the facility staff's responsibility to supervise all residents in order to maintain a safe environment for all residents.On 12/16/25 at 10:16 a.m., OSM (other staff member) #5, the social services assistant, was interviewed. She stated that physical abuse occurs any time an individual intentionally strikes or comes into contact with another person to try to hurt the other person. She stated it is the facility's responsibility to provide supervision to residents to prevent them from abusing each other.On 12/16/25 at 10:37 a.m., LPN #9 was interviewed. She stated that the facility is responsible for providing supervision to all residents. She stated that if a resident has an order for 1:1 supervision, there is no way that resident should be able to become involved in a physical altercation with another resident. She explained that staff members should attempt to redirect or intervene in order to prevent physical abuse resident to resident. She added that if a resident who is on 1:1 supervision is able to engage in a physical altercation with another resident, the facility is not doing its job to adequately supervise the resident on 1:1.On 12/16/25 at 1:26 p.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated if two residents are able to get into a physical altercation with each other, there is no way that they were being given adequate supervision.The facility's deficient practice placed all facility residents at risk of being abused. This resulted in a determination of Immediate Jeopardy (IJ), cited at level four widespread. On 12/15/25 at 3:45 p.m., ASM #2 and ASM #3, the regional director of clinical services, were informed of these concerns and that the facility was in immediate jeopardy (IJ). The facility policy for 1:1 supervision was requested. ASM #2 and ASM #3 stated that the facility did not have a policy on 1:1 supervision.On 12/15/25 at 8:00 p.m., the facility's IJ Abatement Plan was accepted by the SA (state agency) supervisor. Facility Removal Plan Plan of corrective action for those residents found to be affected by deficient practices.Immediate Supervision. Resident #32, # 7, #26 is now under 1:1 supervision 24/7 being close proximities of resident to ensure that staff member can deescalate or intervene with any possible altercations.Resident #40 will not be allowed to smoke unsupervised. Resident #26 will not be allowed to smoke unsupervised.A dedicated staff member has been assigned to always monitor residents 40 and #26 during smoking breaks. The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.Corrective Actions taken for residents with potential to be affected by deficient practiceAll residents have the potential to be affected by this deficient practice. The Facility will educate all staff on the abuse policy. The DON or designee will educate on abuse and 1:1 ensuring that staff doing 1:1 being close proximities of resident to ensure that staff member is able to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door. The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient. Nursing staff on all shifts will document any unusual, increased, or change in behaviors will be reported and documented in the medical records. Then during clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.All residents that require supervised smoking have the potential to be affected by this deficient practice. Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision. Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.The facility will schedule staff member to be in the courtyard while smoking occurs. Systemic changes put into place to ensure the deficient practice does not reoccur:The Interdisciplinary Team( Director of Nursing, Assistant Director of Nursing, Social Services, Activities Director, Dietary Manager, Business Office Manager, Maintenance, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse. IDT will be educated on what a 1:1 entails which will includes maintaining arms length while inside and outside of the room. Nursing staff on all shifts will document any unusual, increased , or change in behaviors will be reported and documented in the medical records. Anyone providing 1:1 care will be scheduled by staffing that will have their relief person for break noted on schedule. Resident on 1:1 will be documented on daily by assigned staff that will be collected daily by charge nurse. Staff will be educated that you may not leave the resident until you have a relief person, you have to remain in close proximities of resident to ensure that staff member is able to deescalate or intervene with any possible altercations while on one to one inside and outside of room. The Regional Director of Clinical Services will also educate the IDT team on the need for supervision for residents identified as supervision while smoking on ensuring all residents requiring supervision are supervised while smoking. The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present. This education will be provided to all staff, and no employee will be allowed to work after 11:59 pm until they are educated to include agency staff. Monitoring for corrective actions to ensure deficient practice does not recur:While the resident remains in the facility, a monthly review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments .The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximities of resident to ensure that staff member is able to deescalate or intervene with any possible altercations. five times a week times 4 weeks then 3 times a week times 4 weeks. Facility will monitor all residents who have been identified as supervised smokers. All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds. If supervision is deemed necessary, the resident will be supervised by a designated staff.The DON or designee will audit residents who are supervised smokers five times a week for 4 weeks then 3 times a week times 4 weeks to ensure they are supervised while smoking.The facility alleges removal of the Immediate Jeopardy on 12/16/25 at 1900 (7:00 p.m.).On 12/17/25 at 9:08 a.m., the survey team began verification of the facility's removal plan. This verification process included observation of residents on 1:1 supervision, observation of residents in the smoking area, staff interviews on all elements of the plan, and review of all smoking safety assessments and trauma screens completed as part of the abatement plan. The survey team was able to verify that the facility completed the abatement plan on 12/16/25 at 10:22 p.m. After immediate jeopardy was removed, the scope and severity were lowered to a level three pattern.A review of the facility policy, Patient Protection, revealed, in part: There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehab Center. This policy did not provide any information related to the facility's responsibility for resident supervision as a part of providing a safe environment.No additional information was provided prior to exit. 4. For Resident #48 (R48), the facility staff failed to provide adequate supervision of resident #26 (R26) who was on one-to-one observation to maintain a safe environment, which resulted in R48 being hit by R26. On 12/16/25, during a clinical record review of R26's chart, it was noted that on 10/18/25, R26 assaulted another resident and was placed on one-to-one observations. There was almost daily entries in R26's progress notes of behaviors from 10/18/25-10/25/25.On 10/25/25 at 1 AM, a progress note in R26's chart read, Writer was called to the unit by the charge nurse to assess Resident [R26's name redacted] who hit another resident also threaten and accuse the charge nurse of not given him his medication and loud verbalization causing peers to be alarmed/frighten. Resident was not able to be deescalated for some time frame for at least 30 to 45 minutes so 911, DON [director of nursing] and Provider was called. 911 team responded, felt that he should go to the hospital because if he was to have a repeat episode other resident or staff may be harmed since he could not be restrained. Resident [R26's name redacted] R/P (responsible party) was called no answer message left for her to call the facility Resident was sent out to hospital to be evaluated since this was the second incident within last 12 hours Resident [R26's name redacted] have a DX. [diagnosis] TTAUMATIC [sic] brain injury which could be worsening [sic]. According to R26's physician orders, there was an order for Resident on 1:1 supervision initiated on 10/18/25 which was an active order at the time of the incident when R26 hit R48. On 12/16/25, the director of nursing (DON) was asked to provide any information she had regarding R26's incident with another resident on 10/25/25, to identify who the other resident was. On 12/16/25, the DON provided the surveyor with an incident summary that identified Resident #48. The facility's incident summary noted, Staff reported that resident [R26's name redacted] was arguing with staff and when resident [R48's name redacted] walked out the room to see what was going on resident [R26's name redacted] punched him [R48] in the face. Residents separated. On 12/16/25, a clinical record review of R48's chart was performed. A nursing note entry dated 10/25/25 read, Resident was standing in the hall while another resident was being aggressive and got struck in the face. On 12/17/25 at 10:45 AM, an interview was conducted with R48. When asked about the incidents involving him and R26, resident #48 said, It was in the hallway. He was going off and I thought he was going to hit this lady [staff member]. He tried to grab me and swung on me and caught me. R48 denied any injuries.On 12/10/25 at 2:28 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated abuse occurs when someone is hurt with an intention of harming another person. She stated residents are able to abuse other residents. She agreed that some residents require more intense supervision in order to prevent them from abusing other residents. She stated close supervision can be as infrequent as 15 or 30 minute checks, or it can be as intense as a 1:1 staff member always with a resident requiring this type of close monitoring. She stated the increased supervision can be a nursing intervention or the provider may write an order for it. She stated it is the facility staff's responsibility to supervise all residents in order to maintain a safe environment for all residents.On 12/16/25 at 10:16 a.m., OSM (other staff member) #5, the social services assistant, was interviewed. She stated that physical abuse occurs any time an individual intentionally strikes or comes into contact with another person to try to hurt the other person. She stated it is the facility's responsibility to provide supervision to residents to prevent them from abusing each other.On 12/16/25 at 10:37 a.m., LPN #9 was interviewed. She stated that the facility is responsible for providing supervision to all residents. She stated that if a resident has an order for 1:1 supervision, there is no way that resident should be able to become involved in a physical altercation with another resident. She explained that staff members should attempt to redirect or intervene in order to prevent physical abuse resident to resident. She added that if a resident who is on 1:1 supervision is able to engage in a physical altercation with another resident, the facility is not doing its job to adequately supervise the resident on 1:1.On 12/16/25 at 1:26 p.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated if two residents are able to get into a physical altercation with each other, there is no way that they were being given adequate supervision.On 12/16/25 at 3:53 p.m., ASM #2 and ASM #3, the regional director of clinical services were informed of these concerns.5. For Resident #45 (R45), the facility staff failed to supervise the resident to prevent the resident from keeping smoking materials in her personal possession.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/3/25, R45 was coded as being moderately cognitively impaired, having scored eight out of 15 on the BIMS (brief interview for mental status).On 12/12/25 at 10:40 a.m., R45 was observed self-propelling down the hallway in her wheelchair. The resident had a pack of cigarettes and a cigarette lighter in her hand in plain view. The resident took her own smoking materials outside into the designated smoking area. While she was self-propelling down the hallway, at least four staff members passed by her. On 12/12/25 at 11:06 a.m., R45 was observed in her wheelchair by the nurses' desk. The resident was holding a pack of cigarettes and a cigarette lighter in plain view. At least three staff members were present at the nurses' station.A review of R45's most recent smoking safety assessment dated [DATE] revealed, in part: Does the resident have cognitive loss? Yes.Score = 5.5 or greater requires supervision with smoking.Care Plan.Supervise with smoking.On 12/16/25 at 10:37 a.m., LPN (licensed practical nurse) #9 was interviewed. She stated a smoking safety assessment tells the staff if a resident needs help or supervision for smoking. She explained that if the resident requires supervision, that resident is not allowed to have smoking materials of any kind with them. She stated there is a box on the central wing medication room that contains smoking materials for all residents requiring supervision. She stated R45 should not have been allowed to carry smoking materials down the hall independently, or to possess these materials while sitting in a wheelchair at the nurses' station.On 12/16/25 at 1:26 p.m., LPN #3, a unit manager, was interviewed. She stated that residents who have been assessed to require supervision for smoking were not allowed to have smoking materials in their personal possession. She stated this was a safety precaution to protect the resident who smokes and all other residents in the facility.On 12/16/25 at 2:19 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated that any resident who has been assessed to require supervision with smoking should not have any smoking materials in their personal possession. She added: This has always been the case. I don't want to risk something related to a fire.On 12/16/25 at 3:53 p.m., ASM #2 and ASM #3, the regional director of clinical services were informed of these concerns.A review of the facility policy, Patient Smoking, revealed, in part, Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment.Based on the Smoking Safety Screen Assessment, a patient may smoke in the designated smoking area(s) either independently or with supervision.If supervision is deemed necessary, the patient will be supervised by staff or other appropriate person.The center will maintain all smoking parap

Based on observation, family interview, staff interviews, and clinical record review, the facility staff failed to provide a provider ordered mechanically altered diet for one of forty-three sampled residents (R)119 resulting in harm. R119 developed pneumonia and required antibiotic treatment.The findings included:R119's diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction.R119's hospital Discharge summary dated [DATE] included dietary orders for a pureed diet. Section C (cognitive patterns) of R119's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/25 included a brief interview for mental status (BIMS) score of 2 out of a possible 15 points, indicating R119 was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate the resident was on a mechanically altered diet.R119's comprehensive care plan (CCP) included the focus area at risk for weight loss or malnutrition related to chronic disease, cognitive impairment, requiring assistance to eat and dysphagia requiring puree diet. Date initiated 12/22/25. R119's clinical record included a provider order dated 12/19/25 for a Regular diet, Dysphagia Advanced texture, Thin Liquids consistency. On 12/22/25 this diet order was changed to include downgrade to puree per recommendations from hospital.On 02/11/26 at 1:10 p.m., the surveyor observed R119 eating lunch. Certified Nursing Assistant (C.N.A.) #4 was standing beside R119 and stated she was not allowing R119 to eat their chicken as she had a question about the consistency. Per request of the surveyor the Dietician and Speech Language Pathologist (SLP) observed the meal tray. The dietician stated the chicken could use more liquid and the SLP stated the chicken was a mixture of mechanically altered and pureed. When asked if it would be safe for R119 to consume the chicken the SLP stated that knowing this resident it would not be safe for them to eat. The tray ticket that accompanied this meal listed puree crispy chicken thigh as an entree.During a family interview on 02/11/26 at 1:20 p.m., this family member expressed concerns over R119 not receiving their correct diet and stated that on super bowl Sunday (02/08/26) R119 was provided with a milkshake that contained Oreo cookies and Reese's Pieces and on three occasions the facility staff had provided R119 with the wrong meal trays. On 02/11/26 the administrative staff terminated C.N.A. #5 for providing R119 the wrong texture milkshake on 02/08/26. This milkshake was described as a milkshake with Oreo's. The facility administrative staff provided the surveyor with emails regarding this incident. In the first email C.N.A. #5 stated she apologized for the mistake involving providing a milkshake with Oreos to a resident who is on a puree diet. The second email stated they would like to clarify that there was a mistake and misunderstanding regarding the milkshake. The milkshake the patient received was safe and appropriate for him to consume on his puree diet. The Oreo milkshake was not given to the patient.R119 was seen by the provider at the facility on 02/11/26 this provider documented .seen today for SNF [skilled nursing facility] follow-up. Chest radiograph obtained today revealed infiltrate consistent with recurrent aspiration pneumonia. It was reported that he recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Given this represents his second pneumonia treatment course in recent weeks, he has been initiated on Augmentin and doxycycline antibiotic therapy. Following discussion with son, prednisone dosage has been increased to 10 mg daily for a seven-day course, after which it will be reduced back to his baseline dose of 5 mg daily. Additionally, a probiotic has been ordered to prevent Clostridioides difficile infection given the recurrent antibiotic exposure.On 02/11/26 at 4:23 p.m., during an interview with R130 this resident confirmed he had door dashed on super bowl Sunday and obtained a cookies and cream milkshake for R119. R130 stated he had told the person who was taking his order to grind up the pieces because the resident was on a puree diet. When asked if he was sure R119 had consumed the item R130 stated Oh yeah I saw him later he said it was good and his son was picky about what he ate. The above issues were reviewed with the Administrator, Director of Nursing (DON), and Regional Nurse on 02/12/26 at 3:01 p.m. and again on 02/13/26 at 12:00 p.m.In addition to R119 being served the milkshake with candy pieces on 02/08/26 and non-pureed chicken on 02/11/26, the DON provided documentation which indicated R119 also received the wrong diet during the weekend of 12/20/25-12/21/25 and provided the survey team with an AD HOC (as needed) quality assurance and performance improvement plan (QAPI) for R119 dated 12/22/25 with a date of compliance of 01/26/26. The plan addressed The resident had the wrong diet served to him which the resident did eat, over the weekend. A chest X ray was ordered and obtained on 12/23/25 with the findings reading Patchy densities are noted involving the perihilar regions.Bilateral perihilar atelectasis/infiltrate. On 12/24/15 the provider ordered the antibiotic Avelox 1 tablet by mouth one time a day for pneumonia. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with a focus on the outcomes of care, quality of life, and to correct quality deficiencies, which resulted in multiple residents residing on three of three units being victims of abuse. The findings included:During a survey conducted with a survey completion date of 4/28/25, the facility was cited for multiple areas of deficient practice involving abuse. Seven residents were identified as having been abused by facility staff and/or other residents, failure to report allegations, investigation of allegations, and failure to investigate, prevent, and correct abuse of residents. During the April 2025 survey, the identification of deficiencies for a safe environment was identified. The facility's quality assurance program was involved in the development of a plan of correction and ongoing monitoring to ensure ongoing compliance to sustain compliance. During this survey in December 2025, the survey team identified nine residents who were victims of abuse and where the facility staff failed to report, investigate, and provide adequate supervision to provide for a safe environment, which resulted in the identification of deficiencies in the areas of abuse and quality of care. Therefore, the facility's Quality Assurance and Performance Improvement actions were ineffective in sustaining ongoing compliance.During a survey ending 4/28/25, the facility was cited for failure to protect residents from abuse, failure to report, investigate and correct repeated willful abuse of residents. The facility's quality assurance program developed a plan of corrective. According to the plan of correction, the facility conducted audits to identify other residents at risk of being affected/abused. All facility staff received education on the facility's abuse policy, audits were conducted and the facility alleged compliance as of 6/12/25. Audits were going to be conducted weekly x 4 weeks, then monthly x 2 months to maintain ongoing compliance, all of which was going to be reported to the Quality Assurance and Performance Improvement Committee for review and recommendations. During the current survey, the survey team identified eleven residents who had been victims of abuse and resulted in the identification of immediate jeopardy for the facility's failure to protect the residents' right to be free from abuse. In multiple instances the facility failed to report the allegations timely, failed to conduct thorough investigations and failed to implement their abuse policy, all of which was previously cited. Instances of non-compliance were identified to have begun July 30, 2025, which was seven weeks after the facility had alleged compliance from the prior citations in April 2025. The facility's quality assurance program failed to implement the following interventions as stated in their plan of correction to prevent further abuse of residents, which resulted in the ongoing abuse of residents and was indicative of systemic failure: 1:1 [one-on-one] supervision, psychiatric services for behavioral management . to prevent the recurrence of verbal/physical abuse toward other residents, corrected with interventions to protect, prevent abuse or recurrence of abuse to resident or other residents, facility reported incident submitted timely with state agencies and APS [adult protective services] as applicable, investigation completed with accuracy of findings based on investigation, and education with all staff regarding the abuse and neglect policy and procedures to ensure ongoing compliance. On 12/17/25 at 2:09 PM, an interview was conducted with the facility's director of nursing (DON). When asked about the Quality Assurance (QA) program of the facility, the DON explained that QA was involved in the development of their plan of correction, monitoring for ongoing compliance and self-identification of areas of concern and development of a system to correct the identified non-compliance. When the above findings were discussed, the DON just stated that she understood that there was a lack of evidence that their QA program was effective and said, We need to do better. A review of the facility's policy titled, QAPI with an effective date of 9/23/24, was conducted. The policy read, The Administrator is responsible for directing the Center's Quality Assurance/Performance Improvement Program and for implementing a Quality Assurance/Performance Improvement (QAPI) Plan that focuses on Center specific indicators that measure quality of care, quality of life and patient choice. The QAPI Plan will systematically identify actual or potential areas of risk or deficiency and will proactively pursue ongoing performance improvement.The facility administrator was not present during this survey and, therefore, was not available for an interview. On 12/17/25, the DON was made aware of the above findings and stated that the quality assurance committee was involved in the plan of correction and ongoing compliance to ensure residents were free from abuse and the facility maintained a safe environment.No additional information was provided.

