Every finding on record at Parkwood in the Pines

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 6 medication carts (medication cart for halls 400, 500, and 600, nurse cart for odd room numbers on hall 100 and 200, and medication cart for hall 100 and 200) reviewed for pharmacy services.The facility failed to remove (1) bottle of expired aspirin 325 mg and (1) box of arginaid powder (medication used to aid in wound healing) and a plastic bag of a white powder without a date from the medication cart for halls 100 and 200 on 4/20/2026.The facility failed to remove (1) box of arginaid powder from the medication cart for halls 400, 500, and 600 on 4/20/2026.The facility failed to remove an expired insulin vial of Humulin R 100 units/ml from the nurse cart for odd room numbers on hall 100 and 200 on 4/20/2026.These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection.Findings included:During an observation on 04/20/2026 at 7:43 am the medication cart for hall 100 and 200 with MA E revealed:*(1) bottle of aspirin 325 mg expired 1/2026 and was opened 7/24/2025*(1) clear, plastic bag of a white substance that says thickener with no date present.*(1) box of arginaid powder expired 4/2/2026 that had (9) packets with an open date of 12/29/2025During an interview on 4/20/2026 at 7:45 am, MA E said the ADONs were responsible for checking the medication carts periodically. She said she checked periodically for expired medications. She said if residents took medications that were expired the medicine would not be as effective. She said she was not aware the cart had expired items. She said the white powder was thickener used to thicken liquids for residents who had trouble swallowing. She said she never used the thickener, and it should have a date or label to indicate what was in the bag.During an observation on 4/20/2026 at 8:19 am the medication cart for halls 400, 500, and 600 with LVN F revealed:*(1) box of arginaid powder expired 4/12/2026During an interview on 4/20/2026 a6 8:22 am, LVN F said whoever was assigned the medication cart was responsible for checking it for expired medications. She said she checked the cart once a week. She said the arginaid was something that they no longer used and was not aware it had expired. She said residents could get sick and cause other issues if residents took medications past their expiration dates.During an observation on 4/20/2026 at 2:29 pm the nurse cart for odd room numbers on hall 100 and 200 with LVN G revealed:*(1) insulin vial of Humulin R 100 unit/ml dated 11/1/2023 with date opened 11/6/2023.During an interview on 4/20/2026 at 2:43 pm, LVN G said the Humulin R insulin was expired. She said the resident that took that insulin was in the secure unit and was not sure why she had insulin was in the cart. She said the unit had a separate medication cart. She said that insulin was good for 28 days after opening. She said if the medicine was given to a resident, it might not be as effective. She said the nurses were responsible for checking the medication carts daily every shift.During an interview on 4/21/2026 at 10:13 am, the ADON said medications carts should be checked periodically but daily by the nurses and med aides and should remove medications that were expired. She said the ADON's and DON checked them weekly. She said they checked the carts about a week ago. She said the thickener should have an attached label with a date. She said insulin was good for 28 days after opening and then should be replaced with a new one and dated. She said medications may not have the therapeutic effects that were intended if given past their expiration dates. During an interview on 4/21/2026 at 10:35 am, the DON said she along with the ADONs were responsible for checking the medication rooms and carts with random audits. She said the staff assigned to the carts should check them daily. She said audits were done by the DON and ADON's at least weekly in the rooms and carts. She said insulin was good for 28 days after opening and then should be discarded. She said medications might be ineffective if given past their expiration dates. During an interview on 4/21/2026 at 12:26 pm, the Administrator said the charge nurses along with the ADON/DON and Pharmacy consultant were responsible for checking the medication carts and medication rooms. She said residents could have a negative effect if medications were taken past their expiration dates. She said they would complete a 1:1 in-service with the staff involved along with group in-services. Record review of a facility policy titled Storage of Medications revised April 2019 indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for facility's only kitchen reviewed for food storage. The facility did not ensure foods in the freezer and dry storage area were stored, labeled and dated when opened or removed from their original packaging or opened on 4/19/2026. This failure could place residents who received their meals from the kitchen at risk of food-borne illness.Findings included: During an observation in the facility kitchen on 04/19/26 at 9:50 AM, the dry storage area had the following:*a container labeled thickener, the lid was open and off center. *a plastic bag with yellow dry mix dated 4/18/26 but no label of contents.*a plastic bag with opened package labeled brown gravy mix with no open date or use by date.*a container of enchilada sauce with no open or use by date, half of contents missing and manufacturer's label of refrigerate after opening. During an observation in the facility kitchen on 04/19/26 at 10:00 a.m., the freezer had the following:* a plastic bag of corn which was undated, not labeled and holes in the bag. During an interview on 4/21/26 at 10:00 a.m., the CDM said it was the responsibility of all kitchen staff to inspect the freezers, refrigerators, and food storage areas for open, undated, or unlabeled food. She said any packages not labeled or dated should be discarded immediately. The CDM said she had signs posted in the kitchen to remind all staff to look for open, undated, or unlabeled food when checking refrigerator and freezer temperatures. She said food storage information is available to all staff and located in 2 areas of the kitchen. The CDM said the risk of improperly stored and/or labeled food was serving expired food to residents and increased risk of food-borne illness. The CDM said, going forward, she planned to conduct an in-service with all kitchen staff covering proper storage and labeling of food and opened items. During an interview on 4/21/26 at 11:00 a.m., the ADM said the CDM was responsible for supervising kitchen staff directly and she was responsible for oversight of ensuring all kitchen policies were followed. The ADM said the facility policy was all food stored in the facility kitchen should be dated, labeled, and sealed. The ADM said her expectation was that all staff follow the facility policy regarding labeling and storing food. The ADM said the risks to residents would be serving unpalatable food to residents or cause food borne illness. Review of a facility policy titled Food Storage, dated 2018, indicated .Open packages of food are stored in closed containers with covers or in sealed bags, and dated as when opened.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 staff (CNA C and LVN D) and 2 of 5 resident (Resident #5 and Resident #7) reviewed for infection control.1.The facility failed to ensure CNA C washed or sanitized her hands between glove changes and did not touch clean items with dirty gloves when incontinent care was provided to Resident #5 on 4/19/2026.2.The facility failed to ensure LVN D washed or sanitized her hands between gloves changes during urinary catheter care to Resident #7 on 4/21/2026These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:1. Record review of an admission Record for Resident #5 dated 4/19/2026 indicated she admitted to the facility 12/16/2021 and was [AGE] years old with diagnosis of COPD (a group of lung diseases that affect breathing), type 2 diabetes, atrial fibrillation (an irregular heart rhythm), and heart failure (the heart is not able to pump effectively).Record review of a Quarterly MDS Assessment for Resident #5 dated 3/6/2026 indicated she did not have any impairment in thinking with a BIMS score of 12. She was dependent on staff for personal hygiene and always incontinent of urine and bowel.Record review of a care plan for Resident #5 dated 11/7/2024 indicated she had bowel and bladder incontinence. Interventions included checking every two hours and as required for incontinence. During an observation on 4/19/2026 at 3:34 pm, CNA C was in the room of Resident #5. She had a plastic bag and a package of wipes in her hands and placed the bag on the floor and the wipes on the bed. CNA C washed her hands in the room and placed gloves on both hands. She opened the resident's brief and placed it between her thighs. She removed wipes and wiped them across the resident's lower abdomen and then down the middle of her vagina and placed the wipes inside the brief. She removed more wipes and wiped down the middle of the vagina from front to back and placed the wipes inside the brief. CNA C removed her gloves and placed them in the trash. CNA C removed gloves from her pocket and placed them on her hands. Resident #5 was rolled onto her right side, and her brief was removed and placed in the trash. CNA C placed a clean brief under the resident's buttocks. CNA C removed wipes from the package and wiped the perineal area from front to back and placed the wipes in the trash. CNA C secured the brief and repositioned the resident in bed. CNA C removed her gloves and placed them in the trash. CNA C washed her hands in the room and placed the trash in the bin that was in the hallway. CNA C placed the package of wipes on n the cart in the hallway.During an interview on 4/19/2026 at 3:41 pm, CNA C said she had been working at the facility for 6 months. She said during the care provided to Resident #5, after she removed her gloves, she should have sanitized or washed her hands. She said gloves should have been on the bedside table on a clean surface and not in her pocket. She said each resident should have a package of wipes in the room and the wipes should not have been placed back on the cart after they were taken into the room. She said before she grabbed the clean brief, she should have removed her gloves and washed or sanitized them before she touched it. She said the DON observed her with a competency skills check off. She said residents could be at risk of cross contamination or infections if staff did not follow proper procedures and protocols. Record review of a competency assessment for perineal care for CNA C dated 12/15/2025 indicated competency was demonstrated and observed by the DON. 2. Record review of an admission Record for Resident #7 dated 4/21/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia (paralyzed on one side of the body), COPD (a group of lung disease that affect breathing) type 2 diabetes, and chronic kidney disease (a condition where the kidneys are damaged).Record review of a Significant Change MDS Assessment for Resident #7 dated 4/3/2026 indicated she had moderate impairment in thinking with a BIMS score of 11. She was dependent on staff for toileting hygiene. She had an indwelling catheter and was always incontinent of urine/bowel. Record review of a care plan for Resident #7 dated 4/19/2026 indicated she was on EBP related to MDRO and had an indwelling medical device.During an observation on 4/21/2026 at 4:10 pm, LVN D was in the room of Resident #7 to provide urinary catheter care. She donned a gown in the hallway and sanitized her hands and placed gloves on them. She had a bottle of normal saline and 4x4 gauze in a plastic cup. She entered the room and placed the cup and bottle of normal saline on the over bed table. She opened the resident's brief and poured normal saline on the gauze that was in the plastic cup. She removed saline soaked gauze and cleaned the catheter tubing at insertion site in a downward motion and placed the gauze in the trash. She removed her gloves and placed them in the trash and did not wash or sanitize her hands before she applied clean gloves. She removed more gauze from the cup and cleaned the tubing again in a downward motion. She removed her gloves and placed them in the trash and did not wash or sanitize her hands and placed clean gloves on her hands. She doffed (took off) her gown in the room and placed it in the trash and washed her hands.During an interview on 4/21/2026 at 4:22 pm, LVN D said during the care provided to Resident #7 she should have washed or sanitized her hands between glove changes. She said she had sanitizer on her cart and got nervous and forgot. She said there could be a risk of residents getting UTI's if proper procedures were not followed. During an interview on 4/21/2026 at 10:13 am, the ADON said the ADON's conducted training on hire and annually on infection control and hand hygiene. She said hand hygiene should be done before care, between glove changes, before going from touching dirty items to clean, and when was completed with soap and water or hand sanitizer. She said when staff change gloves they should wash or use sanitizer. She said residents could be at risk of infections. She said she planned to have a 1:1 education with LVN D and in-services with the other nurses as well.During an interview on 4/21/2026 at 10:35 am, the DON said she along with the ADON's were responsible for training staff on hire, annually, and as needed on infection control and hand hygiene. She said hand hygiene should be done before care, when hands were visibly soiled, after care, and between glove changes. She said staff could use sanitizer or wash their hands. She said staff should never touch clean items with dirty gloves. She said she planned to conduct refresher training with all staff. She said residents could be at risk of infections if they did not follow proper policy.During an interview on 4/21/2026 at 12:26 pm, the Administrator said staff were trained on hire and annually by the ADON or designee on skills. She said she expected staff to follow proper procedures and facility policy to prevent infection control issues.Record review of a Handwashing/Hand Hygiene revised December 22, 2023, indicated, . This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap and water for the following situations: g. before handling clean or soiled dressings, gauze pads etc.; m. After removing gloves .

Based on observation, interview, and record review the facility failed to ensure the resident's right to a safe, clean, and comfortable environment for residents for 1 of 24 residents (Resident #27) observed for resident environment.The facility failed to ensure the floor in Resident #27's room did not have standing water and was without odors from 4/19/2026-4/21/2026.These failures could place residents at risk for an unsanitary environment.Findings included:Record review of an admission Record for Resident #27 dated 4/21/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), malignant neoplasm of lung (lung cancer), major depressive disorder (persistent sadness or loss of interest in doing things), and dysphagia (difficulty swallowing).Record review of a Quarterly MDS Assessment for Resident #27 dated 3/11/2026 indicated he had severe impairment in thinking with a BIMS score of 5. He was dependent on staff to transfer from chair to bed.Record review of a care plan for Resident #27 revised 3/20/2024 indicated he had an ADL self-care performance deficit related to impaired balance. He required the use of a mechanical lift x2 staff for assistance with transfers.During an observation and interview on 4/19/2026 at 10:07 am, Resident #27 was in bed awake and said he had been at the facility for a long time. His bed was in a low position. The floor by his bed had standing water that was seeping from under the wall. Resident #27 said he was not aware his floor was leaking.During an observation and interview on 4/19/2026 at 10:10 am, CNA C was in the room of Resident #27 and said she was aware of the room having a water leak. She said it was coming from the shower room, and she reported it a month or so ago to the charge nurse verbally but was unable to recall who she reported it to.During an observation on 4/20/2026 at 7:20 am, the room of Resident #27 still had water standing on the floor by the wall and smelled like mold/mildew. Resident #27 was not in the room.During an observation on 4/20/2026 at 7:25 am, the shower room on hall 200 that was by Resident #27's room had two showers. The shower on the right side had an out of order sign on the shower that was dripping water hitting the floor going underneath the wall.During an observation on 4/20/2026 at 2:23 pm, in Resident #27's room, water was standing on the floor seeping in from underneath the wall.During an observation and interview on 4/20/2026 at 4:28 pm, CNA H was on the hall where Resident #27 resided. She said she worked the 2 pm-10 pm shift. She said she was aware of the leak in the room of Resident #27. She said it had been reported to the Maintenance Supervisor one day last week. She said the Maintenance Supervisor placed tiles down and placed an out of order sign in the shower room on the affected shower. She observed the shower room and the shower head on the right side of the room had an out of order sign, but the water was still running and hitting the floor. She said Resident #27's room floor stayed wet when they were in the room providing care. She said she would feel overlooked and neglected if it was her living in that room. She said she noticed the room had a water leak about 2 weeks ago before it was reported. During an observation and interview on 4/21/2026 at 7:31 am, CNA K was in Resident #27's room providing care. The floor had standing water coming from underneath the wall. She said the room had been leaking for about a week that she noticed and it was coming from the shower room on the other side of the wall. She said they were told not to use the shower on that side. She said it was reported to the Maintenance Supervisor and had been informed someone would be out to repair it. She said it would make her feel bad and it smelled weird like wet cats if she was a resident that had to live in that room.During an interview on 4/21/2026 at 8:02 am, the Maintenance Supervisor said in the shower room on hall 200 there was a gap under the wall by the shower and he had tried to put a seal and a baseboard to keep water from going underneath the wall. He said a plumber was scheduled to go to the facility that day. He said he had called them that morning. He said the room where Resident #27 resided was reported to him last week by a nurse aide. He said they did not tell him the shower was still running water. He said he would not want to live like that. He said staff reported issues in the logbook and other times it was verbally. He said now they had to put a work order in TELS (a system used to report maintenance issues) and that system was very new to him. He said the shower rooms had a faulty design where the floors were flat and should be angled at a slope for the water to drain into. He said he was doing the best that he could. During an interview on 4/21/2026 at 12:26 pm, the Administrator said she was not aware the shower room on hall 200 was leaking and the water was going into the room of Resident #27. She said staff were supposed to report maintenance issues to the charge nurse who would then place the request in TELS. She said a plumber was going to the facility that day to place a water barrier in the shower room. She said if she were a resident she would expect repairs to be fixed. Record review of a maintenance repair list for the facility dated 12/25/2025 to 3/29/2026 did not indicate a repair was needed for Resident #27's room.Record review of a facility policy titled Quality of Life-Homelike Environment revised May 2017, .Residents are provided with a safe, clean, comfortable and homelike environment .

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 6 residents (Resident #64) reviewed for quality of care.The facility failed to ensure Resident #64's surgical site was monitored for signs and symptoms of infection each shift while a non-removable dressing was in place from 4/9/26 to 4/20/26.This failure could place residents at risk of not receiving appropriate care and treatment and/or decline in their health.Findings include:Record review of a facility face sheet dated 4/19/26 for Resident #64 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing (recovery period after a displaced fracture of the base of the neck of the left femur - which occurs when the upper part of the femur, just below the hip joint, breaks and the bone fragments are misaligned from their normal position).Record review of Resident #64's electronic medical record 4/21/26 indicated she had not been in the facility long enough to have a comprehensive MDS assessment completed.Record review of a baseline care plan dated 4/9/26 for Resident #64 indicated the baseline care plan did not address any current or historical skin integrity issues.During an observation and interview on 04/19/2026 at 11:24 am Resident #64 was observed lying in bed. She said she had been admitted to the facility for rehabilitation after having hip surgery for a broken hip. She said the staff had not changed the dressing on her hip since admission on [DATE]. Observation of a dressing to Resident #64's left hip indicated a date of 4/17/26. She said she had an appointment with the surgeon on Tuesday 4/21/26.Record review of a physician's order report for Resident #64 dated 4/1/26 through 4/30/26 indicated she had the following order: .Wound care: Change aquacell dressing to left hip surgical site area and then apply new aquacell dressing to left hip surgical site area one time only for surgical incision. dated 4/17/26. There was no order in place to monitor site for redness, excess drainage, to ensure no excess drainage to dressing, or signs/symptoms of infection.Record review of a Treatment Administration Record dated 4/1/26 through 4/30/26 for Resident #64 indicated there was no documentation of monitoring surgical area for signs/symptoms of infection.During an interview on 04/20/2026 at 11:29 am the Treatment Nurse said there should always be an order in place to monitor a wound or surgical incision each shift for signs/symptoms of infection. She said if a staff member did not see the order on the MAR or TAR, they may not know they need to monitor the incision area or wound for any signs/symptoms of infection and the resident may exhibit signs/symptoms without having interventions and they could develop an infection.During an interview on 04/21/2026 at 1:00 pm the Administrator said she expected staff to follow policies and procedures when admitting residents' post-surgery. She said residents might be at risk of infections if they were not monitored. She said she would be in-servicing staff to ensure compliance going forward. During an interview on 4/21/26 at 1:10 pm the DON said the surgical incision should have been documented and orders put in place to monitor for signs/symptoms of infection. She said it should have been ordered so it would show up on the TAR for nurses to do and document. She said the resident could have developed an infection and not been caught in time. She said she and the ADONs would be monitoring new admissions going forward to ensure everything was in place. Record review of a facility policy titled Surgery-Related (Pre- and Postoperative) Management - Clinical Protocol dated October 2010 read: .The staff and physician will monitor for, and address, postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal .

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility (3 of 7 mechanical lift slings) reviewed for hazards:The facility failed to remove faded, worn and damaged mechanical lift slings from service. This failure could result in a loss of quality of life due to injuries. Findings included:During an interview and observation of the facility laundry on 04/20/2026 2:30 PM the Laundry Supervisor said she washed the lift slings and hung them up to air dry. Three of the seven mechanical lift slings hanging on the wall racks drying in the clean linen area had faded straps, light in color (light gray, light teal and light purple) not bright and vivid colors as the other mechanical lift slings hanging on the rack. One of the mechanical lift slings care label was faded and attached by a few threads of stitching. The Laundry Supervisor said she had new mechanical lift slings and would replace the 3 damaged lift slings. She said she considered the three lift slings still useable. She said that if a lift sling broke it could cause a fall with injury. During an observation and interview on 04/20/26 at 4:00 PM the Administrator observed the 3 mechanical lift slings. She said the risk to the resident was injury if the lift sling broke during transfer and cause a fall. The Administrator said she would remove the damaged slings from service, and she had replacements already in the facility. The Administrator said the nursing staff must be pulling the damaged slings from closets, because they had just completed a sweep and replaced worn- damaged slings. She said that if the lift sling broke it could cause a fall with injury. During an interview on 04/21/2026 at 10:00 am the Housekeeping Supervisor said she was responsible for housekeeping and laundry service for the facility. She said she and the laundry techs are responsible for pulling the damaged and faded mechanical lift slings from service. She said she would remove the damaged/faded lift slings and replace them with new ones. She said there was a risk of the straps breaking and a fall if damaged lift slings were left in service. She said she trains her laundry technicians and will provide them with additional training. During an interview on 04/21/26 at 1:45 PM, the DON said the straps on the three mechanical lift slings were faded. She said she in serviced nursing staff when to remove lift slings from service. The DON said the straps could break on damaged lift slings and cause a fall with resulting injuries. Record review of a facility policy titled Quality of Life-Homelike Environment revised May 2017, .Residents are provided with a safe, clean, comfortable and homelike environment .Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 04/20/26 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Missing or illegible care labels. Any slings with signs of wear or improper laundering should be immediately removed from use .

