Every finding on record at Peach Tree Place

Based on interviews and record review, the facility failed to ensure the use of a registered nurse for at least 8 consecutive hours a day, seven days a week for 6 of the last 12 months (October 2025, December 2025, January 2026, February 2026, May 2026, and July 2026) reviewed for Registered Nurse staffing. The facility failed to provide Registered nurse coverage for 8 hours on 10/22/2025, 12/27/2025, 12/28/2025, 1/4/2026, 2/8/2026, 2/22/2026, 2/28/2026, 5/16/2026, 7/6/2026 and 7/10/2026. These failures placed all residents at risk for delayed nursing assessments, changes in conditions not being promptly identified, and inadequate clinical oversight.Findings included: In a record review completed on 7/15/2026 of the facility's nursing schedule for Registered Nurse coverage, from 7/1/2025 through 7/12/2026 there were 10 days the facility did not provide 8 consecutive Registered Nurse hours on 10/22/2025, 12/27/2025, 12/28/2025, 1/4/2026, 2/8/2026, 2/22/2026, 2/28/2026, 5/16/2026, 7/6/2026 and 7/10/2026. In an interview on 7/16/2026 at 2:40pm with RCN (Regional Compliance Nurse) she stated her expectation was the facility had a Registered Nurse for 8 hours each day. She stated not having Registered Nurse coverage daily could increase the risk of residents' care being delayed. In an interview on 7/16/2026 at 3:00pm with ADO (Area Director of Operations), she stated her expectation was to have a Registered Nurse to work 8 hours a day, 7 days a week. She stated a negative outcome of not having the required Registered Nurse could result in an overall slower response to resident needs being met. In an interview on 07/16/2026 at 5:15PM, asked if there were any other information, evidence, or policies and procedures the facility would like to provide at which time the ADO stated no, she had no further information to provide.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 1 dining room reviewed for physical environment.The facility failed to repair an area of the ceiling in the dining room where a large section of paint had been damaged and peeled off.The facility failed to repair the attic cover in the dining room which was broken and open to the attic space.The facility failed to ensure the coax cable that was running across the ceiling in the dining room over to the TV was properly secured to the ceiling. This failure could place the residents at risk for decreased quality of life and infection due to unsanitary conditions.The findings included: During an observation on 07/14/2026 at 11:45am, the dining room had a white coax cable hanging down from the ceiling about 12 inches, to the right of the entry way, that was right above a dining table where residents were sitting. During an observation on 07/14/2026 at 11:50am, the dining room ceiling had a large section of paint that had been damaged and peeled off, to the right of the entry way above a dining table where residents were sitting, leaving bare sheetrock exposed. During an observation on 07/14/2026 at 11:52am, the dining room ceiling, in the middle of the dining room, had an attic access with cover which had a corner of the cover broken off and was open into the attic space. In an observation and interview on 07/14/2026 at 12:10pm with Resident #13, he was sitting in his wheelchair at the dining table directly below the area of the ceiling that needed paint. He was laughing with another resident at the table and pointing at the ceiling. Resident #13 stated that he sits at that table every day and the ceiling needed to be fixed. He stated he did not know what happened to it, the paint was just taken off, and did not know what happened with the attic cover or coax cable. In an interview on 07/16/2026 at 2:42pm with the MS (Maintenance Supervisor), he stated the missing paint area, and the broken attic cover was caused by an air conditioner leak that happened on a weekend. He stated he had not seen or been made aware of the coax cable that was hanging from the ceiling. The MS stated that the air conditioning unit had a clogged line and it leaked into the ceiling and that they were to repaint the area and replace the attic cover that week. He stated when State showed up other things took precedence, but he was going to take care of those issues now. The MS stated the expectation was to fix issues at the time they are reported or as soon as possible if a part or something needs ordered. He further stated there was not an actual negative outcome for the residents and that the air conditioner was never broken or not working. In an interview on 07/16/2026 at 3:40pm with the ADO (Area Director of Operations), she stated her expectation for tasks to be completed was as soon as possible. She stated the air conditioner leak happened on a weekend she believes a couple of weeks ago and that she had not noticed or been made aware of the coax cable that was hanging down. She stated her expectation was to keep a clean and safe environment for residents and a negative outcome could be placing the residents at risk for potential harm. The ADO stated she did not have a policy or procedure on maintenance issues, or homelike environments. In an interview on 07/16/2026 at 5:15pm, asked if there were any other information, evidence, or policies and procedures the facility would like to provide at which time the ADO stated no, she had no further information to provide.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service. The facility failed to store dishware in a clean, dry location and not exposed to splashes, dust, or other contamination, covered and/or inverted.The facility failed to ensure that utensils/equipment/flooring were cleaned and maintained to prevent contamination.The facility failed to ensure dinnerware were clean and in good condition (e.g., not cracked or chipped). The facility failed to follow a cleaning schedule for the kitchen and food service equipment. These failures could place residents at risk of foodborne illness.The findings include: In an observation of the 1 kitchen on 7/14/26 from approximately 11:45am to 1:00pm revealedcrumbs, dirt, and debris under the metal clean dishware shelf in addition to crumbs, dirt and debris on the floor between the shelf and the wall.crumbs accumulated on the stainless-steel steam table pans.the binder in the kitchen with labeled tabs included a sheet titled weekly cleaning schedule in which the paper was dated 4/5/26 - 4/11/26. The remainder of the pages within that tabbed section were blank. The next tab revealed a sheet titled monthly cleaning schedule 2026 and revealed that January, February and March had a single vertical line through the entire column. April, May and June columns were incomplete(blank). The remainder of the pages within that tabbed section were blank. In an observation of the 1 kitchen on 7/15/26 from approximately 4:30pm to 4:45pm revealeda soiled reuseable beverage container sitting on a tray in the clean dishware area.a stack of red plastic woven baskets placed upright revealing dust and food debris accumulated.The tray under the baskets revealed a thick residue and food particles accumulated.food debris and a thick black substance that was stuck to the floor between the two stainless steel prep tables.a chipped clear plastic cup containing milk and sitting on the stainless-steel prep table.a waste receptacle lid leaned against the clean dishware metal shelf.approximately 35 white oblong glassware bowls located on the lowest rack of the clean dishware metal shelf. They were unstacked and some were not inverted.the white oblong glassware bowls located on the lowest rack of the clean dishware metal shelf revealed thick dust, food debris and stuck on dried yellow substance resembling scrambled eggs.the tray under the white oblong glassware bowls located on the lowest rack of the clean dishware metal shelf revealed thick dust, food debris and stuck on dried yellow substance resembling scrambled eggs.In an interview on 7/14/26 at 1:16pm Dietary [NAME] A stated he had been an employee with the company for approximately 2 years. He stated that he received training for his position. He stated that he cleaned the kitchen each day. He stated hat he did not always remember to write in the binder when he cleaned. He had been educated on infection control measures. He stated that the kitchen is deep cleaned every couple of months. In an interview on 7/14/26 at 1:25pm Dietary Staff B stated he had been an employee for a few months. He stated that he would clean what he was told to, and he did not use a list when cleaning. He had been educated on infection control measures. He was unaware of when monthly cleaning was performed. In an interview on 7/15/26 at 4:48pm Dietary [NAME] C stated this (7/15/26) was her first day back in the kitchen. She stated that she had been with the facility for about 3-4 months. She primarily worked in laundry, but she was scheduled to cook on this date. She did not recall the cleaning schedule and was unaware of the monthly schedule. In an interview on 7/15/26 at 4:53pm, Dietary Staff D stated that he did not use a cleaning list and did not recall performing a monthly cleaning list. In an interview on 7/15/26 at 5:09pm with the Dietary Manager, she stated that her expectations for the kitchen staff were for them to clean every shift and between meals as necessary. She stated that after the evening meal the staff would meet and deep clean the kitchen. She stated that she reviewed the weekly and monthly cleaning list in the binder to verify that the tasks were completed. She was unaware that the dates in the binder were not up to date. She stated that she would try to locate the papers. She was unable to recall the last time they performed an evening deep clean. She stated that her expectation was that the floors would be cleaned and any visible food debris was removed each shift. She also expected that any broken dishware would be removed and given to her, so it was no longer used. She stated that soiled reusable beverage containers were not supposed to be in the clean dishware area or in the kitchen at all. She did not have any of the [NAME] Glove (a company form for ensuring kitchen cleanliness and sanitation) forms. She gave them to the Administrator and from there she was unaware of what happened to them. She stated that she would complete the [NAME] Glove sheet monthly. She stated that a negative outcome from the kitchen not being cleaned properly was illness to the residents. She did not use the CMS Kitchen Observation form to audit compliance. During an interview on 7/16/26 at 2:21pm with ADO, she stated that the [NAME] Glove program was facility specific. She stated that she expected the kitchen staff to clean the kitchen and dining room according to the facility policy and schedule. She stated that she expected the kitchen staff to uphold a clean environment for the residents. She stated that she was unaware of the location of the previous [NAME] Glove forms during the previous Administrator's time at the facility. She stated that the DSM was responsible for making sure that the cleaning schedule was followed. She stated that a negative outcome could possibly be illness to the residents. Record Review of Dietary Services Policy and Procedure manual dated 2012 revealed [in part]; Infection Control IC 00-1.0 policy - We will ensure that all employees practice infection control in the Dietary Services Department and maintain sanitary food preparation. All dietary service employees will follow Infection Control Policies as established and approved by the Infection Control Committee.Procedure-5. Equipment Sanitationa. All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces.b. After cleaning, equipment and utensils are stored to prevent contamination. Equipment Sanitation IC 00-6.0 Policy- We will provide clean and sanitized equipment for food preparation. The facility will clean all service equipment in a sanitary manner.Procedure-Equipment must be thoroughly sanitized between use in different food preparation tasksAll cracked, chipped, or broken dishes will be discarded.Cleaning Schedules IC 00-13.0 Policy- the dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis.Procedure-It is the responsibility of the Dietary Manager to prepare the daily, weekly, and monthly cleaning schedules.Cleaning schedules are posted at the beginning of each month in the kitchen.It is the responsibility of all employees to follow the cleaning schedule, and to initial by their assignments when completed.See cleaning schedule forms in the appendixCleaning schedules are to be individualized to the facility, and it is the responsibility of the DSM to ensure that the assigned tasks are completed when assigned, and in a thorough manner. The cleaning schedules should be updated routinely to include area that are noted as needing additional cleaning by the white glove inspection check list, the RD sanitation check, DSM or administrator walk through inspections, as well as the CMS kitchen observation audit form that is performed monthly by the dietary manager. Cleaning the Floor IC 00-20.0 Policy:the floors are to be mopped when a spill occurs and at the end of each shift. Wet floor signs are to be placed at the edges of the wet area to warn people of the wet floor.Procedure-After each mealSweep the floor and dispose of dirt particles. Sweep under the equipment. Move the equipment, if mobile, in order to sweep under it.Fill mop bucket with water and floor cleaner per instructions as cleaner.Mop water is to be kept clean/changed as needed.Apply liberally with wet mop.Mop vigorously to remove food spills and stains. Be sure to mop under equipment. Move equipment, if mobile, in order to mop underneath. Floor ledges and baseboards should have special attention to prevent soil build-up. [NAME] Glove Sanitation IC 00-23.0 Policy:the dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. The DSM will monitor this by using the [NAME] Glove Form weekly.Procedure-The DSM will weekly go through the kitchen and dining room using the [NAME] Glove form. The DSM will document any problem areas using the form and report those issues to the dietary employees, Maintenance, or the Administrator and then will take the report to the QA clinical subcommittee monthly. The DSM will take the results to the [NAME] Gove and use the information to modify the cleaning schedules accordingly.It is the responsibility of the DSM to ensure that the [NAME] Glove forms are completed weekly and in a thorough manner.The DSM will keep all [NAME] Glove forms for three months.Kitchen Compliance Audit IC 00-24.0 :Procedure-The DSM will go through the kitchen area using the CMS Kitchen Observation form monthly. This form is to be used in conjunction with the white glove form to monitor the sanitation practices used by the dietary department, and to ensure that the state and federal regulations are being followed.The DSM will take the results of the CMS Kitchen Observation form to the Clinical Sub Committee monthly.These forms are to be kept on file for six months.