Based on staff interviews and facility document review, the facility staff failed to provide a full-time, qualified social services worker to meet the resident's individual needs whenever needed.The findings include:The facility staff failed to employ a full-time social services director.On 12/16/25 at 10:16 a.m., OSM (other staff member) #5, the social services assistant, was interviewed. She stated that her title is social services assistant and that she does not yet have the qualifications to be named the social services director. She stated the facility's social services director works remotely now, and does not come into the facility anymore.On 12/16/25 at 3:52 p.m., ASM (administrative staff member) #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. They stated that the current social services director works remotely, mostly in the evenings and on the weekends.On 12/17/25 at 9:26 a.m., OSM #8, the social services director, was interviewed. She stated that she is still the facility's social services director, but that she does not work full-time. She reported that as of 10/27/25, she has been employed full-time in another job, but that she had agreed to promise to continue working at the facility as needed part-time to make sure things are completed and for compliance. She stated that prior to her resignation from full time work with the facility, she was responsible for completing trauma screenings and psychosocial assessments, MDS (minimum data set) assessment reviews and completion, meeting with residents regarding any psychosocial or discharge needs, and generally working with residents and families to help make sure they received all services they needed. She stated that she also supervised the social services assistant. She explained that now that she is not employed full time at the facility, she does audits, makes sure things have been completed, and checks for compliance. On 12/17/25 at 2:45 p.m., ASM #2 and ASM #3 were informed of these concerns.No additional information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to accommodate resident's choices and/or needs for eight of forty-three residents (R), R102, R116, R138, R139, R140, R141, R143 and R129. The findings included:1. For R102 the facility staff failed to provide the resident with his preference for a shower. R102's diagnoses included multiple sclerosis and muscle weakness. Section C (cognitive patterns) of R102's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/11/25 included a brief interview for mental status (BIMS) score of 15, indicating R102 was cognitively intact. Section GG (functional status) was coded (1) to indicate R102 was dependent on staff for personal hygiene and shower/bathe self. R102's comprehensive care plan included the focus area requires assistance with activities of daily living related to quadriplegia and multiple health issues. Interventions included extensive total assistance needed with bathing, dressing, and grooming. On 02/10/26 at 2:20 p.m., during an interview with R102 this resident stated he had not had a shower in 2 weeks and was .missing my showers. and stated the facility staff charted whatever they wanted. R102 was observed to have crumbs on his shirt and dry flaky skin on his forehead. During a second observation on 02/10/26 at 2:50 p.m., R102 stated the facility staff occasionally gave him a bed bath but he would prefer showers and a shave. R102 was observed with facial hair and stated he did not generally have facial hair. A review of R102's clinical record revealed that R102 shower days were Wednesday, Saturday, and as needed. From the period of 01/27/26-02/12/26 the facility staff had documented showers on 01/28/26 (Wednesday), 01/30/26 (Friday), and 02/11/26 (Wednesday). The facility staff documented R102 had refused a shower on 01/31/26 (Saturday) and 02/07/26 (Saturday). Not applicable was documented X2 on 02/04/26 (Wednesday) and no was documented on 01/27/26 (Tuesday) and 02/06/26 (Friday). For this same time frame the facility staff documented R102 had received bed baths on 01/29/26, 01/30/26, 01/31/26, 02/01/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/08/26, 02/09/26, 02/10/26, and 02/12/26. The above findings were reviewed with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services on 02/11/26 at 4:20 p.m. The DON stated the facility did not have a shower team. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For 5 Residents in the survey sample residing on the East Wing (# 138, #139, #140 and # 141), the facility staff failed to ensure there was a working clock in the bedroom. a) For residents 138. the facility staff failed to ensure there was a clock on the bedroom wall as per the preference of the resident. During the initial tour, as soon as the surveyor walked in the room and asked if there were any concerns, Resident # 138 immediately stated that there was no clock in the room. Resident # 138 stated he wanted a clock and had been asking for one for a while. He stated that this is the only room without a clock on the wall. b and c) For Resident # 139 and Resident # 140 who were roommates, the facility staff failed to ensure the clock on the bedroom wall had the proper time. During the initial tour of the facility at approximately 1 p.m., the clock stated 6:50. Neither resident was in the room during the initial tour. During subsequent rounds throughout the survey, Residents # 139 and # 140 were observed in their room. d). For Resident #141, the facility staff failed to ensure the clock on the bedroom wall had the proper time. During the rounds at approximately 1:20 p.m., the clock exhibited the time 12:10. On 2/10/2026 at 1:40 p.m., during the initial tour of the facility, observations were made in a room on the East Wing. The room was a quad room that housed four residents. There were 4 residents in the room. There was a clock in the far-right corner of the room that was visible to the residents in Bed C and Bed D. The clock displayed the time of 12:10. The resident (Resident # 2) in Bed D closest to the far-right corner directly in front of the clock, was sitting on the side of the bed and stated they did not know what time it was. The resident stated the clock was wrong. e) For Resident # 143, the facility staff failed to ensure the clock on the bedroom wall had the proper time. During the rounds at approximately 1:20 p.m., the clock exhibited the time 4:42. There was a staff member interviewing Resident # 143 behind the privacy curtain during the initial rounds. It was later determined that the staff member was the Social Worker interviewing the resident. Rounds were made on the East Wing several times during the survey. The incorrect times on the clocks were observed during each of the rounds. On 2/11/2026 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be accurate. She stated the correct time helped the residents with the orientation of time. Staff members were observed in the rooms while providing care, administering medications, picking up food trays and delivering ice and water. No staff person addressed the issue of the clocks having the wrong time. The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue. During the end of day debriefing on 2/11/2026, the Facility Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings that several clocks in residents' rooms had inaccurate times, some residents did not have a clock and some residents complained about those issues. They all stated the clocks in residents' rooms should be accurate. During the end of day debriefing on 2/11/2026, the facility Administrator, Director of Nursing, and the Regional Director of Clinical Services were informed of the findings of several rooms with clocks that did not exhibit the correct times. When asked if it was important for the clocks to have the correct time, they all stated yes. When asked about the importance of having the correct times on the clocks, the Regional Director of Clinical Services stated that the clocks help with orientation of the residents. She stated the clocks helped them to know the time for activities, meals, medications and for preferences regarding care. They stated that the clocks help with orientation of the residents. On 2/12/2026, the Director of Nursing presented an audit of all the clocks in the resident's rooms that had been conducted after the end of day debriefing on 2/11/2026. The audit revealed several resident rooms throughout the facility without working clocks. No further information was provided. 3. For resident #129 (R129), the facility staff failed to provide a functional clock to assist the resident with orientation of time. On 2/11/26 at 3:50 PM, while interviewing a roommate, R129 asked the surveyor, What time is it? Is that clock, right? [pointing to a clock on the wall] Is it time to eat? The surveyor notified the resident it was 3:45 PM and she would let the staff know that she was hungry and wanted a snack. The clock on the wall was observed to read 1:15. Upon exiting the room, the west wing unit manager was in the hallway and notified that R129's clock was wrong and she was hungry. On 2/12/26 at 11:30 AM, during a follow-up interview with R129's roommate, R129 again asked if it was time to eat and pointed to the clock said, That clock ain't right. The surveyor noted that the clock was read 1:15. Upon exiting the room, the west wing unit manager was in the hallway and was notified that R129's clock was still not correct. The unit manager confirmed that the surveyor had notified her of this the day prior and she had fixed a different clock. On 2/12/26, during an end-of-day meeting with the facility administrator, director of nursing and regional director of clinical services, the above findings were reviewed. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain resident clinical records in a manner to ensure privacy and confidentiality of records, on two of three nursing units (Central and [NAME] wings). The findings included:The facility staff failed to maintain resident's clinical record access in a manner to safeguard and protect the content of information from authorized disclosure by allowing facility staff to use personal computers for daily tasks and access to resident clinical records on two nursing units. On 2/12/26 at 9:30 AM, observations were conducted on each of the units. Observations revealed that six of the facility nurses working on the central and west wings, were utilizing their own personal laptop computers to access resident clinical records and documents. On 2/12/26 at 9:30- 10 AM, interviews were conducted with the facility staff about the use of their personal computers. The staff reported, They don't have enough computers, there is only one on this unit and there is no charger for it. They are missing chargers, so I bring my own computer. They aren't charged and it makes me late on passing medications, so I bring my own. The employees/nurses reported that they cannot access the clinical records of residents when they are offsite using their personal computers. On 2/12/26 at 2:46 PM, during a meeting with the facility administrator, director of nursing and regional director of clinical services (RDCS), the above concerns were shared. The RDCS stated that facility staff were not to use their personal computers. The RDCS stated that the staff were not able to access the electronic health record of residents when they are not on the facility's network. The discussion was held that there was no system to ensure that facility staff did not save residents' personal medical information or personal identifying information on personal computers for later use. The RDCS went on to state that the management staff could provide the nursing staff with their facility issued laptop computers to use versus staff utilizing their personal computers. During the above meeting, the facility administrator stated that she had sent nine computers back recently and had ordered nine more. When asked what the turnaround time on that was and when the replacement computers would be received, the administrator stated she did not know. According to a facility document titled, Technology & Information Systems Acknowledgement which was updated 09/2023, it read in part, . Employees should use company computers and information systems primarily for company business only. No additional information was provided.

Based on observation, staff interview and facility documentation review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of three units and for failure to keep a homelike environment for 1 Resident (Resident # 142) in a survey sample of 43 residents. The findings included: For residents on the East Wing, the facility staff failed to provide a safe, comfortable, homelike environment. On 2/10/2026 during the initial tour on the East Unit and during subsequent rounds throughout the survey, there were several issues that were not homelike including but not limited to: ceiling tiles in several residents' rooms were observed to be stained and some were bulging, broken blinds, broken nightstand drawers, soiled towels under bins in one room and a brownish stain and gnats were observed in the water fountain near the nurses station. For the residents on East Wing, the failed to ensure the water fountain was clean. A brownish stain and gnats were observed in the water fountain near the nurses station. room [ROOM NUMBER]- several ceiling tiles were bulging room [ROOM NUMBER]-three stained ceiling tiles room [ROOM NUMBER]-Bed 2- nightstand drawers broken, clothes hanging out of the drawers room [ROOM NUMBER]-Bed 1- the third tile above bed stained; Bed 2-Filter from the heating -unit was lying on the floor room [ROOM NUMBER]-blinds were broken on the left side. room [ROOM NUMBER] -two stained ceiling tiles in middle of room, one stained tile on the ceiling between the head of the two beds. room [ROOM NUMBER]- near the window-towel on floor discolored substance, several bins sitting on top of the towels During the end of day debriefings on 2/12/2026 and 2/13/2026, the Administrator, Regional Director of Clinical Services and the Director of Nursing were informed of the findings. They stated residents should have a clean, safe and comfortable homelike environment. No further information was provided. On 2/12/2026 during an afternoon tour of the unit, observed the Water fountain located near the East Wing nurses station -soiled near the drain- approximately 5-inch brownish stain noted around the drain-gnats came out of the drain when the button was pressed to have water flow. Water did flow from the spigot, and several gnats came out of the drain. The Unit Manager for East Wing and the Regional Director of Clinical Services were standing in the hallway directly in front of the nurses station approximately 4 feet from the surveyor. They both saw the gnats and came over to the water fountain. The Unit Manager stated the stain looked like the Med Pass Nutritional supplement that nurses administer during medication pass and pour. She pointed to the container of Med Pass located on top of the medication cart that was located in the hallway near the nurse's station. When asked if the nurses pour the medication or supplement down the drain, the Unit Manager stated no but it's the residents. The Unit Manager was asked if nurses were expected to ensure residents consume medications and/or supplements during the medication administration pass. She stated yes. The Activities Coordinator immediately came over with cleaner and started cleaning the water fountain drain. Gnats were flying over the water fountain and landing on the walls. There were no Housekeeping staff noted in the area. There were residents in the corridor near the nurses station. The Regional Director of Clinical Services asked the staff to put a plastic bag over the water fountain. A staff member was observed placing a large clear plastic bag over the water fountain. During the end of day debriefings on 2/12/2026 and 2/13/2026, the Administrator, Regional Director of Clinical Services and the Director of Nursing were informed of the findings. They stated residents should have a clean, safe and comfortable homelike environment. They also stated nurses should ensure that residents swallow the medication or supplement and do not pour down the water fountain drain. No further information was provided. 2. For Resident # 142, the facility staff failed to ensure a homelike, odor free environment by not maintaining the laundering of personal laundry and placing soiled clothing in the closet. Observed a Pungent, foul-smelling odor of urine near the quad room at the of the hall on the right on the East Wing during the rounds on 2/10/2026, 2/11/2026 and 2/12/202. The smell permeated the hall near that room. Four residents resided in the room. The Residents were observed to sitting up in chairs, lying in bed, sitting in the hallway during various rounds. There were no observations of residents in that room not receiving care. However, the odor of urine was very pungent. Licensed Practical Nurse was interviewed about the odor in that room. LPN # stated she would check each resident for any recent incontinent episode but was sure each resident had received incontinence care timely. LPN stated she could smell the odor also and would try to determine the source. LPN and Certified Nursing Assistant checked each resident for incontinence. None of the residents were wet at that time of the rounds. There was still a pungent odor of urine in the room. The odor seemed to be more pungent near the Resident in Bed B. After the surveyor left the unit, LPN stated that upon further inspection, she determined that the odor was more pungent near Bed B's closet. She stated that when she opened the closet, she found soiled personal clothes in the closet. LPN stated that she asked the laundry staff to launder the soiled clothes. The Housekeeping Director stated he had some staffing issues in the laundry but was going to have the laundry staff focus on laundering personal belongings as well as the linens for the residents. On 2/13/2026 at 9:30 a.m. no pungent odor of urine was smelled in the room nor near Bed B's closet During the end of day debriefings on 2/12/2026 and 2/13/2026, the facility Administrator, Director of Nursing and Regional Director of Clinical Services were informed of the findings that during rounds on the East Wing, there was pervasive pungent smell urine on the corridor at the end of the unit near the rooms with the higher numbers. During each day of survey, the pungent smell of urine was evident on that end of the unit. Interviews were conducted with staff members who stated they had not noticed the smell or the odor but thought it might have been due to recent changes of incontinence episodes with the residents on that end of the unit. They were informed that the staff did not search for the origin of the smell until the surveyor asked them to perform an incontinence check on each resident. No further information was provided. 3. Ceiling tiles in rooms 42, 51, 55, and 57 on the Central unit were observed to have dark brown ringed stains. On 02/10/26 at 2:20 p.m., during a resident interview in room [ROOM NUMBER] the surveyor observed dark brown ringed stains on the ceiling tiles near the individual's window. 02/12/26 at 9:12 a.m., the surveyor observed dark brown ringed stains on the ceiling tiles in rooms [ROOM NUMBER]. The above findings were reviewed with the Administrator, Director of Nursing, and Regional Director of Clinical Services #1 and #2 on 02/13/26 at 12:28 p.m. No further information regarding this issue was provided prior to the exit conference.