Based on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy for 1 of 6 residents reviewed for resident rights. (Resident #64)The facility failed to ensure Resident #64 was treated with dignity and respect when the Treatment Nurse failed to provide privacy during wound care on 4/21/26.This failure could place residents at risk for feeling disrespected, a decreased sense of self-worth, and depression. Findings included:Record review of a facility face sheet dated 4/19/26 for Resident #64 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing (recovery after a displaced fracture of the base of the neck of the left femur - which occurs when the upper part of the femur, just below the hip joint, breaks and the bone fragments are misaligned from their normal position).Record review of Resident #64's electronic medical record reviewed on 4/21/26 indicated she had not been in the facility long enough to have a comprehensive MDS assessment completed.Record review of a baseline care plan dated 4/9/26 for Resident #64 indicated the baseline care plan did not address any current or historical skin integrity issues.During an observation and interview on 04/19/2026 at 11:24 am Resident #64 was observed lying in bed. She said she had been admitted to the facility for rehabilitation after having hip surgery for a broken hip. During an observation on 04/21/2026 at 8:45 am the Treatment Nurse was observed to perform wound care to a skin tear on Resident #64's right buttock. The Treatment Nurse did not pull privacy curtain, or close room door to provide privacy for Resident #64. During wound care while resident was rolled to right side with buttocks exposed, another staff member (male) walked in the open room door looking for Resident #64's roommate. At that time, the Treatment Nurse said Crap, I forgot to close the curtain. The male staff member exited the room after seeing the treatment in progress.During an interview on 04/21/2026 at 9:00 am the Treatment Nurse said she normally always closed the curtain. She said she realized as soon as the other staff member walked in. She said she was nervous because she was being watched and she just forgot. She said it could be embarrassing for the residents if privacy was not provided during treatments.During an interview on 04/21/2026 at 9:05 am Resident #64 said it was a little embarrassing for another staff member, especially a male, to walk in during her treatment to her buttocks.During an interview on 4/21/2026 at 1:25 pm the Administrator said she expected all her residents to be treated with dignity. She said they would be in-servicing staff to ensure all residents are provided with privacy when having care provided. She said it could be embarrassing for them.During an interview on 4/21/26 at 1:10 pm the DON said she expected her staff to treat all residents with dignity and provide privacy. She said she would educate all the staff to ensure compliance going forward. She said all residents have a right to privacy.Record review of a facility policy titled Resident Rights dated October 4, 2022, read: .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence . Record review of a facility policy titled Quality of Life - Dignity dated October 4, 2022, read: .Residents shall be treated with dignity and respect at all times . and .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .

Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #7) residents observed for urinary catheter (tube placed in the bladder that drains into a bag outside of the body) care.LVN D did not provide appropriate catheter care for Resident #7 when she did not use the proper cleaning agent or clean the catheter tubing on 4/21/2026.This failure could place residents at risk for bacterial infections from improper catheter care. Findings include:Record review of an admission Record for Resident #7 dated 4/21/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia (paralyzed on one side of the body), COPD (a group of lung diseases that affect breathing), type 2 diabetes, and chronic kidney disease (a condition where the kidneys are damaged).Record review of a Significant Change MDS Assessment for Resident #7 dated 4/3/2026 indicated she had moderate impairment in thinking with a BIMS score of 11. She was dependent on staff for toileting hygiene. She had an indwelling catheter, and she was always incontinent of urine/bowel. Record review of a care plan for Resident #7 dated 4/19/2026 indicated she was on EBP related to MDRO and had an indwelling medical device.Record review of active physician orders for Resident #7 dated 4/21/2026 indicated an order for catheter: urinary catheter provide care with approved cleaning agent every shift with soap and water or may use wipes as appropriate/desired by patient with a start date of 3/27/2026.During an observation on 4/21/2026 at 4:10 pm, LVN D was in the room of Resident #7 to provide urinary catheter care. She donned a gown in the hallway and sanitized her hands and placed gloves on them. She had a bottle of normal saline and 4x4's in a plastic cup. She entered the room and placed the cup and bottle of normal saline on the over bed table. She opened the resident's brief and poured normal saline on the gauze that was in the plastic cup. She removed gauze from the cup and cleaned the catheter tubing at insertion site in a downward motion twice and placed the gauze in the trash. She did not clean down the tubing. She removed her gloves and placed them in the trash. She doffed (removed) her gown in the room and placed it in the trash and washed her hands.During an interview on 4/21/2026 at 4:22 pm, LVN D said she was taught to clean the catheter tubing at the point of contact until she reached the meatus (body opening). She said she was not taught to clean down the tubing. She said there could be a risk of residents getting UTI's if proper procedures were not followed. During an interview on 4/21/2026 at 10:13 am, the ADON said when urinary catheter care was provided staff should use a wipe and clean from insertion down the tubing about 3-4 inches. She said staff should use incontinent care wipes or soap and water with a washcloth when urinary catheter care is provided and it should be done every shift. She said if staff did not it could place residents at risk of infections.During an interview on 4/21/2026 at 10:35 am, the DON said she along with the ADON's were responsible for training staff on hire and annually and as needed. She said urinary catheter care should be done at least every shift and as needed. She said they should use an appropriate solution like wipes or soap and water with a washcloth. She said they should clean at least four inches down the tubing. She said she planned to conduct refresher training with all staff. She said residents could be at risk of infections if they did not follow proper policy.During an interview on 4/21/2026 at 12:26 pm, the Administrator said staff were trained on hire and annually by the ADON or designee on skills. She said she expected staff to follow proper procedures and facility policy to prevent infection control issues.Record review of a facility policy titled Catheter Care, Urinary revised January 3, 2023, indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward .

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 dining area reviewed for environmental concerns. 1. The facility failed to ensure the dining room ceiling was in good repair and without damage and peeling paint. 2. The facility failed to ensure the dining room lighting and ceiling were free from thick cobwebs and dust. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings include: During observations on 04/19/26 at 12:00 PM revealed the following:*thick cobwebs and dust were noted to the chandelier and extending to the ceiling in the center of the main dining area located above resident dining tables. an area of loose peeling paint was noted to the ceiling located between center island area of the main dining room and resident dining table. During an interview on 04/21/2026 at 10:30 AM, the Housekeeping Supervisor said she was unsure of who would be responsible for cleaning the chandelier in the dining area. She said due to the height of the ceiling that maintenance would have to assist due to needing a ladder to reach the area. She stated maintenance would be responsible for removing chipped paint and repairing the area had peeling paint to the ceiling. During an interview on 04/21/26 at 11:00 AM, the Administrator said maintenance and housekeeping would be responsible for cleaning the chandelier in the dining room. She stated that it had not been part of the cleaning routine at the time of the interview. She stated that she was aware of some areas from old leaks but was not aware of peeling paint. She said that the areas would be repaired. She said she wasn't sure how the cobwebs and small area of peeling paint would affect the residents. Record review of the facility's policy titled Quality of Life - Homelike Environment, dated May 2017, indicated, .the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized setting, homelike setting. These characteristics include: clean, sanitary and orderly environment

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 3 days reviewed (4/19/26) for nurse staffing posting.The facility failed to post the daily staffing information in a prominent place on 4/19/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.Findings included:During an observation on 4/19/26 at 9:30 am upon entrance to the facility, the daily staff posting was not observed in the main entrance lobby.During an observation on 4/19/26 at 10:00 am during initial rounds of the facility, the daily staff posting was not observed at or near the nurse's station for 400/500/600 hallways.During an observation on 04/19/2026 at 3:30 pm the daily staff posting was observed posted at each side of the facility near both nurses' stations. Posting was located on a short, side hall near staff offices. It was not in a prominent location. During an interview on 04/21/2026 at 1:00 pm the Administrator said she would be making the night charge nurse responsible for the daily staff posting. She said she could not think of any negative outcomes related to the daily staff posting not being in a prominent location. Record review of a facility policy titled Posting Direct Care Daily Staffing Numbers undated read: .Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Residents #1) reviewed for medical records.The facility failed to ensure Resident #1's physician's orders were updated to include the resident was a DNR status and was uploaded in his medical record.This deficient practice could place residents at risk of improper care due to inaccurate medical records.The findings include:Record review of Resident #1's admission Record, dated [DATE], indicated a [AGE] year-old male who admitted to the facility on [DATE] and expired [DATE]. Resident #1 had diagnoses which included malignant neoplasm of colon (colon cancer), hypertensive heart disease (damaged heart muscle due to high blood pressure), anemia (not enough healthy red blood cells in the body) and infection of amputation stump, right lower extremity (infection in the right lower leg where it was cut off).Record review of Resident #1's active physician orders, dated [DATE], indicated he was a full code, dated [DATE], and there was not an end date.Record review of Resident #1's MDS Assessments indicated he had a death assessment dated [DATE].Record review of an interim care plan, dated [DATE], indicated he had terminal prognosis related to colon cancer and did not have a code status on the care plan.Record review of Resident #1's MDS Assessments indicated there was an entry assessment dated [DATE].Record review of an OOH DNR for Resident #1 was signed and dated [DATE] by Resident #1 and the MD.During an interview on [DATE] at 4:33 PM, the admission Director said she was responsible for getting residents admitted into the facility and would help them fill out their admission paperwork. She said she remembered Resident #1 when he was at the facility, and he admitted with hospice for a respite stay. She said on [DATE], he was admitted to the facility, and she helped him complete his admission paperwork and it was all electronic. She said he signed an OOH DNR on admission which was included in the admission paperwork. She said the hospice company arranged transport for him to get to the facility and he was adamant he wanted a DNR, and she explained to him what it was, and he signed it. She said he was alert and oriented x3. She said once the DNR was signed, she then gave it to the SW who would facilitate getting it signed by the physician. She said the SW would be responsible for informing the family that a DNR was signed and if one was not signed on admission, then the resident would be a full code which meant CPR would be performed. She said his wishes were to go (he was ready to die). She said the DNR was signed by the physician before he passed and was back in the facility. She said she never saw the family in the facility and only spoke to Resident #1 and the hospice company. She said the resident was able to make his needs known.During an interview on [DATE] at 4:45 PM, the Administrator said the facility had a signed OOH DNR for Resident #1 that was signed on his admission to the facility by him, the admission Director, and the physician. She said she was not sure why the signed DNR was not uploaded into Resident #1's chart. She said all staff were aware Resident #1 had a DNR but recognized there was a system failure when all involved were not aware he had one which included hospice or the family. She said the SW was out of the facility during that time, but the DNR was sent to the MD via fax, and it was signed and sent back to the facility. She said the resident was alert and oriented x3 and knew what he had signed. She said Resident #1 expired on [DATE] in the facility.During a phone interview on [DATE] at 5:18 PM, the MD for Resident #1 said he signed an OOH DNR for the resident electronically and it was signed before the resident expired at the facility.During an interview on [DATE] at 12:05 PM, the Administrator said the DON or designee was responsible for ensuring the medical records were updated and had the OOH DNR on file. She said the SW would be responsible for updating the care plan to reflect the code status and nurses had access to update them. She said Resident #1 had a DNR that was signed on admission but did not get uploaded into the system. She said they were going to implement that a weekend admission was followed up by the weekend RN supervisors. She said she expected the medical records to be accurate and finalized and fully completed for the residents. She said there was a risk of records not being updated and the staff would not have the full information or know if the correct information was being given to all staff.Record review of the facility policy titled Charting and Documentation, revised [DATE], indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

46273 Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 4 of 12 residents (Residents #75, #61, #58 and #79) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service from 2/10/2025-2/12/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: 1. Record review of an Admission Record dated 2/11/2025 for Resident #75 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of fracture of left femur (broken thigh bone), osteoporosis (brittle bones), and Alzheimer's disease. Record review of active physician orders dated 2/11/2025 for Resident #75 indicated there was not an order for the use of a mechanical lift for transfers. Record review of a Quarterly MDS assessment dated [DATE] for Resident #75 indicated she had moderate impairment in thinking with a BIMS score of 9. She was dependent on staff for chair/bed to chair transfers. Record review of a care plan dated 12/31/2024 for Resident #75 indicated she had an ADL self-care performance deficit with interventions for transferring when she required assistance. There was not a care plan for the use of a mechanical lift for transfers. During an observation and interview on 2/10/2025 at 9:21, in the room of Resident #75 said she had been at the facility for 2 months and was getting therapy. There was a mechanical lift sling sitting in a wheelchair by her bed that was faded in color. During an observation and interview on 2/12/2025 at 8:33 AM, Resident #75 was in her room in bed eating breakfast. She said the staff usually got her up with the mechanical lift. She said she would be getting up sometime that day after breakfast. A lift sling was in a chair by the bed that was faded in color. During an observation on 2/12/2025 at 9:13 AM, in the room of Resident #75, CNA C and CNA F were in the room to transfer Resident #75 from her bed to the wheelchair. Both staff transferred Resident #75 safely using the mechanical lift and the faded lift sling that was in the room on the chair. During an interview on 2/12/2025 at 9:26 AM, CNA C said she had been employed at the facility for 4 years on a prn basis and had been working fulltime for the past 2 weeks. She said when a resident had a lift sling that was left in the room, she normally would go and get another one from the shower room and would not use the one that was left in the room. She said they were to check the slings to make sure they were not torn or ripped and did not have any odors. She said she did not notice anything with the sling they used to transfer Resident #75 but only that it was faded. She said most of the lift slings in the facility were faded and thought the laundry bleached them. She said she was not sure if the lift slings were supposed to be bleached or not. During an interview on 2/12/2025 at 9:30 AM, CNA F said she had been employed at the facility for 1 1/2 years. She said the lift sling that was used to transfer Resident #75 was faded and they should be able to tell the color of the rings that attach to the mechanical lift. She said the facility had some newer ones in the facility. She said they were to check the slings before using them to make sure they were not ripped, without holes and they were long enough for the resident. She said there were more slings in the facility that were faded that were being used. 2. Record review of an Admission Record for Resident #61 dated 2/11/2025 indicated he admitted to the facility 12/16/2021 and was [AGE] years old with diagnoses of Alzheimer's disease, cerebral infarction (stroke), and dementia. Record review of active physician orders for Resident #61 dated 2/11/2025 indicated an order for mechanical lift for all transfers with a start date of 10/23/2024. Record review of an Annual MDS Assessment for Resident #61 dated 12/27/2024 indicated he had moderate impairment in thinking with a BIMS score of 7. He was dependent on staff from chair/bed to chair transfers. Record review of a care plan for Resident #61 revised on 3/20/2024 indicated he had an ADL self-care performance deficit related to impaired balance that included interventions for transfers and he required a mechanical lift with 2 staff for transfers. During an observation on 2/10/2025 at 11:40 AM, Resident #61 was sitting in a wheelchair in the dining room. He had a lift sling that was faded in color that he was sitting on. 3. Record review of an Admission Record for Resident #58 dated 2/11/2025 indicated she admitted to the facility 7/28/2023 and was [AGE] years old with diagnoses of peripheral vascular disease (decreased blood flow to the legs and feet), dementia and pseudobulbar effect (outbursts of inappropriate laughing or crying). Record review of active physician orders for Resident #58 dated 2/11/2025 indicated an order for mechanical lift for all transfers that started on 10/23/2024. Record review of a Quarterly MDS Assessment for Resident #58 dated 1/16/2025 indicated she was rarely/never understood. She required substantial/maximal assistance with chair/bed to chair transfers. Record review of a care plan for Resident #58 dated 10/11/2023 and revised on 10/1/2024 indicated she required staff assistance with all ADLs with interventions for transfer she was totally dependent on staff for transfers and required use of a mechanical lift. During an observation on 2/10/2025 at 11:41 AM, Resident #58 was sitting in a wheelchair in the dining room for lunch. She had a lift sling that she was sitting on that was faded in color. 4. Record review of a facility face sheet dated 2/11/25 for Resident # 79 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) and functional quadriplegia (weakness/paralysis to all 4 extremities). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #79 indicated that he had a BIMS score of 11 which indicated that he had moderate cognitive impairment. He was dependent for transfers. Record review of a physician's order summary report dated 2/11/25 for Resident #79 indicated that he had no order for use of a mechanical lift device. Record review of a comprehensive care plan dated 4/17/24 for Resident #79 indicated that he had an ADL self-care performance deficit and had an intervention for the use of 2 staff for transfers with mechanical lift device. During an observation and interview on 2/10/25 Resident #79 was observed sitting up in the dining room in his wheelchair. He had a Hoyer sling underneath him that had faded sling loops and unreadable labels. He said he had been transferred using this sling this morning. During an interview on 2/12/2025 at 10:16 AM, Central Supply said she reordered new lift sling a couple months ago for the facility and ordered to replace them as needed. She said if staff found a lift sling one that was ripped or torn, they would take to her and then she would give them a new one. She said the slings were washed by themselves. During an interview on 2/12/2025 at 10:30 am, the Laundry Aide said she had been employed at the facility for over [AGE] years. She said she did not dry the lift slings; she hung them to dry. She said she did not launder the slings with bleach and washed them on setting 3, which was no bleach added because bleach could fade and damage the slings making them unsafe for use. She said she inspected the slings for loose strings, rips, and tears before hanging them for drying. She said they did not take the slings back to the floor, the CNAs came to the laundry to get the slings that were dry for use. She said if a sling that was unsafe was used for residents, it could tear causing the resident to fall and get hurt. During an interview on 2/12/2025 at 1:31 PM, the DON said the Central Supply person was responsible for the lift slings in the facility because she was over laundry and central supply. She said the lift slings should be checked about every 6 months and checked every time they were washed. She said she was not aware of the manufacturer's guidelines for the lift slings that the slings should not in be use if they were faded. She said they planned to conduct an audit and the facility had new slings in the facility. She said there could be risk for injury if the faded slings were being used. During an interview on 2/12/2025 at 1:43 PM, the Administrator said with the lift slings staff knew to report if they were torn or ripped and to throw them away. She said it was the responsibility of the DON or ADON to make sure they were not using worn or damaged lift slings. She said she was not aware that the faded slings could not be in use and there would be a potential risk for falls or injuries. Record review of the manufacturer instruction for Medline full body slings undated indicated, .Full body slings are made of durable materials and are ideal for patient transferring and toileting activities. Always inspect slings prior to each use. Signs of color fading, bleached areas, indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .

49017 Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals were store in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 3 of 12 residents (Resident #17, #18 and # 86) reviewed for medication storage. 1.The facility failed to ensure Total Beets soft chews was not stored at the bedside of Resident #17 on 2/10/25 . 2. The facility failed to ensure a bottle of OTC (over the counter) throat spray was not stored at the bedside of Resident #18 on 2/10/25. 3. The facility failed to ensure aspercreme with lidocaine and nasal spray was not stored at the bedside of Resident #86 from 2/10/2025-2/11/2025. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings include: 1.Record review of a face sheet indicated that Resident #17 was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes osteoarthritis (a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone), chronic obstructive disease (a condition that limits airflow into and out of the lungs) and macular degenerations (an age-related retinal condition). Record review of a quarterly MDS dated [DATE] indicated that Resident #17 had a BIMS score 12 indicating that the resident has moderate cognitive impairment. She required moderate assistance for all ADL's. Record review of a physician's order summary report dated 2/11/25 for Resident #17 indicated that she did not have an order for Total Beets dietary supplement. Record review of Resident #17 assessments indicated that she did not have a self-administration of medications assessment form. Record review of Resident #17 undated care plan * did not have a care plan reflecting that she could self-administer medications. During an observation and interview on 2/10/25 at 11:00 am a bottle of Total Beets soft chews was observed on a bedside table in Resident #17's room. Resident #17 was sitting up in her wheelchair in her room. Resident #17 stated that her family member had brought her the over-the-counter supplement. She said that she takes them daily. She stated she did not know if the staff was aware of the supplements in her room. She said she was able to administer medications because she had her wits about her. Resident #17 said she took the supplements to help her with her energy. 2. Record review of a face sheet indicated that Resident #18 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes hypertension (High blood pressure), chronic obstructive disease (a condition that limits airflow into and out of the lungs) and chronic heart failure (the heart muscle does not pump blood as well as it should). Record review of an admission MDS dated [DATE] indicated that Resident #18 had a BIMS score 14 indicating that the resident was cognitively intact. She required substantial assistance for all ADL's. Record review of a physician's order summary report dated 2/11/25 for Resident #18 indicated that she did have and order for Chloroseptic mouth/throat spray give one unit every 2 hours as needed for pain with a start date of 11/13/2024. Record review of Resident #18 assessments indicated she did not have a self-administration of medications assessment form. Record review of Resident #18 undated care plan * did not have a care plan reflecting that she could self-administer medications. During an observation and interview on 2/11/25 at 9:00 AM, a bottle of sore throat spray was on the bedside table upon inspection of room. Resident #18 was lying in her bed and stated the sore throat spray belonged to her. She was not able to recall who provided the sore throat spray to her. She stated she only uses the sore throat spray when she needs it. She could not recall the last time that she had used the sore throat spray. 3. Record review of an Admission Record dated 2/12/2025 for Resident # 86 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease (affects memory, thinking, and behavior), type 2 diabetes, generalized osteoarthritis (joint stiffness and pain), and allergic rhinitis (a response triggered by exposure to allergens such as pollen, dust mites, pet dander and mold spores). Record review of active physician orders for Resident #86 dated 2/12/2025 revealed she did not have an order for the saline nasal spray or aspercream. Record review of a Quarterly MDS assessment dated [DATE] for Resident #86 indicated she had moderate impairment in thinking with a BIMS score of 10. She required supervision or touching assistance with all ADL's. During the look back period, the resident did not receive any scheduled pain medication or prn medications. Record review of a care plan dated 11/10/2024 for Resident #86 indicated there was not a care plan for the resident to keep medications at the bedside or to self-administer. During an observation and interview on 2/10/2025 at 9:21 AM, in the room of Resident #86 was alert to person, place, time and situation. She said she had been at the facility since September 2024. There was a bottle of aspercreme with lidocaine and simply saline nasal spray on her nightstand. She said she used the aspercreme often for arthritis pain and brought it from home when she admitted to the facility. During an observation and interview on 2/11/2025 at 4:35 PM, Resident #86 said the bottle of aspercreme, and saline spray were in the drawer in the nightstand and allowed the Surveyor to look inside the drawer where they were placed along with a box of gas x. She said the nurse on yesterday 2/10/2025 placed them there after she checked her blood sugar. She said she brought the medications into the facility when she admitted and was not aware if the facility knew she had them or not. She said no one at the facility told her she could not keep medications in her room. During an interview on 2/11/2024 at 3:39 PM, the DON stated that there were no residents in the facility that were assessed to self-administer medications. She stated the facility did have a policy for self administering of medications, but that she was not aware of any residents that had medications in their room for self-administration. The DON stated an assessment would need to be completed to ensure that the resident could safely administer medications and an order would be obtained if a resident requested to self-administer medications. She stated that there should not be any medications in the resident rooms at this time. During an interview on 2/11/2024 at 3:39 PM, the Administrator stated family members would bring in medications and leave them in the resident's room. She said nursing staff should remove any medications found in the rooms and obtain an order from the doctor for the medications. She said medications are to be kept secured in the medication cart. During an interview on 2/11/2025 at 4:40 PM, LVN G said she was the nurse assigned to hall 600 and even side of hall 500 and was assigned to care of Resident #86. She said she was not aware Resident #86 had medications in her room. She said there could be a risk of not knowing what medications they were taking, medications could have counteractions with other medications, staff not being aware of what they are taking and not aware of what to look for, and the possibility of an overdose of medications. During an interview on 2/11/2025 at 4:43 PM, the ADON said she was not sure if there were any residents in the facility that were able to self-medicate and keep medications at the bedside. She said medications should be stored in the medication room or in the medication cart and not at the bedside. She said only if a resident had an assessment to indicate they were safe to self-administer along with a physician order could they self-administer. She said there could be a risk of another resident wandering into rooms and taking the medications if they were left at the bedside. She said there could also be a risk of taking the wrong amount of a medications. During a follow-up interview on 2/12/2025 at 10:05 AM, the DON she said there were not any residents in the facility that had an order to self-administer, and she was not aware of any residents in the facility with medications at the bedside. She said residents could be at risk of taking too much of a medication or someone going in and taking the medications. She said they made rounds on yesterday 2/12/2025 facility wide and removed the medications in the rooms of the residents and educated the residents of notifying the nurses so they can get an order to be administered. During an interview on 2/12/25 at 10:30 AM pm LVN A, said she provided care and administered medications to Resident #17 and Resident #18. She said she was not aware of any resident having medications in resident rooms and that she did not care for any residents that were allowed to self-administer medications. She stated if medications were found at the bedside, the medications were removed immediately. She said if there was an order for the medication then it was placed on the medication cart. She said if there was not an order for the medication then it was turned in to the director of nurses. She stated that the risk of residents having medications at the bedside include possible interactions with other medications that the resident was taking and residents taking inappropriate doses of the medication. During a follow up interview on 2/12/2025 at 1:43 PM, the Administrator said there were not any residents in the facility that could self-medicate or keep medicine at the beside. She did an audit on yesterday 2/11/2025 and talked to the residents that had medicines in their rooms and told them to take the medications to the nurse and told the nurses to get an order for the medicine. She said they educated the staff on OTC medications. She said there could be a risk of a resident overdosing on the medicine. Record review of a facility policy titled Self- Administration of Medications revised December 2016 read .Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or resident representative and .the interdisciplinary team will perform an assessment of Self Administration of Medications Form .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #62) and1 of 5 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D washed their hands before providing incontinent care to Resident #62 on 2/11/25. The facility failed to ensure CNA D appropriately changed gloves and washed hands while providing incontinent care to Resident #62 on 2/11/15. The facility failed to ensure CNA D properly cleaned the penis of Resident #62 while providing incontinent care on 2/11/25. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of a facility face sheet dated 2/11/25 for Resident #62 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included asthma, malignant neoplasm of head (cancer), face, and neck, and dysphagia (trouble swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #62 indicated that he had a BIMS score of 9, which indicated he had moderate cognitive impairment. He required maximum assistance with toileting and personal hygiene. He was incontinent of bowel and bladder. Record review of a comprehensive care plan dated 6/10/24 for Resident #62 indicated that he had an ADL self-care performance deficit and had an intervention for assistance of 1 staff for personal hygiene and toileting. During an observation on 2/11/25 at 9:30 am CNA D entered room and did not wash hands. He then put on a pair of non-sterile gloves and proceeded to retrieve items from Resident #62's closet. He pulled the curtain to provide privacy. He then unfastened resident's brief, and still wearing the same gloves, he was observed to wipe outer groin/inner thigh area and downward on shaft of penis. He did not lift penis up to clean shaft or tip. He then rolled resident over and wiped bottom area. He then removed old brief and while still wearing the same gloves, he applied the new brief and put clean shorts and shoes on the resident. He then got the resident's wheelchair, while still wearing the same gloves, and placed the chair next to bed and locked the brakes; without removing the gloves or washing his hands. CNA D then transferred resident with gloved hand underneath the right arm of Resident #62 while resident used his left hand on the arm of the wheelchair to steady himself. CNA D removed Resident #62's shirt and put a clean shirt on him while still wearing the same gloves worn while providing incontinent care. He put resident's cap on resident's head while still wearing the same gloves; straightened the bed; got a clean waterproof pad from resident's closet and put it on the bed; straightened the sheets; opened the curtain and walked outside room to put dirty linens in barrel. He returned inside room and opened the resident's bathroom door with gloved hand while still wearing the same gloves worn during incontinent care. He still did not remove gloves or wash hands. CNA D picked up the wastebasket and took it to hall to empty trash into trash barrel. He came back into room while still wearing the same gloves and put the wastebasket down on the floor. He then proceeded to push resident's wheelchair out into the hallway while still wearing the same gloves that were worn during incontinent care. He began pushing the resident down the hallway and then removed gloves and used hand sanitizer from wall dispenser. He then pushed Resident #62 to the therapy room. During an interview on 2/11/25 at 9:50 am CNA D said he had been employed at the facility about 7 or 8 months. When asked if there was anything he would have done differently while providing care to Resident #62, he replied with No, not that I can think of. He was then asked if he washed his hands before providing care. CNA D said No, I did not He was then asked if he changed his gloves during care at all and he responded No, I did not. He said he had received training on infection control and incontinent care. During an interview on 2/11/25 at 10:10 am DON said residents could be at increased risk of infections if proper handwashing and perineal care were not provided. She said she would provide more trainings and education. During an interview on 2/12/25 at 2:20 pm DON said training in the facility was non-stop and all staff had been checked off, handwashing and PPE trainings were done monthly, and they had just recently completed check-offs. She said going forward she would provide more education and expect her staff to provide proper care. She said residents could be at risk for infections if proper infection control procedures were not followed. During an interview on 2/12/25 at 2:35 pm Administrator said going forward she would be doing random audits and more trainings. She said residents could be at risk of passing germs and causing infections if proper infection control procedures were not followed. Record review of a facility policy titled Handwashing/Hand Hygiene dated 2001 and revised December 22, 2023, read .This facility considers hand hygiene the primary means to prevent the spread of infections . and .Use an alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. before and after direct contact with residents; .h. Before moving from a contaminated body site to a clean body site during resident care . Record review of a facility policy titled Perineal Care dated 2001 and revised October 2010 read .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . and .Steps in the procedure: .2. Wash and dry your hands thoroughly .7 .put on gloves .10. For a male resident: .b. Wash perineal area starting with urethra and working outward . (2) wash and rinse urethral area using a circular motion . (3) continue to wash the perineal area including the penis, scrotum, and inner thighs .12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly .

Based on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 4 months (July 2024) reviewed for pharmacy services. The facility failed to document the number of pages that were included and did not have the required witness signatures for drug destruction on 7/12/2024. This failure could put residents at risk for misappropriation and drug diversion. Findings included: Record review of facility drug destruction records for four of the 12 months (April 2024, July 2024, September 2024, and December 2024) reflected that on 7/12/2024 the cover page did not indicate the number of pages that were included, and the attached pages were only signed by the DON and did not include any additional witness signatures. During an interview on 2/12/2025 at 10:00 AM, the DON said the drug destruction sheets were normally signed by the Pharmacy Consultant, one of the ADON's and herself. She said the drug destruction was conducted at the facility about every 3 months and more often if necessary. She said in January 2024 she did not have an ADON at that time. She said the pharmacist completed the cover sheet and sometimes would initial the narcotic sheets. She said the drug destruction sheets needed the Pharmacist signature and two witness signatures and having witnesses could help prevent the risk of a drug diversion. During an interview on 2/12/2025 at 11:18 AM, the Pharmacy Consultant said she visited the facility monthly and conducted drug destruction quarterly and as needed. She said she was responsible for filling out the cover sheet for the drug destruction and it should have the signatures and number of pages that were included. She said she was not sure why in July 2024 she did not have the number of pages included because she was always careful. She said she always stapled the pages together so no other pages could be added. She said the additional pages should also have initials present. She said the DON and one of the ADON's were always present. She said there could be a risk of a drug diversion if the sheets were not signed or documented properly. During an interview on 2/12/2025 at 1:43 PM, the Administrator said the DON and the Pharmacist were responsible for the drug destruction in the facility. She said she was aware that the drug destruction pages needed to be filled out completely with signatures, dates and indicate how many pages were included. She said she knew the sheets had to be signed by at least two nurses. She said there was a risk for drug diversion if they did not have the appropriate signatures on the drug destruction pages. Record review of a facility policy titled Discarding and Destroying Medications revised April 2019 indicated, .Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. Destruction will be carried out by the Pharmacy Consultant and DON or designee. The individual resident narcotics record will be noted as medication being destroyed, then dated and signed by the Consultant Pharmacist and nurse .

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #6) reviewed for ADL care. The facility failed to ensure Resident #6 had nail care done on 2/12/25 and 2/13/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: Record review of a facility face sheet dated 2/10/25 indicated that Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Dementia, epilepsy (seizures), and diabetes mellitus. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated he had a BIMS score of 9, which indicated he had moderate cognitive impairment. He required moderate assistance with all ADL's. Record review of a comprehensive care plan dated 8/8/24 for Resident #6 indicated he was a diabetic and had an intervention that read .Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails . During an observation and interview on 2/11/25 Resident #6 was observed with long and dirty fingernails on his right hand. The thumb and first finger on his right hand had a dark brown substance caked underneath them and the third and fourth finger on right hand had long, thick, yellow nails. When asked the last time the staff cleaned his nails, he answered no and when asked if he would like his nails cleaned and trimmed, he said yes. During an observation and interview on 2/12/25 at 9:38 am Resident #6 was observed to still have long, dirty nails on his right hand. When asked if anyone had offered to clean and trim his nails, he said no. He said he would feel better if his nails were cleaned and trimmed. During an interview on 2/12/25 at 9:44 am CNA C said Resident #6 was diabetic, and the nurses were responsible for diabetic nail care and a foot doctor would come do their toenails if needed. She said CNAs were not allowed to touch the nails of diabetic residents. During an interview on 2/12/25 at 9:49 am LVN B said nurses were responsible for nail care on diabetic residents. She said she had not noticed his nails today, but she would go and clean them for him and trim them. She said residents could be at risk of infections, scratching themselves, or possibly a long nail being broken into the quick causing pain and infection risk. During an interview on 2/12/25 at 2:20 pm DON said diabetic residents nail care was the responsibility of the nurses. She said nail care should be done and nails cleaned with every shower. She said residents could be at risk of scratching themselves and be at risk for infection if nails were not kept clean and trimmed. During an interview on 2/12/25 at 2:35 pm Administrator said she expected her staff to keep residents' nails clean and trimmed. She said they had identified an issue with nail care last month and she was monitoring and doing random checks to try and improve nail care. She said residents could be at risk of infection if nails were not kept clean and trimmed. Record review of an active Performance Improvement Plan dated 1/17/25 indicated that the facility had identified an issue with nail care not being completed as per facility regulations in January 2025. Plan indicated that inadequate nail care could put residents at risk for infection control issues. Plan included a goal for each resident to be treated with respect regarding having their nails cleaned. Goal date was 3/17/25. Monitoring documented on plan read .1/28 Discussed c (with) Medical Director - in-services completed c (with) staff weekly monitoring for compliance, monitoring continues . Record review of a facility policy titled Care of Fingernails/Toenails dated 2001 and revised October 2010 read .General Guidelines: 1. Nail care includes daily cleaning and regular trimming .

Based on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #82) reviewed for assessments. The facility failed to reassess Resident #82 following a hospice admission (specific care for the sick or terminally ill) on 12/17/2024. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments. The findings included: Record review of an Admission Record for Resident #82 dated 2/11/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atherosclerotic heart disease (hardened arteries that prevent blood flow), hypertension, and Alzheimer's disease. Record review of active physician orders dated 2/11/2025 for Resident #82 indicated an order to admit to hospice services with an order date of 12/17/2024. Record review of a Quarterly MDS Assessment for Resident #82 dated 12/26/2024 indicated he had severe impairment in thinking with a BIMS score of 5. Special Treatments, procedures, and programs during the look back period within the last 14 days indicated he received hospice care. Record review of a care plan for Resident #82 dated 12/17/2024 indicated he had terminal prognosis related to Alzheimer's disease and was under the care of hospice. Record review of a facility notification of admission for Resident #82 dated 12/17/2024 indicated care for hospice started on 12/17/2024 at the facility. During an interview on 2/11/2025 at 4:15 PM, MDS Coordinator said he had been employed at the facility for two years and was responsible for completing the Medicaid assessments for the residents in the facility. He said Resident #82 admitted to the facility on [DATE] but did not admit to hospice services until December 2024. He said a significant change assessment should be done when a resident was admitted to hospice and when they were discharged from hospice if there was an ADL decline in more than three areas and if the resident improved. He said a significant change was done in November 2024 for Resident #82 but there was not one completed in December 2024 when he admitted to hospice services. He said Resident #82 had a readmission to the facility on [DATE] and a quarterly assessment was completed on 12/26/2024. He said he did not know why a significant change assessment was not done for Resident #82 on admission to hospice and it should have been. He said he had training on completing MDS assessments when he hired. He said there could be reimbursement problems that occur when assessments were not done timely, and the assessments were done to let the staff know what was going on with the residents. During an interview on 2/11/2025 at 4:23 PM, the Regional Reimbursement Consultant said an in-service was started that morning on 2/11/2025 for the MDS Coordinator on significant MDS assessments and when to do them. She said the significant change assessment should be done when a resident admitted to hospice and when they discharged from hospice. She said staff would not know who to contact if they were not done timely or know the plan of care for the residents if assessments were not done timely. She said they did not have a policy for significant change assessments, and they followed the RAI manual for guidance. During an interview on 2/12/2025 at 1:31 PM, the DON said the MDS nurses were responsible for completing the MDS assessments and sometimes she had to sign them. She said significant change assessments should be completed when a resident was admitted to hospice and when they were discharged and anytime a resident had significant changes. She said every morning at the facility they had a meeting to discuss significant changes and the MDS nurses were present, and she was not sure how it was missed. She said during the meetings they discussed who was admitted to hospice or would be admitted . She said the MDS assessments captured the care for the residents in the facility. During an interview on 2/12/2025 at 1:43 PM, the Administrator said the MDS nurses were responsible for completing the MDS assessments and they updated care plans quarterly with changes. She said significant change assessments were due when there were changes with the resident and if the resident admitted to hospice. She said they would conduct audits of the assessments going forward and would continue to provide training to the MDS nurses. She said staff would not know what plan of care to follow if assessments were not done. Record review of an in-service training record dated 2/11/2025 by the Regional Reimbursement Specialist indicated training was provided to the MDS nurses on significant change assessments and when to complete the significant change assessments. Record review of the CMS RAI version 2.0 revised December 2002 indicated, .A Significant Change in Status Assessment must be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred. A Significant Change in Status MDS is required when: a resident enrolls in a hospice program .

Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #39) reviewed for resident rights. The facility failed to ensure Resident #39's Responsible Party was notified after she experienced pain in her right leg and had an X-ray ordered. This failure could place residents at risk of not being informed of illness, injury, and uncontrolled pain. Findings included: Record review of a facility face sheet dated 2/10/25 for Resident #39 indicated that she was an [AGE] year-old female admitted to the facility 12/16/21 with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. She required maximal assistance with all ADLs, and she was incontinent to bowel and bladder. Record review of a comprehensive care plan dated 10/31/24 for Resident #39 indicated that she had a potential for psychosocial well-being problem and had an intervention that read: .Increase communication between resident/family/caregivers about care and living environment: Explain all procedures and Treatments, Medications, Results of labs/tests, Condition, All changes, Rules, Options . Record review of a progress note dated 1/23/25 at 11:27 am for Resident #39 read .Resident complain of leg pain to the right leg. This nurse assessed resident and noticed swelling to the joint in the inner right ankle. Resident has pain when the foot is pushed toward her and when her leg if lifted. Resident doesn't have pain to the hip when the leg is moved. States only radiating type pain. Ankle is tender as well as knee. Hip is not tender to touch. No bruising noted to the right leg. Spoke with [name] NP for Dr. [name] regarding this information and order is given to obtain an x-ray of the right leg. Order placed with National Mobile x-ray . and was signed by LVN H. Record review of a progress note dated 1/24/25 at 06:42 am for Resident #39 indicated that Xray results were reviewed and negative and was signed by LVN H. Record review of an electronic medical record from 1/23/25 to 2/11/25 for Resident #39 indicated no documentation of responsible party notification was found for Xray on 1/23/25. During an interview on 2/10/25 at 4:40 pm FM E said Resident #39 had begun complaining of pain the week before last and the facility ordered an Xray for her leg or knee, she could not remember which one, but the facility never called and told her. She said she had found out from the sitter. She said she wished the facility had called and told her themselves. During an interview on 2/12/25 at 2:20 pm DON said the nurse had told the sitter that day but should have called the RP as well. She said it could cause family to get upset if they are not kept informed, messages could be misunderstood or not relayed, and family would not know about their family members conditions. She said the nurse should have called the family member themselves. During an interview on 2/12/25 at 2:35 pm Administrator said the sitter had been in the room and had said she would call and tell the family member. Administrator said the nurse should have called themselves and informed the family. She said family should be notified by the facility and not a sitter. Record review of a facility policy titled Change in a Resident's Condition or Status dated 2001 and revised in May 2017 read .Our facility shall promptly notify the resident, his or her Attending Physician or Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . and .regardless of the resident's current mental or physical condition, a Nurse, Physician or Nurse Practitioner will inform the resident of any changes in his/her medical care or nursing treatments .