Based on interviews, and record reviews the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 (resident #18) of 12 residents reviewed for behavioral health services. The facility failed to follow up on referral for a transfer to another facility before and after the SW was terminated. These failures could result in a delay of behavioral health services and care for the residents.The findings include: In an interview on 7/14/26 at 11:40am AHRS stated that the facility did not have a SW. The HR/MR was present during the interview and stated that the previous SW was terminated on 5/28/26. She stated that the new SW would start on 8/03/26. Record review of electronic Facesheet for Resident #18 dated 07/16/26 revealed: a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease with early onset, unspecified depression, generalized muscle weakness, repeated falls, schizoaffective disorder bipolar type, bipolar disorder current episode mixed moderate, unspecified anxiety disorder, Parkinson's disease without dyskinesia. Record review of BIMS evaluations for Resident #18 revealed:BIMS V-2 form completed on 3/30/26 completed by DOR with a result of 13, meaning no cognitive decline.BIMS V-2 form completed on 4/8/26 completed by DOR with a result of 6, meaning severe cognitive decline.BIMS V-2 form completed on 7/7/26 completed by DOR with a result of 15, meaning no cognitive decline. Record review of Resident #18's Social Services Quarterly assessment dated [DATE] revealed it was incomplete and only revealed 1 of 13 questions answered on the assessment. Record Review of Social Service progress notes from 3/31/26 to 4/30/26Social Service note dated 4/30/26 at 4:29pmthe SW sent the corrected Release of Information (ROI) to the psychiatry office with a request for immediate processing and release of records to support transfer coordination to another secured unit. SW provided an update to the resident's via email, including reassurance of continued follow-up and advocacy due to prior delays in communication. previously expressed frustration regarding coordination and urgency of placement; SW continues to provide support and maintain communication. SW will continue to monitor the status of record release and follow up with the psychiatry office and receiving facility to facilitate timely placement.Social Services Note dated 4/30/26 at 4:18pmthe SW Received a call from the resident's regarding the status of transfer to another secured unit. expressed frustration related to delays in the coordination of required psychiatry records and verbalized concern that the current arrangement is not feasible due to distance, stating she does not want to feel as though she is abandoning . SW provided active listening, emotional support, and validation of concerns. SW reported follow-up with the psychiatry office, where it was determined delay was due to an incomplete Release of Information (ROI), as the receiving facility was not listed; a corrected ROI was required to proceed. verbalized understanding and stated she would complete and submit the updated ROI promptly. SW also communicated ongoing attempts to coordinate with the pending referral regarding bed availability and status. was informed that SW will continue to advocate for placement and follow up with involved parties due to communication barriers. SW will continue to monitor and assist with the coordination of records and placement as needed.Social Services Note dated 4/23/26 at 11:56amFollowed up with the resident's regarding potential transfer to another secured facility. inquired about who would initiate contact regarding admission/transfer status. Informed that the [other facility] staff would typically reach out directly; however, offered to contact the [other facility] today to obtain an update and provide follow-up. voiced understanding and appreciation. Will follow up with once additional information is obtained.Social Services note dated 4/22/26 at 11:46amSW contacted the resident's via phone to discuss the coordination of care related to the pending discharge to [another facility] SW inquired about the consent to send a Release of Information (ROI) form to obtain records from the resident's prior psychiatric provider, which are needed to support continuity of care and facilitate timely admission. verbalized understanding and agreement with the plan. SW informed that the [other facility] is working to arrange transfer as early as this week, and expressed agreement with this timeline. SW advised that the ROI form will be sent via email for review and signature. agrees to complete and return the documentation to allow the records to be forwarded to the [other facility]. SW will follow up to ensure receipt of the signed ROI and coordinate with the prior psychiatry office upon completion.Social Services note dated 4/20/26 at 4:35pmSW spoke with the resident's regarding the status of referral to [another facility] as part of ongoing discharge planning efforts. requested an update on the referral process and next steps. The was informed that initial contact had been made and that a referral had been submitted for review. SW advised that additional clinical documentation will be forwarded to support evaluation and level-of-care determination. It was also communicated that the receiving facility has requested physician and psychiatry notes; however, due to the resident's recent admission, the current facility does not yet have established physician documentation, and psychiatry services were not initiated, given the anticipated short stay and discharge planning focus. SW informed that contact information for the resident's previous primary care provider and psychiatrist was shared with the receiving facility to assist with continuity of care and collateral information. verbalized understanding and remained in agreement with the plan. Resident/family preference for placement in the area was acknowledged and incorporated into the discharge planning process to support transition to the least restrictive and most appropriate environment. No concerns were voiced during this interaction. Plan: Continue discharge planning process, coordinate with the [other facility] submit available documentation, provide collateral provider information as needed, and maintain communication with resident/family regarding referral status and next steps.Social Services Note dated 4/14/26 at 9:20amS (Subjective): The resident's called to follow up on the NOMNC appeal status and provided additional updates. O (Objective): reported the appeal process initiated and inquired about medical records transmission. Social Services confirmed the fax number was provided to the requesting party. and SW also discussed the resident's temporary room setup, including the lack of TV access, and plans to bring a TV during the upcoming visit. Additionally, the reported hiring a Medicaid attorney to assist with the application and stated the Business Office has been notified. A (Assessment): actively involved in the resident's care, discharge/appeal process, and financial planning. Ongoing coordination needed across departments. P (Plan): Will monitor for receipt of records and updates regarding the appeal. Continue to support communication with family and coordinate with the Business Office and IDT as needed.Social Services Note dated 4/13/26 at 4:52pmSW contacted the resident's /POA to provide notification of the NOMNC determination. Informed POA that Medicare will no longer cover skilled services, with the last covered day identified as 04/16/26. POA was educated on appeal rights and provided with appropriate contact information to initiate the appeal process. POA verbalized understanding and stated intent to proceed with the appeal. During the conversation, POA inquired about the transfer process following the resident's isolation status, expressing interest in relocating the resident to a facility in closer to her residence. SW encouraged POA to contact the preferred facility to confirm bed availability. Education provided regarding the transfer process, including coordination of medical records, medications, and clinical documentation, either initiated by the receiving facility or the current facility upon request. POA also questioned whether to proceed with the transfer during the appeal process. SW provided general guidance, indicating it may be beneficial to await the appeal outcome before initiating transfer; however, the final decision is left to POA. POA agreed to proceed with the appeal first and revisit transfer planning thereafter. Before this call, SW provided contact information for a sister facility in and offered ongoing support with coordination as needed. SW also informed POA that a copy of the NOMNC will be provided for her records.SS Note dated 4/8/26 at 12:57pmSW met with the resident and at the bedside. reported recently completing POA documentation with a notary. Resident voiced complaint of stomach discomfort during visit; SW notified nursing/ADON for follow-up. SW discussed bringing the resident's home medications for facility review; retrieved medications and provided them to ADON. Environmental concern addressed regarding missing TV remote; SW acknowledged and will assist with resolution. SW also discussed discharge planning, including potential transfer to area. SW provided information for a sister facility in and offered assistance with referral coordination. Response: The was engaged and receptive throughout the interaction. She verbalized understanding of the medication review process and plan for nursing follow-up regarding the resident's reported discomfort. The expressed interest in the identified facility and confirmed it was previously considered. No concerns voiced regarding information provided. Plan: SW to follow up on TV remote replacement and continue to support discharge planning needs. SW to assist with referral coordination as requested and remain available for ongoing communication with and IDT. Social Services note dated 4/8/26 at 11:10amIntervention: SW met with the notary on-site to assist with the facilitation of POA documentation for the resident, before the arrival. SW and the notary met with the resident to assess understanding and ability to participate in decision-making. SW engaged the resident in a discussion regarding a prior conversation about appointing a decision-maker for medical and financial needs in the event she is unable to speak for herself. The resident was alert and able to engage in conversation, demonstrating understanding of the purpose of POA. SW discussed the potential designation of the as POA; the resident was agreeable to this arrangement. SW informed the notary that the was in route to the facility to complete the process. Response: The resident was cooperative, calm, and able to participate in the discussion. She appeared to understand the concept of POA and verbalized agreement with her serving in this role. No distress or confusion noted during interaction. Plan: SW to remain available to support completion of POA process upon arrival and coordinate with notary and IDT as needed.Social Service note dated 4/7/26 at 11:47amSW contacted the resident's to follow up regarding the establishment of a Power of Attorney (POA). reported that , who is an attorney, does not handle POA-related matters. SW provided education that an attorney is not required for POA completion and that documents may be finalized with a notary. SW consulted with the Business Office Manager (BOM) to confirm the process and relayed information to the . agreed to obtain and print appropriate POA documentation (Texas forms). SW coordinated with notary services, and an appointment has been scheduled for tomorrow at 11:00 AM at the facility for the completion of POA documents. Discharge Planning: Establishment of POA is essential to support ongoing discharge planning discussions and decision-making. Discharge plan remains in progress pending completion of POA. Social Services will follow up to ensure completion and update the record accordingly.Social Service noted dated 4/7/26 at 9:51amDischarge plan is currently TBD. During the recent care plan conference, the resident's expressed interest in relocating the resident to the area to be closer to family. Final discharge disposition is pending the establishment of a Power of Attorney (POA). Social Services will continue to follow up with the family and provide support with planning and coordination as updates become available.Social Service note dated 3/31/26 at 2:40pm Social Services contacted the resident's via telephone to notify them of the scheduled care plan conference on 4/2/26 at 11:30 am. Responsible party confirmed telephonic participation. The responsible party was asked if they had any questions, updates, or concerns they would like addressed during the meeting. The responsible party voiced that she had a lot of questions, but did not have time to discuss them as she was at work. SW reassured her that we could discuss them later, either before or during the care plan meeting, at a time that is more convenient for her. In an interview on 7/14/26 at 11:08 am Resident #18 was sitting on the side of her bed in the room. She stated she that she wanted to go to an ALF. She stated that the staff at the facility were nice to her. She must utilize a walker to ambulate. She stated she used to have therapy at the facility, and it really helped her. She stated that her visited every couple of weeks She lived alone prior to being admitted to the hospital and the facility. She had a friend that was her neighbor that helped her with going to doctor appointments and the store. In an interview on 7/15/26 at 3:10pm Resident #18's secondary contact stated that Resident #18 did not need to be in a locked unit, she just needed some assistance. Secondary Contact stated that Resident #18 would be able to transfer to an ALF. In an interview on 7/16/2026 at 2:00pm ADON stated she started working at this facility in March. She stated when a referral for an outside service was requested, it should be completed as soon as it was received. She stated that if the receiving office did not respond within a few days a follow-up correspondence with the provider office would need to occur. ADON stated that she had absorbed extra duties since the SW was terminated. These added duties included processing referrals, completing social histories and quarterly social assessments. She stated that Physical therapy and AD assisted with absorbing other tasks as well. She stated that she was unaware of the referral to another facility for Resident #18. In an interview on 7/16/26 at approximately 2:15pm a transfer policy was requested from the RCN. She provided the admission/readmission policy and the discharge planning process policy. She stated that she did not have a transfer policy. In an interview on 7/16/2026 at 2:40 PM RCN stated the facility not having a SW or someone providing social services had not caused any negative outcomes. She stated the facility Interdisciplinary team had worked together to ensure social service needs were being met. Resident's needs were discussed during stand up meeting each morning and the interdisciplinary team worked together to follow up on those needs. She was unaware of the referral for transfer sent in April of 2026 for Resident #18. In an interview on 7/16/2026 at 3:45 PM ADO stated Social Service needs were being managed by the Interdisciplinary team. She stated that she was unaware of any resident having social service needs that were not addressed. She denied any delay in services. She stated that the role of SW was delegated and there have not been any negative outcomes. She stated that the ADMN would absorb the SW email but was unable to verify that communication occurred between the previous ADMN and SW. She stated a gap in care could result from the facility not having a social worker. She stated she was aware of the regulation to have a social worker on staff at a certified Alzheimer's facility. Record Reviewed of the facility policy labeled Discharge Planning Process undated revealed [in part]; STANDARD: Nursing Facility must complete discharge planning when discharge is anticipated to a private residence, Assisted Living, another Nursing Facility, or another type of residential location.Guidelines:Assess the residents' continuing care needs, including:Consideration of the residents' and family/caregiver's preferences for care.How services will be accessed; andHow care should be coordinated among multiple caregivers, as applicable.Include regular re-evaluations of the resident to identify changes that require modification of the discharge plan.The discharge plan must be updated, as needed to reflect these changes.3. Initiate and maintain collaboration between the Nursing Facility and:a. The local contact agency to support the residents transition to community living, as applicable, includes making referral to the local contact agency under the process established by the State; andb. Assisting the resident and family/caregivers in locating and coordinating post-discharge services.5. A post-discharge plan of care will be developed with the participation of the resident, and with resident's consent, the resident representative(s).