Based on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct a thorough investigation into allegations of abuse and misappropriation involving four residents (Resident #26- R26, Resident #40- R40, Resident #48- R48, and Resident #33- R33), in a survey sample of forty-eight residents. The findings included:1. For an incident of physical assault by Resident #26 (R26) toward Resident #40 (R40), who sustained injury, the facility staff failed to conduct a thorough investigation of the incident. On 12/12/25, during a clinical record review of R26's chart, it was noted in the nursing progress notes that R26 was on one-to-one observation due to a physical assault incident toward another resident. No details of the incident were noted. On 12/12/25, the surveyor asked the facility staff to provide any documentation they had regarding an incident in October 2025, involving R26. The director of nursing (DON) provided the survey team with a file that she indicated was the entire investigation. Included was a facility incident summary, facility synopsis, fax confirmations, one witness statement from another resident (resident #44), and excerpts of the clinical record of R26 and R40. According to the incident summary, the incident was witnessed by a certified nursing assistant, but the investigation file did not indicate who the staff member was, nor did it include a statement from any witnesses other than resident #44 (R44). The written statement from R44 read, I was sitting smoking when I heard [R26 name redacted] shouting profanity at another resident, next he wheeled over to him, grabbed him in the collar, and pulled him to the ground and proceeded to hit him with both fist about the head and face. I yelled several times for him to stop. He finally stopped after punching him four or five times. At this point the nurse [registered nurse #1- RN #1 name redacted] arrived. On 12/12/25 at 10:30 AM, an interview was conducted with R44. When asked about the incident R44 stated that they [multiple residents] were all in the smoking area. R44 identified that resident #41 (R41) and R40 were at a table talking. Resident #26 thought [R40's name redacted] said something to R41, but R40 had not opened his mouth. R26 then went over to R40 cursing at him. Everyone keep saying stop. R44 then stated that R26 grabbed R40 by the collar, pulled him to the ground and started punching him in the face. I rolled up and yelled at [R26's name redacted] to stop it! R44 went on to state that R40 sustained a cut on his head. R44 reported that no staff were present, and another resident came inside the facility to get help and [RN #1's name redacted] came. R44 explained that normally a staff member is present but I think the lady [employee scheduled to supervise smoking] was sick. R44 recalled there were about seven or eight residents in the smoking area but couldn't recall who the other residents were. When asked if R44 had seen R26 with behavior before, R44 said, Constantly. He is always cursing and fighting. When asked if R44 was afraid of R26, the resident said, I'm not, but a lot of people are. On 12/12/25 at 10:45 AM, an attempt was made to interview R41, but the resident was not available. On 12/12/25 at 11:52 AM, an interview was conducted with RN #1. RN #1 reported that the incident occurred a little before 4:30 PM. RN #1 said, One resident said a resident needed help. When I got out there, we got [R40's name redacted] back in the chair and blood was coming from the top of the scalp. They said [R26's name redacted] pulled him out of the chair and was hitting him. They were in the smoking area [enclosed courtyard] at the table and chairs designated for smokers. We brought [R40's name redacted] inside, cleaned the wound and called the nursing supervisor. When asked about R26's behaviors, RN #1 reported, he has a TBI [traumatic brain injury] and starts yelling and getting angry over nothing. RN #1 went on to report that the doctor wanted to send R40 to the hospital, but the resident refused. When asked if a staff member was present or witnessed the incident, RN #1 reported it was not a staff member present and that another resident had come to get him to state that help was needed. On 12/16/25 at 12:40 PM, an interview was conducted with R40. When asked about incident in smoking courtyard where another resident hit him, he said, I don't remember anything about it. 2. For Resident #48 (R48), who was the subject of a physical assault by Resident #26 (R26), the facility staff failed to conduct a complete and thorough investigation. On 12/15/25-12/16/25, during a clinical record review of R26's chart, it was noted that on 10/18/25, R26 assaulted another resident and was placed on one-to-one observations. According to a nursing note entry dated 10/25/25 at 1 AM, which read, Writer was called to the unit by the charge nurse to assess Resident [R26's name redacted] who hit another resident also threaten and accuse the charge nurse of not given him his medication and loud verbalization causing peers to be alarmed/frighten. Resident was not able to be deescalated for some time frame for at least 30 to 45 minutes so 911, DON [director of nursing] and Provider was called. 911 team responded, felt that he should go to the hospital because if he was to have a repeat episode other resident or staff may be harmed since he could not be restrained. Resident [R26's name redacted] R/P (responsible party) was called no answer message left for her to call the facility Resident was sent out to hospital to be evaluated since this was the second incident within last 12 hours Resident [R26's name redacted] have a DX. [diagnosis] TTAUMATIC [sic] brain injury which could be worsening [sic]. There was an additional progress note in R26's chart dated 10/25/25 at 1 AM, that read, Nurses was checking in the room since he is a 1 on 1 on the other patient and the resident stated he never got his medication. Both nurses informed him that he did in fact receive his medication and that he cannot get any more at the time. The resident then stated that he would know if he got his medication and that we were liars. Nurses attempted to deescalate the situation, and he got even more agitated. Resident got up and cursed out the nurse and stated he was going to kill her if he got his hands on her. He then chased her around the facility and punch another resident in the face in the process. Non-pharmacological Intervention: Staffed reassured him that he got his medication and attempted to deescalate the situation. Outcome: Resident has been sent to hospital for reevaluation. According to R26's physician orders, there was an order for Resident on 1:1 supervision initiated on 10/18/25 which was discontinued on 10/25/25 at 12:16 PM, following the resident being sent to the hospital for evaluation. Another progress note entry dated 10/25/25, indicated that the facility staff had spoken to hospital staff who were . looking for a BHU (behavioral health unit) bed for the resident. According to progress notes, the census tab, and physician orders, R26 returned to the facility on [DATE], at which time the one-to-one observation resumed. According to a progress note in R26's chart dated 10/28/25 at 11:01 PM, it read, Writer was at nurses station talking with resident [Resident #48's room number redacted] who was in front of nurse station near soiled utility room. As we where [sic] talking this resident [R26] could be heard coming down the main hallway (connecting all units) yelling out and cursing. Writer immediately came from behind nurses station due to [Resident #48's room number redacted] also going around nurses station to see who was yelling. When writer observed that it was this resident [R26] I stepped in between both parties as this resident was attempting to lunge toward resident [Resident #48's room number redacted] and fell onto his buttocks out the w/c [wheel chair] in front ice machine room. Resident was yelling I didn't forget you stupid mother fucker, you wanna pick on somebody in a w/c, I'll kill you I have killed all the people that needed to be killed, You bitch ass ni**** come on I'm ready to die, come on mother ***** hit me what you go do I'm a cripple but I still will beat you're a$$. Resident continued with behaviors and threats. Other staff members ran to assist resident in calming down and to assist resident back in w/c after assessing that he did not have any injuries and writer continued to stay in between both residents. Resident in [Resident #48's room number redacted] kept telling resident to leave him alone, this not what you want I'm telling you. informed him not to say any thing d/t [due to] it further increased this resident's agitation. This resident was removed from the unit and taken back to his unit, had calmed down shortly after redirection and change of subject. Stated he was tired and wanted to go to bed. His nurse and supervisor made aware of incident and that no physical contact was made between resident's. On 12/16/25, the director of nursing (DON) was asked to provide any information she had regarding R26's incident with another resident on 10/25/25. On 12/16/25, the DON provided the surveyor with an investigation file and according to the incident summary, it identified Resident #48 as the victim. The facility's incident summary noted, Staff reported that resident [R26's name redacted] was arguing with staff and when resident [R48's name redacted] walked out the room to see what was going on resident [R26's name redacted] punched him [R48] in the face. Residents separated. On 12/16/25, a clinical record review of R48's chart was performed. A nursing note entry dated 10/25/25 read, Resident was standing in the hall while another resident was being aggressive and got struck in the face. There was another progress note in R48's chart dated 10/28/25 at 21:15 that read, Writer prevented resident from altercation with another resident: As resident was talking with writer at nurses station resident room [Resident #26's room number redacted] came down hallway yelling and cursing. Writer stepped in between residents as [Resident #26's room number redacted] lunged at this resident. [Resident #26's room number redacted] fell onto floor out of w/c [wheelchair] because of this action. This resident kept telling [Resident #26's room number redacted] to go ahead and leave him alone, this is not what he want. Writer informed resident that it was best if he did not say anything d/t [due to] increased agitation of [Resident #26's room number redacted]. Residents was kept separated and resident [Resident #26's room number redacted] was removed from the unit no physical contact between residents was made. Supervisor made aware of incident. Resident is own RP [responsible party]. On 12/17/25 at 10:45 AM, an interview was conducted with R48. When asked about the incidents involving him and R26, resident #48 said, It was in the hallway. He was going off and I thought he was going to hit this lady [staff member]. He tried to grab me and swung on me and caught me. R48 denied any injuries, reported R26 was gone for a few days but when he returned, we were outside and when we came in, he tried to get to me again, they [the staff] were holding him back. When asked if anyone had talked to him about the incidents, such as a manager or social worker, R26 stated no. Within the investigation file was an incident summary, facility summary/synopsis, and some clinical records from each resident's chart. There was no indication that either resident was interviewed, any staff were interviewed, nor any attempts to determine if there were any other witnesses that could lend any details. According to the documentation, R26 was on one-to-one observation at the time of the assault on 10/25/25, but there was no evidence that the assigned person conducting one-on-one was interviewed. 3. For Resident #33 (R33), who reported an allegation of misappropriation of property, the facility staff failed to have credible evidence of an investigation being conducted. On 12/15/25, during a clinical record review, it was noted that R33 had reported missing money. According to a nursing note entry dated 11/20/25, it read, Writer and another nurse went to resident's room to look for his money that he claims is missing. Upon entering resident's room, several other staff members were present with resident. Permission requested and granted to look through resident's nightstand to see if by chance he misplaced it in the drawer. While looking in the drawer, a paper bag with about 2 baggies of marijuana observed with a wrapped paper that looked to have been smoked. Resident asked what the items were and if they belonged to him. He stated he didn't know what they were and they were not his. Continued search showed no money found. Bag then retrieved and taken to the DON [director of nursing]. On 12/15/25, the DON was asked to provide the survey team with any information she had regarding R33's report of missing money. On 12/15/25, the DON provided the survey team with what she stated was the investigation file for R33's report of missing money. According to the incident summary dated 11/20/25, it noted, Resident reported to writer that someone stole his 150 dollars from his bedside drawer that he last seen in September. Writer stated it was in his old bedside drawer in his room. Investigation initiated. The investigation file contained the incident summary, facility summary/synopsis, fax confirmation sheets and a document that had a handwritten statement that was not dated or signed and read, resident items not found in hold room [room number redacted] drawers cabinet had meeting with resident with administrator about lock box [sic]. Within the facility synopsis they indicated that the resident reported seeing a staff member in the corner mssing with stuff. There was no indication that the facility staff had conducted any interviews with any staff or attempted to determine if anyone had seen the money prior to R33's report of it missing. On 12/16/25 at approximately 11 AM, an interview was conducted with R33. R33 reported that he was in a room on a different unit and was told they were going to re-model the room, so he was moved to his current room. He reported that in the chest of drawers he had cash totaling $150-$200. R33 reported he had a visitor who is like a brother that comes to see him and when he looked in the drawer, he is the one that noticed the money was gone. The resident reported he was moved in September and had not seen the money since then. R33 reported frustration with trusting these people with the move. The facility had no evidence that they had conducted a thorough investigation into R33's allegation that money was stolen from him. On 12/17/25 at 2:09 PM, an interview was conducted with the facility's director of nursing. The facility administrator was not present during the survey and was not available for interview. The DON confirmed that the facility administrator is the abuse coordinator but in her absence the DON serves in that capacity. When asked about the process when an allegation is made the DON explained that they investigate. She described that the investigation included, we get with staff, try to figure out what transpired to get to root cause analysis of what happened. The DON explained that the facility has five days to complete the investigation. The facility policy titled, Patient Protection with an effective date of 10/17/23, was received and reviewed. The policy read in part, . 4. Any and all suspected or witnessed incidents of patient/ patient abuse, neglect, theft, and/or exploitation or any reasonable suspicion of a crime against a patient/patient Center brought to the attention of the Center's administration will result in internal investigation, appropriate and timely reporting to the state survey agency (SSA) and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. According to the facility policy titled, Reporting Requirements/Investigations with an effective date of 2/5/23, it read in part, . 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigation protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations. On 12/17/25, the above findings were reviewed with the DON and regional director of clinical services. No additional information was provided.