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed for accidents/supervision. (Resident #1) The facility failed to ensure Resident #1 was transferred to her bed using a mechanical lift on 10/2/24, causing pain to her right leg. This failure could place residents at risk of severe injuries. Findings included: Record review of Resident #1's undated current admission record indicated that Resident #1 was a [AGE] year-old female admitted to the facility 12/16/21, with diagnoses including hemiplegia (describes severe or complete unilateral loss of strength or paralysis) and hemiparesis (refers to weakness in one leg, arm, or side of the face) following cerebral infarction (the most common form of stroke), dysphagia (difficulty swallowing), muscle wasting and atrophy (wasting or thinning of muscle mass), type 2 diabetes (condition that results from insufficient production of insulin causing high blood sugar), end stage renal disease (kidney failure), and hypertension (high blood pressure). Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] indicated Resident had a BIMS score of 10 indicating moderately impaired cognition. Record review of an undated care plan indicated Resident #1 required staff assistance with mobility. Interventions included: the resident requires extensive assistance by 2 staff to move between surfaces and uses a mechanical lift for transfers. Record review of Resident #1's nurses notes dated 10/2/24 at 6:05 p.m. and signed by LVN E indicated the following: CNA came to nurses' station at 5:20 p.m. and notified me that resident verbalized complaints of pain in right thigh and knee during transfer from wheelchair to bed. Upon arrival into residents' room, resident was in bed and stated her pain was a 9/10. Vital Signs were blood pressure 110/78, heart rate 77, Temp 97.8, O2 96% on room air, Respirations 20. When asking resident if she wanted to go to the ER for evaluation she stated I don't know. My family member is on her way, let me ask her. Family member arrived at 5:25 p.m. and resident decided she wanted to go the ER for evaluation. I called EMS for transport they arrived at 5:38 p.m. Resident left facility at 5:45 p.m. and was transported to hospital ER. Called report to hospital ER at 5:47p.m. Notified MD of sending resident to ER. Record review of Resident #1's nurses notes dated 10/2/24 at 8:44 p.m. and signed by LVN E indicated the following: Received report from hospital ER that resident was ready to come back to facility at 8:35 p.m. Resident has a knee immobilizer in place on right leg. She will need a follow up appointment with an orthopedic in 1-2 days. Record review of Resident #1's nurses notes dated 10/3/24 at 5:50 a.m. and signed by LVN F indicated the following: Patient returned to facility from hospital at approximately 1:08 a.m. Patient returned with brace to right leg to immobilize leg. Results of x-ray taken at hospital were not available. Patient expressed pain and discomfort but was medicated before leaving the hospital. When she returned from hospital mobile x-ray was contacted to conduct another x-ray at the request of on call MD. Mobile X-ray arrived at facility at approximately 3:17 a.m. Record review of Resident #1's nurses notes dated 10/3/24 at 8:10 a.m. and signed by LVN G indicated the following: Xray results received and reviewed with family. The impression shows no definite radiographic evidence of acute fracture or dislocation noted. No joint effusion (swelling of the tissues in or around a joint due to extra fluid). Moderate degree of osteoarthritis (inflammation of one or more joints), osteopenia (loss of bone density), and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Results sent to PA. No new orders received. Resident to follow up with Orthopedics. Awaiting a call back from them with appointment date and time. Family aware. Record review of Resident #1's nurses notes dated 10/3/24 at 1:09 p.m. and signed by LVN E indicated the following: Received a call from Orthopedics with a follow up appointment for 10/8/24 at 9:45 a.m. Resident and family notified. Record review of Resident #1's nurses notes dated 10/3/24 at 2:15 p.m. and signed by LVN E indicated the following: Resident was sent to ER per family request for CT to right knee. Record review of Resident #1's nurses notes dated 10/3/24 at 3:21 p.m. and signed by DON Indicated the following: Spoke with Medical Director. Informed resident had been sent to ER per family request to have CT completed. ER MD did not order CT, stated it was not emergent. Discussed family desire for MRI of right knee. Dr. gave order for MRI right knee. Contacted MRI facility for appointment. Requested order be sent prior to scheduling. Order faxed. Will follow-up for appt time. Record review of Resident #1's nurses notes dated 10/4/24 at 8:30 a.m. and signed by LVN H indicated the following: Follow up call placed to Orthopedics to schedule appointment for MRI. Was notified that unable to schedule appointment due to inability to accommodate resident because she could not ambulate or pivot. When asked if resident could be transported via Ambulance so that EMT'S could assist with transferring resident, staff member states, can't bring that equipment in my room. Call placed to hospital scheduling department, appt. scheduled for Tuesday, October 8th, at 4pm. Resident should arrive at 3:30. Medical Director,administrative staff, and family member notified of appointment. Record review of a mobile x-ray interpretation report dated 10/3/24 indicated exam was done at 5:21 a.m. and reported at 5:22 a.m. Report indicated Resident #1 had a 3-view film of her right knee. Findings showed: no radiographic evidence of acute fracture or dislocation. The patella (kneecap), distal femur (lower part of the thigh bone) , proximal (describes a location closer to the center of the body) tibia (the inner and typically larger of the two bones in the lower leg) and fibula (the smaller of the two bones in the lower leg) were intact. There was no sign to suggest anterior cruciate ligament tear (a partial or complete tear of a specific ligament in the knee). The bony mineralization is moderately decreased. There is no joint effusion. Moderate narrowing of the medial and patella-femoral spaces (where the back of the kneecap and thigh bone meet. Femoral artery stent noted. Impression: No definite evidence of acute fracture or dislocation. If there are persistent symptoms, follow up x-ray or CT may be obtained as clinically warranted. No joint effusion. Moderate degree of osteopenia/osteoporosis. Moderate degree of osteoarthritis. Report was signed by MD on 10/3/24 at 5:21 a.m. Record review of a hospital radiology report indicated that on 10/2/24 at 6:45 p.m. a 2-view film of Resident #1's right knee was done. Findings included: There is a slightly separated fracture through the patella. There is advanced degenerative joint disease of the right knee. The bones are severely osteoporotic. There is soft tissue swelling in the prepatellar regions. There is vascular calcifications (where mineral deposits form on the walls of the blood vessels in the knee area). Impression: Slightly separated patellar fracture. Osteoporosis. Advanced degenerative joint disease of the right knee, Report revealed the MD signed the report on 10/3/24 at 8:13 a.m. The report showed that it was faxed to the facility on [DATE] at 12:51 p.m. Record review of a written statement dated 10/3/24 from CNA D indicated the following: Yesterday 10/2/24 about 5:15 p.m., Resident #1 returned back to nursing home from dialysis. She hit the call light to go to bed. I answered it, I went to get the mechanical lift and asked for help. I asked CNA J for help. Resident #1 asked for a top sheet. I went to get one and CNA J had her in the bed. Resident #1's leg popped, and she started to cry. I went to get LVN E, and we checked her over. Family came. Resident #1 made the statement that CNA J has never transferred her like that. Record review of an undated written statement from CNA J indicated the following: I was putting Resident #1 to bed and as I pick her up she said she was ok until I put her in the bed she said her leg hurt then she said it was her hip. I put her on in the bed and put pillows under her feet. Record review of an Employee Separation Report dated 10/4/24 indicated CNA J was terminated for policy violation. Employee failed to follow care plan when transferring a resident. Resident was care planned for 2-person mechanical lift transfer and staff member transferred her without assistance. Last day worked was 10/2/24. Record review of Resident #1's kardex (a documentation system used to reference key patient information for care planning) indicated Resident #1 required extensive assistance by 2 staff to move between surfaces and uses a mechanical lift for transfers. Record review of Resident #1's pain scale and Medication Administration Record dated October 2024 indicated Resident #1 received the following pain medications: -Acetaminophen with Codeine 10/3/24 pain level 4 10/4/24 pain level 7 10/5/24 pain level 3 -Tylenol 325 mg 10/3/24 pain level 5 -Tramadol 10/3/24 pain level 7 10/4/24 pain level 8 Pain levels are documented using a scale of 0-10, with 0 indicating no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain. During an interview on 10/3/24 at 10:19 a.m. Family member A said Resident #1 had lived in the facility for over 5 years and required a mechanical lift to be transferred. Family member A said her family member B had contacted her on 10/2/24 after she had been notified of the incident. Family member A said Resident #1 was at dialysis that day. Family member A said two aides came in her room and Resident #1 was still in her wheelchair. The lady aide left the room to go get a sheet, and the guy lifted Resident #1 out of the wheelchair and put her in the bed. Resident #1 said that her leg popped and they had cameras in the room and her family member saw it and went to the facility. Family member A said Resident #1 was crying, then EMS came. Family member A said Resident #1 told the guy you can't lift me like this, and he kept doing it. Family member A said no one had come in the room on this date , (10/3/24) to check on Resident #1. Family member A said the nurse from the prior evening stood in the doorway and just looked in the room and did not come in to check on Resident #1. Family member A said on this date , (10/3/24) her family member went up to the front and was told Resident #1's knee was not broken. Family member A said she was unsure where she actually went or who her family member had talked to and that the facility was always short staffed, and the Administrator had not even come to check on Resident #1. During an interview on 10/3/24 at 12:00 p.m. during entrance conference, the Administrator said they had a family that was not happy and an aide transferred Resident #1 without using the mechanical lift. The Administrator said the Resident went to the hospital yesterday (10/2/24), and the x-ray done at the hospital was not going to be read until 10/3/24, so they called mobile x-ray to come in so they could see what was going on. Administrator said the report indicated no fracture and said CNA J should have waited for another CNA. She said Resident #1 was transferred incorrectly, and CNA J had probably seen the therapist do it and thought it was ok. The Administrator said CNA J said he asked Resident #1 if it was okay to transfer her to the bed and she said yes. The ADON said CNA J picked Resident #1 up and transferred her to the bed, and after that Resident #1 complained of hip/leg pain. ADON said there was no bruising noted to her leg. The DON said the aide should have waited for physical therapy to give the go ahead to transfer the resident without the mechanical lift. DON said in-service training was initiated for all staff on use of the mechanical lift and using it until therapy okay's not using it. During an interview and observation on 10/3/24 at 1:00 p.m. Resident #1 was noted to be lying in bed with her eyes closed. An immobilizer was noted to Resident #1's right leg. Three family members were present. Family member A stated her phone broke, and she did not have video footage on her phone. Family member B said she worked nights, and that on 10/2/24 she woke up to look at the camera in Resident #1's room to see if she had returned from dialysis and was in her room. She said she went to the bathroom and when she came back there was a tall man and a lady in the room. The man reached for Resident #1's arm where her dialysis catheter was. Family member B said she hollered don't grab her stop. Family member B stated he picked Resident #1 up and she started hollering. At this time, Resident #1 opened her eyes and said, I begged him to stop. Family member B stated she had a video on her phone. The first clip showed Resident #1 in her room sitting in her wheelchair. Family member B stated this was after she returned from dialysis. The second video clip showed Resident #1 lying in the bed as the male aide appeared to be placing a pillow under Resident #1's legs. Resident #1 appeared to be making a noise, but audio was very low and unable to make out what was said. The third video clip showed a man and a woman in the room. Family member B said she did not have a video of the aide transferring Resident #1, and she stated no, it may have been my phone. Family member B stated Resident #1 told the aide he could not get her up without the lift. Family member B stated that Resident #1 was paralyzed on the right side. Family member C stated there was a girl in the room that told her the man lifted Resident #1 up and her leg was bent. Family member B stated she did not know her name. Family member C stated she had the same videos on her phone as well, but none of the actual transfer. Observation of the video clips provided lasted about 3-5 seconds each. No videos were seen of Family member B telling the aide to stop, when he was reaching for the Resident's arm, the actual transfer of Resident #1, or Resident #1 asking the aide to stop. Resident #1 was dozing on and off and did not answer any further questions. During an interview on 10/3/24 at 2:00 p.m. The DOR said she had worked in the facility since 2018. DOR said the PTA had been working with Resident #1 on transfers from the wheelchair to the bed and had been for quite some time. The DOR said Resident #1 felt comfortable with him as her therapist. DOR said staff knew that Resident #1 used a mechanical lift. DOR stated Resident #1 could be agreeable at times to certain things, and later will say she is not okay. DOR said they always had two people work with her for that reason. DOR said Resident#1 may have felt ok with CNA J transferring her, with him being a man. DOR said, I can't see the aide doing the transfer without Resident #1 telling him it was okay. I believe she would have said yes when he asked if he could transfer her. During an interview on 10/3/24 at 2:36 p.m. the PTA said he had worked in the facility for 1 1/2 years. The PTA said Resident #1 had been on service for a couple of months. PTA said he had been working with her on bed mobility, sitting on the edge of the bed, and transfer to wheelchair management. PTA said Resident #1's progress on transferring from sitting to standing to wheelchair was very slow. Said Resident #1 had weight bearing issues and paralysis to the right arm and leg. Said Resident #1 was making some progress, but it was slow. PTA said CNA J should have transferred Resident #1 with the mechanical lift. During an interview on 10/3/24 at 2:40 p.m. CNA D said she had worked in the facility since July of this year. CNA D said on 10/2/24, Resident #1 came back from dialysis around 5:10 p.m. Said Resident #1 used her call light and wanted to go back to bed. Said she went and got the mechanical lift and asked CNA J for help. CNA D said she left the room to go get a sheet, and CNA J transferred Resident #1 while she was out of the room. CNA D said she came back in the room as he was in the middle of transferring Resident #1 to the bed. CNA D said CNA J stated he had put Resident #1 to bed like that before. CNA D said Resident #1 was crying so she went and got the LVN E. Resident #1 said she had pain in her right upper hip and knee area. CNA D said Resident #1 was sent to the hospital. CNA D said she had not taken care of Resident #1 before and was just answering her light. CNA D said Resident #1 asked her if she heard the pop in her leg and, she said yes but did not know where it came from. CNA D said Resident #1 stated CNA J had never transferred her like that before. CNA D said she received mechanical lift training on hire, and recently had training, and had to complete a check off list. During an interview on 10/3/24 at 3:09 p.m. LVN E said she had worked in the facility for 2 weeks. LVN E stated that on 10/2/24 she was at the nurses' station and CNA D came up to her around 5:15 p.m. and told her Resident #1 was in pain. LVN E went in the room and Resident #1 was in bed crying, saying she was hurting in her right leg/thigh area. Resident #1 said her pain was a 9 out of 10. LVN E said Resident #1 had Tylenol ordered. LVN E said she told Resident #1 she wanted to send her to the hospital. Resident #1 said she had already called her family member, who came up and wanted her sent out as well. LVN E said she notified the ADON and called EMS. EMS arrived and left around 5:45 p.m. LVN E said she got report from the hospital that Resident #1 had a knee mobilizer in place and that the x-ray would be read on Thursday, 10/3/24 . LVN E said she was told the ER doctor saw the x-ray but could not say anything until the Radiologist read it. LVN E said she notified the NP and asked for a mobile x-ray to be done. During an interview on 10/3/24 at 4:00 p.m. The DON stated Resident #1's family was adamant that Resident #1 be sent out on this date, 10/3/24 for a Cat Scan of her leg. The DON said the family took Resident #1 to the hospital and was told it was not urgent and that they had already done an x-ray. DON said she notified the Medical Director as the family asked for an MRI. The doctor ordered it and it had to be scheduled due to not being urgent. DON said it was scheduled for Tuesday 10/8/24. DON said the x-ray done in the facility was negative, and the one at the hospital showed a fracture. During an interview on 10/7/24 at 8:45 a.m. LVN G said she had worked in the facility for 1 year. LVN G said she was not working the day of the incident with Resident #1. LVN G said she had heard that CNA J had transferred Resident #1, picked her up and transferred her to the bed. LVN G said she was not sure if CNA J knew that Resident #1 used a mechanical lift, but if there was a mechanical lift pad in the wheelchair, you are a mechanical lift. LVN G stated Resident #1 told a nurse (unknown name) her knee popped and that she had told CNA J to stop. CNA J said he had transferred Resident #1 that way before. LVN G said CNA J had been working in the facility maybe 3 weeks and worked 2-3 days a week. LVN G said she would notify her aides how they were to be transferred, and if there were any questions about transferring, she would wait for therapy to evaluate them. LVN G said the aides also have a kardex to refer to. LVN G said she received training on the mechanical lift upon hire which included a hands-on checkoff. LVN G said they had also received recent training and checkoffs. During an interview on 10/7/24 at 9:05 a.m. LVN H said she had worked in the facility for 2 years. LVN H said the aides have access to a kardex that indicates how a resident is to be transferred. LVN H said she received training on the mechanical lift on hire and completed skills check offs throughout the year. LVN H said she had not taken care of Resident #1 but knew she had always used a mechanical lift. LVN H said CNA J had only worked in the facility about 4 weeks. LVN H said he was a decent aide, always willing to help out. During an interview on 10/7/24 at 9:30 a.m. Resident #2 said she had lived in the facility for 6 years. Resident #2 said staff used a mechanical lift to get her in and out of bed. Resident #2 said sometimes she was not comfortable with her transfers. Said it was nothing the staff did, it's just me, being lifted up and moved. Resident #2 said there had not been any incidents and the staff did a good job. Said there were always 2 staff present. Said no one had tried to transfer her without using the mechanical lift. During an interview on 10/7/24 at 10:10 a.m. Resident #3 said he had lived in the facility for 1 1/2 years. Resident #3 said staff got him up using the mechanical lift. Resident #3 said he did not like being suspended in the air, but he was unable to walk. Resident #3 said he had not had any falls or any incidents when transferring. Said he only got up 1-2 times a week by his choice. Resident #3 said there were always 2 staff present to do his transfers and had no concerns. Said no one had tried to transfer him without using the mechanical lift. During an interview on 10/7/24 at 10:15 a.m. Resident #4 said he was not sure how long he had lived in the facility, but thought it was around 2 months. Resident #4 said he was transferred with a mechanical lift. Resident #4 said there were always 2 staff present and that he had not had any issues. Resident said no one had tried to transfer him without using the mechanical lift. During an interview on 10/7/24 at 10:42 a.m. CNA K said she had worked in the facility since July of this year. CNA K said she would check the kardex to see how residents were to be transferred. CNA K said the PTA would get Resident #1 up most of the time. Said he would transfer her from the bed to the wheelchair. CNA K said staff would transfer her back to bed with the mechanical lift. CNA K said she had never heard Resident #1 complain when being transferred. Stated Resident #1 always told staff how to do it. CNA K said she had received training on the mechanical lift when hired, and had an in-service last week, and had to do hands on demonstration. During an interview on 10/7/24 at 10:47 a.m. CNA J said he was hired as prn and had worked in the facility for 3 weeks. CNA J said he had worked over 30 hours per week. CNA J said on 10/2/24 he was sitting in the lobby and CNA D asked him to help transfer Resident #1. CNA J said he went into Resident #1's room, and he had seen the therapist transfer Resident #1 without using the mechanical lift. CNA J said he had transferred Resident #1 at least 2 other times without the mechanical lift, stating that's why I did it I saw the therapist do it. CNA J said once I got Resident #1 in the bed she complained of pain in her hip area, then she said it was her leg in the area of her knee. CNA J said he picked her up out of the wheelchair and transferred her to the bed. CNA J said he was told by other staff (unknown names) that when Resident #1 came back from dialysis that evening, she was complaining of hip pain. CNA J said he asked Resident#1 if she wanted him to transfer her like he did before, and she agreed. CNA J said she had not had any complaints any other time he had transferred her to bed. If she had complained at any point, I would never have done it again, if she had any pain. CNA J said he did not hear anyone talking on the camera in her room while he was in there. CNA J said he did not know Resident #1 used a mechanical lift, he had just seen how therapy transferred her. CNA J said Resident #1 did not complain of any pain until she was in the bed. CNA J said when he asked Resident #1 if she wanted him to transfer her, he told her remember how I transferred you the last time?, and the Resident said, okay baby. CNA J said Resident #1 never asked him to stop while he was transferring her. CNA J said he had transferred Resident #1 2-3 times before by himself, without the mechanical lift. CNA J said this was a big accident, and it has been heavy on my heart. I am very regretful, and now going forward I'll always use the [mechanical lift] and will always check the kardex. I had no intentions whatsoever to do any harm to the Resident. CNA J said he had been an aide for 9 months. During an interview on 10/7/24 at 11:08 a.m. CNA L said she had worked in the facility since the end of May this year. CNA L Said she had received training on the mechanical lift on hire and had just recently had another training with check off skills. CNA L said she always checked the kardex if she did not know how a resident transferred. CNA L said there always had to be 2 people doing a mechanical lift, and you need to make sure they are in it right, or you can jack them up. CNA L said she had never transferred a resident on the mechanical lift by herself. CNA L said Resident #1 never complained of not wanting to get in the mechanical lift. CNA L said she was not working the day of the incident, but the next day Resident #1 told her she was transferred without the mechanical lift the night before, and her leg got twisted but she never hit the floor. CNA L said Resident #1 was alert and oriented and said she had pain in her right leg. CNA L said Resident #1 had never asked her to be transferred the way therapy did (not using the mechanical lift). CNA L said she always waited for a 2nd person to assist with any mechanical lifts. During an observation on 10/7/24 at 11:49 a.m. CNA M, CNA N, and CNA O were observed doing a wheelchair to bed mechanical lift transfer on Resident #5. Resident was non interviewable. During an observation on 10/7/24 at 12:10 p.m. CNA M, CNA O, and CNA P were observed doing a bed to wheelchair mechanical transfer on Resident #6. Resident was non interviewable. During an observation on 10/7/24 at 12:25 p.m. CNA K, and CNA Q were observed doing a wheelchair to bed transfer on Resident #7. Resident #7 was non interviewable. During an observation and interview on 10/7/24 at 12:45 p.m. CNA R, and CNA L were observed doing a wheelchair to bed transfer with the mechanical lift on Resident #8. Resident #8 said he felt comfortable during transfers, had never had any problems and had no issues with the staff transferring him. No issues were found with observations. During an interview on 10/7/24 at 1:05 p.m. the DON said that all staff were being inserviced on the mechanical lift, and competency check offs were being done. Record review of a facility policy titled Lifting Machine, Using a Mechanical with a revision date of 1/125/24 indicated At least two nursing assistants are needed to safely move a resident with a mechanical lift Record review of in-service training records provided by the facility indicated the following: On 10/2/24 CNA J was inserviced on[mechanical] lift transfers/2 person assist. All residents listed as 2 person assist/mechanical lift transfers must be transferred per kardex/care plan for safety of staff and resident. Training record was signed by CNA J. On 10/2/24 clinical staff were inserviced on mechanical lift transfers/2 person assist. On 10/4/24 clinical staff were inserviced on how to access care information on the kardex. Record review of a Competency Assessment form for lifting machine, mechanical lift indicated that from 10/4/24-10/6/24, 43 staff members had completed competency check offs on using the mechanical lift.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: During the initial observation on in the kitchen the low temperature, chemical sanitation dish machine, did not reach the manufacturer's recommended minimal water temperature of 120 degrees Fahrenheit, (F) during the final rinse cycle This failure could place the residents at risk of foodborne illnesses. Findings included: During an observation and interview 01/08/24 beginning at 9:15 a.m., DA-N was standing at the dish machine washing the breakfast dishes, he said he had worked at the facility for two years. He said he was trained to test the machine by the DM. Upon request the DA-N tested the dish machine, and it tested at 50 parts-per-million, (PPM), of hypochlorite (chlorine), and the water temperature read 111 degrees Fahrenheit, (F). DA-N ran the machine five times to try to get the water temperature up to required 120 degrees Fahrenheit, (F). On the fourth time the machine reached 118 degrees F, but on the fifth time it dropped back down to 116 degrees F. DA-N said the dish machine had been having a problem reaching the required 120 degrees F, for a while. He said he ran the dishes through the machine three times to make sure they were sanitized. The Surveyor notified the DM that the facility could not use the dish machine until the water reached the minimum required water temperature of 120 degrees F. During an interview 01/08/24 at 9:30 a.m., DM said she had worked at the facility for four years, she said they had been having problems with the machine not reaching the proper temperature since October. She said they had a plumber come out and replaced a hot water heater, because they thought the old hot water heater wasn't large enough to provide hot water to the washing machines in the laundry, and the dish machine in the kitchen. Then an electrician came out and replaced a plug because they thought maybe it wasn't getting enough power. She said last week they ordered a hot water booster for the machine, but it had not come in yet. She said the staff were trained not to use the machine if it was not reading at the proper temperature. She said the dish machine not sanitizing the dishes could make the residents sick. During a phone interview 01/09/24 @ 8:36 a.m., the service representative, for the machine said the facility never notified them of the machine's low water temperature reading, if they had they could adjust the sanitizer level up to compensate for the low water temperature. He said the manufacture's recommendations for a low temperature chemical sanitation machine's minimal water temperature, should reach 120 degrees F. During an interview on 01/09/24 @ 10:30 a.m., the Administrator said they had ordered a booster for the dish machine on 12/29/23 and was waiting for it to be delivered. When asked why they didn't stop using the machine she said she makes rounds in the kitchen every morning. She said she checks the log on the wall to make sure the staff had tested the machine. She said they were aware at times of the machine losing temperature, that was the reason they ordered the booster. She said the staff know and are trained to not use the machine if it is not reading at proper temperature. She said she was never aware that the machine was used when it wasn't sanitizing correctly. During an interview on 01/10/24 at 2:52 p.m., the Administrator said the DM would be responsible for in servicing the staff, and she expected the staff to test the dish machine before use as required. She said if the dish machine was not working, she needs them to call out the service technician to test the machine. She said moving forward she would continue to check logs every morning and once a week she would monitor staff testing the machine for accuracy. She said the dishes not being sanitized could make the residents sick. Review of a policy titled Dish machine Use; revised March 2010 indicates: 7. The operator will check temperatures using the gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. 