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #1 and, Resident #5) reviewed for care plans. The facility failed to ensure the comprehensive care plan for Resident #1 addressed a fall, preferences, and discharge planning. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #5 to address nutrition, dental, pressure ulcer, communication, ADL function/rehabilitation potential, and discharge planning. This failure could place the residents at risk of inadequate care and services.Findings included: Record review of Resident #1's face sheet dated 4/18/2026 revealed a [AGE] year-old female with an admission date of03/13/2026. Her diagnoses included Alzheimer's Disease (a brain disorder that slowly destroys a person's memory and thinking skills), Dementia (loss of mental ability that interferes with daily life), chronic kidney disease, stage 3 (mild to moderate kidney damage affecting the kidney's not filtering waste from your blood), Depression (persistent sadness impacting daily life), anxiety disorder (persistent, excessive fear that interferes with daily life). Record review of Resident #1's MDS dated [DATE] in the CAA summary indicated that falls was a triggered area and that it was addressed in the care plan.Record review of Resident #1's comprehensive care plan undated and reviewed on 4/18/2026 revealed no evidence that falls was addressed in the care plan.Record review of Resident #1's comprehensive care plan undated and reviewed on 4/18/2026 revealed no evidence of documented discharge plans or discharge assessment. Records review of Resident #1's Event nurse's note dated 3/18/26 indicated a fall occurred with no injury. Record review of Resident #5's face sheet dated 4/18/2026 revealed a [AGE] year-old male with an admission date of 03/07/2026. His diagnoses included Acute kidney failure (rapid loss of kidney function to filter waste from the blood), Wernicke's Encephalopathy (acute neurological condition of intense swelling of the brain), severe protein calorie malnutrition (inadequate intake of protein and calories), Hypertensive heart and chronic kidney disease with heart failure and stage one through stage 4 chronic kidney disease (Complex cardiorenal syndrome where high blood pressure causes both heart dysfunction and progressive kidney damage), depression (persistent sadness affecting daily life), anxiety disorder (persistent worry and fear affecting daily life), dementia (loss of mental ability affecting daily life), Gastro esophageal reflux disease without esophagitis (Stomach acid frequently flows back into the esophagus causing heartburn, chest pain and regurgitation), calculus of gallbladder without cholecystitis without obstruction (gallstones without inflammation or blocked bile ducts), Occlusion and stenosis of bilateral carotid arteries (plaque buildup narrows or blocks both main neck arteries restricting blood flow to the brain). Record review of Resident #5's MDS dated [DATE] indicated a BIMS of 15 (cognitively intact).Record review of Resident #5's MDS dated [DATE] in the CAA summary indicated that communication, ADL functional/rehabilitation potential, nutritional status, dental care, and pressure ulcer were triggered areas. The CAA summary further indicated that these areas were addressed in the care plan.Record review of Resident #5's comprehensive care plan undated and reviewed on 4/18/2026 revealed no evidence that communication, ADL functional/rehabilitation potential, nutritional status, dental care, and pressure ulcer were addressed in the care plan.Record review of Resident #5's comprehensive care plan undated and reviewed on 4/18/2026 revealed no evidence of documented discharge plans or discharge assessment. Record review of Resident #5's progress notes reviewed on 4/18/26 indicated he had a dental appointment scheduled and his dietary preferences were noted. In an interview on 4/17/26 at 5:28 p.m. with Resident #5, he stated that his needs were met. He stated he did his own showers and toileting, and he did not have any sores. Resident #5 stated he can get where he wanted to go on his own in his wheelchair. Resident #5 was able to express his wants and needs with clear communication. In an interview on 4/18/2026 at 12:25 p.m. with ADON-B, she revealed that it was the responsibility of MDS-A to complete the MDS assessment and initial comprehensive care plans after the MDS assessment was completed. ADON-B stated she was not sure who was responsible for including the discharge planning information in the care plan. ADON-B stated a negative effect from fall risk not being in the care plan may prevent the falls from being addressed if interventions were not in the care plan. She stated that Resident #1's falls were due to her behavior and the facility worked hard on minimizing the risk. ADON-B stated that the residents were all getting their needs met. In an interview on 4/18/26 at 4:48 p.m. with MDS-A, she stated she was responsible for the MDS assessment and completing the initial comprehensive care plans. MDS-A stated she was not aware of the care plans for Resident #1 and Resident #5 missing CAA triggered areas. She stated a negative impact from the information not being documented in the care plan could mean the residents' needs would not be person-centered or not be met. MDS-A stated she felt that had not happened in this case and the facility was meeting the residents' needs. In an interview on 4/18/26 at 5:20 p.m. with DON-C, she stated that MDS-A was responsible for initial and comprehensive care plans. DON-C stated MDS-A was available and responsible for the care plans created for Resident #1 and Resident #5. DON-C stated that Resident #1 was a fall risk and it should have been in the care plan. She stated Resident #1 had no injury from her falls. A negative effect of the CAA triggers not being addressed in the care plan could break communication between all departments but felt facility staff knew the residents and met their needs. In an interview on 4/18/26 at 6:42 p.m. with ADM-D, she stated that MDS-A was responsible for the MDS assessment and comprehensive care plans. ADM-D stated the department heads rely on MDS-A to update changes to the care plan. ADM-D stated a negative effect could have been that Resident #1 could have fallen and broken something. She stated the documentation could avoid immediate issues. Record Review of the Comprehensive Care Planning policy undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include, but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and. The residents' goals for admission and desired outcomes. The resident's preference and potential for future discharge. The facility documents on whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. Discharge plans and the comprehensive care plan, as appropriate. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects, the resident. Documentation regarding these assessments and the facilities rationale for deciding whether or not to pursue with their planning for each area trigger will be reported in the medical records.If The decision to proceed to care planning is made, the interdisciplinary team (IDT), in conjunction with the resident and/ or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when four facility staff (LVN A, RN B, NA C and Laundry Staff D) grabbed Resident #1 and forcibly carried him by his extremities and dragged him on the floor to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress. Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of a skin assessment dated effective 8/17/25 and signed by the ADON on 8/18/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Left pinky finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of Resident #1's skin assessment dated effective 8/19/25 and signed by the ADON on 8/19/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Right ring finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. admit date [DATE], and an order dated 9/9/23 : Admit to Hospice, and order dated 8/19/25 cleanse skin tear to left arm with normal saline and pat dry . Apply steri strips, cover with xeroform gauze and a padded dressing. Wrap with Kerlix daily and prn. There was no order for physical restraints. There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day ordered on 8/17/25 by the Hospice physician. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record Review of Resident #1's Care Plan dated revised 8/18/25 reflected Focus: Resident has an actual impairment of skin integrity . Intervention : use caution during transfers and bed mobility to avoid striking arms, hands, and legs against any sharp or hard surface (dated initiated 8/18/25). Record review of Resident #1's care plan last dated revised on 8/18/25 included: Focus: The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by (1/3/24); Hospice to evaluate medication list with psych. (3/17/25); If a resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby (4/22/25); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed (12/5/23); Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his family member and let him speak to her (3/13/25) Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/24/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possibleInvolve resident in secure unit activitiesNotify physician and family of changes Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25. Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider.Perform the following de-escalation techniques (there were no de-escalation techniques listed for staff to follow). Record review of Residents #1's Nurse's Progress Notes revealed: Author: LVN EEffective Date: 08/17/2025 3:30 PM Type: Nursing NoteNote Text : Resident was being combative with staff and was escorted back to room, Resident started throwing things at the window in his room and broke his window, Police and EMS was called to deescalate the situation. Will continue to monitor, Hospice gave new orders for Haldol 5mg/1ml. Resident has been given Haldol 5mg/1ml, POA notified. Interventions: 1 on 1 monitoring, Directed to the resident's room to decrease stimulation, Assess for pain. During an interview with N/A C on 8/18/25 at 4:20 PM. NA C stated she worked 6 AM to 6 PM on 8/17/25 and they had an incident occur between 2:00 PM and 4 PM when the Nurses had to call the police due to Resident #1's behaviors. She stated he broke glass in his room and the police came and they had to handle the situation, and the police had to restrain him by holding him down. She stated she was unable to leave him because he was so violent . She stated they did not have enough help at times to deal with the behavior, and stated 4 people was not enough to watch people with wandering and combative behavior. She stated she thought the Nurse notified the DON of the resident's behavior, but no one else came to help them. She did not mention that the resident was restrained, carried to his room and she prevented him from opening his room door by holding the door knob during this interview . During an interview on 8/19/25 at 9:24 AM RN B stated that on Sunday, 08/17/ 2025, Resident #1 was sitting in a chair near the nurses station. She stated she noticed he seemed withdrawn, which was not like him. She stated another staff member told her he is like that sometimes. She stated she had always seen him friendly, verbal, confused, and smiling. She stated he suddenly became violent toward other patients near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, but he was very resistant and extremely strong. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to make their way down the hall while he continued to attempt to break lose, kick, and punch the staff. Resident #1 did manage to break free ahead of them, and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they were struggling to hold Resident #1 but were finally able to get him through the door of his room and close it, with one aide having to brace herself against the wall to hold it shut by the doorknob. Resident #1 was throwing things very hard against the door, trying to open it. She stated the staff outside Resident #1's door heard several loud bangs on the door and banging in the room and then they heard glass breaking. They did not enter the room to check on the resident. She stated LVN A had notified the DON by phone, after which she stated she (RN B) instructed LVN A to call the police and EMS. She stated they heard intermittent loud bangs continue on the door. They continued to hold the door closed . She stated it was determined after the police arrived and the door was open he had removed the toilet tank lid and threw it through the window and possibly at the door. She stated, We were all afraid for our own safety and that of other residents. She stated several police officers arrived and were able to lay him on the bed and hold him so that Resident #1 could not move. She stated a hospice nurse that had been called to come to the facility by LVN A was then able to administer an injectable behavioral medication. She stated Resident #1 was not transported to the hospital by the EMS. During an Interview on 8/20/25 at 10:33 AM with Laundry Staff D, she stated she worked in the laundry and was there on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him physically hitting her coworkers and trying to hit residents. She stated he was trying to hit a lady sitting in the chairs across from the nursing station and then four of the staff including herself restrained him. She stated Resident #1 was on the floor, he had a cord in his hand, and she was afraid he was going to use it to swing at them and hurt other people. She stated she took the cord away and picked up his legs and feet . She stated she picked up his feet and then 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide was holding on to the doorknob to keep him in the room and prevent him from opening the door. An observation of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other resident's rooms, taking items from other resident's rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM Resident #1 walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. At 2:55 PM Resident #1 started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand. It had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into Laundry Staff Member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity. RN B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. N/A C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry Staff D held onto the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident#1 as he tried to kick Laundry Staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A moved to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room, ran out of the room, and closed the door of his room. The staff took turns holding his door closed and did not allow him to come out of the room. While other staff stood nearby, NA C placed her foot up against the wall or door frame to allow her to keep the door closed as the resident pulled on the door from the inside. At 3:11PM the police arrived and stood outside the door with the staff. At 3:12 PM the EMS arrived, and the police and EMS went into Resident #1's room. During an interview with LVN E on 8/20/25 at 11:51AM, she stated she worked on 8/17/26, and was coming out of the med room and turned to the right and saw the Resident #1 had a cord in his hand, and he was swinging it around. All the others were trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. She said they were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was just kind of tricky on how they respond, and things were getting worse. She stated the Administrator was the abuse coordinator. She stated the types of abuse were physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. She said, I didn't like the situation because I don't think I've had to restrain a patient in a long time, so it just didn't make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them they had told me they did not know about it. During an observation on 8/20/25 at 12:30 PM Resident #1 had dressings to his right arm and was awake and alert, but unable to answer direct questions regarding the incident. He had no recall of an incident and was not interviewable at the time. He did not realize why he had a dressing on his arm or that he had one. He appeared quiet and calm. During an interview on 8/21/25 at 1:04 pm with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation on 8/17/25 and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all she was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs' actions. She stated in that situation she would have gotten down on the ground on the resident's level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threatened and needed more education . During an interview on 8/21/25 at 1:24 PM with the Administrator, she stated she would have liked to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall by picking him up by his arms and legs and taking him to his room. She stated she would have preferred to have her staff step back and not take items away from Resident #1, if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out. She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON on 3/17/25 at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video after the surveyor asked to see the video footage. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called Maintenance to go to the facility to fix the window at that time. She wasn't aware of anything else. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview on 8/21/25 at 4:30 PM with Resident #1's POA she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated she was told by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can 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. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. This was determined to be an Immediate Jeopardy (IJ) on 8/25/25 at 5:07 PM. The Interim Administrator, Corporate Nurse, Corporate Regional [NAME] president, DON, and Corporate Clinical Leader RN were informed of the IT. The interim Administrator was provided with the IJ template on 8/25/25. The following Plan of Removal was accepted on 8/26/25 at 9:54 AM: Please see the attached POR for F600. Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal: Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate threat by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the Immediate Jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25.o Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse.o Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.o Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. o Trauma informed Care (an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect),to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. o Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25.o Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse.o Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.o Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. o Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. o Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. Monitoring of the facility's Plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse.She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some s[TRUNCATED]