Based on observations, staff interviews, resident interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to ensure the environment remained safe for residents and was free from hazards for one (1) resident (Resident #61) and potentially other residents, in a survey sample of 57 residents, resulting in a finding of Immediate Jeopardy. Unrelated to the IJ, the facility staff failed to ensure that the exhaust pipe from the generator was in good repair. The findings included: 1. The facility staff failed to ensure that a hazardous environment and other materials were not accessible to Resident #61. Resident #61 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, type 2 diabetes, hypertension, difficulty walking, shortness of breath, chronic kidney disease stage 3, obstructive sleep apnea, peripheral vascular disease, and major depressive disorder. Resident #61's most recent MDS (Minimum Data Set) dated 3/31/25 coded Resident #61 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment. On 4/17/25 at 8:45 a.m., outside the rear of the building, Resident #61 was observed ambulating in his wheelchair, opening and reaching into a large lidded 55-gallon red biohazard bin/receptacle. Twenty (20) unsecured, dirty, biohazard containers were observed in this area. When the resident was asked if he knew what the bin was used for, he stated, Yes, pointing toward the Biohazard label on the bin, It is for needles, blood, and stuff. Also observed on 4/17/25, at the rear of the building in the same area, Resident #61 had access to an open generator that appeared to be in the process of being repaired; the housing was off, exposing the running motor and inner mechanical parts. A power drill and drill bits were left on the ground directly in front of the generator. Additionally, on 4/17/25, a third hazardous area accessible to Resident #61 was an extensive collection of paint cans and wooden pallets with exposed nails stacked against an outside wall. It was unknown to the facility how long these had been there, as they consisted of large, old paint cans and wooden pallets with exposed nails stacked against an outside wall. Approaching the rear entrance to the facility, the walkway was littered with sharp louvered machinery panels, cardboard, and other debris. This unsecured area led to the mechanical room, which was cluttered with tools, sharp objects, electrical cords, drills, rolling metal carts, and lawn equipment. Upon proceeding through this area, it was observed that the door leading to the resident hallway was unsecured and unlocked, as it had neither a doorknob nor any other method to prevent residents from entering the hazardous area. At the time of the survey, residents were observed ambulating in the hallways with walkers and wheelchairs, as well as independently, and had access to these hazardous areas. On 4/18/25 at 4:00 pm, an interview was conducted, and Employee F stated that he had informed the Maintenance Director, Around 2 weeks ago (4/4/25), that they needed a new doorknob and lock for the maintenance room door. Employee F said, All of us maintenance staff have to go into that room. It's where the tools are stored. On 4/17/25 at 9:15 a.m., an interview was conducted, and Employee F stated, We try to keep him [Resident #61] out of this area; he comes out here all the time. When asked why the bins were in this area, he stated that he was responsible for bringing the full bins outside when the biohazard company came to pick them up, but he noted that these were already empty. Employee F was asked how long the Resident had been accessing this area, and he estimated approximately 3 weeks, 3/31/25. Employee F requested that LPN C come outside. When asked about the risks to residents who go into the biohazard bins, she stated that they could get stuck with a needle or come into contact with infectious substances. A review of the clinical record revealed the following progress notes: Effective Date: 04/17/2025 10:28 AM Type: Health Status -Resident spoken with about rummaging in trash outside the building and safety risk involved with items that are possibly located in the trash. Resident stated that he only lifted the lid of trash can. Resident encouraged to wash hands stated that he was coming in the building. Resident own RP provider made aware of resident's behaviors. Entry by DON Effective Date: 04/17/2025 10:58 AM Type: Behavior Note - Type of Behavior: Going in hazard waste outside the building after multiple attempts to stop him from going in the trash. Residents have been educated multiple times r/t medical debris. Non-pharmacological Intervention: Educated on dangers of sharp objects and human waste effect: Resident continues to go through the trash outside PRN Medication: none Outcome: Resident remains going in trash outside after multiple attempts from the staff. Entry by LPN B. Effective Date: 04/17/2025 3:15 p.m. Spoke with resident about the back portion of the building being for staff and that the resident should not be back there. Resident acknowledged that he would not go back there after speaking with writer and being made aware. Resident asked what he use to-do, and he stated that he was previously a Maintenance man. Writer talked with resident about his tools that he works with and how he keeps them locked away. Resident verbalized understanding. Entry by LPN B Effective Date: 04/17/2025 6:57 p.m. - Communication - with Resident DON and RDCS spoke to resident regarding suicidal ideation with use of sharp something, he reports it has been a year ago and has not had any further thoughts since that time. He declines psych services, declines social service, he said he will speak to Reverend [NAME], declined for us to call and said he will call if needed. He denies feeling depressed, reports I am fine, reiterated about maintaining safety with not going to outside work area, he agreed and reports understanding. Entry by Regional Director of Clinical Services (Employee C) On April 18, 2025, at 2:30 p.m., after consultation with the state survey and certification agency office supervisors, the survey team notified the facility that it was in immediate jeopardy (IJ) in the areas of accidents and hazards. The survey team, along with the state survey and certification agency supervisors, accepted the IJ removal plan. The survey team validated the IJ Plan, and the Immediate Jeopardy was removed on 4/22/25 at 2:37 p.m. The removal plan read as follows: 1. Resident #61 who was observed accessing hazardous areas including biohazard containers, an open generator, and paint materials, was immediately removed from all hazardous areas and assessed by the nurse on 4/17/25. Resident #61 no signs of injury or contamination were observed on 4/17/25. Resident #61 received individualized education on the risks associated with biohazard, unauthorized access to restricted zones with understanding to prevent injury and maintain safety on 4/17/25. Resident #61's care plan was updated on 4/17/25. The Regulated Medical Waste policy was reviewed and implemented on 4/18/25 by the Administrator. All 20 biohazard containers were secured with locks or discarded as of 4/18/25. The biohazard bins were locked and secured on 4/18/25 with a tarp placed and labeled with biohazard signage until a POD to store or biohazard waste company pick up the bins tentative date 4/21/25. When the POD is picked up by the company the biohazard waste company will pick up the biohazard waste from the utility rooms with biohazard waste. The generator was repaired, closed and secured on 4/18/25. All tools and maintenance equipment were removed from the resident assessable areas immediately on 4/18/25. Debris cleared from all walkways and exterior areas on 4/18/25. Door to mechanical room was fitted with keypad lock and auto-closure mechanism on 4/17/25. All maintenance areas are marked with signage 4/18/25 to prevent the entrance of residents. The dirty utility storage rooms on the units had signage posted with biohazard signs on 4/18/25. Resident #61 and no other residents have been identified outside in the rear of the building on 4/18/25. At the rear of the building in the same area of the biohazard materials, the maintenance staff and designees immediately removed, discarded or placed in appropriate secured storage areas, all biohazard materials, mechanical tools, paint cans, wooden pallets, with exposed nails stacked against the wall, sharp louvered machinery panels, cardboard and other debris were cleared, and the generator repaired, closed and secured with tools retrieved and securely stored. Security measures were promptly implemented, including reinforcement or replacement of doorknobs and or locks to secure access to the maintenance doors, dirty utility rooms and posted warning signage for areas of biohazard waste and containers storage area outside and units to prevent entry of residents in hazardous areas and maintain safety. Current residents of the facility have the potential to be affected by the deficient practice. By 4/20/25 the Director of Nursing or designee conducted a facility wide assessment of all residents to identify anyone else with similar behaviors who may attempt to access restricted or hazardous areas. All ambulatory residents and those using mobility devices will be assessed for risk entering the rear side of the building. The identified residents will be educated to not enter the rear of the building. The identified residents will be educated to not enter the rear of the building of the maintenance service area, biohazard waste and bins to prevent injury and maintain safety with understanding safety boundaries. The maintenance director or designee conducted a full facility inspection of the inside and outside grounds to identify any additional hazardous areas accessible to the residents beyond those already identified. No other areas identified with this practice. 2. The SDC or designee initiated on 4/18/25 in-service training for all staff, regarding biohazard waste and bins, secured areas doors closed and locked, posted signage, removal and storage of biohazard waste in designated bins and secured to prevent accessibility to residents and maintain safety in addition the maintenance and housekeeping staff received training by the Administrator or designee on this information as well, ensuring biohazard bin are secured and not accessible to the residents, ensure picked up by the waste management company, tool security, chemicals, paints, and work areas contaminants are not accessible to residents, maintenance and housekeeping door remain closed and locked when not in use. 3. The maintenance director or designee will complete weekly audits of all biohazard containers and storage areas for 4 weeks, then monthly for 2 months, to ensure residents are protected from avoidable hazards in multiple locations surrounding the building including (1) unsecured 55 gallon red biohazard receptacle (2) an open generator with scattered mechanical tools; (3) paint can and wooden pallets with exposed nails and (4) a unsecured mechanical room containing sharp tools, lawn equipment, and exposed wiring. All corrective action, audit findings and incident reviews will be integrated into the facility's performance improvement plan to ensure ongoing vigilance and proactive culture of safety. The review results will be presented to the QAPI committee for review and recommendations. Any identified issues will trigger immediate corrective action and may lead to the revision of protocols. The review will be conducted randomly once the committee determines that the problem no longer exists and is sustained. The survey team validated the facility's removal plan by proceeding to the rear of the building to inspect the walkways, generator, and area where the biohazard bins were to ensure they had been placed in the POD awaiting pickup. The bins were locked in the POD, and the walkways were clean and free of debris; the generator was no longer open. The doorknob and locks had been repaired so that the mechanical room was no longer accessible to the residents. The pallets had been stacked out of the way of residents, and the paint, chemicals, and tools had all been put away. Inside the building, the doors to all dirty utility rooms were locked, and biohazard bins were stored in the biohazard room. The survey team reviewed the policies and procedures and interviewed staff regarding the proper storage of biohazardous materials. The staff were interviewed and expressed understanding that the bins were to stay locked in that room until picked up by the biohazard waste company. Resident #61 was interviewed, and he verbalized an understanding of the importance of not going to the rear area of the building. Ambulatory residents, either by walking or wheelchair, were interviewed and expressed knowledge of the area behind the building being designated for staff use. The Immediate Jeopardy was removed on 4/22/25 at 2:37 p.m., and the scope and severity were lowered to Level 2, Pattern. 2. Unrelated to the IJ, on the morning of 4/21/25, observation was made of an exhaust pipe leading from the generator up past the window that vents into the building. The exhaust pipe had a large rusted-out hole at the level of the window vent. An interview was conducted with the Maintenance Director at that time, and he stated that it was the first time he had observed the hole, but that it needed to be fixed. When asked what kind of fumes are emitted from a generator when it's running, he stated, Possibly Carbon Monoxide. When asked if these fumes could leak into the building from the hole in the exhaust pipe that runs parallel to the window vent, he stated that it was possible. On 4/22/25, the state Life-Safety department was notified and subsequently visited the facility. The facility was notified that the temporary fix they had in place on 4/22/25, was only a temporary measure until the company servicing the generator could come and replace the pipe. Life-Safety notified the facility that in the event the generator was required due to a power outage, the facility would have to implement a 15-minute fire watch until the pipe was replaced. On 4/22/25, during the end-of-day meeting, all of the aforementioned issues were reviewed, and no further details were provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases for one (1) resident (Resident #61) in a survey sample of 57 residents, resulting in a finding of immediate Jeopardy. The findings included: The facility staff failed to ensure that Resident #61 did not have access to dirty, biohazard containers, which posed a risk of injury and the transmission of disease to other facility residents. Resident #61 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, type 2 diabetes, hypertension, difficulty walking, shortness of breath, chronic kidney disease stage 3, obstructive sleep apnea, peripheral vascular disease and major depressive disorder. Resident #61's most recent MDS (Minimum Data Set) dated 3/31/25 coded Resident #61 as having a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/17/25 at 8:45 a.m., outside in the rear of the building, Resident #61 was observed ambulating in his wheelchair, opening and reaching into a large lidded 55-gallon red biohazard bin/receptacle. Twenty (20) unsecured, dirty, biohazard containers were observed in this area. When the resident was asked if he knew what the bin was used for, he stated, Yes, pointing toward the Biohazard label on the bin, It is for needles, blood and stuff. A review of the clinical record revealed the following progress notes: Effective Date: 04/17/2025 10:28 Type: Health Status -Resident spoken with about rummaging in trash outside the building and safety risk involved with items that are possibly located in the trash. Resident stated that he only lifted the lid of trash can. Resident encouraged to wash hands stated that he was coming in the building. Resident own RP provider made aware of resident's behaviors. Entered by DON Effective Date: 04/17/2025 10:58 Type: Behavior Note -Type of Behavior: Going in hazard waste outside the building after multiple attempts to stop him from going in the trash. Residents have been educated multiple times r/t medical debris. Non-pharmacological Intervention: Educated on dangers of sharp objects and human waste effect: Resident continues to go through the trash outside PRN Medication: none Outcome: Resident remain going in trash outside after multiple attempts from the staff. Entry by LPN B. Effective Date: 04/17/2025 3:15 p.m. Spoke with resident about the back portion of the building being for staff and that the resident should not be back there. Resident acknowledged that he would not go back there after speaking with writer and being made aware. Resident asked what he use to-do, and he stated that he was previously a Maintenances man. Writer talked with resident about his tools that he works with and how he keeps them locked away. Resident verbalized understanding. Entry by LPN B Effective Date: 04/17/2025 6:57 p.m. - Communication - with Resident DON and RDCS spoke to resident regarding suicidal ideation with use of sharp something, he reports it has been a year ago and has not had any further thoughts since that time. He declines psych services, declines social service, he said he will speak to Reverend [NAME], declined for us to call and said he will call if needed. He denies feeling depressed, reports I am fine, reiterated about maintaining safety with not going to outside work area, he agreed and reports understanding. Entry by Regional Director of Clinical Services On April 18, 2025, at 2:30 p.m., after consultation with the state survey and certification agency office supervisors, the survey team notified the facility that it was in immediate jeopardy (IJ) in the areas Infection Control. The survey team, along with the state survey and certification agency supervisors, accepted the IJ removal plan. The survey team validated the IJ Plan, and the Immediate Jeopardy was removed on 4/22/25 at 2:37 p.m The removal plan read as follows: Resident #61 who was observed accessing hazardous areas including biohazard containers, an open generator, and paint materials, was immediately removed from all hazardous areas and assessed by the nurse on 4/17/25. Resident #61 no signs of injury or contamination were observed on 4/17/25. Resident #61 received individualized education on the risks associated with biohazard, unauthorized access to restricted zones with understanding to prevent injury and maintain safety on 4/17/25. Resident #61's care plan was updated on 4/17/25. The Regulated Medical Waste policy was reviewed and implemented on 4/18/25 by the Administrator. All 20 biohazard containers were secured with locks or discarded as of 4/18/25. The biohazard bins were locked and secured on 4/18/25 with a tarp placed and labeled with biohazard signage until a POD to store or biohazard waste company pick up the bins tentative date 4/21/25. When the POD is picked up by the company the biohazard waste company will pick up the biohazard waste from the utility rooms with biohazard waste . All maintenance areas are marked with signage 4/18/25 to prevent the entrance of residents. The dirty utility storage rooms on the units had signage posted with biohazard signs on 4/18/25. Resident #61 and no other residents have been identified outside in the rear area of the building on 4/18/25. Security measures were promptly implemented, including reinforcement or replacement of doorknobs and or locks to secure access to the maintenance doors, dirty utility rooms and posted warning signage for areas of biohazard waste and containers storage area outside and units to prevent entry of residents in hazardous areas and maintain safety. Current residents of the facility have the potential to be affected by the deficient practice. By 4/20/25 the Director of Nursing or designee conducted a facility wide assessment of all residents to identify anyone else with similar behaviors who may attempt to access restricted or hazardous areas. All ambulatory residents and those using mobility devices will be assessed for risk entering the rear side of the building. The identified residents will be educated to not enter the rear of the building. The identified residents will be educated to not enter the rear of the building of the maintenance service area, biohazard waste and bins to prevent injury and maintain safety with understanding safety boundaries. The maintenance director or designee conducted a full facility inspection of the inside and outside grounds to identify any additional hazardous areas accessible to the residents beyond those already identified. No other areas identified with this practice. The SDC or designee initiated on 4/18/25 in-service training for all staff, regarding biohazard waste and bins, secured areas doors closed and locked, posted signage, removal and storage of biohazard waste in designated bins and secured to prevent accessibility to residents and maintain safety. The facility staff will be educated on infection control protocols, safety and the facility's obligation to ensure environmental security with specific accountability and focus on hazardous areas. In addition, the maintenance and housekeeping staff received training by the Administrator or designee on this information as well, ensuring biohazard bin are secured and not accessible to the residents, ensure picked up by the waste management company, tool security, chemicals, paints, and work areas contaminants are not accessible to residents, maintenance and housekeeping door remain closed and locked when not in use. The IP nurse or designee will complete weekly audits of all biohazard containers and storage areas for 4 weeks, then monthly for 2 months, to verify that they are secured and that no patients have access to the areas.This practice aims to ensure the facility maintains good infection control practices. Additionally, the Director of Environmental Services will conduct daily rounds to ensure all biohazard containers remain secure, with documentation on a compliance checklist. The review results will be presented to the QAPI committee for review and recommendations. Any identified issues will trigger immediate corrective action and may lead to the revision of protocols. The review will be conducted randomly once the committee determines the problem no longer exists and is sustained. The survey team validated the facility's removal plan by proceeding to the rear of the building to inspect the walkways, generator, and area where the biohazard bins were to ensure they had been placed in the POD awaiting pickup. The bins were locked in the POD. Inside the building, the doors to all dirty utility rooms were locked and biohazard bins, currently being utilized, were stored in the room. The survey team reviewed the policies and procedures and interviewed staff regarding the proper storage of biohazardous materials. The staff were interviewed and expressed understanding that the bins were to stay locked in that room until picked up by the biohazard waste company. Resident #61 was interviewed, and verbalized understanding of the importance of not going into the rear area of the building. Residents who are ambulatory, either by walking or wheelchair were interviewed and expressed knowledge of the area behind the building being designated for staff use. The Immediate Jeopardy was removed on 4/22/25 at 2:37 p.m., and the scope and severity were lowered to Level 2, Pattern. On 4/22/25 during the end of day meeting the above concerns were reviewed with the Administrator. No further information was provided.