9. If hot water temperature or chemical sanitation concentrations do not meet requirements, cease use of the machine immediately until temperature or PPM of sanitizer are adjusted.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual and physical abuse for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area on 10/8/23. The facility failed to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear on 10/11/23. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse and Neglect - Clinical Protocol, revised 10/15/2022, revealed the following: Policy Statement The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation Different Abuse of any Types: . Resident to Resident Abuse of Any Type: o Altercations between residents should be reviewed as a potential situation of abuse. For example, infrequent arguments or disagreements that occur during the course of normal. Social interactions (e.g., dinner table discussions) would not meet the definition of abuse. o Both residents having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. o It is important to remember that abuse included the term willful which means that the individual'[s action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. If it is determined that the action was not willful (a deliberate action) that the facility is in compliance with the requirements to maintain an environment free of accident hazards as possible, and each resident receives adequate supervision . Definitions Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse is defined at S483.5 as non-consensual sexual contact of any type with a resident. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. For any alleged violation of sexual abuse the facility will: a. Immediately implement safeguards to prevent further potential abuse; . Physical Abuse -this includes but is not limited to hitting, slapping, pinching, and kicking . Review of a facesheet for Resident #1, dated 10/10/2023, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cognitive communication deficit, dementia, severe major depressive disorder, and anxiety disorder. Review of Resident #1's MDS assessment, dated 08/10/2023, revealed she had a BIMSscore of 99, indicating severe impairment. Resident #1's functional status revealed she was non-ambulatory and required extensive assistance with one-person physical assist support for bed mobility, transfer, and dressing. Review of Resident #1's care plan, dated 10/09/2023, revealed she had goals to include symptoms of delirium will resolve without lasting effects; anxiety does not interfere with functional abilities; remains free from skin breakdown; with interventions to report changes in alertness or memory to doctor; assess for changes in mood status, assist in determine source of anxiety and precipitating events, allow to verbalize feelings, provide environment that respects privacy. Review of Resident #1's skin care alert, dated 10/08/2023, revealed she had scratches to right thigh and redness to perineal area (vaginal region below the pelvic diaphragm). Review of Resident #1's progress notes by treatment nurse, dated 10/09/2023, revealed skin assessment was completed and resident was noted with blanchable redness and scratches to peri area. Review of a face sheet for Resident #2, dated 10/10/2023, revealed he was an [AGE] year-old male, admitted on [DATE] and discharged to behavioral hospital on 10/09/2023. Resident #2's face sheet revealed he had diagnoses including depression, muscle weakness, and insomnia. Review of Resident #2's MDS assessment, dated 07/31/2023, revealed he had a BIMS score of 09, indicating moderate impairment. Resident #2's functional status revealed he required setup help only for locomotion on unit and bed mobility. Resident #2's behavior revealed he had no physical or wandering behavior. Review of Resident #2's care plan, dated 10/08/2023, revealed DON note that he had no history of behaviors while recievingpsychiatric services, a risk of side effects for antidepressant and hypnotic medication use, difficulty with sleeping with interventions to include monitor patterns of target behaviors, monitor and record sleep patterns, assess for adverse side effects, document and report, assess for changes in mood status, and provide environmental changes to facilitate sleep. Review of employee statement by CNA A, dated 10/08/2023, revealed the following: As I was making rounds I discovered (Resident #2) in (Resident #1)'s room with his hand placed in her diaper. I immediately yelled stop, get out, and never kept my eyes off of him. I yelled for the aide, and the med-aide down the hall. He backed his wheelchair up and went into his room to wash his hands. We immediately notified the nurse. Review of employee statement by MA E,dated 10/08/2023, revealed the following: As I came down the hall to assist (CNA A) was in (Resident #1) room and (Resident #2) exiting to go into his room and began to wash his hands and nurse was immediately notified. Review of employee statement by LVN A, dated 10/08/2023, revealed the following: Assisting another resident to her room on 300 hall when called by (CMA A) to come to 200 hall. As going immediately to CNA, informed by her that (Resident #2) was seen in (Resident #1)'s room fondling her. It was then reported that (Resident #2) was seen going back to his room and was washing his hands. Immediately started walking down hallway and observed (Resident #2) washing his hands at sink in room. (Resident #1) checked on and she appeared to be visibly upset. Crying and very emotional. Inquired from her if anyone came to room and she was unable to state anything. (Normal behavior). Immediately called ADON and reported incident to her. ADON stated she was calling administrator. Went to question (Resident #2) about incident. Inquired if he went across hallway and was touching someone inappropriately. He stated that he did touch her. Asked if this was first time doing this in which he denied doing it before. (Witness CNA A present when admitted to touching her) management then placed (Resident #2) on one-on-one. Review of Resident #2's progress notes by RN A, dated 10/08/2023 at 4:00 p.m., revealed CNA reported to RN A that resident was in a female resident's room at bedside with his hand in her brief and he was immediately removed from her room and assisted back to his room. Review of Resident #2's progress notes by DON, dated 10/08/2023 at 7:00 p.m., revealed investigation into allegation of abuse was opened. (RP A) was contacted and spoke with administrator, police Officer A, and Officer B present. Responsible party and resident consented to referral to behavioral hospital for evaluation. Resident assessment revealed he was awake, alert, and answered questions without signs of emotional distress and resident denied incident occurred. Resident was on one-to-one monitoring by staff until transfer. Review of Resident #2's progress notes by LPN A, dated 10/09/2023 at 12:32 p.m., revealed resident was transferred to behavioral hospital and no behaviors were noted. Review of in-service provided by DON, dated 10/08/2023, revealed education was provided on abuse and neglect with the following objectives: recognizing abuse, reporting abuse, resident safety, and seven components of abuse. Review of in-services, dated 10/08/2023, revealed education was provided to nursing staff on recognizing and reporting abuse, resident safety, seven components of abuse, and elder sexual abuse and warning signs and included the following: Sexual abuse of an elderly person occurs when a caregiver or another person forces unwanted sexual contact or penetration with an elderly person. Older adults are especially vulnerable to perpetrators of sexual abuse. Perpetrators target individuals who they perceive are vulnerable or easy to overpower. They also abuse elders who they think are unlikely to report the abuse or be believed. Elder sexual abuse can include: sexual contact with an elderly person who is confused or unable to give consent sexual contact or penetration without the victim's consent forced nudity photographing a person in a sexual way without that person's consent Some elderly victims are unable to give consent due to health conditions, such as dementia or Alzheimer's disease. Elderly women are much more likely to be abused than elderly men. Most reports of older sexual abuse come from nursing homes . Review of Resident #2 behavioral hospital interdisciplinary notes and labs, dated 10/09/2023 and 10/10/2023, revealed he was admitted on [DATE] for inappropriate behavior. Interdisciplinary notes revealed resident was sent from nursing facility and had no history of sexual, physical, or emotional abuse. Interdisciplinary notes revealed he has insomnia and does not sleep well at night. This patient lacks insight and judgment is poor. This patient behavior was inappropriate, and he is a danger to others. Labs revealed he had no indication for a urinary tract infection. Review of police report, dated 10/17/2023, revealed the following narrative by Officer A: On October 8, 2023, at around 4:40 PM, (Officer A) was dispatched to (facility name and address) nursing home for a sexual assault report. On scene, (Officer A) spoke with nursing staff and witness, (CNA A), who stated that as she was walking down the hallway and passing room (Resident #1's room number), she observed (Resident #2) with his hand down the front of the incontinence diaper of [NAME] Doe. (CNA A) said she confronted (Resident #2) and he yelled at her and swung at her then wheelchaired himself out of the room, across the hallway to his room (Resident #2's room number). Staff nurses interviewed [NAME] Doe in the presence of (Officer A) and she had no recollection of anyone coming in her room and stated she did not have any pain or discomfort to report. [NAME] Doe is a [AGE] year-old female with severe cognitive impairment. (Forensic interviewer) was contacted to determine of SANE exam was necessary and to schedule it if so. (Forensic interviewer) stated that due to mental status of both parties, that a SANE exam did not seem necessary. (Forensic interviewer) and (Officer A) believed it best to contact [NAME] Doe's [family member], (RP A), to ask whether he wanted to pursue charges given the circumstances. (RP A) told (Officer A) that he did not believe charges were necessary and that the steps the nursing home was taking to move (Resident #2) to another location were sufficient. (Officer A) next contact Adult Protective Services (APS) to inform them of the situation and obtain a reference number . Review of police report, dated 10/08/2023, revealed the following supplement by Officer B: (Officer B) arrived at (facility name and address) in regard to a sexual assault report. (Officer B) spoke with witness, (CNA A). She stated she walked into room (Resident #1's room number) at approximately 1600 hours [4:00 PM] and observed (Resident #2) sitting on [NAME] Doe's bed with [NAME] Doe laying down. (CNA A) stated she observed his hand in the side of [NAME] Doe's diaper and when she made her presence known, (Resident #2) removed his hand quickly and exited her room. (Officer B) then went with complainant, (ADON), to question (Resident #2). (Resident #2) stated he did not enter the room he just went to the doorway to speak with [NAME] Doe. (Resident #2 denied any sexual involvement with [NAME] Doe and advised he was too old to be doing sexual things. (ADON) advised (Resident #2) has a moderate cognitive impairment . Review of Provider Investigation Report, dated 10/08/2023, revealed the administrator was notified by ADON of the sexual abuse incident between Resident #1 and Resident #2 with one witness, CNA A. Police, both residents' responsible parties, and medical director was contacted. The responsible party of Resident #1 declined the offer of being sent out for SANE (Sexual Assault Nurse Examiner) exam and hospital for evaluation. The responsible party also declined the same offer from Officer A. Resident #1's room is directly across from Resident #2. One on one with Resident #2 was performed until discharges to behavioral hospital on 10/09/2023 with alternative placement recommended. Full body assessment was performed by ADON on Resident #1 with findings of redness to peri area. Safe surveys were performed on all residents with no concerns to ensure no other residents were involved or had contact with Resident #2 and safe surveys will continue weekly times 4. Staff in-serviced abuse, neglect, and sexual abuse in the elderly. During an interview on 10/12/2023 at 12:13 p.m., the administrator, DON, and ADON said the sexual abuse allegation incident occurred on 10/08/2023 at 3:45 p.m. CNA A witnessed the incident and LVN A was notified and assessed residents. The administrator said she was the abuse coordinator and when interviewed Resident #2 denied close contact with Resident #1. The administrator said Resident #2 was placed on one-to-one monitoring until he was sent to a behavioral hospital on 10/09/2023. The administrator said Resident #2 was not anticipated to return. The administrator said Resident #1 was smiling and in no distress during her interview following the incident and Resident #1 reported no harm and did not remember event. The administrator said police were notified and interviewed residents on-site. The administrator said to prevent further abuse Resident #2 received one-to-one monitoring until he was discharged to behavioral hospital, safe surveys and skin assessments were completed on all residents by 10/09/2023, and staff received in-services on sexual abuse completed 10/09/2023 and safe surveys will continue weekly times 4 weeks. The administrator said she had an additional self-report recently submitted to HHSC. During an interview and observation on 10/12/2023 at 1:43 p.m., Resident # 1 was sitting in her geriatric chair in common lobby area near nursing station. Resident #1 said everyone was nice to her and that she was doing good and had no concerns. Resident #1 appeared pleasant, free from apparent injury, and in no distress. During an interview on 10/12/2023 at 2:40 p.m., CNA B said she was not at the facility during the incident with Resident #1 and Resident #2 but that she normally takes care of Resident #2. CNA B said that if she witnessed a male resident with his hand in a female residents brief she would immediately get the charge nurses. CNA B said Resident #2 had no inappropriate behavior under her care and would have never thought he would have sexually abused a resident. CNA B said Resident #1 is crying and emotional at baseline and that they do not normally interact. CNA B said she did not talk with either resident about what happened and that residents have been getting along. CNA B said to prevent abuse the facility has provided in-services on abuse. During an interview on 10/12/2023 at 3:01 p.m., CNA C said she had been employed at the facility for [AGE] years and did not take care of Resident #1 or Resident #2. CNA A said she arrived to the facility during reporting of the incident and was aware that Resident #2 was reported to have been fondling Resident #1. CNA C said she felt that residents are safe and that there were no other residents involved with Resident #2 because she knew a majority of the residents for a long time when they were at the old facility building. During an interview on 10/12/2023 at 3:11 p.m., LVN C said she had been employed at the facility for [AGE] years and normally cares for Resident #1 and Resident #2. LVN C said Resident #1 was pleasant today and sometimes cries for unknown reasons at baseline. LVN C said Resident #2 had never had any history of inappropriate behavior. LVN C said she was not working when the event occurred, but that Resident #2 was sent to the behavioral hospital and will not be coming back. LVN C said there was an additional fight since incident between two residents and that it was behavior on aggressors' part, and he was also sent to a behavioral hospital. LVN C said she felt that residents are safe with those two residents out of the facility. LVN C said Resident #4 went into Resident #3's room and accused him of laying in his bed, but he was not in his right room. LVN C said she was taking care of Resident #3 and that he was doing good and had no changes in his mood or behavior. Review of a facesheet with no date and admission MDS , dated 08/24/2023, for Resident #3 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, muscle weakness, and intermittent explosive disorder. Review of MDS, dated [DATE], for Resident #3 revealed he had a BIMS score of 13, indicating he was cognitively intact and functional status revealed he was non-ambulatory. Review of care plan dated 10/12/2023, for Resident #3 revealed the resident has limited physical mobility related to dementia with a goal to remain free from complications of skin breakdown to include interventions of wheelchair use for locomotion. Review of a facesheet with no date and admission MDS, dated [DATE], for Resident #4 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: Parkinson's disease, psychotic disorder with delusions and hallucinations due to known physiological condition, schizoaffective disorder, bipolar type, dementia, insomnia, and recurrent depressive disorders. Review of MD notes, dated 09/28/2023, for Resident #4 revealed his psychiatric affect and mood were appropriate and that he was cooperative with care. MD notes revealed his current plan of care and medications were continued as ordered and to notify of any changes. Review of MDS for Resident #4, dated 10/12/2023, revealed Resident #4 had a BIMS score of 05, indicating severe cognitive impairment. Review of care plan for Resident #4, dated 10/11/2023, revealed he had a focus including Parkinson's disease and psychotropic medication use with goals for him to remain free of further signs and symptoms, discomfort, or complications related to Parkinson's disease and psychotropic drug use through review date. Care plan interventions for Resident #4 included to monitor/document /report any signs and symptoms of medication side effects such as dizziness, somnolence, insomnia, confusion, and any targeted behavior such as violence/aggression towards staff and others. Review of progress notes dated 10/11/2023, for Resident #3 revealed resident had a physical altercation with another male resident who entered his room while he was laying in the bed. Progress notes revealed that Resident #3 reported, he came into my room, and I asked him to get out, but he wouldn't leave. He told me that l was in his room in his bed! I told him no I was in my bed, and he needed to leave. He came and started to hit me, and I hit him back. Progress notes revealed Resident #3 had a laceration to his nose and a bruise to his left ear and received an order for x-ray of facial bones. Progress notes revealed staff attempted to notify RP B and a message was left by staff on his voicemail. Progress notes revealed resident was resting in bed without distress post incident, first aid provided, and that staff would continue to observe. Progress notes revealed Resident #3 refused transfer to emergency room for evaluation and treatment and left ear was swollen and reddish/purple in color. Review of Skin Observation Worksheet signed by the DON, dated 10/11/2023, revealed Resident #3 had a bloody nose, skin split to bridge of nose, red edema, and a possible scratch behind his left ear. Review of x-ray of facial bones report, dated 10/12/2023, revealed Resident #3 had no significant findings. Review of progress notes, dated 10/11/2023, revealed Resident #4 was involved in a physical altercation with another male resident. Progress notes revealed Resident #4 was noticed at 200 hall exit door and then entered another resident's room at the end of that small hallway. The resident room he entered then activated the call light for assistance with getting him out of his room and told Resident #4 several times to get out of his room. Progress Notes revealed Resident #4 then became angry telling Resident #4 to get out of my bed. Progress notes revealed Resident #4 then hit Resident #3 in his nose and ear causing his nose to bleed. Progress notes revealed Resident #4 continued to swing at nursing staff when removing him from room. Progress notes revealed Resident #4 continues to have increased anxiety, uncooperative with redirection, and residents family member was informed. Progress notes revealed staff approached Resident #4 to interview him on alleged incident and he was noted to be sitting up in wheelchair in doorway of room, agitated, verbally aggressive, and had attempted to swing his fists at staff members in the hallway who were standing outside doorway of resident room. Progress notes revealed staff approached him in calm, friendly voice and asked what was going on and resident stated nothing. Progress notes revealed that when asked if he hit another resident, Resident #4 stated, Yes, I went down there. I started hitting him. Progress Notes revealed he then began to mumble and was incomprehensible. Progress notes revealed Resident #4 had unclear and unintelligible speech at times and MD was notified new order was received to transfer resident to behavioral hospital. Review of witness statement by CNA D, dated 10/11/2023, revealed she went to answer the call light for Resident #3's room and found Resident #4 in the room with Resident #3. Witness statement revealed residents were fighting and CNA D tried to break it up when Resident #4 turned and began trying to fight her. Witness statement revealed CNA D then told her coworker to get the nurse. Review of witness statement by CMA B, with no date, revealed the following: We were at the nurse's station. A staff ran up and said two men residents are fighting. One of the residents got CNA D blocked in the room. Two nurses and I ran down the hall to the last room. We walked in the room. It was (Resident #3)'s room and his nose was red and bleeding. Nurse asked him what happened because he was laying in the bed bleeding. He said he hit me in the nose. (Resident #4) had hit him. Staff removed (Resident #4). He was still trying to fight. Another nurse helped and took care of (Resident #3)'s nose. Review of witness statement by LVN D, dated 10/11/2023, revealed the following: This nurse was at the nurse's station when CNA's called for me to come down the hall because two residents were having an altercation. Upon arrival to (Resident #3's) room this nurse observed (CNA D) trying to remove (Resident #4) from the room. (Resident #4) was being combative and very upset. (Resident #3) is noted to be bleeding from his nose and all down his face. A laceration is noted to the left side of (Resident #3's) nose and a bruise to his left ear. (Resident #3) reports that he asked (Resident #4) to get out of his room and (Resident #4) hit him telling him this was his room and he needed to get out of his bed. (Resident #3) reports that he hit him back defending himself. (Resident #4) is up the hallway with other staff at this time. (Resident #3) denies any pain. No distress noted. Review of employee statement by LVN B, dated 10/11/2023, revealed the following: This nurse was walking up toward 100 hall when I saw staff members rushing towards (Resident #3's room). I brought coffee to a resident and then started down 200 hall. I saw the resident (Resident #4) being wheeled out of the (Resident #3) room by a staff member. He was swinging trying to hit her. The resident had hit another resident (Resident #3's room number) in the face and ear causing that resident's nose to bleed. This nurse cleaned the blood off the resident (Resident #3). (Resident #4) also tried to hit various other staff members. Review of provider investigation report with no date revealed Resident #3 and Resident #4 had an altercation on 10/11/2023 at 1:10 p.m. witnessed by CNA D. The brief narrative summary of report revealed Resident #4 entered Resident #4's room and an argument ensued resulting in physical aggression with each other. Assessment details of report revealed Resident #4 struck Resident #4 in the nose leading to epistaxis (nosebleed), bruising, and edema to left ear and Resident #4 had superficial scratch to this face left of nose with no other injuries noted. Assessment details revealed Resident #4 was referred for a psychiatric evaluation at behavioral hospital and Resident #4 assessments to be completed every shift to monitor for emotional distress. Actions and Notifications section revealed MD, both RP's, administrator, and DON were notified, and staff in-services were conducted on resident-to-resident violence and de-escalation of situation, reporting, and abuse and neglect. Provider investigation report revealed one on one supervision with Resident #4 was completed on 10/11/2023 and 10/12/2023. Review of Provider Investigation Report by DON, with no date, revealed resident-to-resident altercation incident between Resident #3 and Resident #4 occurred on 10/11/2023 at 1:10 p.m. Provider Investigation Report revealed in-services were provided to staff on resident-on-resident violence and de-escalation of situation, reporting, abuse and neglect. Review of progress notes for Resident #4, dated 10/12/2023, revealed he continued to be combative with staff during transport to behavioral hospital and driver had to pull over and contact EMS. During an interview on 10/12/2023 at 4:07 p.m., LVN A said she was taking a resident back to her room on 10/08/2023 and heard the aide yell for her. LVN A said they started walking down the hall to the aide and Resident #2 was seen with his hand in Resident #1's brief and was then seen in his room washing his hands. LVN A said Resident #1 was crying and upset but she was not able to say what happened. LVN A said she notified ADON immediately and the administrator and protected Resident #1 until they arrived. LVN A said when she asked Resident #2 at first, he denied the incident then later when asked he said, Yeah, I did it. LVN A said she asked Resident #2 if he did it before and he said no it was the first time. LVN A said Resident #2 kept trying to avoid that question. LVN A said she assessed Resident #1, obtained her vital signs, took a picture of the brief before they took it off and looked at the skin in that brief area and she had a very little fingernail width scratch to the right side and if you dab it with a wet cloth it had a drop of blood on it so it was fresh and from what LVN A saw it did appear he assaulted her due to her scratch in area and because she blurted out don't put it in there which was not normal for her to say. LVN A said CNA A told her she saw Resident #2 with his hand in Resident #1's brief and CMA A was the aide that came to the 200 hall calling her name. LVN A said Resident #2 had no history of inappropriate behavior since she has been employed in April 2023 and that their rooms were directly across from each other. LVN A said the resident had a roommate but that it appeared Resident #2 shut that curtain in her room because the curtain was pulled all the way to the end of the bed. LVN A said the incident happened on Sunday, 10/8/23, and that she had taken care of Resident #1 following the incident and appeared at baseline in no distress. LVN A said the facility put interventions in place to protect the resident and prevent sexual abuse from occurring by placing Resident #2 on one-on-one monitoring until he was discharged , frequent 30 minute checks on Resident #1, police were notified and investigated on-site, and staff had received a couple of in-services on different kinds of abuse and neglect following the incident. LVN A said she had no concerns with any other residents showing signs of sexual abuse. During an interview on 10/13/2023 at 9:27 a.m., CNA A said the administrator was the abuse coordinator. CNA A said she was coming out of hall on 10/08/2023 around 3:45 p.m. to do her rounds and Resident #2 was in Resident #1's room with his hand in her brief and she told him to stop and yelled for two aides to assist. CNA A said Resident #1 was crying and Resident #2 backed his wheelchair in the other room and started washing his hands. CNA A said Resident #2 did not say what he was doing and that she suspected sexual abuse. CNA said the nurse called and notified someone to let them know it happened and did a skin assessment. CNA A said the brief was open and appeared it had been messed with. CNA A said Resident #1 was doing fine now at baseline and does not remember what happened. CNA A said the nurse called the responsible party and let him know what happened and the police came the same day. Resident #2 had no behavior prior to this and had no behavior and did not know if this had happened before. CNA A said interventions were put in place to protect residents from further abuse by placing Resident #2 on one-to-one monitoring, moving Resident #2 to a behavioral hospital, and in-services were conducted on sexual abuse. CNA A said it was important to protect residents from any kind of sexual abuse because she would not want that to happen to her family and that the facility was their home and wanted to protect them from abuse, make sure nothing would happen to them, and prevent any physical or emotional harm. CNA A said she believed the facility residents were safe with Resident #2 out of the facility. CNA A said she also took care of Resident #3 on 10/13/2023 and that he appeared to be in no distress and usually gets along with other residents. CNA A said she was not here during his altercation with Resident #4, but that nursing staff are monitoring rooms every 2 hours, checking residents daily for any bruises or

Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. The facility failed to implement policies and procedures to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area. The facility failed to implement policies and procedures to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse and Neglect - Clinical Protocol, revised 10/15/2022, revealed the following: Policy Statement The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation Different Abuse of any Types: . Resident to Resident Abuse of Any Type: o Altercations between residents should be reviewed as a potential situation of abuse. For example, infrequent arguments or disagreements that occur during the course of normal. Social interactions (e.g., dinner table discussions) would not meet the definition of abuse. o Both residents having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. o It is important to remember that abuse included the term willful which means that the individual'[s action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. If it is determined that the action was not willful (a deliberate action) that the facility is in compliance with the requirements to maintain an environment free of accident hazards as possible, and each resident receives adequate supervision . Definitions Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse is defined at S483.5 as non-consensual sexual contact of any type with a resident. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. For any alleged violation of sexual abuse the facility will: a. Immediately implement safeguards to prevent further potential abuse; . Physical Abuse -this includes but is not limited to hitting, slapping, pinching, and kicking . Review of a facesheet for Resident #1, dated 10/10/2023, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cognitive communication deficit, dementia, severe major depressive disorder, and anxiety disorder. Review of Resident #1's MDS assessment, dated 08/10/2023, revealed she had a BIMSscore of 99, indicating severe impairment. Resident #1's functional status revealed she was non-ambulatory and required extensive assistance with one-person physical assist support for bed mobility, transfer, and dressing. Review of Resident #1's care plan, dated 10/09/2023, revealed she had goals to include symptoms of delirium will resolve without lasting effects; anxiety does not interfere with functional abilities; remains free from skin breakdown; with interventions to report changes in alertness or memory to doctor; assess for changes in mood status, assist in determine source of anxiety and precipitating events, allow to verbalize feelings, provide environment that respects privacy. Review of Resident #1's skin care alert, dated 10/08/2023, revealed she had scratches to right thigh and redness to perineal area (vaginal region below the pelvic diaphragm). Review of Resident #1's progress notes by treatment nurse, dated 10/09/2023, revealed skin assessment was completed and resident was noted with blanchable redness and scratches to peri area. Review of a face sheet for Resident #2, dated 10/10/2023, revealed he was an [AGE] year-old male, admitted on [DATE] and discharged to behavioral hospital on 10/09/2023. Resident #2's face sheet revealed he had diagnoses including depression, muscle weakness, and insomnia. Review of Resident #2's MDS assessment, dated 07/31/2023, revealed he had a BIMS score of 09, indicating moderate impairment. Resident #2's functional status revealed he required setup help only for locomotion on unit and bed mobility. Resident #2's behavior revealed he had no physical or wandering behavior. Review of Resident #2's care plan, dated 10/08/2023, revealed DON note that he had no history of behaviors while recievingpsychiatric services, a risk of side effects for antidepressant and hypnotic medication use, difficulty with sleeping with interventions to include monitor patterns of target behaviors, monitor and record sleep patterns, assess for adverse side effects, document and report, assess for changes in mood status, and provide environmental changes to facilitate sleep. Review of employee statement by CNA A, dated 10/08/2023, revealed the following: As I was making rounds I discovered (Resident #2) in (Resident #1)'s room with his hand placed in her diaper. I immediately yelled stop, get out, and never kept my eyes off of him. I yelled for the aide, and the med-aide down the hall. He backed his wheelchair up and went into his room to wash his hands. We immediately notified the nurse. Review of employee statement by MA E,dated 10/08/2023, revealed the following: As I came down the hall to assist (CNA A) was in (Resident #1) room and (Resident #2) exiting to go into his room and began to wash his hands and nurse was immediately notified. Review of employee statement by LVN A, dated 10/08/2023, revealed the following: Assisting another resident to her room on 300 hall when called by (CMA A) to come to 200 hall. As going immediately to CNA, informed by her that (Resident #2) was seen in (Resident #1)'s room fondling her. It was then reported that (Resident #2) was seen going back to his room and was washing his hands. Immediately started walking down hallway and observed (Resident #2) washing his hands at sink in room. (Resident #1) checked on and she appeared to be visibly upset. Crying and very emotional. Inquired from her if anyone came to room and she was unable to state anything. (Normal behavior). Immediately called ADON and reported incident to her. ADON stated she was calling administrator. Went to question (Resident #2) about incident. Inquired if he went across hallway and was touching someone inappropriately. He stated that he did touch her. Asked if this was first time doing this in which he denied doing it before. (Witness CNA A present when admitted to touching her) management then placed (Resident #2) on one-on-one. Review of Resident #2's progress notes by RN A, dated 10/08/2023 at 4:00 p.m., revealed CNA reported to RN A that resident was in a female resident's room at bedside with his hand in her brief and he was immediately removed from her room and assisted back to his room. Review of Resident #2's progress notes by DON, dated 10/08/2023 at 7:00 p.m., revealed investigation into allegation of abuse was opened. (RP A) was contacted and spoke with administrator, police Officer A, and Officer B present. Responsible party and resident consented to referral to behavioral hospital for evaluation. Resident assessment revealed he was awake, alert, and answered questions without signs of emotional distress and resident denied incident occurred. Resident was on one-to-one monitoring by staff until transfer. Review of Resident #2's progress notes by LPN A, dated 10/09/2023 at 12:32 p.m., revealed resident was transferred to behavioral hospital and no behaviors were noted. Review of in-service provided by DON, dated 10/08/2023, revealed education was provided on abuse and neglect with the following objectives: recognizing abuse, reporting abuse, resident safety, and seven components of abuse. Review of in-services, dated 10/08/2023, revealed education was provided to nursing staff on recognizing and reporting abuse, resident safety, seven components of abuse, and elder sexual abuse and warning signs and included the following: Sexual abuse of an elderly person occurs when a caregiver or another person forces unwanted sexual contact or penetration with an elderly person. Older adults are especially vulnerable to perpetrators of sexual abuse. Perpetrators target individuals who they perceive are vulnerable or easy to overpower. They also abuse elders who they think are unlikely to report the abuse or be believed. Elder sexual abuse can include: sexual contact with an elderly person who is confused or unable to give consent sexual contact or penetration without the victim's consent forced nudity photographing a person in a sexual way without that person's consent Some elderly victims are unable to give consent due to health conditions, such as dementia or Alzheimer's disease. Elderly women are much more likely to be abused than elderly men. Most reports of older sexual abuse come from nursing homes . Review of Resident #2 behavioral hospital interdisciplinary notes and labs, dated 10/09/2023 and 10/10/2023, revealed he was admitted on [DATE] for inappropriate behavior. Interdisciplinary notes revealed resident was sent from nursing facility and had no history of sexual, physical, or emotional abuse. Interdisciplinary notes revealed he has insomnia and does not sleep well at night. This patient lacks insight and judgment is poor. This patient behavior was inappropriate, and he is a danger to others. Labs revealed he had no indication for a urinary tract infection. Review of police report, dated 10/17/2023, revealed the following narrative by Officer A: On October 8, 2023, at around 4:40 PM, (Officer A) was dispatched to (facility name and address) nursing home for a sexual assault report. On scene, (Officer A) spoke with nursing staff and witness, (CNA A), who stated that as she was walking down the hallway and passing room (Resident #1's room number), she observed (Resident #2) with his hand down the front of the incontinence diaper of [NAME] Doe. (CNA A) said she confronted (Resident #2) and he yelled at her and swung at her then wheelchaired himself out of the room, across the hallway to his room (Resident #2's room number). Staff nurses interviewed [NAME] Doe in the presence of (Officer A) and she had no recollection of anyone coming in her room and stated she did not have any pain or discomfort to report. [NAME] Doe is a [AGE] year-old female with severe cognitive impairment. (Forensic interviewer) was contacted to determine of SANE exam was necessary and to schedule it if so. (Forensic interviewer) stated that due to mental status of both parties, that a SANE exam did not seem necessary. (Forensic interviewer) and (Officer A) believed it best to contact [NAME] Doe's [family member], (RP A), to ask whether he wanted to pursue charges given the circumstances. (RP A) told (Officer A) that he did not believe charges were necessary and that the steps the nursing home was taking to move (Resident #2) to another location were sufficient. (Officer A) next contact Adult Protective Services (APS) to inform them of the situation and obtain a reference number . Review of police report, dated 10/08/2023, revealed the following supplement by Officer B: (Officer B) arrived at (facility name and address) in regard to a sexual assault report. (Officer B) spoke with witness, (CNA A). She stated she walked into room (Resident #1's room number) at approximately 1600 hours [4:00 PM] and observed (Resident #2) sitting on [NAME] Doe's bed with [NAME] Doe laying down. (CNA A) stated she observed his hand in the side of [NAME] Doe's diaper and when she made her presence known, (Resident #2) removed his hand quickly and exited her room. (Officer B) then went with complainant, (ADON), to question (Resident #2). (Resident #2) stated he did not enter the room he just went to the doorway to speak with [NAME] Doe. (Resident #2 denied any sexual involvement with [NAME] Doe and advised he was too old to be doing sexual things. (ADON) advised (Resident #2) has a moderate cognitive impairment . Review of Provider Investigation Report, dated 10/08/2023, revealed the administrator was notified by ADON of the sexual abuse incident between Resident #1 and Resident #2 with one witness, CNA A. Police, both residents' responsible parties, and medical director was contacted. The responsible party of Resident #1 declined the offer of being sent out for SANE (Sexual Assault Nurse Examiner) exam and hospital for evaluation. The responsible party also declined the same offer from Officer A. Resident #1's room is directly across from Resident #2. One on one with Resident #2 was performed until discharges to behavioral hospital on 10/09/2023 with alternative placement recommended. Full body assessment was performed by ADON on Resident #1 with findings of redness to peri area. Safe surveys were performed on all residents with no concerns to ensure no other residents were involved or had contact with Resident #2 and safe surveys will continue weekly times 4. Staff in-serviced abuse, neglect, and sexual abuse in the elderly. During an interview on 10/12/2023 at 12:13 p.m., the administrator, DON, and ADON said the sexual abuse allegation incident occurred on 10/08/2023 at 3:45 p.m. CNA A witnessed the incident and LVN A was notified and assessed residents. The administrator said she was the abuse coordinator and when interviewed Resident #2 denied close contact with Resident #1. The administrator said Resident #2 was placed on one-to-one monitoring until he was sent to a behavioral hospital on 10/09/2023. The administrator said Resident #2 was not anticipated to return. The administrator said Resident #1 was smiling and in no distress during her interview following the incident and Resident #1 reported no harm and did not remember event. The administrator said police were notified and interviewed residents on-site. The administrator said to prevent further abuse Resident #2 received one-to-one monitoring until he was discharged to behavioral hospital, safe surveys and skin assessments were completed on all residents by 10/09/2023, and staff received in-services on sexual abuse completed 10/09/2023 and safe surveys will continue weekly times 4 weeks. The administrator said she had an additional self-report recently submitted to HHSC. During an interview and observation on 10/12/2023 at 1:43 p.m., Resident # 1 was sitting in her geriatric chair in common lobby area near nursing station. Resident #1 said everyone was nice to her and that she was doing good and had no concerns. Resident #1 appeared pleasant, free from apparent injury, and in no distress. During an interview on 10/12/2023 at 2:40 p.m., CNA B said she was not at the facility during the incident with Resident #1 and Resident #2 but that she normally takes care of Resident #2. CNA B said that if she witnessed a male resident with his hand in a female residents brief she would immediately get the charge nurses. CNA B said Resident #2 had no inappropriate behavior under her care and would have never thought he would have sexually abused a resident. CNA B said Resident #1 is crying and emotional at baseline and that they do not normally interact. CNA B said she did not talk with either resident about what happened and that residents have been getting along. CNA B said to prevent abuse the facility has provided in-services on abuse. During an interview on 10/12/2023 at 3:01 p.m., CNA C said she had been employed at the facility for [AGE] years and did not take care of Resident #1 or Resident #2. CNA A said she arrived to the facility during reporting of the incident and was aware that Resident #2 was reported to have been fondling Resident #1. CNA C said she felt that residents are safe and that there were no other residents involved with Resident #2 because she knew a majority of the residents for a long time when they were at the old facility building. During an interview on 10/12/2023 at 3:11 p.m., LVN C said she had been employed at the facility for [AGE] years and normally cares for Resident #1 and Resident #2. LVN C said Resident #1 was pleasant today and sometimes cries for unknown reasons at baseline. LVN C said Resident #2 had never had any history of inappropriate behavior. LVN C said she was not working when the event occurred, but that Resident #2 was sent to the behavioral hospital and will not be coming back. LVN C said there was an additional fight since incident between two residents and that it was behavior on aggressors' part, and he was also sent to a behavioral hospital. LVN C said she felt that residents are safe with those two residents out of the facility. LVN C said Resident #4 went into Resident #3's room and accused him of laying in his bed, but he was not in his right room. LVN C said she was taking care of Resident #3 and that he was doing good and had no changes in his mood or behavior. Review of a facesheet with no date and admission MDS , dated 08/24/2023, for Resident #3 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, muscle weakness, and intermittent explosive disorder. Review of MDS, dated [DATE], for Resident #3 revealed he had a BIMS score of 13, indicating he was cognitively intact and functional status revealed he was non-ambulatory. Review of care plan dated 10/12/2023, for Resident #3 revealed the resident has limited physical mobility related to dementia with a goal to remain free from complications of skin breakdown to include interventions of wheelchair use for locomotion. Review of a facesheet with no date and admission MDS, dated [DATE], for Resident #4 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: Parkinson's disease, psychotic disorder with delusions and hallucinations due to known physiological condition, schizoaffective disorder, bipolar type, dementia, insomnia, and recurrent depressive disorders. Review of MD notes, dated 09/28/2023, for Resident #4 revealed his psychiatric affect and mood were appropriate and that he was cooperative with care. MD notes revealed his current plan of care and medications were continued as ordered and to notify of any changes. Review of MDS for Resident #4, dated 10/12/2023, revealed Resident #4 had a BIMS score of 05, indicating severe cognitive impairment. Review of care plan for Resident #4, dated 10/11/2023, revealed he had a focus including Parkinson's disease and psychotropic medication use with goals for him to remain free of further signs and symptoms, discomfort, or complications related to Parkinson's disease and psychotropic drug use through review date. Care plan interventions for Resident #4 included to monitor/document /report any signs and symptoms of medication side effects such as dizziness, somnolence, insomnia, confusion, and any targeted behavior such as violence/aggression towards staff and others. Review of progress notes dated 10/11/2023, for Resident #3 revealed resident had a physical altercation with another male resident who entered his room while he was laying in the bed. Progress notes revealed that Resident #3 reported, he came into my room, and I asked him to get out, but he wouldn't leave. He told me that l was in his room in his bed! I told him no I was in my bed, and he needed to leave. He came and started to hit me, and I hit him back. Progress notes revealed Resident #3 had a laceration to his nose and a bruise to his left ear and received an order for x-ray of facial bones. Progress notes revealed staff attempted to notify RP B and a message was left by staff on his voicemail. Progress notes revealed resident was resting in bed without distress post incident, first aid provided, and that staff would continue to observe. Progress notes revealed Resident #3 refused transfer to emergency room for evaluation and treatment and left ear was swollen and reddish/purple in color. Review of Skin Observation Worksheet signed by the DON, dated 10/11/2023, revealed Resident #3 had a bloody nose, skin split to bridge of nose, red edema, and a possible scratch behind his left ear. Review of x-ray of facial bones report, dated 10/12/2023, revealed Resident #3 had no significant findings. Review of progress notes, dated 10/11/2023, revealed Resident #4 was involved in a physical altercation with another male resident. Progress notes revealed Resident #4 was noticed at 200 hall exit door and then entered another resident's room at the end of that small hallway. The resident room he entered then activated the call light for assistance with getting him out of his room and told Resident #4 several times to get out of his room. Progress Notes revealed Resident #4 then became angry telling Resident #4 to get out of my bed. Progress notes revealed Resident #4 then hit Resident #3 in his nose and ear causing his nose to bleed. Progress notes revealed Resident #4 continued to swing at nursing staff when removing him from room. Progress notes revealed Resident #4 continues to have increased anxiety, uncooperative with redirection, and residents family member was informed. Progress notes revealed staff approached Resident #4 to interview him on alleged incident and he was noted to be sitting up in wheelchair in doorway of room, agitated, verbally aggressive, and had attempted to swing his fists at staff members in the hallway who were standing outside doorway of resident room. Progress notes revealed staff approached him in calm, friendly voice and asked what was going on and resident stated nothing. Progress notes revealed that when asked if he hit another resident, Resident #4 stated, Yes, I went down there. I started hitting him. Progress Notes revealed he then began to mumble and was incomprehensible. Progress notes revealed Resident #4 had unclear and unintelligible speech at times and MD was notified new order was received to transfer resident to behavioral hospital. Review of witness statement by CNA D, dated 10/11/2023, revealed she went to answer the call light for Resident #3's room and found Resident #4 in the room with Resident #3. Witness statement revealed residents were fighting and CNA D tried to break it up when Resident #4 turned and began trying to fight her. Witness statement revealed CNA D then told her coworker to get the nurse. Review of witness statement by CMA B, with no date, revealed the following: We were at the nurse's station. A staff ran up and said two men residents are fighting. One of the residents got CNA D blocked in the room. Two nurses and I ran down the hall to the last room. We walked in the room. It was (Resident #3)'s room and his nose was red and bleeding. Nurse asked him what happened because he was laying in the bed bleeding. He said he hit me in the nose. (Resident #4) had hit him. Staff removed (Resident #4). He was still trying to fight. Another nurse helped and took care of (Resident #3)'s nose. Review of witness statement by LVN D, dated 10/11/2023, revealed the following: This nurse was at the nurse's station when CNA's called for me to come down the hall because two residents were having an altercation. Upon arrival to (Resident #3's) room this nurse observed (CNA D) trying to remove (Resident #4) from the room. (Resident #4) was being combative and very upset. (Resident #3) is noted to be bleeding from his nose and all down his face. A laceration is noted to the left side of (Resident #3's) nose and a bruise to his left ear. (Resident #3) reports that he asked (Resident #4) to get out of his room and (Resident #4) hit him telling him this was his room and he needed to get out of his bed. (Resident #3) reports that he hit him back defending himself. (Resident #4) is up the hallway with other staff at this time. (Resident #3) denies any pain. No distress noted. Review of employee statement by LVN B, dated 10/11/2023, revealed the following: This nurse was walking up toward 100 hall when I saw staff members rushing towards (Resident #3's room). I brought coffee to a resident and then started down 200 hall. I saw the resident (Resident #4) being wheeled out of the (Resident #3) room by a staff member. He was swinging trying to hit her. The resident had hit another resident (Resident #3's room number) in the face and ear causing that resident's nose to bleed. This nurse cleaned the blood off the resident (Resident #3). (Resident #4) also tried to hit various other staff members. Review of provider investigation report with no date revealed Resident #3 and Resident #4 had an altercation on 10/11/2023 at 1:10 p.m. witnessed by CNA D. The brief narrative summary of report revealed Resident #4 entered Resident #4's room and an argument ensued resulting in physical aggression with each other. Assessment details of report revealed Resident #4 struck Resident #4 in the nose leading to epistaxis (nosebleed), bruising, and edema to left ear and Resident #4 had superficial scratch to this face left of nose with no other injuries noted. Assessment details revealed Resident #4 was referred for a psychiatric evaluation at behavioral hospital and Resident #4 assessments to be completed every shift to monitor for emotional distress. Actions and Notifications section revealed MD, both RP's, administrator, and DON were notified, and staff in-services were conducted on resident-to-resident violence and de-escalation of situation, reporting, and abuse and neglect. Provider investigation report revealed one on one supervision with Resident #4 was completed on 10/11/2023 and 10/12/2023. Review of Provider Investigation Report by DON, with no date, revealed resident-to-resident altercation incident between Resident #3 and Resident #4 occurred on 10/11/2023 at 1:10 p.m. Provider Investigation Report revealed in-services were provided to staff on resident-on-resident violence and de-escalation of situation, reporting, abuse and neglect. Review of progress notes for Resident #4, dated 10/12/2023, revealed he continued to be combative with staff during transport to behavioral hospital and driver had to pull over and contact EMS. During an interview on 10/12/2023 at 4:07 p.m., LVN A said she was taking a resident back to her room on 10/08/2023 and heard the aide yell for her. LVN A said they started walking down the hall to the aide and Resident #2 was seen with his hand in Resident #1's brief and was then seen in his room washing his hands. LVN A said Resident #1 was crying and upset but she was not able to say what happened. LVN A said she notified ADON immediately and the administrator and protected Resident #1 until they arrived. LVN A said when she asked Resident #2 at first, he denied the incident then later when asked he said, Yeah, I did it. LVN A said she asked Resident #2 if he did it before and he said no it was the first time. LVN A said Resident #2 kept trying to avoid that question. LVN A said she assessed Resident #1, obtained her vital signs, took a picture of the brief before they took it off and looked at the skin in that brief area and she had a very little fingernail width scratch to the right side and if you dab it with a wet cloth it had a drop of blood on it so it was fresh and from what LVN A saw it did appear he assaulted her due to her scratch in area and because she blurted out don't put it in there which was not normal for her to say. LVN A said CNA A told her she saw Resident #2 with his hand in Resident #1's brief and CMA A was the aide that came to the 200 hall calling her name. LVN A said Resident #2 had no history of inappropriate behavior since she has been employed in April 2023 and that their rooms were directly across from each other. LVN A said the resident had a roommate but that it appeared Resident #2 shut that curtain in her room because the curtain was pulled all the way to the end of the bed. LVN A said the incident happened on Sunday, 10/8/23, and that she had taken care of Resident #1 following the incident and appeared at baseline in no distress. LVN A said the facility put interventions in place to protect the resident and prevent sexual abuse from occurring by placing Resident #2 on one-on-one monitoring until he was discharged , frequent 30 minute checks on Resident #1, police were notified and investigated on-site, and staff had received a couple of in-services on different kinds of abuse and neglect following the incident. LVN A said she had no concerns with any other residents showing signs of sexual abuse. During an interview on 10/13/2023 at 9:27 a.m., CNA A said the administrator was the abuse coordinator. CNA A said she was coming out of hall on 10/08/2023 around 3:45 p.m. to do her rounds and Resident #2 was in Resident #1's room with his hand in her brief and she told him to stop and yelled for two aides to assist. CNA A said Resident #1 was crying and Resident #2 backed his wheelchair in the other room and started washing his hands. CNA A said Resident #2 did not say what he was doing and that she suspected sexual abuse. CNA said the nurse called and notified someone to let them know it happened and did a skin assessment. CNA A said the brief was open and appeared it had been messed with. CNA A said Resident #1 was doing fine now at baseline and does not remember what happened. CNA A said the nurse called the responsible party and let him know what happened and the police came the same day. Resident #2 had no behavior prior to this and had no behavior and did not know if this had happened before. CNA A said interventions were put in place to protect residents from further abuse by placing Resident #2 on one-to-one monitoring, moving Resident #2 to a behavioral hospital, and in-services were conducted on sexual abuse. CNA A said it was important to protect residents from any kind of sexual abuse because she would not want that to happen to her family and that the facility was their home and wanted to protect them from abuse, make sure nothing would happen to them, and prevent any physical or emotional harm. CNA A said she believed the facility residents were safe with Resident #2 out of the facility. CNA A said she also took care of Resident #3 on 10/13/2023 and that he appeared to be in no distress and usually gets along with other residents. CNA A said she was not here during his altercation with Resident #4, but [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 2 residents reviewed for accidents. (Resident #1) Resident #1 sustained burns on the left and right shoulder due to the heat level of the hot pack used in the therapy department for treatment. The facility did not prevent burns to Resident #1. Prior to the beginning of the survey, the facility recognized and corrected this failure. The incident occured on 5/26/15 and the facility corrected the failure on 5/27/15. This failure could place 2 residents who use hot packs at risk for burns. Findings included: The most recent MDS dated [DATE] indicated Resident #1 admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was capable of making his needs understood. The MDS indicated Resident #1 was receiving four days of physical therapy. A physician order [REDACTED].#1 required evaluation and treatment of [REDACTED]. A physical Therapist Progress and Discharge summary dated 06/04/15 indicated Resident #1 required physical therapy to treat joint pain in his shoulder. An incident report dated 05/27/15 indicated Resident #1 acquired blisters on 05/26/15 during therapy when a hot pack was applied to his shoulder. Physician orders [REDACTED].#1 was to cleanse burns to left and right shoulder, avoid excessive force, pat dry, apply gel and cover for wound healing. A physician order [REDACTED].#1 was to continue to cleanse both shoulders and apply cream. A nursing care plan dated 08/04/15 indicated Resident #1 was at risk for infection due to an open burn to the left and right shoulder, onset date 05/26/15. The plan indicated Resident #1 required treatment to keep the dressing clean, dry, and intact to prevent drainage/bleeding and complications of healing. A wound care sheet dated 05/29/15 indicated Resident #1 had a burn to his front right shoulder, length 6.0 centimeters (cm), width 5.5 cm and depth 0.2 cm. The wound care sheet indicated he had a burn to his left front shoulder, length 5.2 cm, width 3.0 cm and depth 0.2 cm. The wound care sheet indicated the right front shoulder was a bit larger burn than the left shoulder, and the left shoulder presented with an open burn due to hot packs from the therapy department. The wound care sheet indicated Resident #1 had mild pain from the burns. During an observation and interview on 08/04/15 at 12:13 p.m., Resident #1 said he was in therapy and PTA A applied a hot pack to both sides of his shoulder. Resident #1 left and right side shoulder was covered with a dressing. He said he complained several times the hot pack was too hot before she removed it. He said PTA A responded the hot pack was supposed to be hot, and applied a towel on his shoulder. He said he could still feel the heat even with his shirt on and the padding of the towel. He said afterwards PTA A placed her arms around him and told him she was sorry. He said his shoulders were burned from the hot pack. During an interview on 08/04/15 at 11:44 a.m., Treatment nurse B said she was treating Resident #1 for a second degree burn to the shoulders he received during treatment in therapy. She said Resident #1 refused to return to therapy. She said Resident #1 reported he told the therapist a couple of times the hot pack was too hot. She said Resident #1 reported PTA A placed padding on his back and did not remove the hot pack from his shoulders. She said the next morning; Resident #1 showed his blisters to a nurse. She said when she measured Resident #1's blisters the next day, his right shoulder had a small scab with no drainage, and the size was 0.5 centimeters x 0.3 centimeters and his left shoulder was an open pink moist scab with no drainage and the size was 1.0 x 0.3 x 0.1 centimeters. She said the injury to his shoulders may have been avoided if the hot pack was removed sooner. A wound care sheet dated 08/04/15 indicated Resident #1 had a burn to his right and left shoulders. The document indicated the shoulder burns were pink and moist with moderate drainage and redness to the skin. The wound sheet indicated Resident #1 had mild pain. During an interview on 08/04/15 at 12:38 p.m., LVN C said Resident #1 reported he was burned on his shoulders. She said she checked Resident #1 ' s skin and he had a bubbled water blister on his right and left shoulder. She said Resident #1 reported he was in therapy and he complained several times to the therapist the hot pack was too hot. She said he reported the therapist did not remove the hot pack when he first complained they were too hot on his shoulders. She said the doctor came into the facility and evaluated and treated the blisters. She said Resident #1 still received wound care treatment. During an interview on 08/04/15 at 2:48 p.m., PTA A said Resident #1 complained of pain during therapy and she asked him if he wanted to use the hot pack treatment to relieve his pain. She said she applied the hot pack to Resident #1's shoulder. She said Resident #1 complained to her twice before she removed the hot pack. She said when Resident #1 complained the first time; she checked his skin for discoloration. She said there was no change in his skin coloration. She said she padded his shoulder with 8 layers of cloth. She said the second time he complained she removed the hot pack. She said when he complained the first time; she should have removed the hot pack. She said she probably should not have used the hot packs due to his age. She said the same day she saw him in the hallway and saw the blisters. She said she was trained on 5/27/14 regarding the proper use of the hot pack and resident monitoring. During an interview on 08/04/15 at 1:04 p.m., the ADON said Resident #1 did not complain about the blisters on his shoulders until the next day. She said the nurse practitioner assessed him within a few days. She said treatment was started the same day of Resident #1's complaint. During an interview on 08/04/15 at 1:56 p.m. the administrator said Resident #1 was burned in therapy from use of hot pack treatment. She said training on the hot pack temperature modalities, cold and hot pack treatment and policy was conducted in the physical therapy department on 5/27/15. She said she did a three day follow up with the therapy department and checked temperatures of the equipment, and there were no problems. She said PTA A was trained on abuse and neglect. The hot packs policy/procedure dated 08/17/14 indicated hot packs can cause burns and therefore, only trained and certified staff may apply them. The policy included to check the patient ' s skin and sensation at the treatment site. The policy indicated to provide adequate supervision by visually and verbally assessing the patient's skin every 5 minutes, ask the patients for their level of comfort and if the patient complains of being too hot, add more insulating layers to the skin. During an interview on 08/04/15 at 2:48 p.m., PTA A said 2 residents used a hot pack during therapy.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent elopement for 3 of 18 residents reviewed for accident supervision. (Resident #s 88, 61, and 16) The facility failed to provide supervision to prevent a resident from being attacked by an aggressive resident for 1 of 1 resident reviewed with aggressive behaviors. (Resident #87) IMMEDIATE JEOPARDY 1. The facility failed to supervise Resident #88 who had a history of [REDACTED]. The facility failed to supervise Resident #88 or ensure the Wander Guard system was functioning. Resident #88 eloped from the facility and was found at a local cleaners on a high-traffic street approximately 1 mile from the facility. The facility was not aware Resident #88 was missing until called by an anonymous person. 2. The facility failed to ensure Resident #61 wore a functioning Wander Guard bracelet. The facility did not check the functioning of the bracelet. The bracelet was stamped with an expiration date of ,[DATE]. 3. The facility failed ensure all staff were aware when LVN F placed a Wander Guard on Resident #16 when he was wandering in his wheelchair. LVN F did not report to other staff that Resident #16 needed increased monitoring or placement of a Wander Guard on the resident. NON-IMMEDIATE JEOPARDY 4. The facility failed to monitor aggressive behaviors exhibited by Resident #87. Resident #87 punched Resident #14 in the face causing him to fall from his wheelchair. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems and Resident #87's accessibility to all the residents in the facility. This failure could place the census of 86 residents at risk for injury or death. Findings included: IMMEDIATE JEOPARDY 1. Physician orders [REDACTED]. A comprehensive admission assessment dated [DATE] indicated Resident #88 had no history of elopement risk. The most recent MDS assessment dated [DATE] indicated Resident #88 had impaired cognition. The MDS did not indicate there were wandering behaviors. A care plan for Resident #88 updated [DATE] indicated he was at risk for elopement. "Apply a Wander Guard and check function and placement every shift. Communicate to all staff resident was a wander risk." During a phone interview on [DATE] at 3:30 p.m., LVN Q said she worked as a charge nurse on [DATE]. She said Resident #88 was wandering off the unit downstairs and off the property. She said it was on the weekend and she did not have access to a new Wander Guard bracelet, so she got an old one that was in the nursing desk drawer and put it on Resident #88. She said she did check it to see if it worked and did not check the expiration date. She said she did not document putting the Wander Guard on in the nursing notes or the 24 hour report, but she told the night nurse when she came on shift. A Wandering and Elopement Risk assessment dated [DATE] indicated Resident #88 was at risk for wandering and elopement. The intervention was to utilize the wander detection system and care plan for elopement risk. A telephone order dated [DATE] was for Resident #88 to have on a Wander Guard at all times and check every shift for exit seeking behaviors. A nursing note dated [DATE] at 4:45 a.m. indicated Resident #88 was wandering up and down the halls and from unit 2 to unit 3, both located on the second floor. He had episodes of cursing at staff and refusing to return to unit 2. He said, "This place is run like a prison and I have been there and am not going back." There was no nursing note for [DATE] to reflect the events as described by LVN Q in the interview above. The 24 hour report dated [DATE] indicated for Resident #88 to continue the Wander Guard device. An incident accident investigation report dated [DATE] indicated Resident #88 left the facility unknown to staff. The report indicated he was discovered at a local cleaners about 4 blocks from the facility by an anonymous person. The anonymous person, who knew Resident #88 from another nursing home, called the facility at 11:14 a.m. and informed them of where the resident was. During an observation on [DATE] at 9:30 a.m., mileage was checked on the street from the facility to the local cleaners where Resident #88 was found. The distance was 0.9 miles. The street was a high-traffic, four-lane street which included a fifth lane for turning. A nursing note dated [DATE] at 1:08 p.m. indicated at 9:30 a.m., Resident #88 was sitting in his room smiling and making no indication of leaving. A nursing note dated [DATE] at 1:32 p.m. indicated the facility was called at approximately 11:15 a.m. by a caller asking if they were missing a resident and informing them Resident #88 was at local cleaners down the street from the facility. A nursing note dated [DATE] at 6:10 p.m. indicated Resident #88 was discharged to another facility with a locked unit. The DADS investigation report dated [DATE] indicated the administrator was informed of the elopement. The family and police were notified by the administrator. The DON and activity director went to get Resident #88 and returned him to the facility. The administrator noted the Wander Guard device on Resident #88 was on his ankle. She removed it from the ankle and placed it on his wrist. She believed this was why it did not work. On [DATE], (name omitted--Resident #63) who wore a Wander Guard on her ankle was checked for function, and it did not work. All staff were informed to place Wander Guards on residents' wrists. The undated Wander Guard instruction booklet noted, "Adjust the band so that the transmitter is in a comfortable position the resident's wrist or ankle." The booklet also indicated transmitters (the bracelet) were only good for a year and would expire the last day of the month stamped on the Wander Guard transmitter. It noted to discard immediately if expired. During an observation on [DATE] at 10:05 a.m., no doors on the first floor leading to the outside had Wander Guard detectors. During an interview on [DATE] at 12:30 p.m., LVN G said the elevator on the second floor had a detector that would lock the elevator if Wander Guard bracelet was detected, but there were no Wander Guard detectors on the doors to the outside downstairs. During an interview on [DATE] at 12:50 p.m,. LVN G said they depend on the Wander Guard alarms to alert them of residents elopement attempts, but they also tried to watch them. During an interview on [DATE] at 6:30 p.m., the activity director said on [DATE] at 9:00 a.m., she went to a meeting and got out about 10:00 a.m. At 10:30 a.m., she saw Resident #88 downstairs in the dining room. She did not know he had a Wander Guard on or she would have said something. During an interview on [DATE] at 10:50 a.m., the DON said she believed the reason Resident #88 got out of the facility was because the Wander Guard system did not work. They called the Wander Guard service people out to adjust the sensor at the elevators because another residents' alarms did not function when checked on [DATE]. 2. Physician orders [REDACTED]. She had an order for [REDACTED]. A care plan updated [DATE] indicated Resident #61 had behavior problems evidenced by unsafe wandering to potential dangerous places such as stairs and outside. During an observation on [DATE] at 11:00 a.m., Resident #61 was walking on A hall on unit 3. During an observation on [DATE] at 12:30 p.m., Resident #61's Wander Guard bracelet was tested . Resident #61 walked to the elevator doors and the alarm did not sound. Resident #61 was taken away from the elevator doors and brought back and second time. The alarm still did not sound. During an observation on [DATE] at 12:34 p.m,. the Wander Guard bracelet for Resident #61 was stamped with an expiration date of ,[DATE]. During an interview on [DATE] at 1:00 p.m., LVN B said Resident #61's Wander Guard came off and she replaced it with one she found in a drawer. It was not a new one and she said she did not check the expiration date. 3. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #16 had a cognition score of 14 meaning alert and oriented. He needed some assistance with activities of daily living but was independent in transfer, toileting, personal hygiene, had full range of motion and used a walker and wheelchair for mobility. He was not documented to have any behaviors. During an observation on [DATE] at 12:58 p.m., Resident #16 had a Wander Guard bracelet on his wheelchair. Resident #16 was not on the list of residents who had Wander Guards. During an interview on [DATE] at 1:00 p.m., LVN G said she was not aware Resident #16 had a Wander Guard. During an interview on [DATE] at 2:00 p.m., LVN F said he put the Wander Guard on Resident #16 on [DATE] because the resident was confused and wandering the hall. He said he called the physician and got an order, but forgot to write it. He said he did not put it on the medication administration record or tell anyone about it. He said he was aware he should have. During an interview on [DATE] at 3:45 p.m., the DON said she was the one that wanted a Wander Guard placed on Resident #16 because the resident was confused and also because of what happened to Resident #88. She said Resident #16 did not really need one. The administrator and DON were notified on [DATE] at 5:00 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:02 p.m. and included: "Wanderguard (sic) system 1. Resident (name deleted--#88) was discharged to locked unit at (name deleted - local nursing home) and will not be accepted back at this facility. 2. 12 residents had the potential to be affected by this alleged deficiency. 3. When assessment warrants a wanderguard (sic), MD/FNP (medical doctor/family nurse practitioner) will be notified of findings and order obtained. 4. Don (sic) will be notified immediately of assessment findings and order. 5. Charge nurse completing assessment will write out a 'resident specific' inservice for new wanderguard (sic) resident. This resident specific inservice will be given to oncoming shifts and other units to ensure all direct care staff is aware of new assessment findings. 6. Inservice will be taken to standup meeting so all ancillary departments are aware of new wanderguard (sic) order. 7. A running list of all active residents requiring wanderguards (sic) will be written on 24 hour report and discussed at shift change. 8. Charge nurse will check expiration date of wanderguard (sic) and document each shift on TAR (treatment administration record). 9. Charge nurse will monitor all wanderguard (sic) residents every hour and document residents' location and initial form. This form will be kept with residents' TAR. 10. A list of wanderguard (sic) residents are to be kept at each unit and therapy. 11. Charge nurse will check doors each shift and document on log. 12. Staff to be inserviced on discarding expired wanderguard (sic) unit. 13. Administrator or designee will monitor daily for one week, two times a week for three weeks, then once a week for three weeks then monthly. 14. Any failure to this plan will be referred to the QA (quality assurance) committee. 15. Will update care plans on all wanderguards (sic). The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Six nurses were interviewed and said when a Wander Guard was initiated, all staff would be notified on that shift. An in-service training would occur at the end of shift to notify the oncoming shift and so on. To get a Wander Guard, they would first get an order, then write the order. They would update the medication administration records to reflect checking every shift, including checking the expiration dates of the transmitter. The in-services would occur on all units 1,2, and 3. The 24 hour report would reflect the information and the DON and administrator would be notified. They would get the new Wander Guards from central supply. A list of all residents who wandered would be kept at each nursing station. The residents who wandered would be placed on an hourly check and documented on the treatment administration record. They all said they had been in-serviced on these procedures. Three CNAs, 2 MAs, and 1 activity director said they were in-serviced on what to do in the event a resident had a Wander Guard. The list would be kept at the nursing station. All staff were to be notified of a resident who got a Wander Guard. The Wander Guards were to be checked every shift, including the expiration date, and do not use if expired. They were to do hourly checks on residents who wandered. On [DATE] at 10:50 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. NON-IMMEDIATE JEOPARDY 4. Physician orders [REDACTED]. A correctional managed care outpatient mental health services form dated [DATE] noted a target problem of difficulty interacting with others. Nursing notes dated [DATE] at 2:01 p.m. noted, "Resident (#87) arrived to facility at approximately 1:30 p.m. Resident pleasant at first but then became upset and cussing. Resident threatening staff." Nursing notes dated [DATE] at 9:16 p.m. noted, "Late entry: 2:30 p.m. Resident (#87) aggressive towards nursing home staff and other residents. Also made verbal threats to his roommate (Resident #14) saying, 'I am going to beat him up with my cane.' To prevent further occurrences, cane was taken away from the resident and a walker was provided. Resident overly agitated, cussing at other residents, and was about to fight the nursing home administrator for taking his cane away from him. (Local) police department was called." An incident report dated [DATE] noted Resident #87 was physically abusive to Resident #14. CNA H heard a noise from the residents' room and entered the room to find Resident #14 on the floor with Resident #87 standing over him hitting him. An assessment of Resident #14 noted a 3.5 cm by 3.5 cm redness to the left temporal side of his head. The resident was taken to the emergency room for evaluation. There were no other injuries. During an interview on [DATE] at 10:38 a.m., the administrator said Resident #87 was an admission directly from Texas Department of Corrections. During an interview on [DATE] at 10:55 a.m., LVN G said on [DATE], Resident #87 was admitted , placed in a room with Resident #14, and "words were exchanged." The administrator witnessed the altercation and aggressive behavior towards staff and his new roommate. Resident #14 was moved to another room for a couple of days. LVN G was not sure why the Resident #14 was moved back into the room with Resident #87. During an interview on [DATE] at 3:45 p.m., the social worker said she had heard about the incident that occurred on [DATE] later in the week, but had no involvement. She said if her involvement was requested, she would have made sure Resident #14 was safe, but she knew Resident #14 was moved to a different room. She thought Resident #14 was moved back in with Resident #87 on Monday, [DATE]. It was announced in the morning meeting that Resident #14 would be moved back in with Resident #87and there was no discussion. She stated, "It would not be normal to move a resident back in with the aggressor after a threat was made." During an interview on [DATE] at 1:50 p.m., CNA J said on [DATE], she heard a co-worker hollering for help and went into Resident #s14 and 87's room. Resident #14 was in the floor on his right side and Resident #87 had hit him in the head. Resident #87 yelled at her to "get her m---f--- a-- out of the room." CNA J helped Resident #14 back into his wheelchair and she left the room because the nurse was there. During an interview on [DATE] at 2:10 p.m., LVN K said on [DATE], she heard a CNA call for help from Resident #s 14 and 87's room. She entered the room and Resident #14 was lying on the floor and Resident #87 was on the bed "cussing everyone" saying he was "gonna whoop your a--." Resident #14 said Resident #87 hit him and Resident #14 was moved out of the room. During an interview on [DATE] at 10:30 a.m., Resident #14 said his roommate (Resident #87) hit him. When he came out of the bathroom, he asked Resident #87 to turn off the TV so he could rest and Resident #87 started hitting him in the head. After the altercation, he said the facility removed his roommate and he had not seen him since. During an interview on [DATE] at 4:10 p.m., the administrator said following the incident on [DATE], Resident #87 was sent to a psychiatric hospital and would not be accepted back to the facility. She further said the incident on [DATE] could have been prevented if the Resident #14 had not been placed back in the room with Resident #87. During an interview on [DATE] at 10:05 a.m. the DON said she would not have accepted Resident #87 into the facility. A list provided by the facility on [DATE] indicated there were 11 residents with Wander Guards. The CMS 672 dated [DATE] indicated a census was 86.