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from involuntary seclusion for 1 of 7 residents (Resident #1) reviewed for involuntary seclusion. The facility failed to ensure LVN A, RN B, N/A C, and Laundry Staff D did not isolate Resident #1 as a method of addressing his behaviors. The staff placed Resident #1 in his room and held the door closed by the doorknob so that he could not leave his room as he struggled to get the door open and leave the room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure affected Resident #1 and could place residents with behavior healthcare needs at risk of injury and isolation, leading to a decreased quality of life, severe emotional distress and trauma leading to distrust of staff.Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), and Alzheimer's Disease. Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. There was no order for physical restraints . There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day ordered on 8/17/25 by the Hospice physician. There was an order dated 8/19/25 cleanse skin tear to left arm with normal saline and pat dry . Apply steri strips, cover with xeroform gauze and a padded dressing. Wrap with Kerlix daily and prn. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record review of Resident #1's care plan last revised on 8/18/25 included: Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by initiated 1/3/24. Hospice to evaluate medication list with psych initiated 3/17/25. If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby initiated 4/22/25. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed initiated 12/5/23. Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his family member and let him speak to her initiated 3/13/25.Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/24/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possibleInvolve resident in secure unit activitiesNotify physician and family of changes Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25.Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider. Perform the following de-escalation techniques (there were no de-escalation techniques listed). An observation of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other resident's rooms, taking items from other resident's rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM Resident #1 walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. At 2:55 PM Resident #1 started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand. It had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into Laundry Staff Member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity. RN B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. N/A C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry Staff D held onto the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident#1 as he tried to kick Laundry Staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A moved to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room, ran out of the room, and closed the door of his room. The staff took turns holding his door closed and did not allow him to come out of the room. While other staff stood nearby, NA C placed her foot up against the wall or door frame to allow her to keep the door closed as the resident pulled on the door from the inside. At 3:11PM the police arrived and stood outside the door with the staff. At 3:12 PM the EMS arrived, and the police and EMS went into Resident #1's room. Record review of a skin assessment dated effective 8/17/25 and signed by the ADON on 8/18/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Left pinky finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. Record review of a skin assessment dated effective 8/19/25 and signed by the ADON on 8/19/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Right ring finger and a 2-centimeter x 2- centimeter skin tear to his left upper arm. During a telephone interview with N/A C on 8/18/25 at 4:20 PM via phone regarding another incident NA C stated she worked 6 AM to 6 PM on 8/17/25 and an incident had occurred with Resident #1 between 2:00 PM and 4 PM when the Nurse had to call the police due to Resident #1's aggressive behaviors. She stated he broke the window glass in his room and the police were called. She stated the staff, and the police had to restrain him by holding him down. During an interview on 8/19/25 at 9:24 AM RN B stated on Sunday, 08/17/ 2025, Resident #1 was sitting in a chair near the nurses station. She stated Resident # 1 suddenly became violent toward other residents that were near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, but he was resistant. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to attempt to make their way to take him down the hall while he continued to attempt to break lose, and kick, and punch the staff. She stated Resident #1 did manage to break free and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they struggled to hold Resident #1 but were finally able to get him through the door of his room and close it. She stated one aide had to brace herself against the wall to hold it shut by the doorknob while Resident #1 was throwing things against the door. She stated the staff outside Resident #1's door heard several loud bangs on the door and banging in the room, and then they heard glass break. She stated they did not enter the room to check on the resident. She stated LVN A had notified the DON by phone, after which she stated she (RN B) instructed LVN A to call the police and EMS. She stated they heard intermittent loud bangs continue on the door. They continued to hold the door closed. She stated it was determined after the police arrived and the door was open he had removed the toilet tank lid and threw it through the window and possibly at the door. She stated, We were all afraid for our own safety and that of other residents. She stated several police officers arrived and were able to lay him on the bed and hold him so that Resident #1 could not move. She stated a hospice nurse that had been called to come to the facility by LVN A was then able to administer an injectable behavioral medication During an Interview with Laundry Staff D at 10:33 AM on 8/20/25 she stated she worked in the laundry and was there on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him physically hitting her coworkers and trying to hit residents. She stated he was trying to hit an unidentified lady sitting in the chairs across from the nursing station. She stated 4 staff restrained him. She stated Resident #1 was on the floor and had a cord in his hand. She stated she took the cord away and picked up his legs and feet . She stated 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide (name unknown) was holding on to the doorknob to keep him in the room and prevent him from opening the door. In an interview with LVN E on 8/20/25 at 11:51AM, she stated she worked on 8/17/26, and was coming out of the med room and turned to the right and saw the Resident #1 had a cord in his hand, and he was swinging it around. All the others were trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. She said they were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was just kind of tricky on how they respond, and things were getting worse. She stated the Administrator was the abuse coordinator. She stated the types of abuse were physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. She said, I didn't like the situation because I don't think I've had to restrain a patient in a long time, so it just didn't make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them they had told me they did not know about it. During an observation on 8/20/25 at 12:30 PM Resident #1 had dressings to his right arm and was awake and alert, but unable to answer direct questions regarding the incident. He had no recall of an incident and was not interviewable at the time. He did not realize why he had a dressing on his arm or that he had one. He appeared quiet and calm. During an interview on 8/21/25 at 1:04 pm with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all she was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs' actions. She stated in that situation she would have gotten down on the ground on the resident's level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threatened and needed more education . During an interview with the Administrator on 8/21/25 at 1:24 PM she stated she would have liked to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall in the manner that they did. She stated would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out . She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON on 3/17/25 at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called Maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview with Resident #1's POA on 8/21/25 at 3 :15 PM she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, secluded him or that he was had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated she was told by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can 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. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping punching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective action Please see the attached POR for F603 Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. The surveyor monitored the facility's plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews 8/26/25 from 9:58 AM to 5:50 PM. Interviews with Facility staff members from 9:58 AM on 2:10 PM revealed they had been educated on abuse, neglect, behavior management, Resident Rights, Trauma Informed Care, and the facility restraint policy. During an interview with LVN F 6AM- 6PM shirt on 8/26/25 at 9:59 PM. He stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management, H stated a restraint is holding their arms down or holding their door shut would be isolation, He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G 6AM - 6PM shift on 8/26/25 at 10:10 AM - she stated she was Inserviced on 8/19/25, and 8/26/24 by the Corporate Nurse. She stated neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them , not making sure that they've eaten, Abuse can be verbal it can be physical it can be mental. She stated have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntary and unreasonable confinement is abuse. You report everything to the administrator. The administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. Restraint policy - We are actually a no restraint facility. That is a big No, no . you use Behavior management which would be do every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H 6AM - 6PM shift on 8/26/25at 10:15 AM She stated that she was Inserviced on abuse and neglect, restraints, and seclusion today. 8.26.25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming , or body harm that is sexual or physical or mental health . She stated Resident restraining it's like from having something on them to keep them from moving or that that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated :I would have to report it to the to the administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can.by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician . She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA, I 6 PM to 6 AM shift on 8/26/25 at 10:30 AM stated the typers of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms , sexual and stealing from residents. She stated you report abuse immediately. Stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other resident's she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, we have to report it to the administrator or abuse coordinator for the facility . We learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. We have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior manage you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. I would give them space provide one-on-one food and snacks go a long way you could take them to the bathroom start an activity just go down the list basically until something works you could look in their care plan and see if there's any interventions in there.- check to see if they are wet or hungry or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced8/26/25 and earlier in the week by the RN corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM. She stated she was Inserviced on 8/19/.25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care ( an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect. She stated she learned about isolation. She stated the corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the administrator, whether it's an interim or permanent administrator . She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement Trauma informed care assessment should be done on residents after incidents unauthorized restraint seclusion unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive b[TRUNCATED]

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical or chemical restraints imposed for purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms for 1 of 7 residents (Resident #1) reviewed for physical restraint/chemical restraints. The facility failed to protect Resident #1 from physical restraint when LVN A, RN B, N/A C, and Laundry Staff D grabbed Resident #1 by his arms and legs which restricted his movement and dragged the resident across the floor and carried him by holding onto his arms and legs down to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 8/25/25. The IJ template was provided to the facility on 8/25/25 at 5:07 PM While the IJ was removed on 8/26/25, the facility remained out of compliance at a scope of isolated, and a severity level of no actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress.Findings include:An observation on 8/20/25 of the electronic monitoring system video dated 8/17/25, showed these events: At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. At 2:44 PM resident number one went into another residents' room and took a small fan out of that room and carried it down the hallway. Resident #1 became agitated when housekeeping staff took the fan away from him. At 2:53 PM resident number one walked out of his room with a bedside table. Resident #1 pushed the bed side table forcefully into Rn B and hit her in the shins of both legs. RN B and NA C walk away towards the nurses station and resident number one walk after them. 2:55 PM incident number one started running toward N/A C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. N/A C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff member D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swinging the cord . Resident number one tripped on a chair and fell to the floor. There were four other residents in the vicinity. Rn B motioned with her hand to two unidentified residents that were sitting in the row of chairs at the nurses station to go down the hallway away from resident #1. The two residents walked away. N/A C removed another resident away from resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held onto the cord and sat in a nearby chair as resident #1 held the cord and sat on the floor. Rn B and LVN A walked around Resident#1 as he tried to kick laundry staff D. RN B and LVN A grabbed resident number one by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. N/A C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried resident number one to his room. Staff carried him into the room ran out of the room and closed the door of his room. During a telephone interview with N/A C on 8/18/25 at 4:20 PM via phone regarding another incident NA C stated she worked 6 AM to 6 PM on 8/17/25 and an incident had occurred with resident #1 between 2:00 PM and 4 PM when the Nurse had to call the police due to Resident #1's aggressive behaviors. She stated he broke the window glass in his room and the police were called. She stated the staff, and the police had to restrain him by holding him down. She stated she was only involved in this incident. During an interview on 8/19/25 at 9:24 AM RN B stated on Sunday, 08/17/ 2025, Resident #1 was sitting in chair near the nurses station. She stated Resident # 1 suddenly became violent toward other residents that were near him and attempted to strike them. She stated she tried to assist him to a standing position and called for help. She stated she tried to guide him to his room, he was resistant. She stated he tried to strike at her with his fists. She stated other staff members responded, and they continued to attempt to make their way to take him down the hall while he continued to attempt to break lose, and kick, and punch the staff. She stated Resident #1 did manage to break free and grabbed a bedside table, picked it up, and threw it at them. She stated it struck her hard on her shins and left bruises on both legs. She stated she was afraid for herself and the other residents. She stated they struggled to hold Resident #1 but were finally able to get him through the door of his room and close it. She stated one aide had to brace herself against the wall to hold it shut by the doorknob while Resident #1 was throwing things against the door. She stated the staff outside Resident 1's door heard several loud bangs on the door and banging in the room, and then they heard glass break. She stated they did not enter the room to check on the resident. During an Interview with laundry staff D at 10:33 AM on 8/20/25 she stated she worked in the laundry and was here on 8/17/25 and witnessed the incident with Resident #1 . She stated she saw him being physically hitting coworkers and trying to hit residents. She stated he was trying to hit an unidentified lady sitting in the chairs across from the nursing station. She stated 4 staff restrained him. She stated Resident #1 was on the floor and had a cord in his hand. She stated she took the cord away and picked up his legs and feet . She stated 4 staff carried him down to his room and they shut the door and left him in there so he wouldn't hurt anybody. An aide (name unknown) was holding on to the doorknob to keep him in the room and prevent him from opening the door. Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), And Alzheimer's Disease . Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's active physician orders dated 8/20/25 reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. There was no order for physical restraints . There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day. Record review of the MAR dated 8/1/25 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record review of Resident #1's care plan last dated revised on 8/18/25 included : Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by (1/3/24); Hospice to evaluate medication list with psych. (3/17/25); If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby (4/22/25); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed (12/5/23); Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his granddaughter and let him speak to her( 3/13/25)During an interview at 1:04 pm on 8/21/25 with the DON she stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8.19.25. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated she would have like to have seen RN B, LVN A, Laundry staff D, and N/A C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs actions. She stated in that situation she would have gotten down on the ground on the Residents level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threated and needed more education . During an interview with the Administrator on 8/21/25 at 1:24 PM she stated she would have would like to see an attempt at de-escalation of the situation by her staff first. She stated she did not expect them to move him down the hall in the manner that they did. She stated would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated she would have expected that they would not pick Resident #1 up and take him to the room, shut the door and then hold the door closed so he could not get out . She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. She stated she was notified by the DON at 4:58 PM that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 PM by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 PM LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she went outside to see if she could see what Resident #1 had done after she heard glass break. She stated the housekeeper came out and relieved her and stayed until the police entered the room. She stated she saw a drawer on the floor and a lot of broken glass in the room and the resident was still agitated. She stated she had called the police when she heard the window break. She stated the police handcuffed the resident and restrained him until he was given the Haldol (antipsychotic) by the hospice nurse. During an interview with the resident POA on 8.21.25 at 3 :15 PM she stated the facility did not notify her of the behaviors her grandfather was exhibiting and that they had restrained him, or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day by the facility. She stated she got mixed reports from the facility on how and when this had all happened , but stated was told to her by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated : I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. During an interview at 4:32 PM on 8.21.25 with the Hospice phy 8.21.25 he stated I do believe that the situation with Resident #1 was handled appropriately by calling Hospice, and I do believe that they attempted preventative measures prior to chemical sedation and physical restraints according to the information the facility relayed to the Hospice RN who notified him. He stated The fact that two faculty staff had been assaulted, and I believe the chair had been thrown into a window damaging property. This could also potentially harm the resident as well. I do think that they managed it appropriately. During an interview with The Primary physician of Resident #1 on 8/21/25 at 4:50 PM he stated he was not informed of the incident with resident #1 until he was notified by the DON on 8/19/25. He stated he couldn't comment on whether he thought the situation was handled appropriately because he was not informed at the time of the incident. He stated he felt the DON was trying to make some positive changes at the facility. Record review of the facility policy titled Abuse/Neglect dated revised 9/9/24 reflected the following in part: The resident has the right to be free from abuse neglect misappropriation of property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment and involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents consultants or volunteers, staff of other agencies serving the resident family members or legal guardians friends or other individuals. Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition can 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. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping pinching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation, mistreatment means inappropriate treatment or exploitation of a resident. Record review of the facility policy titled Restraints not dated, reflected the following in part: It is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline or convenience restraint usage should be limited to circumstances in which the resident has medical symptoms that warrant the use of restraints a resident assessment committee will evaluate the facilities is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint free environment. Definitions physical restraint- any manual method or physical mechanical device material or equipment attached or adjacent to the residence body that the resident cannot remove easily which restricts freedom of movement or normal access to 1's body physical restraints include but are not limited to leg restraints arm restraints hand mitts soft tire best wheelchair safety bars [NAME] chairs lap cushions and trays that residents cannot move. Procedure restraints will only be applied after it has been determined that a medical symptom requiring restraint usage exists and only after all other alternatives have been tried unsuccessfully a physicians order shall be necessary to begin a restraint assessment evaluation for the resident, the restraint assessment committee shall meet to assess the necessity of restraints for a resident by completing a pre-restraining assessment worksheet the restraint assessment committee will identify an alternate method, or the type of restraint needed, when and how often a restraint is to be used, and why the restraint is to be used. Contact the resident and our family member responsible party to discuss the plan of care and obtain informed consent if needed. Obtain A physicians order for the restraint to specify type of restraint and length of time the resident is to be in the restaurant facility staff will develop a care plan for the alternate method identified and or the restraint usage. Physical restraints for behavior control shall only be used in an emergency which threatens to bring immediate injury to the resident or others. In such an emergency an order may be received by telephone and shall be signed by the physician within 48 hours. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, and the length of time, effectiveness of the physical restraint time and the name of the individual applying the restraint. Such measures shall be entered in the residents medical record . Every effort shall be made to calm the resident first , however personal safety must be considered. There should be no prn order for behavioral restraints. Residents requiring restraints for behavioral control on more than one occasion shall be considered for alternate placement to a facility that can meet their needs without the use of restraints. This was determined to be an Immediate Jeopardy (IJ) on 8/25/25 at 5:07 PM. The Interim Administrator, Corporate Nurse, Corporate Regional [NAME] president, DON, and Corporate Clinical Leader RN were informed of the IJ. The interim Administrator was provided with the IJ template on 8/5/25. Please see the attached POR for F604 Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal Interventions: On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. The surveyor monitored the facility's plan of removal and confirmed it was sufficient to remove the IJ t Monitoring of the facility's Plan of removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a long way. She said you could take them to the bathroom, start an activity, just go down the list basically until something works. She said you could look in their care plan and see if there's any interventions in there. She said check to see if they are wet or hungry or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced 8/26/25 and earlier in the week by the RN Corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM, she stated she was Inserviced on 8/19/25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care She stated she learned about isolation. She stated the Corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the Administrator, whether it's an interim or permanent Administrator. She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement. She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion. She said unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive. She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off. She stated the Abuse Coordinator is the Administrator. During an interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25. She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed. All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator. The restraint policy is no restraints. We learned about resident rights that they have the right to be abuse free. Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse . Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inse[TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to implement policies and procedures for reporting when the administrator and the State Survey Agency were not notified immediately notified of abuse on 8/17/25 when 4 facility staff (LVN A, RN B, NA C, and Laundry attendant D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and held the door closed so that he could not leave his room. The abuse was not reported to the administrator until 8/19/25. This failure could place residents at risk of physical injury, psychological trauma, and severe emotional distress.An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 5:07 PM While the IJ was removed on 9/14/25, the facility remained out of compliance at a scope of isolated, and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. Findings include: A record review of the facility policy Abuse/Neglect, dated as revised 9/9/24, revealed the following [in part]: Policy Statement: Reporting any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse neglect or exploitation must report this to the Don, administrator, state, and our adult Protective Services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated. Employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury and unknown source to the facility administrator. The facility administrator or designee will report to HSC all incidents that meet the criteria of provider letter 2024-14 dated 8/29/24. A record review of Provider Letter No. 2024-14, dated 8/29/24 revealed the following [in part]: 1. Abuse: A NF must report incidents a nursing facility must report to CII the following types of incidents in accordance with applicable state and federal requirements: abuse, neglect, exploitation, due to unusual circumstances, a missing resident misappropriation drug theft, suspicious injuries of unknown sources, fire emergency situations that pose a threat to resident health and safety, communicable disease, situations that are an unusual or abnormal event that possess a threat to resident health and safety. Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Record review of Residents #1's nursing progress note Author: LVN EEffective Date: 08/17/2025 3:30 PM Type: Nursing NoteNote Text: Resident was being combative with staff and was escorted back to room, Resident started throwing things at the window in his room and broke his window, Police and EMS was called to deescalate the situation. Will continue to monitor, Hospice gave new orders for Haldol 5mg/1ml. Resident has been given Haldol 5mg/1ml, POA notified. Interventions: 1 on 1 monitoring, Directed to the resident's room to decrease stimulation, Assess for pain. Record review of the Incident Investigation Worksheet, dated 8/19/25, revealed the following [in part]: It was reported to the DON on 8/17/25 that Resident #1 threw a drawer through his window. During the course of investigation, it was discovered on 8/19/25 that the resident had previously thrown an over bed table out of a room at the staff and that the staff carried Resident #1 to his room, put him in his room and held the door closed. The staff members were suspended pending investigation. Inservice on abuse/neglect. Family notified; physician notified. An observation on 8/19/25 at 12:24 PM of the electronic monitoring system video dated 8/17/25, showed these events: -At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents' rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. -At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway, Resident #1 became agitated when housekeeping staff took the fan away from him. -At 2:53 PM Resident #1 walked out of his room with a bedside table and pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. -At 2:55 PM Resident #1 started running toward NA C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand, it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. NA C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swing the cord. Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity, RN B motioned with her hand to two unidentified residents that was sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. NA C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held on to the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident #1 as he tried to kick laundry staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. NA C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room ran out of the room and closed the door of his room. During an interview on 8/21/25 at 1:04 p.m., the DON stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/19/25. The DON stated her expectation of them was to fully inform her of the situation on 8/17/25 and the severity of the behaviors and the interventions they had been used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated abuse should have been reported immediately to the administrator and all staff were responsible to do this. During an interview on 8/21/25 with the Administrator at 1:24 p.m., she stated she was notified by the DON at 4:58 p.m., that the resident had broken the window out in the room. She stated that is all she was told until 8/19/25 when she viewed the video. The administrator stated she was notified at 4:58 p.m., by the DON that Resident #1 was agitated and punched out the window in his room. She stated she called maintenance to go to the facility to fix the window at that time. During an interview on 8/21/25 at 2:18 p.m., LVN A stated it was a collective decision of the 4 staff to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated she told the DON that they forcibly carried the resident down the hall and held the door in his room closed so that he could not get out and the DON was aware of what all occurred on 8/17/25 on that date. During an interview on 8/20/25 at 11:51 a.m., LVN E stated she worked on 8/17/25. and was coming out of the med room and turned to the right and saw Resident #1 had a cord in his hand. He was swinging it around and all the other staff was trying to get it out of his hands. Two of the nurses had grabbed his arms, and 2 other people grabbed his legs and carried him back to the room because he was fighting. They ended up putting him in his room and closed the door. They kept the door closed by holding the doorknob. One of the aides was holding the door and he was grabbing stuff in his room and throwing it and broke the window. She stated she had asked NA C if she could open the door because he was pushing on the door and hitting the door trying to get out. The EMS and the police had arrived by this time. After that he settled down. She stated she had tried to call the DON, but she didn't answer, and she told the other nurse (LVN A) to call the DON. We were all trying to call to see what we could do in that situation. LVN E stated she was concerned about the way the incident was handled because of him acting out like that. She stated that with Alzheimer's it was kind of tricky on how they respond, and things were getting worse. She stated the administrator was the abuse coordinator. She stated the types of abuse are physical. mental, sexual, verbal. She stated during the incident with Resident #1 on 8/17/25, she didn't like that they had to restrain him. She stated, I was trying to tell them (the other staff present) that I felt uncomfortable. She stated she didn't like how it was done by the staff or the police restraining him. I did not like the situation because I don't think I've had to restrain a patient in a long time, so it just did not make me feel comfortable. To my knowledge I thought that the Administrator and the DON knew about it, but when I talked to them, they had told me they did not know about it. This was determined to be an Immediate Jeopardy (IJ) on 9/12/25 at 2:04 PM. The Interim Administrator, Corporate Compliance Nurse, Corporate Regional [NAME] President, DON, and were informed of the IJ. The interim Administrator was provided with the IJ template on 9/12/25 2:04 PM. The following Plan of Removal was accepted on 9/13/25 at 1:15 PM: Please see the attached POR for F609. Please note that our dates will reflect 8/19, when our POR was completed after facility identified correction needed. Plan of Removal:Facility: Peach Tree Date: 9/12/25Plan of RemovalProblem: F609 Reporting of Alleged ViolationsAll residents had the potential to be affected by this deficient practice. Interventions:1. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topic as of 9/12/25. The Administrator will report to the State immediately or within 2 hours any incidents in accordance with state and federal requirements of abuse in situations that are an unusual or abnormal event that poses a threat to residents' health and safety. A post-test was provided to the Administrator and DON by the Regional Compliance Nurse. Completed 9/12/25.2. On 8/19/25, staff members NA, LVN and Laundry Aide were immediately suspended by the administrator. LVN returned 9/5/25 and the Laundry Aide returned 8/25/25. NA was terminated on 8/30/25. Completed 9/5/253. 1:1 in-service was conducted with both employees by the secure care consultant and Regional Compliance Nurse. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.4. On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25.5. On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25.6. The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25.7. On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25.8. On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25.9. On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/2510. The medical director was notified of the immediate jeopardy by the Administrator on 9/12/25.11. On 9/12/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 9/12/25.12. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Inservices:The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. All staff will report abuse immediately to abuse coordinator (administrator). If the abuse coordinator is not available, the DON will be notified immediately. Examples of abuse are physical, verbal, sexual, and emotional. Specific examples are mentioned on the policy. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints, seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitely. The ADO/Compliance Nurse/Designee staff are at the facility 7 days a week interviewing staff for comprehension and reviewing facility monitoring tools and video footage of any new incidents reported that may require state reporting. 15- 20 staff members are asked situational questions per week related to abuse and neglect.13. Upon return, staff members brought back from suspension were given secure care dementia training on crisis vs. non crisis, The role of the care plan, and abuse reporting by the Director of Secure Care Services. Videos were reviewed on how to de-escalate residents with difficult behavior, with a return demonstration of understanding. LVN returned 9/05/25 and the Laundry Aide returned 8/25/25. 14. Risk management is reviewed on a daily risk call with the DON and Administrator to review all events to rule out Abuse and Neglect.15. The Administrator/DON review all events on the video surveillance system immediately upon notification of events and report findings to the risk management IDT to determine state reportable within 2 hours. Abuse and any incident that results in serious bodily injury is reportable within 2hrs.16. There is a daily 3 o'clock call with the ADO/RCN reviewing risk management, any incidents of behaviors or allegations for reportable purposes to ensure timely reporting. The facility's plan of removal monitored and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM and on 9/14/25 from 6:00 AM to 1:00 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a long way. She said you could take them to the bathroom, start an activity, just go down the list basically until something works. She said you could look in their care plan and see if there's any interventions in there. She said check to see if they are wet, hungry, or thirsty. She stated the facility is a restraint free facility. She stated she was inserviced 8/26/25 and earlier in the week by the RN Corporate Nurse and she has a handout to keep in her pocket at all times for reference. During an interview with CNA K on 8/26/25 at 11:10 AM, she stated she was Inserviced on 8/19/25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care She stated she learned about isolation. She stated the Corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets. She stated all allegations of possible abuse must be reported immediately to the Administrator, whether it's an interim or permanent Administrator. She stated abuse is to be reported immediately at the time it happens. She stated residents have the right to be abuse free. She stated that meant no restraints or involuntary seclusion and unnecessary confinement. She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion. She said unreasonable confinement can cause unnecessary trauma. She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive. She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off. She stated the Abuse Coordinator is the Administrator. During an interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25. She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed. All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator. The restraint policy is no restraints. We learned about resident rights that they have the right to be abuse free. Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse . Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25. She stated the following topics were discussed by the RN Consultant: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care - the use of unauthorized restraints, seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During an interview with the MDS Nurse on 8/26/25 at 11:40 AM, she stated she was Inserviced on 8/19/25. She stated she had a sheet to keep with her at all times. She stated the Inservice covered the following areas: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care - the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25. The topics included: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. She showed a copy of the handout to the surveyor that she was given to keep in her pocket and it . Resident Rights -[TRUNCATED]