2. The facility's staff failed to identify Resident #156's pressure ulcer prior to progression to a Stage 3 and they failed to provide care and services to promote pressure ulcer healing that resulted in harm. Resident #156 was originally admitted to the facility 2/8/2025 and readmitted [DATE] after a right above the knee amputation (RAKA). The resident's current diagnoses included atherosclerosis, diabetes and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #156's cognitive abilities for daily decision making were intact. In MDS section GG0130. Self-Care the resident was coded as requiring supervision or touching assistance with eating, oral hygiene, rolling from left to right, sitting on side of bed to lying flat, partial/moderate assistance with lower body dressing and chair/bed-to-chair transfers, substantial/maximal assistance with toileting hygiene, shower/baths, and upper body dressing, dependent with putting on/taking off footwear, sit to stand, toilet transfers and wheeling a wheel chair. A review of the CMS 802 revealed that Resident #156 had a stage 3 pressure ulcer. A further review of the clinical record revealed a full body skin assessment was completed by the wound/skin Nurse Practitioner (NP) on 3/12/25 and the resident presented with a RAKA surgical site and a left heel stage 1 pressure ulcer. The next wound/skin assessment dated [DATE] revealed the resident continued with the left heel stage 1 pressure ulcer and the RAKA surgical site was worsening because it dehisced (opened/split). On 3/28/25 the wound care NP assessed a new wound to Resident #156's right buttock reported by nursing. The wound care NP identified the new right buttock wound as a stage 3 pressure ulcer. The right buttock pressure ulcer measured; length 3.00 centimeters (cm) by width 2.80 cm by depth 0.20 cm. Further assessment of the right buttock pressure ulcer revealed it was with 10% epithelial tissue, 10% granulation tissue, and 80% slough (dead tissue) as well as a moderate amount of light pink, watery drainage. A review of Resident #156's pressure ulcer interventions to promote healing revealed as of 4/28/25 there was not a nutrition assessment or orders for nutritional support to promote healing of the newly identified Stage 3 pressure ulcer. An interview was conducted with the Director of Nursing (DON) on 4/28/25 at approximately 3:30 PM. The DON stated the resident was currently nutritionally supported and provided a copy of the Registered Dietitian progress notes which included an initial assessment conducted at the time of the resident's admission to the facility dated 2/10/25. On 3/13/25 a nutritional review was conducted because the resident was readmitted to the facility after the RAKA. At that time a house supplement 90 ml by mouth, two times a day was ordered for prevention of malnutrition/wound healing of the surgical wound and the stage 1 heel ulcer). On 3/17/25 an adult multivitamin with minerals oral tablet was ordered for daily administration. The next nutrition assessment was conducted on 3/26/25 for a significant weight change which was associated with the RAKA. On 4/7/25 another nutritional note addressed a weight change which also was associated with the RAKA. There was not a nutritional assessments which addressed the newly identified Stage 3 pressure ulcer on 3/28/25 and there was no evidence that the resident received additional nutritional support after identification of the Stage 3 pressure ulcer. An interview was conducted with the wound care Nurse Practitioner (NP) on 4/23/25 at 1:40 PM. The wound care NP stated it had been recommended that there be ongoing pressure reduction, including pressure reduction to the heels and all bony prominences, turning/repositioning, incontinence management with application of barrier cream afterwards and use of emollients daily. The wound NP also stated the more interventions the more likely the pressure ulcer would not have complications, but improve and heal. On 4/24/25 at approximately 4:20 PM an observation was made of Resident #156's right buttock pressure ulcer while he was lying in bed with it exposed. The pressure ulcer was clean, with a moderate amount of drainage, absent of odor, and appeared to have approximately 100 percent of granulation tissue. On 4/25/25 at approximately 12:40 PM an interview was conducted with the Licensed Practical Nurse (LPN) C. LPN C stated Resident #156 refused wound care on 4/24/25 but that it was not his normal behavior. LPN C also stated she was not aware of the resident having a Stage 3 pressure ulcer for she was told he had moisture-associated skin damage (MASD). When LPN C returned, she stated the resident did have a Stage 3 pressure ulcer and if she had been aware additional interventions such as more frequent turning/positioning, an air mattress and protein supplements would likely had been discussed and instituted during the weekly Interdisciplinary Team (IDT) meeting. On 4/25/25 at approximately 5:00 PM the DON provided a action plan for pressure ulcers. The plan dated 4/8/25 stated the problem was pressure ulcers Stage 3 or higher and weekly wound measurements not consistently completed and/or documented weekly by the facility nurse or wound NP or clinic staff. The Action Plan was reviewed on 4/28/25. The Immediate response: DON reviewed and identified the areas and initiated an action plan to correct processes and prevent reoccurrences. How to identify other residents that might be impacted: current residents have a potential to be affected. An audit of current residents with pressure ulcers were conducted by the wound nurse or designee to identify pressure ulcers identified at stage 3 or higher had Physician orders, interventions, care plan, physician and responsible party (RP) notifications and to verify weekly wound measurements were completed by the facility nurse, wound NP or wound clinic staff. Findings will be corrected. What measures were put in place to prevent reoccurrence: the Staff Development Coordinator (SDC) or designee would educate the licensed nurses on the wound management process, implement preventative interventions, notifying, obtaining and performing treatment orders per MD with RP notification of wound progress and orders. Weekly skin assessments with wound measurements, if the wound clinic visits are completed, the nurse should verify the wound clinic measurements. If the measurements are not performed by the wound clinic the measurements will be completed and documented weekly on the skin observation tool. How to monitor to ensure the problem does not reoccur: the wound nurse or designee will complete weekly audits for 4 weeks on residents with pressure ulcers identified at Stage 3 or higher. Have physician orders, interventions, and care plan updated. MD/RP notification, verify weekly wound measurements were completed by the facility nurse, wound NP or clinic staff. Findings will be corrected. Date of compliance 4/14/25. Quality Assurance (QA): the results will be reported to the monthly QA committee for review and discussion to ensure substantial compliance. Once the QA committee determines the problem no longer exists, the reviews will be completed on a random basis. During the interview conducted with the Director of Nursing (DON) on 4/28/25 at approximately 3:30 PM. The DON stated a support surface (a medical device used to relieve or redistribute pressure) had been added to the resident bed to aid in pressure relief. Observations were made of Resident #156's bed daily from 4/22/25 through 4/25/25 and a standard mattress was identified on the bed. The Director of Nursing (DON) also stated on 4/28/25 at approximately 3:30 PM, that the resident would have ongoing weekly assessments of the pressure ulcer for management. A review of the resident's weekly pressure ulcer assessment revealed the resident's pressure ulcer was not assessed/measured in-house or by the wound care NP between 4/10/25 and 4/22/25. The resident also did not receive a nurse skin observation between 3/29/25 and 4/13/25. On 4/28/25 at approximately 4:00 PM a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Operations and a Regional Nurse Consultant. The DON and Regional Nurse consultant requested an additional review of their Action Plan although for this resident measures in the action plan had not instituted, after their alleged date of compliance, 4/14/25. In Grade 3 pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged, but the underlying muscle and bone are not damaged. The ulcer appears as a deep cavity like wound. The characteristics are: Full thickness skins involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. Presents clinically as a deep crater with or without undermining. (https://pmc.ncbi.nlm.nih.gov/articles/PMC4413488/) Pressure ulcers are considered to be largely preventable via the use of pressure-relieving processes in those considered at risk. Additionally, pressure relief is part of the treatment offered to those with ulceration. Support surfaces are specialized medical devices designed to relieve or redistribute pressure on the body, or both, in order to prevent and treat pressure ulcers. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8407250/) Based on observation, staff interview, resident interview, facility documentation review, and clinical record review the facility staff failed to manage and prevent pressure ulcers for two (2) residents (Resident #50, and Resident #156) in a survey sample of 57 Residents with constituted harm. The findings included: 1. The facility staff failed to ensure the necessary services were provided to prevent the development of a pressure ulcer that was identified at an advanced stage, resulting in harm. Resident #50 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included quadriplegia, unspecified. The significant Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/12/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #50 cognitive abilities for daily decision making were intact. Section M Skin Conditions coded the resident as having a stage one or greater unhealed pressure ulcers/injuries. The resident was coded as having one stage 3 pressure ulcer. The number of these stage 3 pressure injuries present on admission/entry was coded as 0. The person-centered care plan dated 9/18/24 read that the resident had a pressure ulcer to the Left Elbow. The resident has a risk for worsening wound(s) or the development of additional wounds related to chronic health conditions Date Initiated: 09/18/2024. The goal for the resident was that the resident's wound will show s/s of healing through the review period. The interventions for Resident #50 was skin assessments as indicated and treatment per Treatment Administration Record (TAR). The Braden Scale was completed on 9/12/24: Resident #50 scored 16 on the Braden Scale which placed the resident at risk for developing pressure ulcers. 1.SENSORY PERCEPTION:Ability to respond meaningfully to pressure-related discomfort. No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 2. MOISTURE: Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. ACTIVITY: Degree of physical activity: Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 4. MOBILITY: Very Limited: Changes independently. 5. NUTRITION: Usual food intake pattern: Adequate: Eats over half of most meals. Eat a total of 4 servings of protein (meat, dairy products per day. 6. FRICTION & SHEAR: Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. SCORING: 16. AT RISK 15-18. MODERATE RISK 13-14. HIGH RISK 10-12. VERY HIGH RISK 9 or below. The Physician's Order Summary (POS) for September 2024 read: Low air loss mattress- Check placement and function every shift for wound management-Order Date 09/10/2024 4:59 pm. The POS for November 2024 Prostat SF one time a day for prevention of malnutrition/wound healing 30ml QD -Order Date- 09/06/2024 10:41 pm., discontunued Date- 12/11/2024 2:52 pm. The Physician's Order Summary (POS) for December 2024 dated 12/06/24 at 11:10 am., read: Wound care:(R) Ischium- Cleanse with wound cleanser, apply manuka HD alginate and cover with border gauze dressing every day shift for wound management-Order Date 12/06/2024 11:10 am. A review of the Treatment Administration Record (TAR) read: Wound care: (R) ischium- Cleanse with wound cleanser, apply manuka HD alginate and cover with border gauze dressing every day shift for wound management. (12/06/24). A review of skin assessments read: 9/04/24=No skin issues 10/07/24= small open area to right buttocks 1cm x 1cm red and pink MD aware TX. in place. 10/14/24=Tx cont. to wound to buttocks. Wound is healing. 10/21/24= Wound to right buttocks is healed. 10/28/24=No open areas noted to skin. 11/05/24=no open areas 11/11/24=No open areas noted 11/25/24=Healed areas noted to sacrum, condom catheter in place, tx cont. to fungal rash noted to face and scalp 12/02/24=Treatment in place to face and scalp A review of the above skin assessments do not mention any pressure ulcers of the right Ischium prior to 12/05/24. The wound assessment report dated 12/05/24 read: Pressure Ulcer of the right Ishium: Length: 1.50 cm Width: 3.50 cm L x W: 5.25 cm 2 Depth: 0.20 cm. Acquired in House: as a stage 3 pressure ulcer, 50% slough, subcutaneous, moderate exudate, serosanguineous. A skin/wound note dated 12/05/24 at 11:32 am., written by the WCNP read: Wound Assessment: Wound: 2 Location: right ischium Primary Etiology: Pressure Stage/Severity: Stage 3. Wound Status: New Odor Post Cleansing: None. Size: 1.5 cm x 3.5 cm x 0.2 cm. Calculated area is 5.25 sq cm. Wound Base: 0% epithelial , 50% granulation , 50% slough , 0% eschar Wound Edges: Attached. Periwound: Fragile, Dryness. Exposed Tissues: Subcutaneous. Exudate: Moderate amount of Serosanguineous. Procedure: A sharp debridement was not performed today. Initial assessment completed, wound debridement pain management discussed with patient for future wound care if appropriate. Preventive Measures: The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for incontinence management. Pain management: Tylenol, Oxycodone. Anticoagulant: Xarelto. Supplements: Multivitamins, Vitamin D3 New Recommendations: 12/5/24 - new sacral pressure wound, stage 3 identified by nursing staff. The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions with per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed the staff at the time of the visit. Recommend low air loss mattress. Recommend continued zinc oxide prn incontinence care, pressure reduction and offloading, daily emollients, and floating heels while in bed. On 04/22/25 at approximately 11:47 am., an interview was conducted with Resident #50. Resident #50 said that he got the pressure ulcer on his bottom because they were short staffed, they wouldn't get him out of the bed nor turn and reposition him every two hours. On 04/23/25 at approximately 1:55 pm, an interview was conducted with the Wound Nurse Practitioner (WNP) Wound NP. The WNP said I did an initial wound assessment on the resident and staged it at as a stage 3 pressure ulcer in December 24. The WNP also said that the resident was known to sit in his wheelchair for an entire day not allowing him to shift his weight or reposition. The WNP also mentioned that Resident #50s wound evolved, became deep, but the slough is all gone now. The WNP also said that she staged the wound as a stage 4 instead of stage 3. A review of the medical records did not mention that Resident #50 was non-compliant until after the Stage 3 pressure ulcer of the Ischium was identified. A review of a 60 day recertification note dated 12/03/24 read that resident has an open area on his right buttock measuring 1x1 centimeters (cm) but did not mention if a pressure ulcer was found on the right Ischium. A (Late Entry) review of a Skin/Wound Note dated 12/5/2024 at 6:15 PM., read: Resident receiving ADL care, while this writer and Wound Care Services Nurse Practitioner (WCNP) on weekly wound rounds. Certified Nursing Assistant (CNA) asked writer to come and assess area to the resident's buttocks area. Upon assessment with Wound Care Nurse Practitioner (WCNP), resident noted with a pressure wound to right ischium. POC is manuka HD alginate and border gauze dressing daily. Resident is own RP and aware. On 4/25/25 at approximately 4:55 pm., Corporate staff C was asked if The Plan of Correction document (POC) for pressure wounds was available for review. The Corporate staff said, I will email the document tonight. From 4/25/25-4/27/25-no document was received via email from the facility or corporate staff. On 4/28/25 at approximately 9:10 am., The Director of Nursing (DON) presented a POC (document) on pressure ulcers stage 3 or higher and weekly wound measurements. The date of implementaion was dated 4/08/25 and the date of compliance was dated 4/14/25. There were no resident specific names entered in the document. What Is a Stage 3 Bedsore? A stage 3 bedsore, also known as a grade 3 pressure sore, has burrowed past the dermis (the skin ' s second layer) and reached the subcutaneous tissue (fat layers) beneath. Stage 3 pressure ulcers pose a high risk of infection and can take months to heal. Some pressure sores may even progress to the fourth and most dangerous stage without proper treatment. Nursing homes that hire enough staff and train them properly can avoid most causes of stage 3 bedsores. So, if a resident develops a stage 3 bedsore, it may be due to negligence. stage 3 pressure ulcers can usually be prevented even in high-risk patients. It ' s the duty of nursing home staff members to identify these risk factors in residents and take steps to prevent bedsores from forming. https://www.nursinghomeabusecenter.com/nursing-home-injuries/bedsores/stages/stage-3/ On 04/28/25 at approximately 3:15 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON said that she presented the survey team with the Plan of Correction (POC) book on Friday (4/25/25). No other documents were presented.