Based on observation, interview and record review, the facility failed to have a written plan for evacuation of 1 of 2 sampled bariatric residents (Resident #54) and for 13 of 13 residents who were dependent on staff for transferring who resided on the second floor of the facility. (Resident #s 93, 2, 41, 22, 32, 38, 54, 63, 67, 78, 52, 70, and 72) The facility did not have a written plan for evacuating bariatric (obese residents who require oversize equipment) or dependent residents. The facility is a three story building with residents who cannot transfer themselves located on the second floor. Staff said they would place the bariatric and dependent residents on mattresses to move them down the stairwell. The facility's policy did not mention the use of mattresses in moving the residents. In January 2012 a tornado hit a neighboring town. The facility was under a tornado alert. Resident #54 could not be removed from her room. Staff moved the resident away from the window and placed blankets and pillows over her because the bed would not fit through the doorway. This failure created an Immediate Jeopardy situation identified on 1/31/12. While the Immediate Jeopardy was removed on 2/1/12, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents who were dependent on staff on the upper levels of the facility (units 2 and 3) at risk for injuries or death in the event of an emergency. Findings included: Resident #54's January 2012 physician orders [REDACTED]. Resident #54 was observed on 1/31/12 at 7:35 p.m. lying in a bariatric bed. The annual MDS dated [DATE] indicated Resident #54's weight was 253 pounds. She was dependent on staff for all activities of daily living. She was unable to transfer or ambulate. Her MDS indicated she was alert and oriented. The facility's disaster plan dated 02/19/09 did not address emergency evacuation procedures for totally dependent or bariatric residents who were housed on the second floor nursing unit. The facility's disaster plan listed the following terms in reference to moving residents in the event of an emergency: wing carry, extremity carry, three person carry and cradle drop. There was no description or procedure how theses types of transfers would be performed. The facility disaster plan indicated in the event of an emergency, power to the elevator located on the second floor would be turned off automatically. Observation of a sign posted by elevator door instructions read "IN THE EVENT OF A FIRE DO NOT USE ELEVATOR, USE STAIRS". In an interview on 1/31/12 at 9:25 a.m., RN B said in the event of an emergency in which Resident #54 would have to be moved downstairs she would be moved on her mattress and dragged down the stairs. RN B was not able to verbalize the meaning of terms used in the facility disaster plan as appropriate measures for resident transfer, (Wing carry, pack strap carry, hip carry, and cradle drop). RN B denied knowledge of these terms being in the facility disaster plan. The use of the mattress to move the resident down the stairs was not covered in the disaster plan. In an interview on 1/31/12 9:35 a.m., CNA H said she would place dependent or obese residents on a mattress and drag them downstairs to safety using the stairs. She was unaware of the terms used in the facility disaster plan for forms of transfer. In an interview on 1/31/12 at 9:40 a.m., CNA G said she did not know what wing carry, pack strap carry, hip carry or cradle drop pertained to. She said that in the event of an emergency bedbound residents would be moved on the mattress and dragged downstairs via the stairwell. In an interview on 1/31/12 at 9:45 a.m. LVN K said she would transfer bedbound or obese residents using a mattress from their beds and she would drag them down the stairs. She was unaware of the meaning of the transfer terms as listed in the facility disaster manual plan. In an interview on 1/31/12 at 10:15 a.m., MA J said he did not have any knowledge of the meanings of the terms for resident transfer as currently listed as methods for transfer of residents during an emergency situation. He said he would slide her and her mattress onto the floor and drag the resident out of her room and down the stairs. In an interview on 1/31/12 at 10:40 a.m., assistant MDS coordinator R said she was not aware of what the terms as described in the disaster manual meant. She said they would to use the mattress to get those kind (referring to bedbound/obese residents) out from the second floor. In an interview on 1/31/12 at 11:08 a.m., the administrator said that in the event of an emergency, staff members would remove Resident #54 on her mattress using the stairwell located at the end of the hall on unit two. She said the mattress on Resident #54's bed had handles that would be used to assist in the transfer. In an interview on 1/31/12 at 11:40 a.m., CNA Q said she did not know the meanings of the terms listed in the facility disaster manual for modes of transfer during an emergency. She said the way she would remove a bedbound or obese resident from the second floor would be to use their mattress and drag them downstairs. In an interview on 1/31/12 at 2:20 p.m., LVN L said she would drag bedbound or obese residents down the stairs on their mattress in the event of a fire or other emergency. She said she had never heard the terms for transfer as described in the facility disaster manual. In an interview on 1/31/12 at 2:30 p.m., CNA P said last week when the facility had to move residents out of their rooms into the hallway due to a tornado in a nearby town, the staff did not move Resident #54 out of her room. CNA P said Resident #54's bed would not fit through the doorway. Resident #54 was moved away from her side of the room, (which is located by a window), and placed closer to the exit door of the room. CNA P said staff members covered Resident #54 with blankets and pillows and pulled the privacy curtain to act as a barrier to shield resident from possible injury. CNA P said she would transfer obese or bedbound residents by dragging them on a mattress down the stairs at the end of the hall. In an interview on 1/31/12 at 2:35 p.m., CNA O said the staff were unable to remove Resident #54 out of her room last week when a tornado hit in a nearby town. CNA O said Resident #54's roommate's bed was removed from the room and Resident #54 was placed close to the door, covered with pillows and blankets for protection. CNA O said the privacy curtain was pulled. CNA O said she would transfer bedbound or obese residents by dragging them on a mattress down the stairs. During an observation on 1/31/12 at 9:15 a.m., Resident #54's door measured 45.5 inches in width. Resident #54's mattress and her bed frame measured 49.5 inches in width. The door frame would not accommodate the removal of her bed from the room. Inspection of the stairwell on the facility indicated that Resident #54's mattress would be wider than the dimensions of the doorframe, and therefore would not accommodate her removal using the mattress on her bed. The stairwell door width measured 44.0 inches, stair rails measured 44.5 inches apart. The stairwell door exit to the outside corridor on the first floor measured 43.0 inches in width. There were no straps on Resident #54's mattress as previously indicated by the administrator to assist with transfer of the mattress from the room. In an interview on 1/31/12 at 2:45 p.m., RN T said he was not aware of the terms listed in the disaster manual for forms of ways to transfer residents until today . He said he was in-serviced on the meaning of these terms prior to starting his evening shift today. He said in an emergency he would remove the residents who were bedbound or obese or unable to transfer themselves on a mattress down the stairs. During an interview on 1/31/12 at 5:10 p.m., Resident #54 said during a storm last week the staff pushed her bed against the wall and pulled the privacy curtain. She went on to say the staff covered her with pillows and a blanket. The staff told her the bed would not fit out the door. On 1/31/12 at 1:05 P.M., the survey team determined the failure to ensure a safe environment related to emergency evacuation and procedures constituted an Immediate Jeopardy. The administrator and DON were notified on 1/31/12 at 1:10 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted and included the following: "1. (A) All staff will be in-serviced by Administrator and Environmental Services on Emergency management Plan to include bedfast, wheelchair and Bariatric residents. With a demonstration interactive training to every employee. This will be conducted by 1/31/12. All new staff will be in-serviced on disaster plan on hire. (B) All bariatric residents will be housed on the first floor to ensure safe evacuation. This will be completed by 1/31/12. 2. 67 residents have the potential to be affected by this alleged deficient practice. 3. All residents will be evacuated in this order: (a) Those in immediate danger (b) Ambulatory (c) wheel chair, Bedfast, Bariatric will be moved with blankets as described in the disaster plan as necessary. IE: Four person carry: Resident lowered to the floor on two blankets, one rescuer at each side of the resident's shoulder and knees. Head rescuer grip blanket above the knees. All rescuers roll blanket tightly to resident. Lift and carry resident with arm extended to safety. Code for bariatric will be "need lift assist in room #", This means after all other residents are evacuated, those that need more than 2 person lift will be requested to come to the room that is being requested to assist in evacuation. Staff is instructed to assist other floors as needed once their floor is completely evacuated. Each unit will have enough staff to evacuate all that require 2 person transfer or less. All staff on unit 2 and 3 will have all residents out and then will come to assist unit 1. 911 are immediately notified when the fire alarms go off and will assist as they can to help with evacuation. 4. This plan will be monitored by the Administrator or designee monthly for the next 3 months and then yearly with updated in-services, any failure of this system will be brought to Quality Assurance meeting." The surveyors confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ by: Eight CNAs were interviewed and said they understood and were able to verbalize to surveyors how to transfer a resident during an emergency Staff members were given a demonstration on how to carry out transfer this procedure. All were aware of the meaning of terms used in the disaster plan for evacuation. Three nurses were interviewed and said they were in-serviced on the disaster plan and how to evacuate dependent residents. They were aware of the modes of transfer listed in the disaster plan. All staff had been shown a demonstration on transfers of dependent residents using blankets. The new policy for Emergency Removal of Residents was reviewed and contained the requirements for evacuation. Care plans on bariatric and dependant residents were updated. Through interviews and observation, the survey team determined the facility implemented its plan of removal sufficiently to remove the immediate jeopardy. The facility in-serviced staff on emergency procedures, terms used for transfer in the disaster manual and performed a demonstration on how to transfer obese residents whose mattress will not fit through the bedroom door. On 2/1/12 at 3:00 p.m,. the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm because of the facility's need to monitor and evaluate whether the systems put in place were effective. A list provided by the facility on 2/15/12 indicated there were 13 residents who resided on the second floor that were dependent on staff for transfers.