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to implement de-escalation techniques listed on the care plan were not implemented when 4 facility staff , (LVN A RN B, NA C and Laundry staff D) grabbed Resident #1 and forcibly carried him by his extremities to his room. The staff placed Resident #1 in his room and forcibly held the door closed so that he could not leave his room. An Immediate Jeopardy was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 5:07 PM While the IJ was removed on 9/14/25, the facility remained out of compliance at a scope of isolated, and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of their corrective actions. These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs and maintain their highest level of well-being mentally and physically. Findings include: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 5 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's care plan last revised on 8/18/25 included: Focus The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by initiated 1/3/24. Hospice to evaluate medication list with psych initiated 3/17/25. If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby initiated 4/22/25. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed initiated 12/5/23. Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his granddaughter and let him speak to her initiated 3/13/25.Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/`4/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possible.Involve resident in secure unit activities.Notify physician and family of changes.Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25.Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider.Perform the following de-escalation techniques (there were no de-escalation techniques listed for staff to implement). An observation on 8/19/25 at 12:24 PM of the electronic monitoring system video dated 8/17/25, showed these events: -At 2:20 PM Resident #1 began showing behaviors which included: wandering into other residents' rooms, taking items from other residents rooms, dropping clothing items in the hallway, and pulling a bedside table down the hallway. -At 2:44 PM Resident #1 went into another residents' room and took a small fan out of that room and carried it down the hallway, Resident #1 became agitated when housekeeping staff took the fan away from him. -At 2:53 PM Resident #1 walked out of his room with a bedside table and pushed the bed side table forcefully into RN B and hit her in the shins of both legs. RN B and NA C walked away towards the nurses station and Resident #1 walked after them. -At 2:55 PM Resident #1 started running toward NA C down the hallway towards the nurses station with a call light cord which resembled an outdoor extension cord in his hand, it had an approximately 1.5-inch metal prong on one end and the other end was plastic with a red call button on the end in his hand. NA C started running away from Resident #1 toward the nurses station. Resident #1 swung the call light cord while he ran toward the nurses station following staff. He bumped into laundry staff D as he ran, and she held her hands up in the air. Resident #1 continued to run and chase the staff and was swing the cord. Resident #1 tripped on a chair and fell to the floor. There were four other residents in the vicinity, RN B motioned with her hand to two unidentified residents that was sitting in the row of chairs at the nurses station to go down the hallway away from Resident #1. The two residents walked away. NA C removed another resident away from Resident #1 down the other hallway. An unidentified 4th resident stood back and watched. Laundry staff D held on to the cord and sat in a nearby chair as Resident #1 held the cord and sat on the floor. RN B and LVN A walked around Resident #1 as he tried to kick laundry staff D. RN B and LVN A grabbed Resident #1 by the arms and twisted his body to lay on his back. They pulled him approximately 5 feet on the floor. Resident #1 tried kicking and resisting staff as the laundry staff got up and hung on to the cord and walked beside them down the hall as they continued to drag him. Resident #1 continued to kick with both feet to resist the staff. LVN A moved to his right leg as he tried to kick her. NA C held on to his left arm. Resident #1 kicked with both feet as LVN A move to his left leg and laundry staff grabbed his right leg. The 4 Staff picked him up off the floor by his extremities with no support to his back or midsection and carried Resident #1 to his room. Staff carried him into the room ran out of the room and closed the door of his room. During an interview on 8/21/25 at 1:04 p.m., the DON stated she did not know how her staff handled the incident with Resident #1 until she watched the video on 8/1925. The DON stated her expectation of them was to fully inform her of the situation and the severity of the behaviors and the interventions they had used when they called her. She stated she was aware that he was agitated, and he had broken his bedroom window and that was all I was told. She stated she would have liked to have seen RN B, LVN A, Laundry staff D, and NA C put the safety of the other residents first and remove them from the situation. She further stated she would have liked to have seen them keep him in eyes view and not congregated around him. She stated that she could see that he could feel threatened by the staffs actions. She stated in that situation she would have gotten down on the ground on the residents level and asked him in a calm voice what can I do to make you feel safe. She stated she felt the staff acted the way that they did because they felt threated and needed more education. She stated it was the responsibility of the nurses to update care plans and monitor to see that interventions were followed. She stated she felt the failure occurred because the staff needed education. She stated she expected staff to follow the care plan She stated an adverse outcome for the resident was that he did not receive the behavioral interventions he needed to de-escalate. During an interview with the Administrator on 8/21/25 at 1:24 p.m., she stated she would have liked staff to follow the resident's care plan and make an attempt at de-escalation of the situation first. She stated she did not expect them to move him down the hall in the manner that they did. She stated she would have preferred to have her staff step back and not take items away from Resident #1 if the items were not doing any harm to him or the other residents. She stated they could not see him. She stated she would have liked to have seen the staff keep Resident #1 in eyes view, because the video showed the resident was obviously upset and angry. She stated she would have preferred that the staff did not congregate around Resident #1. During an interview on 8/21/25 at 2:18 p.m., LVN A stated it was a collective decision of the 4 staff present to forcibly carry the Resident #1 to his room and hold the door shut. She stated they did it this way because it was easier for them to carry him down there, put him in his room and hold the door shut, than it was to get the other residents out of the way. She stated they did not try any other interventions because they knew it would not do any good. During an interview with Resident #1's POA on 8/21/25 at 3 :15 p.m., she stated the facility did not notify her of the behaviors Resident #1 was exhibiting and that they had restrained him, secluded him or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened , but stated was told to by Hospice that it started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated: I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. She stated she had discussed with staff and asked that she be called when he had behavioral issues. She stated so much more could have been done to prevent the incident if they followed the intervention to call her before his behavior escalated. Record review of the facility policy Comprehensive Care Planning, not dated stated in part: The facility will develop and implement the comprehensive person-centered care plan for each resident consistent with the residents rights that includes measurable objectives and time frames to meet a resident medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the highest practicable physical, mental and psychosocial well-being, and the right to refuse treatment. The following Plan of Removal was accepted on 9/13/25 at 1:15 PM:Peach Tree September 12, 2025 Plan of RemovalF656 Develop/Implement Comprehensive Care Plans Intervention:All residents care plans reviewed by Regional Compliance Nurse and DON to ensure proper interventions are in place for all residents with behaviors on 9-12-25. 40/40 residents care plans identified to have behavior care plan in place with interventions. All care plans were verified to have the appropriate interventions for behaviors.The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on care plan policies and procedures, Comprehensive Care plans of residents with behaviors with interventions to implement for resident overall mental, physical, and psychological health on 9/12/25. Post test was completed for the comprehension of the in-service.All staff will be in-serviced on 9/12/25 by the DON/designee regarding the following and all staff not in-serviced by 9/12/25 will not be allowed to work in their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Comprehensive Care Plan- Clinical staff were educated on how to access the resident care plan/Kardex for residents with behaviors to review the interventions to implement for residents overall mental, physical, and psychological health on 9/12/25. The IDT will review and reassess care plans and interventions quarterly, and as needed for changes of condition in the resident by the IDT. On 8/19/25 the staff involved in the incident were suspended, they were educated upon suspension and upon return to the facility. The Secure Care Specialist had additional Dementia and Secure care training with staff. On 9/8/25 staff were given education, by Secure Care Specialist, along with a scripted scenario of the actual event that took place then they were asked questions after she gave the scenario to ensure comprehension. She also educated staff on their responsibility to protect residents and themselves, to include what is abuse and neglect, and exploitation, Reporting steps, who to tell, why reporting matters, and how to de-escalate. Resident #1 has rummaging boxes added on 8/25/25 to his care plan as an intervention to distract him when he is wandering looking for his items. On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25.On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25.On 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25.The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25.On 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25.On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. Completed 8/19/25.On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25The medical director was notified of the immediate jeopardy by the Administrator on 9/12/25.On 9/12/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 9/12/25.The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de- escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove al residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. Inservices: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de- escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitely. Compliance nurse/designee will monitor weekly for care plan behavioral intervention implementation; findings will be addressed immediately. Interventions:On 8/19/25, staff members LVN A, RN and NA were immediately suspended by the administrator. Completed 8/19/25. All three staff members remain suspended as of 8/25/25. Verified 8/26/25 @ 3:53 PM.On 8/19/25 Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders. Completed 8/19/25. (Completed by [NAME] LVN) Verified 8/26/25 @ 4:13 PMOn 8/19/25 Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted. Completed 8/19/25. Verified 8/26/25 @ 4:13 PM The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents. This was completed on 8/19/25. Verified 8/26/25 @ 3:40 PMOn 8/19/25, safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted. Completed 8/19/25. Verified 8.26.25 @ 4:00 PM On 8/19/25, head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered. 8.19.25 Verified 8.26.25 @ 4:20 PM On 8/19/25 staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted. Completed 8/19/25 Verified 8.26.25 @ 4:20 PM The medical director was notified of the immediate jeopardy by the Administrator on 8/25/25. On 8/19/25 an ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 8/19/25.Verified 8/26/25 @ 4:26 PM The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies. Completed 8/19/25.Verified 8.26.25 4:27 PMAbuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician. In-services: The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 8/19/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completed 8/20/25. Verified 8.26.25 from 10 :07 AM to 12:00 Noon. Horn RN Interviews completedAbuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement. All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent. Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement. Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma. Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily. A reasonable rationale for a restraint is when all other interventions have been attempted. A restraint evaluation will be completed. The resident or responsible party will consent to all restraints. A restraint will not be applied unless ordered by the physician.Monitoring: Administrator/DON/Designee will ask 15-20 staff members per week situational questions related to abuse. Any corrective action needed from situational questions will be addressed immediately with a 1:1 written in-service prior to returning to work. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will ask 5 residents per week how staff treat them. Any corrective action needed from resident interviews will be immediately reported to the Abuse Preventionist and an internal investigation will be conducted. Monitoring will begin on 8/25/25 and will continue indefinitely. The Administrator/DON/Designee will complete incident/event reviews in daily standup to ensure the facility is free of any potential abuse/neglect. Monitoring will occur 7 days per week beginning 8/25/25 and will continue indefinitelyThe facility's plan of removal monitored and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 8/26/25 at 9:58 AM to 5:30 PM and on 9/14/25 from 6:00 AM to 1:00 PM as follows: During an interview with LVN F (6AM- 6PM shift) on 8/26/25 at 9:59 AM, he stated he was Inserviced on 8/19/25 and 8/26/25 on the abuse and neglect policy, trauma informed care assessments, the restraint policy for the facility, behavior management. He stated a restraint is holding their arms down or holding their door shut would be isolation. He stated restraints, involuntary seclusion, and unreasonable confinement were not tolerated and prohibited in this facility. During an interview with LVN G (6AM - 6PM shift) on 8/26/25 at 10:10 AM, she stated she was Inserviced on 8/19/25, and 8/26/25 by the Corporate Nurse. She stated, neglect is not doing things for patients intentionally and just let them sit all day in their chair, not changing them, not making sure that they've eaten. Abuse can be verbal, it can be physical, it can be mental. She stated, I have my Cheat Sheets with the highlights of the Inservice on it. You can't use restraints, secluding them involuntarily and unreasonable confinement is abuse. You report everything to the Administrator. The Administrator is the abuse coordinator, and you should report it immediately when it happens. That way you've reported it because you realize it could be wrong or considered abuse. She stated, We are actually a no restraint facility. That is a big No, no. You use Behavior management which would be doing every single thing that we're supposed to do first. Make sure that they've been to the toilet, see if they need a drink or if they are wet, go for a walk, start an activity. During an interview with CNA H (6AM - 6PM shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25. She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health. She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing. Even if the physician does know, then is it still a restraint and you shouldn't do that. She stated, I would have to report it to the Administrator immediately. Resident rights means that residents have the right to ask for snacks or anything they need . They have the right to our respect and to be free from abuse or seclusion. Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first. Never do it without the permission of the physician. She stated she would look in the Kardex or care plan for resident specific interventions. During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents. She stated you report abuse immediately. She stated she had never witnessed abuse in the facility. She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it. She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility . She stated they learned about rights. They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to. She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation. Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to. She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention. She stated you can always try later after they are calm. During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space. She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a[TRUNCATED]

Based on record reviews and interviews the facility failed to develop implement and maintain an effective training program for all new and existing staff individuals providing services under a contractual management and volunteers consistent with their expected roles for 2 of 12 employees (LVN A and RN B) reviewed for required training. The facility failed to ensure LVN A and RN B had annual dementia and restraint reduction training. This failure could place residents at risk of receiving care from individuals who have not been properly trained. Findings include: Record review of employee training files reflected LVN A was hired 3/1/24 and her last dementia training was dated 3/15/24 . There was no evidence of restraint reduction training in her file other than a copy of a restraint reduction policy that was signed on 10/13/24. Record review of RN B's Employee files reflected the date of hire as 1/16/25. Ungraded dementia test dated 1/16/25. No restraints training. During an interview on 8/23/25 at 1:30 PM, LVN A stated Everyone that works in that building has had training for dementia and behaviors. We have in-services. We were supposed to do an in-person course not too long ago on behaviors and dementia, but it got cancelled. We have all our courses online now, and that is where the dementia and behavior is located. At the beginning of the month, Admin staff will go over stuff before we get our check. The old ADM did it before. The HR lady that quit has also done it before. It's just verbal and then you sign it at the end. They read it and there has been other ones we read, and sign stated she doesn't remember dates. LVN A did not answer when her last training was on behaviors and dementia. During an interview on 8/23/25 at 0:00, RN B she stated: I don't recall any training on dealing with behaviors. They say no restraints or nothing like that, and I absolutely support that. The interim administrator stated in an interview on 8/23/25 at 2:00 PM, the staff was responsible to complete their own training online. She stated each employee knows how to sign in and the trainings are assigned by the program for them to do. She stated the company had recently changed training programs which made it more difficult to keep up with the employee's progress. The administrator stated the facility was currently without an HR person, she recently resigned. She stated she would look for a training policy, a policy was not provided by the time of exit.