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide pain management for two Residents (Resident #1 and #6) in a survey sample of eight Residents. For Resident #6, the facility staff failed to initiate any pain relieving measures following a fall resulting in a fracture, resulting in harm. The findings included: For Resident #6, who had a fall on 9/15/22 resulting in a complete displacement femoral neck fracture, and who reported pain, the facility staff failed to assess for pain, and failed to implement any pain relieving measures, resulting in unrelieved pain, and continued distress for three days. Resident #6 was admitted to the facility on [DATE]. On 10/19/22, a review of Resident #6's clinical record revealed Resident #6 fell on [DATE]. The nursing note dated 9/15/22 at 7:30 AM read, Resident noted on floor near sink lying flat on her back. Resident states she got [up] and tried to walk to the bathroom because she had to urinate badly. Wheelchair was parked next to her bed. Assessment performed. Abrasion to right knee noted. Resident c/o (complained of) of mild pain to right knee and right hip. MD (medical doctor) aware gave order to obtain right knee and right hip x-ray to ensure no injury is presenting. Vitals are WNL (within normal limits). RP (responsible party) notified. Review of the September 2022 MAR (Medication Administration Record) and physician orders revealed resident #6 had no physician orders for any type of pain management/reducing medications at the time of the fall, despite rating pain a 4 on a scale of 1-10 (documented in the vital signs portion of the clinical record 20 minutes after the fall occurred). Review of the nursing notes and care plan revealed no evidence of any non-pharmacological interventions being implemented. Review of the physician orders revealed an order for Acetaminophen Tablet 325 MG (milligrams), Give 2 tablets by mouth every 8 hours as needed for generalized pain. The order date was 9/17/22, with a created and start date of 9/18/22. The order was also discontinued on 9/18/22. The Medication administration record (MAR) revealed that this medication was not given/administered at all. On 10/19/22, Resident #6 was interviewed and reported that she was in pain and hurt following the fall. During the interview, Resident #6's sister entered the room. The sibling added to the interview, and stated the Resident was in pain until she had surgery. On 10/19/22, the Resident #6's daughter reported that she visited the resident on the evening of 9/15/22, following the fall. She stated Resident #6 was in obvious distress and guarding her hip. She stated she visited another day following the fall, prior to hospitalization , and again the Resident was in pain. The daughter said she had daily pain. There were no notes or assessments in the clinical record to indicate Resident #6 had been assessed for pain, medicated for pain, or had any nursing interventions following the fall, until 9/18/22 at 12:09 PM, when Resident #6 was recorded as having had a pain rating of 5 on a scale of 1-10 in the weight and vital signs portal on the electronic medical record (EMR). The facility staff did not record any pain assessments for Resident #6 on the MAR or under the Assessments tab in the EMR. A progress note dated 9/18/22 at 2:16 PM, read, Resident had a fall on 9/16/2022 complained of pain on her right side. X-ray was done on right hip. Results shows right femoral fx (fracture) Dr. [name redacted] was call [sic] and new order received to send resident to [hospital name redacted] for evaluation. RP [name redacted] was called and made aware. Resident was sent to [hospital name redacted] via ambulance. This note was written by LPN (licensed practical nurse) B. On 10/19/22 at 3:27 PM, LPN B was interviewed. The nurse stated, I was in providing incontinence care and the Resident was in pain and not her usual self, so I was going to order an x-ray. When I called [x-ray company name redacted] they said one had been done, and they had tried to call the facility but no one would answer. I had them fax me the report, and I called the doctor and they sent her out [to the hospital]. Resident #6's x-ray results were reported to the facility on [DATE] at 5:55 a.m. Review of this report revealed: There is an acute femoral neck (hip) fracture with complete displacement . The provider/doctor was not made aware of the x-ray results until 9/18/22, when a nurse observed Resident #6 to not be her usual self, grimacing in pain during incontinence care. Following the end of day meeting held on 10/20/22, the facility submitted a statement from LPN B, which read: On 9/17/22- Obtained an order for Tylenol due to resident, [Resident #6's name redacted] complaining of discomfort, no location of pain indicated. The daughter was at bedside. Nurse [LPN B's name redacted] states that the Tylenol was administered 9/17/22 . A review of the facility policy, Pain Management Assessments, revealed, in part: Assess all patients for pain as part of the admission nursing assessment. 2. Initiate a pain assessment any time thereafter should a patient experience pain that is not usual for the patient. 3. Administration of pain medication and effectiveness will be documented. 4. Non-pharmacological interventions will be documented with the administration of PRN ([as needed). 5. If pain is not relieved, notify physician. Any unusual findings and follow-up interventions are to be documented on the progress notes including notification of physician and responsible party. 6. Care plan specific interventions will be developed based on pain assessment and individual patient needs. On 10/21/22, the facility Administrator and Corporate staff were again made aware of the above findings, and that the lack of intervention resulted in Resident #6 having pain that was not treated, constituting harm. No additional information was provided. 34894

Based on clinical record review, Resident, family and staff interviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to promptly notify the physician of x-ray results which indicated a fracture, and resulted in a delay in treatment/harm for one Resident (Resident #6) in a survey sample of six Residents. The findings included: For Resident #6, who had an x-ray confirmed fracture, the facility staff failed to notify the physician for 3 days, which resulted in a delay in treatment. On 10/19/22, a clinical record review was conducted of Resident #6's electronic health record. This review revealed the following: 1. On 9/15/22, Resident #6 was found on the floor by facility staff. The Resident reported she fell while attempting to go to the bathroom. 2. On 9/15/22, the provider/doctor was notified and gave orders for a hip and knee x-ray. 3. On 9/15/22, the x-ray was performed as ordered. 4. On 9/16/22 at 5:55 AM, the x-ray results were reported to the facility/uploaded into the resident's clinical record. Review of this report revealed, in part: There is an acute complete femoral neck (hip) fracture with complete displacement . 5. There was no evidence of the physician being made aware of the x-ray report confirming a fracture on 9/16/22 or 9/17/22. 6. There was no documented evidence of any nursing assessment, intervention or response, to the known fracture on 9/16/22 or 9/17/22. 7. Resident #6's progress note dated 9/18/22 at 2:16 p.m. documented: Resident had a fall on 9/16/2022 complained of pain on her right-side. X=ray was done on right hip. Results shows right femoral fx (fracture). Dr. [name redacted] was call and new order received to send resident to [hospital name redacted] for evaluation. RP [responsible party] [name redacted] was called and made aware. Resident was sent to [hospital name redacted] via ambulance [sic]. This note was written by LPN (licensed practical nurse) B. On 10/19/22 at 3:12 PM, an interview was conducted with Employee K, the Nurse Practitioner (NP). When asked to discuss how soon an x-ray should be done after being ordered, Employee K said, As soon as possible, sometimes it has been within 2-3 hours or within 24 hours. Employee K said that if the x-ray companies lets the nursing staff know they can't get to the facility or there will be a delay, They generally will let us [medical providers/doctor or nurse practitioner] know. Employee K said, If the patient is really uncomfortable or in pain, I would expect them to let us know if there is a delay. When asked why that communication is important, the NP said, because that may change their orders and treatment options. The NP reviewed Resident #6's electronic health record and confirmed that an x-ray was ordered on 9/15/22, and the x-ray was performed on the evening of 9/15/22, read by the radiologist on 9/16/22, and the results were uploaded into Resident #6's chart on 9/16/22 at 5:55 AM. The NP confirmed that had they [medical providers] been aware of the fracture on 9/16/22, they would have ordered the Resident to be sent to the hospital at that time. On 10/19/22 at 3:27 PM, an interview was conducted with LPN B. The nurse stated, I was in providing incontinence care and the Resident was in pain and not her usual self, so I was going to order an x-ray. When I called [x-ray company name redacted] they said one had been done, and they had tried to call the facility but no one would answer. I had them fax me the report and I called the doctor and they sent her out. The delay in notification of the medical doctor and/or Nurse practitioner of the fracture/x-ray results caused Resident #6 to have a delay in treatment for the fracture. This constituted harm. On 10/19/22 at 3:51 PM, an interview was conducted with the Supervisor/Employee V, the facility's contracted provider for x-rays. Employee V was asked about the x-ray performed on Resident #6, ordered 9/15/22. Employee V said, The technician completed the x-ray at 23:13 [11:13 PM] and it was faxed to the facility on [DATE] at 5:50 AM. With COVID, we had a back-up in reading the results. We tried to call with no answer at the facility on 9/16/22 at 9:44 AM, 9:54 AM, and 10:54 AM. We re-faxed the report on 9/18/22 at 9:18 AM. When asked if the x-ray results were available to the facility staff, employee V said, It was uploaded into the system at 5:55 AM on 9/16/22. On 10/19/22 at 3:59 PM, an end of day meeting held with the facility Administrator, Director of Nursing, Regional Director of Clinical Services and [NAME] President of Operations. The Director of Nursing (DON) was asked to explain the process when a provider gives an order for a lab or diagnostic test. The DON said, The order is put in, they fill out the request form and call [x-ray company name redacted]. Typically within 24 hours it is done. If they don't show by the end of the shift, we will call the provider and get further directives. When asked to explain the process of receiving results of x-rays, the DON said, Typically they upload into the system [clinical chart of the Resident], if it is a critical lab or fracture, they will call the nurses and follow-up and they notify the doctor immediately. When asked if she had identified any problems with this process, the DON said, Yes, we had one Resident who had an x-ray and we didn't get the results within 24 hour timeframe. The DON named Resident #6 and said the doctor was notified, family was notified, and she had a conversation with the diagnostic company, who said they were short staffed and backed up. On 10/19/22, the DON provided a copy of the x-ray report from 9/15/22, nursing notes for Resident #6 from 9/15/22-9/18/22, a wound evaluation conducted 9/22/22 of a right hip surgical wound, and a physician history and physical dated 9/23/22. These documents confirmed the findings noted above, which were: the x-ray was performed 9/15/22, the results were received 9/16/22, which confirmed a fracture. The provider was not made aware until 9/18/22, at which time they ordered for the Resident to be sent to the hospital, where she underwent surgical repair and returned to the facility on [DATE]. A review of the facility policy titled, Documentation and Notification, was conducted. This policy read, 1. The charge nurse is responsible for notifying the Physician (MD) and/or the Responsible Party (RP) whenever there is a change related to the care of the patient . 2. Whenever there is a notification of the MD/RP, the charge nurse will include this information in the shift report and document the notification on the appropriate forms . A copy of the facility 24 hour reports/shift reports for 9/15/22 through 9/19/22 were requested. The facility Administrator reported to the survey team on 10/21/22 that they were not available. On 10/21/22, during an end of day meeting the facility Administration were made aware of the above findings. No further information was provided.

Based on observations, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to prevent significant weight loss for Two Residents (Resident #105, and #110 ) in a survey sample of 58 Residents, resulting in harm for Resident #110. Findings include: 1. For Resident #110, the facility staff failed to prevent an unplanned significant weight loss, failed to feed the resident their therapeutic diet, failed to institute weight loss interventions recommended by dietary, failed to involve the doctor in weight loss evaluation and intervention, which culminated in harm for the Resident. Resident #110 was admitted to the facility on [DATE]. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4-20-22, was a quarterly assessment. The document revealed the Resident had moderate cognitive impairment and further documented the Resident was on a Mechanically altered Diet. The Resident required feeding, and was documented as having no weight loss. The Resident's weight record was reviewed and revealed the following; 1-1-22 - 143.5 lbs via mechanical lift 3-11-22 - 130.0 via mechanical lift This revealed no monthly weight obtained for February 2022, and a greater than 7.5% significant weight loss of 13.5 lbs in 2 months and 10 days. Review of the Resident's care plan revealed the following; Focus: dated 2-13-18, revised 3-23-21, Nutrition risk related to advanced [CONDITION(S)] disease failure to thrive, mechanically altered diet provided for ease of chewing and swallowing, and history of dysphagia. Goal: created 3-26-21, revised 3-30-22, Resident will avoid significant weight change through next review. Interventions: all were created on 3-23-21, with no new additions on 3-30-22 monitor and report signs of dysphagis (pocketing, choking, coughing, drooling, difficulty swallowing, refusing to eat, appears concerned during meals., monthly weights, provide and serve supplements as ordered, provide and serve diet as ordered, monitor intake and record every meal, RD (registered dietician) to evaluate and make recommendations as needed, staff assistance with feeding. No special diet, thickened liquids, nor supplements were documented on the care plan for nursing to provide. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2-26-20 regular diet easy to chew (mechanical soft) with mildly thick liquids. 6-29-21 Ensure plus supplement one time per day. From 1-1-22 through the time of significant unplanned weight loss on 3-11-22, no RD evaluation was found in the clinical record. The progress notes were reviewed from November 2021 through April 2022 and revealed that on 3-11-22 a dietary note was documented stating that the Resident had a 7.5% significant weight loss, and was eating well with a good intake. The note went on to say that the Resident's supplement had been reduced because of good oral intake. The Resident was reweighed and the weight loss was acknowledged. The Dietary representative recommended magic cups with lunch and dinner to supplement the Resident, and to establish weekly weights to evaluate success. Neither recommendation was ordered, implemented, nor care planned. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During initial tour of the facility on 4-24-22 lunch trays were observed being delivered to resident rooms at 1:30 p.m. by 2 CNA's (certified nursing assistants) for approximately 60 residents, 8 of which needed to be fed by staff, as they were unable to eat independently. The 2 LPNs (Licensed practical nurses) on the unit were passing medications at the time. Resident #110 was in bed and asleep. The Resident's meal tray was on the over bed table, untouched. The drinks on the tray were thin liquids with no thickening, and no supplements were on the tray. This situation was observed for 30 minutes, as the CNAs continued to open, prepare, and pass out the trays, one resident at a time. At 2:00 p.m. one LPN was seen helping and the surveyor asked her why the lunch meal was so late, and she responded We have bare bones staff, most of the staff are from agencies and don't know the residents needs, there are only 3 of us to get people fed 2 meals, pass meds, keep everyone clean, and do treatments, and it's impossible, it's like a pressure cooker here. A dietary staff member was asked when seen on the hall, why all of the carts were not delivered at the same time. The response was There are only 3 of us in the kitchen, and no way could we bring out six carts at the same time, we are running late today. At 2:00 p.m., Resident #110's room was again observed with no change. The tray was still on the overbed table untouched, and the Resident was sleeping. The CNA on the hall was asked when the Resident would be fed, and she stated as soon as all of the trays are passed we will feed the feeders. At 2:30 p.m. Resident #110's room was entered and the tray was gone. The surveyor went to the cart in the hall and found the tray back in the cart untouched. A different CNA was on the hall removing trays and was asked why Resident #110 didn't eat, and she stated I don't know she was not my feeder. The second CNA could not be found. On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), and Administrator were made aware of the issues with Resident #110's significant weight loss and harm. The DON, Regional RN, and Administrator were asked what their expectation was for a Resident with weight loss, and it was collectively stated that the Registered Dietician should be made aware, and the physician. Also, an assessment should be completed with new interventions care planned immediately as soon as the weight loss was identified. They stated they had nothing further to provide. 2. For Resident #105, the facility failed to prevent significant weight loss. Resident #105 was admitted to the facility on [DATE]. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3-24-22, was a quarterly assessment. The document revealed the Resident had minimal cognitive impairment and further documented the Resident was on a Therapeutic Diet, and had no weight loss. The Resident was independent in eating, and required no assistance. The Resident's weight record was reviewed and revealed the following; 12-18-21 - 165.1 lbs standing 3-10-22 - 156.6 lbs standing This revealed no monthly weight taken for January and February 2022, and a greater than 5% weight loss of 8.75 lbs in less than 3 months. Review of the Resident's care plan revealed the following; Focus: created 12-20-21 Nutrition risk on admission. Goal: created 12-20-21, revised 3-30-22, resolved 12-20-21 Will avoid significant weight change through next review. No interventions were planned for this focus, and the resident's weight loss was found after the goal resolved date. Focus: created 12-20-21 Nutrition Risk related to recent hospitalization , therapeutic diet related to insulin dependent diabetes mellitus, history of [CONDITION(S)] (low sodium) respiratory failure and hypertension. Interventions: all created 12-20-21 Labs as ordered, Provide,serve diet as ordered, monitor intake and record every meal, RD (Registered Dietician) to evaluate and make diet change recommendations as needed, weekly weights related to admission, created 4-11-22 (after weight loss) Monthly weights, On 4-15-22 a doctor's order was received for Ensure Plus once in the evening as a supplement, and Med plus 2.0 twice per day as a supplement, over a month after the Resident's weight loss was known. These interventions were not documented on the Resident's care plan for nursing staff to provide. No RD evaluation was found in the clinical record. No therapeutic Diet was ever ordered, and weekly weights were never obtained. Monthly weights were not obtained for January, and February 2022. On 4-26-22, and 4-27-22 at 5:00 PM, the Director of Nursing (DON), Regional RN, and Administrator were made aware of the issues with Resident #105's weight loss. The DON and Administrator were asked what their expectation was for a Resident with weight loss, and it was collectively stated that the Registered Dietician should be made aware, and the physician. Also, an assessment should be completed with new interventions care planned immediately as soon as the weight loss was identified. They stated they had nothing further to provide.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide infection control measures in accordance with the Center for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC) recommendations, to prevent the spread of COVID-19, for 5 Residents (Resident #6, #7, #8, #9 and #10) in a survey sample of 32 Residents and for 5 facility staff (LPN A, LPN B, RN D, CNA D, CNA E) 1. The facility staff permitted employees who had confirmed positive test for COVID-19 to continue to work, without meeting the CDC return to work (RTW) criteria, which exposed Residents #6, #7, #8, #9, and #10, who were all previously negative for COVID-19. 