Based on observation, interview and record review, the facility failed to ensure 12 of 12 employees interviewed for disaster preparedness (RNs B and T, CNAs H, G, Q, P and O, LVNs K and L, MA J, Assistant MDS coordinator R, and administrator) were trained on emergency preparedness and evacuation procedures for 1 of 2 sampled bariatric residents (Resident #54) and for 13 of 13 residents who were dependent on staff for transferring who resided on the second floor of the facility. (Resident #s 93, 2, 41, 22, 32, 38, 54, 63, 67, 78, 52, 70, and 72) Twelve staff (RNs B and T, CNAs H, G, Q, P and O, LVNs K and L, MA J, Assistant MDS coordinator R, and administrator) said they would place the bariatric and dependent residents on mattresses to move them down the stairwell. The facility's policy did not mention the use of mattresses in moving the residents. Eleven of the 12 staff said the facility had not trained them regarding evacuation procedures. In January 2012 a tornado hit a neighboring town. The facility was under a tornado alert. Resident #54 could not be removed from her room. Staff moved the resident away from the window and placed blankets and pillows over her because the bed would not fit through the doorway. This failure created an Immediate Jeopardy situation identified on 1/31/12. While the Immediate Jeopardy was removed on 2/1/12, the facility remained out of compliance at a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents who were dependent on staff on the upper levels of the facility (units 2 and 3) at risk for injuries or death in the event of an emergency. Findings included: Resident #54's January 2012 physician orders [REDACTED]. Resident #54 was observed on 1/31/12 at 7:35 p.m. lying in a bariatric bed. The annual MDS dated [DATE] indicated Resident #54's weight was 253 pounds. She was dependent on staff for all activities of daily living. She was unable to transfer or ambulate. Her MDS indicated she was alert and oriented. The facility's disaster plan dated 02/19/09 did not address emergency evacuation procedures for totally dependent or bariatric residents who were housed on the second floor nursing unit. The facility's disaster plan listed the following terms in reference to moving residents in the event of an emergency: wing carry, extremity carry, three person carry and cradle drop. There was no description or procedure how theses types of transfers would be performed. The facility disaster plan indicated in the event of an emergency, power to the elevator located on the second floor would be turned off automatically. Observation of a sign posted by elevator door instructions read "IN THE EVENT OF A FIRE DO NOT USE ELEVATOR, USE STAIRS". In an interview on 1/31/12 at 9:25 a.m., RN B said in the event of an emergency in which Resident #54 would have to be moved downstairs she would be moved on her mattress and dragged down the stairs. RN B was not able to verbalize the meaning of terms used in the facility disaster plan as appropriate measures for resident transfer, (Wing carry, pack strap carry, hip carry, and cradle drop). RN B denied knowledge of these terms being in the facility disaster plan. The use of the mattress to move the resident down the stairs was not covered in the disaster plan. RN B said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 9:35 a.m., CNA H said she would place dependent or obese residents on a mattress and drag them downstairs to safety using the stairs. She was unaware of the terms used in the facility disaster plan for forms of transfer. CNA H said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 9:40 a.m., CNA G said she did not know what wing carry, pack strap carry, hip carry or cradle drop pertained to. She said that in the event of an emergency bedbound residents would be moved on the mattress and dragged downstairs via the stairwell. CNA G said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 9:45 a.m. LVN K said she would transfer bedbound or obese residents using a mattress from their beds and she would drag them down the stairs. She was unaware of the meaning of the transfer terms as listed in the facility disaster manual plan. LVN K said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 10:15 a.m., MA J said he did not have any knowledge of the meanings of the terms for resident transfer as currently listed as methods for transfer of residents during an emergency situation. He said he would slide her and her mattress onto the floor and drag the resident out of her room and down the stairs. MA J said the facility had not trained him regarding emergency procedures. In an interview on 1/31/12 at 10:40 a.m., assistant MDS coordinator R said she was not aware of what the terms as described in the disaster manual meant. She said they would to use the mattress to get those kind (referring to bedbound/obese residents) out from the second floor. MDS coordinator R said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 11:08 a.m., the administrator said that in the event of an emergency, staff members would remove Resident #54 on her mattress using the stairwell located at the end of the hall on unit two. She said the mattress on Resident #54's bed had handles that would be used to assist in the transfer. In an interview on 1/31/12 at 11:40 a.m., CNA Q said she did not know the meanings of the terms listed in the facility disaster manual for modes of transfer during an emergency. She said the way she would remove a bedbound or obese resident from the second floor would be to use their mattress and drag them downstairs. CNA Q said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 2:20 p.m., LVN L said she would drag bedbound or obese residents down the stairs on their mattress in the event of a fire or other emergency. She said she had never heard the terms for transfer as described in the facility disaster manual. LVN L said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 2:30 p.m., CNA P said last week when the facility had to move residents out of their rooms into the hallway due to a tornado in a nearby town, the staff did not move Resident #54 out of her room. CNA P said Resident #54's bed would not fit through the doorway. Resident #54 was moved away from her side of the room, (which is located by a window), and placed closer to the exit door of the room. CNA P said staff members covered Resident #54 with blankets and pillows and pulled the privacy curtain to act as a barrier to shield resident from possible injury. CNA P said she would transfer obese or bedbound residents by dragging them on a mattress down the stairs at the end of the hall. CNA P said the facility had not trained her regarding emergency procedures. In an interview on 1/31/12 at 2:35 p.m., CNA O said the staff were unable to remove Resident #54 out of her room last week when a tornado hit in a nearby town. CNA O said Resident #54's roommate's bed was removed from the room and Resident #54 was placed close to the door, covered with pillows and blankets for protection. CNA O said the privacy curtain was pulled. CNA O said she would transfer bedbound or obese residents by dragging them on a mattress down the stairs. CNA O said the facility had not trained her regarding emergency procedures. During an observation on 1/31/12 at 9:15 a.m., Resident #54's door measured 45.5 inches in width. Resident #54's mattress and her bed frame measured 49.5 inches in width. The door frame would not accommodate the removal of her bed from the room. Inspection of the stairwell on the facility indicated that Resident #54's mattress would be wider than the dimensions of the doorframe, and therefore would not accommodate her removal using the mattress on her bed. The stairwell door width measured 44.0 inches, stair rails measured 44.5 inches apart. The stairwell door exit to the outside corridor on the first floor measured 43.0 inches in width. There were no straps on Resident #54's mattress as previously indicated by the administrator to assist with transfer of the mattress from the room. In an interview on 1/31/12 at 2:45 p.m., RN T said he was not aware of the terms listed in the disaster manual for forms of ways to transfer residents until today . He said he was in-serviced on the meaning of these terms prior to starting his evening shift today. He said in an emergency he would remove the residents who were bedbound or obese or unable to transfer themselves on a mattress down the stairs. RN T said the facility had not trained him regarding emergency procedures. During an interview on 1/31/12 at 5:10 p.m., Resident #54 said during a storm last week the staff pushed her bed against the wall and pulled the privacy curtain. She went on to say the staff covered her with pillows and a blanket. The staff told her the bed would not fit out the door. On 1/31/12 at 1:05 P.M., the survey team determined the failure to ensure a safe environment related to emergency evacuation and procedures constituted an Immediate Jeopardy. The administrator and DON were notified on 1/31/12 at 1:10 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted and included the following: "1. (A) All staff will be in-serviced by Administrator and Environmental Services on Emergency management Plan to include bedfast, wheelchair and Bariatric residents. With a demonstration interactive training to every employee. This will be conducted by 1/31/12. All new staff will be in-serviced on disaster plan on hire. (B) All bariatric residents will be housed on the first floor to ensure safe evacuation. This will be completed by 1/31/12. 2. 67 residents have the potential to be affected by this alleged deficient practice. 3. All residents will be evacuated in this order: (a) Those in immediate danger (b) Ambulatory (c) wheel chair, Bedfast, Bariatric will be moved with blankets as described in the disaster plan as necessary. IE: Four person carry: Resident lowered to the floor on two blankets, one rescuer at each side of the resident's shoulder and knees. Head rescuer grip blanket above the knees. All rescuers roll blanket tightly to resident. Lift and carry resident with arm extended to safety. Code for bariatric will be "need lift assist in room #", This means after all other residents are evacuated, those that need more than 2 person lift will be requested to come to the room that is being requested to assist in evacuation. Staff is instructed to assist other floors as needed once their floor is completely evacuated. Each unit will have enough staff to evacuate all that require 2 person transfer or less. All staff on unit 2 and 3 will have all residents out and then will come to assist unit 1. 911 are immediately notified when the fire alarms go off and will assist as they can to help with evacuation. 4. This plan will be monitored by the Administrator or designee monthly for the next 3 months and then yearly with updated in-services, any failure of this system will be brought to Quality Assurance meeting." The surveyors confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ by: Eight CNAs were interviewed and said they understood and were able to verbalize to surveyors how to transfer a resident during an emergency Staff members were given a demonstration on how to carry out transfer this procedure. All were aware of the meaning of terms used in the disaster plan for evacuation. Three nurses were interviewed and said they were in-serviced on the disaster plan and how to evacuate dependent residents. They were aware of the modes of transfer listed in the disaster plan. All staff had been shown a demonstration on transfers of dependent residents using blankets. The new policy for Emergency Removal of Residents was reviewed and contained the requirements for evacuation. Care plans on bariatric and dependant residents were updated. Through interviews and observation, the survey team determined the facility implemented its plan of removal sufficiently to remove the immediate jeopardy. The facility in-serviced staff on emergency procedures, terms used for transfer in the disaster manual and performed a demonstration on how to transfer obese residents whose mattress will not fit through the bedroom door. On 2/1/12 at 3:00 p.m,. the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm because of the facility's need to monitor and evaluate whether the systems put in place were effective. A list provided by the facility on 2/15/12 indicated there were 13 residents who resided on the second floor that were dependent on staff for transfers.