Based on interview and record review, the facility failed to immediately inform the resident/resident representative and consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure LVN A and LVN E communicated to the physician and POA a change in Resident #1's behavioral status that led to a change in his treatment regimen.The facility failed to ensure that RN NB communicated to the physician and the POA a change in Resident#6's health status that led to a change in his treatment regimen. This failure could place residents at risk of unmet physical and psychosocial needs, physical harm and a decrease in quality of life. The findings included: The findings included: Record review of Resident # 1's face sheet dated 8/24/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life that can lead to a range of behavioral symptoms), anxiety disorder ( a nervous disorder that significantly impairs daily life by causing constant, debilitating fear and worry that make every day activities difficult to complete), unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), and Alzheimer's Disease . Record review of Resident #1's Quarterly MDS, dated [DATE] revealed in Section C that he had a BIMS score of 05 which indicated severe cognitive impairment. Section E behavior indicated no psychosis, no presence of physical behavioral symptoms directed toward others, no presence of verbal behavioral symptoms directed toward others, and he had no behaviors such as wandering, pacing, or rummaging. Section N indicated the resident did not take an antipsychotic or an antidepressant since admission, re-entry or the last OBRA assessment. Record review of Resident #1's active physician orders dated 8/20/25, reflected Resident #1 had an order dated 10/17/24 which reflected: Admit to secure unit due to history of elopement with exit seeking behavior. There was no order for physical restraints. There was a one-time order for Haldol 5 mg/ml 1 time only for 1 day. Record review of the Resident #1's MAR dated 08/2025 reflected that Haldol 5mg was administered at 6:49 PM on 8/17/25. Record review of Resident #1's Skin Assessments revealed:effective 8/17/25 and signed by the ADON on 8/18/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Left pinky finger and a 2-centimeter x 2- centimeter to his left upper arm.effective 8/19/25 and signed by the ADON on 8/19/25 reflected a 2-centimeter x 2-centimeter skin tear of Resident #1's Right ring finger and a 2-centimeter x 2- centimeter to his left upper arm. Record review of Residents #1's Nurse's Progress Notes revealed: Author: LVN EEffective Date: 08/17/2025 3:30 PM Type: Nursing NoteNote Text: Resident was being combative with staff and was escorted back to room, Resident started throwing things at the window in his room and broke his window, Police and EMS was called to deescalate the situation. Will continue to monitor, Hospice gave new orders for Haldol 5mg/1ml. Resident has been given Haldol 5mg/1ml, POA notified. Interventions: 1 on 1 monitoring, directed to the resident's room to decrease stimulation, assess for pain. Record review of Resident #1's care plan last dated revised on 8/18/25 included: Focus: The resident has a behavior problem - will become aggressive with staff and residents pushing and hitting. Purposely places himself on the floor. Interventions: Caregivers to provide for positive interaction, attention, stop and talk with him as they pass by (1/3/24); Hospice to evaluate medication list with psych. (3/17/25); If resident becomes aggressive towards another resident remove him from the situation. Take him to a quiet area to talk. Resident likes to talk, walk outside and sit on the couch in the lobby (4/22/25); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate place location as needed (12/5/23); Resident enjoys prayers. When resident is combative ask him if he needs to pray (3/13/25); When resident has increased confusion and or combativeness call his granddaughter and let him speak to her (3/13/25) Focus: Resident is at risk of feelings of isolation due to being on a secure unit because of high risk of elopement Revised 5/4/25.Interventions: Admit to secure unit per Dr orders.Assist and monitor resident for off unit activities if possible.Involve resident in secure unit activities.Notify physician and family of changes. Focus: The resident has a history of trauma that may have a negative impact. Created 8/11/25 by DON and interventions initiated on 8/11/25. Interventions: Monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, physician, and mental health provider.Perform the following de-escalation techniques (there were no de-escalation techniques listed for staff to follow) During an interview on 8/21/25 at 2:28 PM with the DON, she stated as far as she knew no one notified the attending physician until she did on 8/21/25. During an interview on 8/21/25 at 3 :10 PM, Resident #1's POA stated the facility did not notify her of the behaviors her grandfather was exhibiting and that they had restrained him; or that he had broken the window out in his room. She stated she did not give consent for restraints or Haldol to the facility before the medication was given. She stated the person that notified her was a Hospice nurse after it was all said and done. She stated she did not know why she was not notified sooner in the day. She stated she got mixed reports from the facility on how and when this had all happened, but stated she was told by Hospice that it had started earlier in the day, and she felt she should have been called then. She said if she had known she would have come up to the facility and helped calm him down. She stated, I don't understand why the police were called on a [AGE] year-old man that has dementia and was placed in a facility that specializes with Alzheimer's and dementia. During an interview on 8/21/25 at 3:15 PM, the Hospice RN stated I can tell you that when I arrived at the facility on 8/17/25 the patient was in his room, and because of his actions they had called the police. There was three police officers which was outside the room, they had also dispatched out a fire truck. There were three firemen, two paramedics, Resident #1 was on the bed. They were trying to get his vital signs and put him on a heart monitor. I had spoken to the hospice doctor on my way to the facility because I had been notified that he had thrown a drawer and broken a window and had also struck a couple of people before I got there. I talked to the hospice doctor on the way in about how to handle the situation. He gave me some medication orders. I took those orders and when I got there and the EMS crew was working with him to get his vital signs, I had LVN A, get the medication that I needed to give him for the agitation and combativeness from the emergency supply. After we did that, we went back into the room, and he was not as combative when we got back. The paramedics asked me what I wanted them to do with him. They wanted to know if they should transport to the hospital him since he was hospice. I told them the Hospice Dr. would like for him to stay here, if at all possible, that's why I gave him this medication. I told them we would get more medication. He stated he then went down and talked to the nurse, and she asked if I notified the POA. I said no and then called the POA and told her what had occurred. The POA was frustrated and complained that the facility or someone should have called her earlier. During an interview on 8/21/25 at 4:32 PM, the Hospice Physician stated: I do believe that the situation with Resident #1 was handled appropriately by calling Hospice, and I do believe that they attempted preventative measures prior to chemical sedation and physical restraints according to the information the facility relayed to the Hospice RN who notified me. He stated The fact that two faculty staff had been assaulted, and I believe the chair had been thrown into a window damaging property. This could also potentially harm the resident as well. I do think that they managed it appropriately. During an interview on 8/21/25 at 4:50 PM, the Primary physician of Resident #1, he stated he was not informed of the incident with Resident #1 until he was notified by the DON on 8/19/25. He stated he could not comment on whether he thought the situation was handled appropriately because he was not informed at the time of the incident. Record review of Resident # 8's face sheet dated 9/17/25, reflected he was a [AGE] year-old male readmitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbance (a condition characterized by progressive and persistent loss of intellectual functioning with impaired memory and abstract thinking and personality change resulting from organic disease of the brain), malignant neoplasm of the lung (a cancerous tumor), malignant neoplasm of the prostate (a cancerous tumor), and stage 3 pressure area of right buttocks ( full thickness skin loss that extends into the subcutaneous tissue, but does not expose muscle, tendon, or bone). Record review of Resident #8's Discharge MDS, dated [DATE] revealed in Section C that he had a BIMS score of 0 and had severe memory impairment and cognitive impairment. Section K documented he had no pressure areas or other skin problems. Resident was incontinent of bowels and had a suprapubic catheter (a catheter placed directly in the bladder to drain urine from the bladder). Record review of Resident 8's active physician orders dated 9/17/25, reflected an order dated 9/9/25 and a start date of 9/10/25 to cleanse wound to right buttocks cheek and pat dry. Apply collagen sheet and exuderm ( a hydrocolloid dressing designed to keep a moist wound environment) three times weekly. Record review of Residents #8's Nurse's Progress Notes dated 8/27/25 revealed:Effective 8/27/25 8:00 PM: Nursing NoteNote text: Initial skin assessmentSkin color: NormalTemperature of skin: warmBruise present: noAbrasion present: noLaceration present: noSurgical incision present: noRash Present : noMoisture associated skin damage: noPressure, venous, arterial or diabetic ulcer: yes. Stage 1 on coccyx (redness on intact skin that does not turn white when pressed and often feel swarmer, firmer, or softer than the surrounding skin)Record review of a nursing progress note:Author: DONEffective date: 9.8.25 at 12:30 PMNote text: In Part: .Cognitive impairment, requires cueing. Resident # 8 was in his wheelchair in the dining room and trying to remove himself from the lunch table. Another resident attempted to move out of the way and ran over his foot with her wheelchair. Resident #8 yelled and hit the other resident on the right side of her head. X-ray of foot ordered. Resident stated that hurt! MD/NP notified 9/8/25 at 1:00 PM. Responsible part notified 9/8/25 1:00 PM Record review of Nursing Progress note : Effective Date: 09/8/2025 3:30 PM Type: Nursing NoteNote Text: Resident was noted to have a pressure area on the right buttock, appearing to be nearly a Stage 3 ulcer. The area was cleansed thoroughly, and wound care was notified. Wound care is scheduled to see he resident tomorrow. The resident will be monitored closely for changes or complications. During an interview on 9/16/25 with NP of Resident #8, she stated she last saw Resident #8 on 8/28/25. She stated he was sitting at the desk in his wheelchair. She stated she based her assessment on the information received from the nurses and she did not receive information that he had a pressure area on that date or since that time. She stated it was her expectation that the nurses monitor the resident's skin and notify her of any condition changes or changes in their plan of care. She stated she would have ordered a pressure relieving mattress on his bed and to reposition the resident every 2 hours to avoid pressure on pressure points. During an interview with the DON on 9/17/25, she stated she did attempt to notify Resident # 8's responsible party regarding the incident on 9/8/25, but she did not speak with him because he did not answer the phone. She stated she did not leave a message. She stated she should have documented this in her progress note dated 9/8/25. She stated she did not know why she failed to do so. During an interview on 9/18/25 at 11:30 PM with RN NB, she stated she did not notify the primary physician or the residents POA of the Stage 3 Pressure Area. She stated she was very busy and did contact wound care but failed to notify the Resident #8's family member/POA. She stated failure to notify the physician, and the family could prevent the resident from receiving timely and needed treatment. During an interview on 9/14/25 at 4:50 PM, the Primary physician of Resident #8, he stated he was not informed of the Stage 3 Pressure area on Resident #8 on 9/8/25. He stated he usually left wound care to the wound care physician since he was the expert in that area. During an interview on 9-18-2025 at 7:40 am with the wound care physician, he stated the Resident # 8's Stage 3 pressure area on his right buttocks had decreased 44% since his last visit on 9/10/25. He stated 9/10/25 was the first time he saw Resident #8. He stated he was not notified prior to that date. Record review of the facility policy titled Resident Rights dated revised 11/28/16, stated in part: The resident has a right to a dignified existence self-determination and communication with an access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity, and care for each resident in a manner and in an environment which promotes maintenance or enhancement of his or her quality of life. Recognizing each resident's individuality, the facility must protect and promote the rights of the resident. Notification of Changes - The facility must immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority resident representatives when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention. Of the significant change in the residence physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status, and either life threatening conditions or clinical complications.A need to alter treatment significantly, that is a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment, or a decision to transfer discharge resident from the facility.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 (Residents # 21, #25, and #145) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #21 had a care plan in place regarding hospice services. The facility failed to ensure Resident #25 had a care plan in place regarding her diagnosis of seizure disorder. The facility failed to ensure Resident #145 had a care plan in place regarding his DNR status. These failures could place residents at risk for not receiving appropriate care and supervision. Findings included: Record review of Resident #21's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to thrombosis of right middle cerebral artery (a stroke caused by a blood clot in an artery that supplies oxygen and nutrients to the right side of the brain). Record Review of Resident #21's Significant Change MDS assessment dated [DATE] revealed he had a BIMS score of 4 indicating severe cognitive impairment, a diagnosis of Cerebral Vascular Attack (stroke), and that he was receiving hospice services. Record review of Resident #21's Order Summary Report dated [DATE] revealed an order to Admit to 'hospice company' for diagnosis cerebral infarction dated [DATE]. Record review of Resident #21's comprehensive care plan, most recent revision date of [DATE], revealed no care plan in place regarding the resident's hospice services. Record review of Resident #25's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of [DATE], with diagnoses including metabolic encephalopathy (brain dysfunction resulting from metabolic imbalances or underlying conditions) and dementia. Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment and she received anticonvulsant medication. Record review of Resident #25's Comprehensive Care Plan, most recent revision date of [DATE], revealed no care plan related to her diagnosis of seizure disorder. Record review of Resident #25's Order Summary Report dated [DATE] an order for oxcarbazepine 150mg by mouth twice a day for seizures dated [DATE]. Record review of Resident #145's admission Record revealed he was an [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admission date of [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), liver failure, Type 2 Diabetes mellitus, and a history of lung cancer. Record review of Resident #145's miscellaneous documents revealed an Out of Hospital Do Not Resuscitate form signed and dated [DATE]. Record review of Resident #145's Comprehensive Care Plan, most recent revision date [DATE] revealed no care plan in place regarding the resident's DNR status. In an interview on [DATE] at 9:18 am LVN B stated if she walked in a room and a resident was not breathing, she would ask another nurse or aide to go look in the chart to check the code status. She stated when nursing staff opened a resident's electronic health record, the header had the resident's code status on the front page, or they could look at the documents scanned into the resident's chart to see what was is uploaded, or in the orders, or care plan. She stated if there was conflicting information she would talk to the DON, Administrator, and/or family to get clarification and the correct documentation. She stated an adverse outcome would be breaking the wishes of the resident if he/she wanted to be a DNR, but the computer showed them to be a full code somewhere such as in the care plan. In an interview on [DATE] at 09:23 am the DON stated the chart would say on the header, and there was also a DNR book at the nurse's station. She stated that a copy of all DNR's were uploaded into chart under Miscellaneous. She stated if a nurse walked in on a resident and isn't sure, he/she would ask someone to go get the book to find code status. She stated if there was not a DNR on file or uploaded into the electronic health record, the resident was considered a full code. She stated her expectation was if the staff do not see a DNR in the book or in the scanned documents, the resident was considered a full code. The DON stated that an adverse outcome would be bringing someone back that didn't want to be brought back. The DON stated the MDS Coordinator completed the admission MDS assessment and initiated the care plan and diagnosis list on admission, and the DON added all the medications into the resident's chart. The DON stated that all nurses were responsible for putting in orders after the admission process was completed. She stated the DON reconciled medications and diagnoses on admission and if there were conflicting orders, or a medication order with a diagnosis not listed in the resident's chart, she would call the diagnosing or prescribing physician to get clarification, and then update the chart (including the care plan) accordingly. She stated an adverse outcome could be the resident receiving the wrong medication, or not receiving the medication they need, and could have adverse side effects. In an interview on [DATE] at 9:32 am the MDS Coordinator stated completing and updating care plans was is a team effort. She stated she would look in the electronic health record on the resident's header to verify code status, and/or orders to look for a DNR. She stated there was a book at the nurse's station with a copy of all resident's DNR forms. She stated if there was conflicting information