2. The facility staff failed to don (put on) all necessary PPE (personal protective equipment) prior to entering rooms with enhanced droplet precautions. Immediate Jeopardy was identified on 1/27/2021 at 6:15 PM for finding number 1. After verification, Immediate Jeopardy was removed on 2/2/2021 at 2:00 PM, and the scope and severity was lowered to a Level 2, pattern due to finding number 2. The findings included: 1. The facility staff permitted employees who had confirmed positive test for COVID-19 to continue to work, without meeting the CDC return to work (RTW) criteria, which exposed Residents #6, #7, #8, #9, and #10, who were all previously negative for COVID-19. On 1/26/21 at approximately 3:30 PM, during Entrance Conference, a telephone interview was conducted by Surveyor B with the Facility Administrator (Employee A). The Facility Administrator was asked if he ever had to implement emergency staffing strategies during the COVID-19 pandemic, he stated, No. The Facility Administrator was asked if the facility had experienced any staffing problems, he stated, No. The Facility Administrator was asked if resident care had been impacted by any staffing concerns, he stated, Not at all. On 1/26/21 during the afternoon, Surveyor A conducted a tour of the facility. Surveyor A was accompanied by Employee B, the Director of Nursing (DON) during this tour. Surveyor A had asked the DON how the outbreak had affected staffing, the DON stated what we did was based on the need at that time, if this unit was positive and staff were positive and asymptomatic we allowed them to work on the positive unit. On 1/26/21, the facility staff provided the survey team with a staff surveillance log. On 1/27/21, this log was reviewed and revealed that employees were listed with a COVID positive date, first back to work date, and actual column. The facility Administrator was asked to explain the form. The Administrator stated, the first back to work date is the first day after a 10 day quarantine they could return and the actual date is the date they actually returned. Surveyor A identified that there were multiple staff listed who had a COVID positive test date of 12/22/20-12/29/20, who did not have actual return to work dates listed and there was no indication of the position the employees held. The facility Administrator indicated he would review the form and provide a revised copy. On 1/27/21, the facility Administrator provided the survey team with a revised Employee Surveillance log which included employee's position. This log included green, yellow and red highlighting. The Administrator explained that red, these people are still sick, yellow, they could return but have not, green, they have recovered. This log was reviewed and revealed the following: 1. LPN A tested positive for COVID-19 on 1/8/21, with a return to work date of 1/8/21. 2. RN D tested positive for COVID-19 on 1/11/21, with a return to work date of 1/11/21. 3. LPN B tested positive for COVID-19 on 1/19/21, with a return to work date of 1/24/21. 4. CNA D tested positive for COVID-19 on 1/5/21, with a return to work date of 1/8/21. 5. CNA E tested positive for COVID-19 on 1/5/21, with a return to work date of 1/5/21. The facility census on 1/5/21 indicated 119 beds of 180 beds total were occupied. There were 56 vacant beds within the facility on units located outside of the designated COVID positive unit. The facility census on 1/8/21 indicated 121 beds of 180 beds total were occupied. There were 51 vacant beds within the facility on units located outside of the designated COVID positive unit. The facility census on 1/29/21 indicated 130 beds of 180 beds total were occupied. There were 33 vacant beds within the facility on units located outside of the designated COVID positive unit. Review of the clinical records revealed the following: 1. Resident #6, who has a [CONDITION(S)] and had never tested positive for COVID-19. Resident #6 remained on the COVID positive unit and received [CONDITION(S)] care as well as medication administration by COVID positive staff who had not met the CDC RTW criteria on 1/8/21, 1/11/21, 1/12/21, 1/13/21, 1/16/21, and 1/17/21 per the MAR (Medication Administration Record) and Treatment Administration Record, therefore exposing Resident #6 to the COVID-19 virus. 2. Resident #7, who was COVID negative until 1/11/21, was a Resident of the COVID positive unit and was cared for on 1/11/21, by 2 COVID positive staff (LPN A and RN D) who had not met the RTW criteria. 3. Resident #8, was COVID negative and was housed on the COVID positive unit, when other beds were available within the facility. Per the MAR for Resident #8, he was cared for by COVID positive staff (LPN A and RN D) who had not met the CDC RTW criteria on 1/8, 1/11, 1/12, 1/13, 1/16, 1/17. Subsequently Resident #8 tested positive for COVID-19 on 1/26/21. 4. Resident #9, who was COVID negative until 1/11/21, was a Resident of the COVID positive unit and was cared for on 1/8/21 and 1/11/21 by a COVID positive staff (LPN A) who had not met the RTW criteria. 5. Resident #10, who was COVID negative until 1/18/21, was a Resident of the COVID positive unit and was cared for on 1/11, 1/12, 1/13, 1/14, 1/16, and 1/18 by 2 COVID positive staff (LPN B and RN D) who had not met the RTW criteria. On 1/27/21 at 10:19 AM, when the facility Administrator was asked again about staffing and if they had implemented their emergency staffing plan, the Administrator stated, I guess based on this, we were because it is a transition from the normal process. When asked what strategies they implemented based on their emergency staffing plan, he stated, we contracted with agency staffing and called 3 other sister facilities. On 1/27/21 at 11:12 AM, Surveyor B received an email from the Facility Administrator which read, I wanted to follow-up on the discussion for staffing usage for the center. We have initiated staffing agency contracts with [name redacted] Healthcare staffing since the second week in December. This was due to the first week COVID out break and the need to have assistance with staffing. The account manager that we discuss needs and go through is [name and phone number redacted]. We continue to use the RTW [Return to Work] strategies within the CDC [Center for Disease Control and Prevention] recommendations and Guidance as attached. Also, as mentioned discussions regarding staffing strategies have been had with our public health nurses and epidemiology teams. The frequent contact is listed below. This is to include contingent and crisis staffing. Henrico Public Health Contact: [name and phone number redacted, assigned 'Other A' on survey identifier] Thanks [name redacted, Facility Administrator]. On 1/27/21 at approximately 11:40 AM, Surveyor B conducted a telephone interview with Henrico Health Department Public Health Nurse (Other A) who confirmed that she was a point of contact for the facility as previously identified by the Facility Administrator. The Public Health Nurse stated she was unaware of any recent staffing shortages at the facility and has regular contact with facility staff, including the Facility Administrator. The Public Health Nurse stated, In the middle of December, [name redacted, Henrico Health Department Infection Control Specialist, assigned 'Other B' on survey identifier] conducted a site visit to [the facility] in response to an [COVID-19] outbreak and [the Facility Administrator] was advised at that time that it was not recommended to have [COVID] positive staff that have not completed a quarantine work with [COVID] negative staff because they [the facility] could not properly and safely accommodate this staffing arrangement. On 1/27/21 Surveyor A had a conversation with the facility contact person for the nursing staffing agency. The nursing staffing agency representative did confirm that the facility had initiated a contract with them the second week of December and due to being a new contract and the upcoming Christmas and New Year Holidays staffing had been challenging. The nurse staffing agency representative did provide details of how many nursing shifts, to include nurses and CNA's they had been able to cover on a weekly basis since the inception of the contract. The agency had provided as few as 2 shifts in a week to as many as 20 shifts within a week. The facility Administrator did not provide any evidence of communication with local healthcare coalitions, federal, state and other public health partners nor any development of regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with [CONDITION(S)]-CoV-2 infection, as CDC guidance suggests to mitigate staffing shortages. The facility Administrator also failed to provide any evidence of reaching out to sister facilities for staffing assistance, as the Administrator indicated in their Emergency Staffing plan. On 1/27/2021 at 6:15 PM, Immediate Jeopardy (IJ)was called , due to the facility allowing COVID-19 positive staff to work, prior to meeting the CDC return to work criteria care for COVID-19 negative Residents. By allowing this, it created the likelihood that serious harm or death could occur if the Resident's contracted COVID-19. The facility staff, which included the Administrator and the Director of Nursing (DON) were made aware of IJ. On 1/28/21, the Facility Administrator submitted an IJ abatement plan, which the survey team accepted. The abatement plan stated: A. All staff working today will be tested for COVID-19 and all staff not tested today will be tested prior to their next shift. All COVID-19 positive staff members will be sent home to quarantine until they have met CDC return to work criteria. Any previous positive staff members that have not met return to work criteria will be sent home to quarantine. B. All residents that are eligible for testing have been tested and no new positive cases were identified. All residents that are negative but exposed will be placed on enhanced droplet precautions for 14 days. Any residents that test positive will be placed on a hot unit on enhanced droplet precautions. Two negative residents from the hot unit have been moved to a separate unit and placed on enhanced droplet precautions for 14 days. The Center will ensure that positive and negative patients will not be cohorted in the same room. C. The DON or designee will continue COVID-19 testing on staff and residents for COVID-19 based on current CDC guidelines. D. The DON or designee will educate all staff that are currently working and all other staff prior their next shift on CDC return to work criteria. E. Date of completion 01/28/2021 On 1/29/21, the survey team was onsite to verify the IJ removal plan had been implemented as follows: 1. On 1/29/21 the survey team conducted a review of all staff working 1/28/21 and 1/29/21. This review revealed that LPN C worked 1/28/21 and on the testing log hx was noted beside her name to indicate she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA G was noted on the staff working list for 1/28/21. Review of the testing log for 1/28/21 revealed CNA G with a hx to indicate she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the surveillance log did not list CNA G as having had a positive COVID test. 2. During staff interviews on 1/29/21, CNA H indicated she had not been tested for COVID-19 since 1/21/21. CNA H was noted on the staff testing log for 1/28/21 with no indication of being tested . 3. On 1/29/21, staff interviews were conducted with 7 staff members regarding the CDC return to work criteria and education they received. Of the 7 staff, they all consistently reported that the facility Administrator or DON would let them know how long they would have to be out of work, depending upon their symptoms. When asked what the minimum time for the quarantine period was, only 1 staff member was able to state I think it is 10 or 14 days, I'm not sure. The survey team determined that the facility had not removed IJ at this time, for the reasons noted above and notified the facility of these findings on 1/29/21 at 1:15 PM. The facility Administrator submitted a revised Abatement Plan to the survey team on 1/29/21, with a revision to the completion date, which now stated 2/1/21. The survey team then returned to the facility on [DATE]. The survey team verified that all Residents who had not tested positive for COVID-19 within the last 90 days were re-tested on [DATE]. The survey team verified that any Resident who resided on the COVID hot unit and had never tested positive had been moved off of the Hot unit and placed on enhanced droplet pre-cautions. The survey team verified the COVID status of all Residents and ensured that Residents were cohorted with Residents of the same COVID status (COVID negative with COVID negative, recovered with other recovered and COVID positive with COVID positive). The survey team conducted observations on 1/29/21 and verified that all Residents exposed to COVID-19 positive staff that had not met the CDC return to work criteria, were placed on enhanced droplet precautions due to exposure. The survey team reviewed staff testing logs for the past 10 days and identified all staff that had tested positive for COVID-19. The as-worked schedule was then reviewed for 1/28 and 1/29 to ensure those staff had been removed from the schedule and were not currently working. The survey team reviewed all staff currently working and ensured they had been tested for COVID-19 on 2/1/21 or prior to their shift on 2/2/21. If they were not eligible for testing due to a previous positive COVID-19 test they had met the CDC RTW criteria for a 10 day quarantine period. The survey team verified that any Resident admissions since the review conducted on 1/29/21, were properly cohorted with a Resident of the same COVID-19 status. The facility census was reviewed to ensure no room changes had been performed since 1/29/21, that may have caused cohorting concerns. The survey team conducted staff interviews to verify that staff were aware of the CDC RTW criteria and need for a quarantine period if they test positive for COVID-19. IJ was then removed at 2:00 PM on 2/2/21. Review of the facility policy titled, COVID-19 stated, 11. Containment/Management c. cohort like patients in a designated area (i.e. a close group of rooms on a certain hall). Per the CDC Return to Work Criteria for HCP with [CONDITION(S)]-CoV-2 Infection. Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [CONDITION(S)] diagnostic test. Accessed online 1/27/2021: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html Per the CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages the following guidance is provided to healthcare facilities: Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for healthcare personnel (HCP) and safe patient care. As the COVID-19 pandemic progresses, staffing shortages will likely occur due to HCP exposures, illness, or need to care for family members at home. Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these There are Contingency and Crisis Capacity Strategies that healthcare facilities should consider in these situations: When staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use contingency capacity strategies to plan and prepare for mitigating this problem. At baseline, healthcare facilities must: Be in communication with local healthcare coalitions, federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed. The CDC article continues to state Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with [CONDITION(S)]-CoV-2 infection. Developing plans to allow asymptomatic HCP who have had high risk unprotected exposure to [CONDITION(S)]-CoV-2 (the virus that causes COVID-19) but are not known to be infected to continue to work onsite during their 14-day post-exposure period. CDC has provided Options to Reduce Quarantine for Contacts of Persons with [CONDITION(S)]-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing. These options could be considered as a measure to mitigate staffing shortages and not as a preferred option. Healthcare facilities should understand that shortening the duration of work restriction might result in additional transmission risks. Healthcare facilities management that elect to implement approaches other than those described in the CDC scientific brief should understand that there might be additional transmission risks posed by their approach. Accessed online 1/27/2021: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html No further information was received. 2. The facility staff failed to don (put on) all necessary PPE (personal protective equipment) prior to entering rooms with enhanced droplet precautions. On 1/29/21 at approximately 9:45 AM, Surveyor A observed Employee E enter room [ROOM NUMBER]. Employee E had on an N-95 mask, isolation gown and gloves. The room door had signage that read, Enhanced droplet-contact precautions. Perform hand hygiene, surgical mask when entering the room, eye protection when entering the room, gown when entering the room, gloves when entering the room. Employee E was observed with no eye protection on, when asked about eye protection and the sign was pointed to, Employee E was asked if her prescription eye glasses are considered eye protection. Employee E stated, they said I could use them as eye protection because the goggles keep falling off my face. On 1/29/21 at 10:05 AM, Surveyor A enters the Central Wing. The hall-way housing rooms 46-58 were all noted to be on enhanced droplet precautions with signage on each door as well as PPE stations throughout. RN F, the unit manager was asked to identify the unit and she stated, these rooms are all on precautions because we had a staff member test positive yesterday and was sent home so they have all been exposed. Surveyor A proceeded onto the hall and observed RN E was passing medications. RN E was observed with an N-95 mask on, hair covering, isolation gown which was only tied at the neck. She prepared medications for the Resident in room [ROOM NUMBER] and then entered the room with no gloves on. She touched the bedside table and administered medications. She did use hand sanitizer prior to exit. She had on prescription eye glasses and prior to entering the room failed to don eye protection to include a faceshield or goggles and failed to put on gloves. On 1/29/21 at 10:17 AM, Surveyor A returned to the nursing station to question RN F, the unit manager again. RN F stated prior to entering a room she expects staff to put on gown, gloves, goggles and N-95. When asked if prescription eye glasses are considered eye protection she stated, no, you should have goggles over them. Surveyor A then returned back to the unit and then observed CNA I enter a Resident room with enhanced droplet precaution signage on the door. CNA I had on an isolation gown, N-95 mask and gloves. She failed to put on eye protection. CNA I was asked what PPE was required to enter the room and she stated, gloves, gown, goggles or faceshield. When asked why she didn't have goggles or a faceshield on she stated, I had them during COVID but when we went off of precautions I didn't need them so I quit bringing them. We just went on precautions yesterday and I didn't bring them. RN F then entered the unit and proceeded to hand CNA I and RN E a pair of goggles and asked them to wear them. Review of the facility policy titled, Transmission Based Precautions-General Practice read, 4. e. The health care team and visitors will be instructed on the importance and necessity of maintaining TBPs [transmission based precautions] before entering the patient's room. The CDC gives the following guidance to nursing facilities regarding how to don PPE: How to Put On (Don) PPE Gear. More than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of donning. 1. Identify and gather the proper PPE to don. 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). 5. Put on face shield or goggles. 6. Put on gloves. 7. Healthcare personnel may now enter patient room. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html The facility Administrator and Director of Nursing were made aware of the findings during an end of day meeting held on 1/29/21. No further information was provided. Complaint related deficiency.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to mitigate an accident hazard during ADL care for 1 resident (Resident #39) of 57 residents in the survey sample resulting in harm. Resident #39 was coded as two person assistance when turning and repositioning in bed. During incontinence care provided by one staff person, the resident fell out of bed and fractured her shoulder. The findings included: Resident #39, a [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an annual assessment with an assessment reference date of 9/5/18. Resident #39 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required extensive assistance with her activities of daily living. On 12/4/18 at 2:10 p.m., an interview was conducted with Resident #39. Resident #39 was sitting up in a bariatric bed. During the interview, Resident #39 stated that she fell out of bed while being changed. She stated that she was turned on her right side facing the window while staff changed her. When asked how many staff were in the room, Resident #39 stated there was one male certified nursing assistant (CNA) in the room. When asked for the CNA's name, Resident #39 provided the name. Resident #39 stated that she fell from the bed and broke her arm near the shoulder. She stated that the CNA tried to grab her as she fell . She stated that she rolled out of the bed towards the window. Resident #39 stated she had an abdominal mass that shifted causing her to fall. Resident #39 stated that since the fall, she had pain in her shoulder. When asked if she participated in therapy to help with her arm, Resident #39 stated that the orthopedic doctor recommended therapy but the facility did not comply. When asked if she ever gets up out of bed, Resident #39 stated no. During the interview, CNA D knocked on the door. He stated he was there to provide care, as this was the time he usually did so with Resident #39 in the afternoon. He was asked to return in 10 minutes. The CNA involved in the fall incident was identified. He is referenced as CNA H in this deficiency. The following nursing notes were documented in the clinical record: - 3/27/18 17:03, Incident Note, Resident rolled out of bed during ADL (activities of daily living) care. Resident c/o (complained of) right shoulder pain resident sent to (hospital) for further evaluation. - 3/27/18 23:04, Order Note, [MEDICATION NAME] 10-325 milligram give 1 tablet by mouth every 6 hours as needed for pain - 3/28/18 01:14, Post Fall Note, situation: resident had a fall, background: diabetes, [MEDICAL CONDITION], assessment: resident has a sling on right shoulder fracture - 3/28/18 16:01, Discharge Planning Progress Meeting held with patient, ___ case worker/ friend, _____ DON (director of nursing), ____ UM (Unit Manager), and ____ DDP (director of discharge planning) to discuss patient's plan of care. Patient had reported to (friend) issues with being changed timely and pain being unaddressed. Patient continues with refusals of care including medications, treatments, showers, supplements. Patient is also receiving occupational therapy for [MEDICAL CONDITION] treatment. Patient does not tolerate treatment and exercises and at times refuses treatment. Patient states understanding the need to transfer to a different facility if plan of care is not followed. Patient stated last night's fall was unpreventable and that the CNA assisting her could not have done anything to prevent the fall. Patient will have two staff assisting with care. A copy of the hospital discharge summary dated 3/27/18 was reviewed. The summary read, Your exam shows you have a fractured shoulder. The summary also read, You have been prescribed narcotic. Narcotic medications are used to relieve pain. The x-ray read, There is a mildly displaced [MEDICATION NAME] fracture through the surgical neck of the humerus. On 12/5/18 at 2:25 p.m., it was reviewed with the DON that Resident #39 was coded on the 3/6/18 MDS assessment to need a two person assist for bed mobility. The DON stated that the MDS coding was wrong and that Resident #39 was a one person assist for ADLs before the fall. The DON was asked to provide documentation of the type of assistance Resident #39 needed for her ADLs. She was also asked to provide the CNA care plan (kardex). The DON stated that after the fall, the facility added a concave overlay to the mattress and added a two person assist during ADL care due to the left lower abdominal mass. She stated that the body habitus changed and was larger at this time. The facility was asked to provide a physician progress notes [REDACTED]. The following physician progress notes [REDACTED].>-2/14/18: large eccentric pannus with infection possible mass effect no evidence for abdomen hernia. - 2/14/18: Gastrointestinal (Abdomen: soft, nontender, nondistended, no masses or organomegaly. Large pannus with some dependent [MEDICAL CONDITION]. No sign of panniculitis, No abdominal hernia. -2/26/18: ABDOMEN: Obese with large pannus, particularly protruding from the left side. No masses are felt with palpation. SKIN: slightly pinkend and warm on bilateral lower extremities, which is baseline. She states there is pain with palpation, intermittent weeping. -3/6/18: The patient states that she is having pain in her lower extremity. She is on multiple pain medications: [REDACTED]. Bowel sounds active. No guarding or masses with palpation. Obese with large pannus that also has some [MEDICAL CONDITION]. EXTREMITIES: She does have 3 to 4+ bilateral lower extremity [MEDICAL CONDITION]. Assessment and Plan: 1. [MEDICAL CONDITION]. She is working with physical therapy. -3/13/18: Reason for visit: Per patient request to visualize lower extremities. She does continue to have 4+ [MEDICAL CONDITION]. Also the patient states that the itching has improved but is still present in her lower extremities. She does use a back scratcher down there and itch. She also states that the pain is significant. Examination: Obese with large pannus and [MEDICAL CONDITION] up to abdomen. Extremities: 4+ [MEDICAL CONDITION]. Bilateral lower extremity weakness. The MDS assessment completed prior to the fall had an assessment reference date of 3/6/18. Resident #39's assessment was coded as follows: G0110. A. Bed mobility, describes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident was coded as 3/3, indicating that extensive assistance (resident involved in activity, staff providing weight-bearing support) involving two+ persons physical assist was needed. G0400. Functional Limitation in Range of Motion: coded no impairment to upper or lower extremity J0400. Pain Frequency: coded as a 1 indicating almost constantly. K0200. Height and Weight: coded as 62 inches and 420 pounds The CNA Activities of Daily Living (ADL) tracking information for (MONTH) (YEAR) was reviewed. Coding on the document was defined as follows: Self-Performance section 3= Extensive Assistance: Resident involved in activity, staff provide weight-bearing support 4= Total Dependence: Full staff performance Support Provided section 2= One person physical assist 3= Two+ persons physical assist The (MONTH) (YEAR) ADL tracking document was provided. The Bed Mobility section was set up so that documentation could be completed for each shift. According to the (MONTH) (YEAR) ADL tracking, Resident #39 was coded as 4/3 (total dependence of 2+ staff physical assist) for bed mobility on six occasions prior to the time of the fall. CNA H (staff involved in the fall), documented a 4/3 on four of the six occasions. The fall occurred during the evening shift on 3/27/18. During the day shift on 3/27/18 (prior to the fall), the CNA providing care documented a 4/3. According to the (MONTH) (YEAR) ADL tracking document, Resident #39 was coded as 4/2 (total dependence of 1 staff physical assist) for bed mobility on 39 occasions prior to the time of the fall. Out of 79 documented opportunities for the month, the CNAs coded total dependence for bed mobility on 45 occasions. CNA H coded total dependence for every shift he worked in March, a total of nine occasions. This meant that Resident #39 was not able to assist with moving or turning in the bed on any day that CNA H worked with her. The CNA kardex was provided. While the document did not include a date, the section titled Safety included the concave overlay, an intervention initiated after the 3/27/18 fall. There is no information on the kardex indicating the number of staff that are supposed to assist with Resident #39's ADL care. On 12/6/18 at 10:10 a.m., CNA C was interviewed regarding how the CNAs had been trained to code ADL tracking information. CNA C stated that the CNAs documented ADLs electronically. She logged into the computer to show this surveyor. CNA C stated that she was supposed to document the level of care provided for each ADL task she provided to the residents she cared for during her shift. She stated that ADL documentation was completed every shift. When asked to explain the coding choice Total Dependent, CNA C stated that it meant the resident could not do anything for themselves and staff would need to do everything. CNA C stated that when a resident was total dependent, two people were required to provide care and sometimes more than two were needed. When asked how she knew how many people were required to perform ADLs for a resident, CNA C stated she would find out from the meeting at the beginning of the shift. When asked to give examples of a resident who would be coded as total dependent, CNA A stated a resident with a very high weight or a small resident with fragile skin would be considered total dependent and require 2 staff. CNA C stated that the goal when providing care was to maintain safety for the resident and herself. On 12/6/18 at 10:30 a.m., Registered Nurse A (RN A) stated that she was the Staff Development Coordinator. RN A was asked when she began her role at the facility. She stated (MONTH) (YEAR). RN A was asked to review the training provided to the CNAs upon hire. RN A provided a document titled, ADL Documentation Teaching/ Learning Module (MONTH) 2014. When asked if this training was used at the facility prior to her assuming the position, RN A stated yes. When asked if she had changed the training at all, RN A stated no. The section ADL Definitions defined self performance as what the patient actually did; not what he is capable of doing. The Self Performance section read 3= Extensive Assist for bed mobility, Patient can help turn himself/herself grabbing onto the side rail, the CNA tells her what to do, She needs the CNA to lift her bottom and guide her legs into position. Hint: The CNA provides weight bearing support and use of muscles. The section also read, 4 Dependent, but did not provide instruction for bed mobility. A slide titled Noteworthy Comment read, If a patient participates in the activity, it is NOT a 4. The training also provided guidance on Staff Support and read, Highest level of support provided by staff. In addition, the Staff Support section read, On person physical assist- CNA uses muscles with the patient giving little assistance and Two person physical assist- (MONTH) be required to accomplish a specific ADL; Transfer patient with limited or no ability to assist with the transfer. 2-One person physical assist for bed mobility read, A CNA turns patient without additional staff assistance. 3-Two person physical assist for bed mobility read, CNA needs help in turning and repositioning the patient. Pulling the patient up in the bed would require two person physical assist. In addition to the CNA training provided upon hire, the facility used a computer based training developed by the facility corporation titled, Safe Patient Handling: Positioning Patient to a Side-Lying Position. The section titled Bed Mobility read, When patients are not able to independently turn and reposition in bed, CNAs or nurses are needed to assist with bed mobility tasks to meet the patient's turning and repositioning needs. Turning a patient to a side lying position may be needed in order: to perform certain procedures and care measures such as providing perineal care. The slide titled Planning and Preparation read, Determine how much assistance is needed: Staff- You need at least 1 co-worker to help you. Depending on the patient's size, 3 or more staff members may be needed. Another slide read, Decide how to safely turn the patient before starting the procedure- if you need more than one additional staff person to help, ask before beginning the task. Protect the patient from falling when the bed is raised: Remember the opposite side of the bed is open and in a raised position, therefore implement safety measures to prevent a fall from occurring, to the extent possible, i.e . station 1-2 staff members to the opposite side of the bed. The slide titled Turning Patients read, When turning a patient away from a staff member, ask that one or more staff members stand on the opposite side of the bed from you before turning the patient. According to CNA H's training log, he completed the Safe Patient Handling: Positioning Patient to a Side-Lying Position training on 5/30/18. Resident #39's comprehensive care plan was reviewed. The focus The resident has limited physical mobility r/t (related to) weakness was created on 12/14/15. On 12/5/18 at 2:30 p.m., the DON was asked to explain Resident #39's weakness. The DON stated Resident #39 had lower extremity weakness d/t obesity. The care plan did not include the level of care or number of staff that were needed to assist during ADL care. On 12/6/18 at 8:30 a.m., the DON was asked to provide the fall investigation. The Post Fall Assessment form was provided. The fall occurred on 3/27/18 at 4:30 p.m. The form read, RSD (resident) rolled out of bed while assisting staff during ADL care. The section Action following fall read, Resident sent to ER. It was documented that six staff members assisted the resident getting up after the fall. At this time, the DON also stated that the Occupational Therapy [MEDICAL CONDITION] specialist began working with Resident #39 on 2/28/18 regarding the left abdominal mass that was due to [MEDICAL CONDITION]. Physician orders [REDACTED]. The order read, Pt (patient) will benefit from skilled OT/CLT 5-7x/ 12 weeks, for manual lymphatic drainage, measure/fit/mgmt. (management) of bandaging equipment, self care retraining including skin care mgmt., thera ex, and measure/fit/mgmt. of maintenance compression equipment not to exclude pneumatic compression device. The Occupational Therapy Evaluation & Plan of Treatment document dated 2/28/18 was reviewed. The form read, Reason for Referral: Patient referred to OT/ CLT due to significant [MEDICAL CONDITION] B Les (bilateral lower extremities) and abdomen with associated wounds and recurrent [MEDICAL CONDITION]. The Evaluation Summary read Patient presents with impairments in mobility, sensation, strength, self modification and use of coping strategies resulting in limitations and/or participation in the areas of general tasks and demands, self care and mobility. In the section titled self care, Resident #39 was documented as dependent for toilet hygiene. She was documented as Partial/Moderate Assistance for washing upper body. The Occupational Therapy Discharge Summary dated 5/24/18 was reviewed. In the section titled self care, Resident #39 was documented as dependent for toilet hygiene. On 12/6/18 at 9:00 a.m., it was reviewed with the DON that the survey team would like to see the full investigation. She stated that it was part of the quality assurance documentation and she could not provide copies to the survey team. She stated that the surveyors could read the investigation on the computer. On 12/6/18 at 10:30 a.m., the fall investigation was reviewed in the presence of the DON, two corporate nurses and Surveyor B. The DON provided a copy of a form titled Witnesses Fall which read, Resident rolled out of bed while assisting staff during ADL care, rsd (resident) started dangling her feet when she turned to the right side assisting CNA while holding side bars. Resident then released sidebars and landed on her right shoulder. Resident stated the size of her mass pulled her down to the floor while she was holding on to the side bars. The Mobility section on the form was documented as bedridden. CNA H was listed as a witness. The DON sat with this surveyor and Surveyor B while the printed investigation documents were reviewed. The DON documented in her investigation summary that Resident #39 was on her right side holding on to the bed rail. Resident #39's left leg was over the right leg while CNA H was cleaning the resident's bottom. The summary read that Resident #39's leg slipped and the resident pulled harder on the bed rail. Resident #39's weight shifted and she slid out of bed. The resident continued to hold onto the bed rail as she slid off the bed. It was documented that Resident #39 complained of right shoulder pain. The summary documented that the resident was assisted to the floor by the Unit Manager. The DON was asked how the Unit Manager knew that Resident #39 had fallen out of bed. The DON stated that CNA H called for the Unit Manager to help him CNA H's statement was reviewed. The statement read, res rolled over to the other side grab bar, and her mass pulled her down off bed. The DON was asked what new interventions the facility implemented for Resident #39 as a result of the fall. The DON stated that a concave mattress overlay was applied to the bed. In addition, two person assist with ADLs was implemented. There was no documentation provided by the facility indicating Resident #39 was a one person assist for ADL care prior to the fall and there was no documentation provided indicating Resident #39 was a two person assist for ADL care after the fall. The (MONTH) (YEAR) ADL tracking was reviewed. Unlike the (MONTH) (YEAR) ADL tracking, the (MONTH) (YEAR) tracking did not include Bed Mobility documentation for all three shifts. It only included documentation for the 3-11 shift, twice weekly, to coincide with the twice a week shower days. As of 12/6/18, bed mobility was only coded once for the month. On 12/4/18, bed mobility was coded as 3/2 (extensive assist/ 1 person). On 12/4/18, bath/ shower was coded as 4/2 (total dependence/ one person assist). On 12/4/18, 7-3 shift, toileting was coded by CNA D as 4/2 (total dependence/ one person assist). Toileting was coded 12/1/18-12/4/18 and only 1 person assist was coded on these days. On 12/6/18, the DON was asked why bed mobility was not documented per shift on the (MONTH) (YEAR) ADL tracking. She stated that she just realized when she printed the tracking that the bed mobility tracking was not input into the computer system correctly, so tracking was not completed per shift. When asked why staff were coding toileting for the resident when she did not get out of bed to toilet and instead wore an incontinent brief, the DON stated that toileting documentation was not supposed to occur in the toileting section for Resident #39 because she did not toilet. The DON stated during interviews that the corrective action after the fall was two person assist for ADL care. It does not appear from the documentation on the (MONTH) (YEAR) ADL tracking that two persons were being used for Resident #39's ADL care. On 12/4/18 at 2:28 p.m., Surveyor A observed Resident #39's incontinence care with CNA D and CNA J. While at the nursing station, Surveyor A announced that she wanted to watch incontinent care and observe for a wound. CNA J told CNA D that she would help him. Licensed Practical Nurse G was also in the room to assist with the wound observation. The two CNAs performed incontinent care during the observation. CNA D is the CNA who had knocked on the door during Resident #39's interview at 2:10 p.m. and stated he was there to provide care. He did not have another staff with him when he initially came to the room to provide care. On 12/5/18, the survey team held an end of day meeting with the Administrator, Director of Nursing, two Corporate nurses, and the Administrator in Training. At this time, the facility staff were notified that the survey team was considering Resident #39's fall with fracture a possible harm level deficiency. The facility staff were asked to provide all documentation regarding the incident. In summary, the facility staff stated that Resident #39 fell out of bed due to the large abdominal mass affecting Resident #39's stability during bed mobility and ADL care. The large abdominal mass was first assessed by the physician on 2/14/18. The facility was aware of the large abdominal mass for more than a month prior to the fall without implementing interventions to ensure safety while turning and repositioning the resident in bed. The 3/6/18 MDS prior to the fall coded Resident #39 to need extensive assistance involving two+ persons physical assist for bed mobility. Only a one person assist was used to perform ADL care when Resident #39 had the fall with fracture. On the (MONTH) (YEAR) ADL tracking, total dependence on staff for bed mobility was documented over 50% of the time. CNA H documented that Resident #39 was total dependence for bed mobility for all nine shifts that he worked with her during the month. According to the interview with CNA C, when staff provide support of total dependence, two persons should be use to assist in care. According to the Safe Patient Handling: Positioning Patient to a Side-Lying Position training developed by the facility corporation, staff should Determine how much assistance is needed: Staff- You need at least 1 co-worker to help you. The DON stated that after the fall, two person assist was implemented for Resident #39's ADL care. No documentation was provided showing that staff had been instructed to use two persons when providing Resident #39's ADL care. The (MONTH) (YEAR) ADL tracking form documented that only one person has been involved when providing ADL care for Resident #39.