she would go to DON or Social Worker to clarify which one was right for the resident. She stated she was not sure of the expectation for care planning since I've only been doing this February. She stated that an adverse outcome for not having the correct advanced directive information care planned could be that CPR might be performed which would go against the resident's or the family's wishes, the resident could sustain CPR related injuries, and not be able to pass peacefully. The MDS Coordinator stated it was a team effort in completing the diagnosis/medications/orders/care plan for a new resident. She stated the MDS wasis updated annually, quarterly, or if there was a significant change for the resident. She stated she was not sure how the chart was corrected if a diagnosis was not in the care plan but would find out. She stated when a resident went on hospice services, an MDS significant change assessment was completed, hospice staff conducted a medication review, and sent the facility orders for any changes. She stated after receiving information related to hospice services, she would then update the care plan as per the expectation of the DON. She stated she was not sure what adverse outcomes could occur if a resident's care plan was not kept updated. In an interview on [DATE] at 10:15 am the Regional MDS Coordinator stated she found and corrected the care plan for a Resident #21 as hospice had not been added and services were started on [DATE]. She stated the expectation was the care plan should immediately be updated once hospice services start and the MDS Significant Change is done. She stated there really would not be any adverse outcomes to the resident if the care plan was not updated. In an interview on [DATE] at 2:42 pm the Administrator stated that when hospice services were started for a resident, an MDS significant change assessment was completed and an update to the care plan was done to reflect the changes by the MDS Coordinator. She stated the nursing staff collaborate with hospice for orders and care plans. She stated the staff nurses review resident's medications with diagnoses. She stated the previous DON would put in the diagnoses and reconcile them with orders. She stated the procedure was for the floor nurses to put orders in the chart when they were received. The Administrator state that during the facility's daily clinical meetings, department heads updated any information regarding care plans, went over assessments, orders, and diagnoses for each resident. She stated that nursing staff do audits on medication and diagnoses in addition to the medication regimen reviews done by the consultant pharmacist. She stated the MDS coordinator completes the initial MDS Assessment upon admission, MDS wasis updated annually, quarterly, and with any significant changes and based on changes, the RN/DON initiated and completed the care plans, and the MDS Coordinator updates the care plans quarterly and as needed. She stated she could not think of any adverse outcome that could come of the care plan not being updated. A copy of the facility's care plan policy/procedure was requested from the MDS Coordinator on [DATE] and had not been provided to the survey team by the time of exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: A. The food fryer was left in an unsanitary condition, food fryer had not been cleaned after use, food crumbs dried to fryer baskets (2) and inside fryer walls. B. Bottom shelf of food prep table was not clean and hads food crumbs on shelf and food crumbs on container lids containing flour, sugar and powder milk that wasis stored on shelf. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings include: On 5/13/25 at 9:34am during the observation of dietary kitchen, the fryer was not clean, there were had food scraps on the baskets and fryer. Bottom shelf on prep table had , food crumbs on bottom shelf and containers lids of flour, sugar and powered milk lids covered with food crumbs. On 5/13/25 at 10:50am interview with the Dietary Manager, the Dietary Manager stated that the fryer was last used on 5/11/25 for the dinner meal, chicken tenders were fried using the fryer. The Dietary Manager stated that fryer and fryer baskets should have been cleaned after dinner on 5/11/25. The Dietary Manager stated that bottom prep table should be cleaned daily, and container lids should not have food particles on lids. The Dietary Manager stated that there wasis a cleaning schedule that staff wereare to follow, Dietary Manager stated that equipment should be cleaned and sanitized after each use to prevent food borne illness, and the kitchen should be cleaned daily, and no food scraps or particles should be left out as to not attract pests. 5/15/25 at 2:00 PM, in an interview with the Administrator, stated it was her expectation for the kitchen to be cleaned daily, food particles wereare not to be left on food containers or shelves,d,, it should be cleaned up daily, and food equipment should be cleaned and sanitized after use, failure to do so has the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised September 2020, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (LVN A) of three staff reviewed for infection control practices. LVN A did not perform any hand hygiene before or after medication administration for Resident #26, Resident #4, or Resident #8. LVN A did not sanitize reusable electronic wrist blood pressure cuff before or after use during medication administration for Resident #4 or Resident #8. These failures could place residents at risk of the spread of infections. Findings included: During an observation on 05/14/25 at 07:09 AM, LVN A prepared Resident #26's medication without performing any hand hygiene beforehand. LVN A provided Resident #26 with their medication and the resident had a bit of a coughing spell. LVN A provided the resident with additional water and watched resident until she was fine. LVN A then left room, went back to the medication cart, and charted the medication administration via electronic MAR. LVN A did not perform hand hygiene after administering Resident #26's medication. During an observation on 05/14/25 at 07:25 AM, LVN A proceeded to pick up the reusable electronic wrist blood pressure cuff off the medication cart and took blood pressure and pulse of Resident #4. LVN A did not sanitize the electronic reusable wrist blood pressure cuff before or after use and did not perform any hand hygiene before or after taking the measurement. LVN A then went back to the medication cart and began preparing medication for Resident #4. LVN A did not perform any hand hygiene before he began the preparation of the medication. LVN A provided Resident #4 with their medication then left room, went back to the medication cart, and charted the medication administration via electronic MAR. LVN A went to the Medication room and retrieved an over the counter vitamin for Resident #4 that had not been in the medication cart. LVN A, then prepared the vitamin for Resident #4 and went back into the resident room and administered the vitamin to Resident #4. During the time LVN A went to the medication room and prepared the vitamin, he did not perform any hand hygiene. LVN A then pushed the medication cart down the hall to another resident. LVN A did not perform any hand hygiene after he provided Resident #4 with their medication. During an observation on 05/14/25 at 07:39 AM, LVN A picked up the reusable electronic wrist blood pressure cuff off of the top of the medication cart and went into Resident #8's room and obtained a blood pressure and pulse. LVN A did not perform any hand hygiene before or after obtaining the readings. LVN A did not sanitize the reusable electronic wrist blood pressure cuff before or after use for Resident #8. LVN A then preceded to prepare medication for Resident #8. LVN A then provided Resident #8 with their medication and then left the room and charted the medication administration via electronic MAR. During an interview on 05/14/25 at 07:44 AM with LVN A, he stated that he did not perform hand hygiene between each resident medication administration. LVN A said he did not sanitize the reusable electronic wrist blood pressure cuff between each resident use. LVN A said his failure to perform hand hygiene or sanitize the equipment could cause resident infections. LVN A said he just did not have ABHR on his medication cart or in his pocket to sanitize his hands. He did state that the facility had ample supply of ABHR for staff to utilize, but he just simply did not have one at the time of his medication administration. LVN A produced the equipment sanitizer wipes from the bottom drawer of the medication cart and said that the wipes were supposed to be used to wipe down the equipment used for residents before it was used and then again after it was used. During an interview on 05/14/25 at 01:39 PM the RCRN stated that hand hygiene was supposed to be performed between each time a nurse prepared and administered medications to a resident and to sanitize the equipment between each use. During an interview on 05/15/25 at 03:06 PM the DON and RCRN stated that they expected that hands were washed or sanitized before preparing a resident medication and again after administering medication. Then when staff finished administering the medication, they were to sanitize their hands again either by handwashing with soap and water or using ABHR. The RCRN said it was expected that the equipment like a blood pressure cuff would be sanitized before it was used and then after it was used, that way it was ready for the next resident. The DON and RCRN said that they did not have a policy that was for sanitizing equipment such as the reusable electronic wrist blood pressure cuff, but did have a policy regarding sanitizing of the blood glucose monitor for resident use. It was not provided for review. Record Review of LVN A's personnel file revealed a hire date of 11/27/24. LVN A had Infection Control training during orientation dated 12/17/24. Record Review of facility policy labeled Fundamentals of Infection Control Precautions updated 3/24 revealed: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after direct resident contact; . Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); . After contact with a resident's mucous membranes and body fluids or excretions; . After handling soiled equipment or utensils; . Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections . Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR are also appropriate for cleaning hands and can be used for direct resident care.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 3 of 7 staff (LVN #1, [NAME] #2,CNA #3, and CNA #4) reviewed for background screenings. The facility failed to ensure that employees were screened for a history of abuse, neglect, exploitation, or misappropriation prior to employment for LVN #1, Cook# 2, and CNA #3, and CNA # 4. Criminal history checks, and checks of the EMR/NAR were not conducted prior to employment. These deficient practices could place residents at risk for abuse and neglect. The findings were: 1.Review of the personnel file for LVN #1 indicated a hire date of 07/2/2024 and the Criminal History background check was verified on 12/3/24, and initial EMR/ NAR verified on 3/4/25. 2. Review of the personnel file for [NAME] # 2 indicated a hire date of 12/02/2024 and the Criminal History background check was verified on 01/13/2025, and initial EMR/NAR verified on 01/21/2025. 3. Review of the personnel file for the CNA # 3 indicated a hire date of 06/28/2024 and the Criminal History background check was verified on 12/03/2024, and the initial NAR/EMR verified on 03/04/2025. 4. Review of the personnel file for CNA # 4 indicated a hire date of 06/28/2024 and the Criminal History Background Check was verified 0on 12/02/2024, and the initial NAR/EMR verified on 03/04/2025. During an interview with the Administrator, on 03/25/2025 at 1:00 PM the administrator stated her expectation is for Criminal History and EMR/NAR searches to be completed prior to hire. She stated conducting these searches was the responsibility of Human Resources, however in mid-January the process changed, and she began to monitor and sign off on audits. She stated around January of 20254, she noticed that searches were not being completed and she requested an audit which was completed on 1011/20/2025 . She stated all DPS, and license checks were completed at that time. However corporate did not audit the EMR/NAR checks but stated they would be back to complete the audit which had not occurred. The administrator stated a negative outcome that could occur by not completing the Criminal background and EMR/NAR searches would be that someone with a criminal background could be hired and put the residents a risk of abuse. During an interview on 03/05/2025 at 2:55 PM, the Human Resource staff (HR) stated the criminal history background checks had not been verified prior to the hiring of the LVN #1, [NAME] #2, CNA #3, or CNA #4. She stated the HR stated that all NA's should have background checks within 72 hours of hire. She stated she was responsible, and the administrator and the corporate Human Resources monitored to see that they were in compliance. She stated the negative impact of not performing the background check on staff could have possibly caused harm to residents. She stated by not doing so, the residents could be harmed by abuse or neglected. She stated the failure was the background check verifications did not occur the 72 hours, with her expectations was for every potential employee to have a background check prior to working with any resident going forward. During an interview on 09/06/2024 at 3:10 PM, the ADMN stated all staff needed to have background checks prior to working with residents as it could have resulted with staff working with residents that should not be allowed to work. She stated in doing so could have led to Abuse, Neglect, and Exploitation. The ADMN stated her expectations wasere for the criminal history background checks should to be performed prior to being allowed to work in the facility and around residents. Record review of facility document Criminal Background Checks dated revised 01/31/2017 revealed: It is the policy of this facility to conduct criminal background checks of all applicants within 72 hours of employment according to the State of Texas law. This facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. All potential employees will be screened for history of abuse, neglect, or mistreating of elderly individuals as defined by the applicable requirements of 483.13 ( c ) (1) (ii) (A) and (B). The facility will check potential employees with the Texas Nurses Aide Registry or Misconduct Registry. The facility will not employ individuals who have been found guilty abusing, neglecting, mistreating residents, or misappropriation, of a resident's property; as determined by the Texas Nurse Aide Registry or Misconduct Registry, or have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property . Employees whose background check reveals convictions or formal action of the type prohibited by law or company policy will not be eligible for employment. An employee who has been discharged due to information revealed from the background check may obtain a copy of the Criminal History Check from the local law enforcement agency.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident # 4) of 6 residents reviewed for infection control, in that: The facility failed to implement Enhanced Barrier Precautions for Resident #4 who required feedings via a gastrostomy tube (a surgically created hole with a tube inserted into the stomach to provide an alternative route for nutrition and hydration for the resident). This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #4's electronic face sheet dated 03/05/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Dysphagia (difficulty swallowing), Dementia, and Multiple sclerosis (a disease that affect the nervous system that leads to muscle loss and weakness) The resident had a gastrostomy tube (a surgically created hole with a tube inserted into the stomach to provide an alternative route for breathing). During observation of perineal care on Resident # 4 on 3/5/25 at @ 2:55 p.m, it was observed that CNA A and CNA B did not follow enhanced barrier precautions by donning a gown during incontinent care. There was a sign indicating Resident #4 was on enhanced barrier precautions on the outside of the resident's door. The resident did not respond verbally to the surveyor, but he did follow her movement with his eyes. In an interview with CNA A on 3/5/25 at 3:10 p.m., she reports she identifies when a resident is on enhanced barrier precautions by looking for the sign outside the resident's door. She stated acknowledged that she should have gowned up for perineal care but forgot to do so. She stateds she was provided training from the facility regarding enhanced barrier precautions in the form of an in-service. When asked about any negative outcomes that could occurring if enhanced barrier precautions are not followed, she stateds not really, the g-tube doesn't have an infection. In an interview with CNA B on 3/5/25 at@ 3:11 p.m., she stated she is new, and it was only her second day working in this facility. She reporteds she did not see the sign prompting her to gown up and does not know where to find PPE. She reported she hads not been provided enhanced barrier training at this facility but hads taken trainings in the past at other facilities. She stated that an enhanced barrier precaution sign is typically outside a room and the sign indicateds you should wear PPE which included gowns. When asked what negative outcome could occur by not following enhanced barrier precautions, she stateds, You or the patient could become sick. In an interview on 3/5/25 at 3:30 PM the DON (who is also the Infection Preventionist) said the facility should have implemented Enhanced Barrier Precautions for the rResident # 4's gastrostomy tube. She said a possible negative outcome could be the possible spread of infection. She provided a copy of the policy Enhanced Barrier Precautions. Record review of dated 4/1/2024 Titledthe Enhanced Barrier Precautions policy dated 4/1/2024 which stated [in part] : Multi Drug Resistant Organisms are common in long term care facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROS. Enhance Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove use during high contact resident care activities. Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status

Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 3 of 3 medication storage areas (medication room, Short Hall Cart, and Long Hall Cart ) reviewed for medication storage. The facility failed to ensure that all medications and supplies stored in the medication room the short hall Medication Cart were properly labeled and not past their expiration date. The Change-of-Shift Record of Control Substance Log for the Short Hall Medication Cart, and the Long Hall medication carts were missing signatures. These failures could place resident's at risk of ineffective therapeutic response to medications and a decline in health. The findings included: Record review of Resident #12's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: diabetes (high blood sugar). Record review of Resident 12's active physician orders revealed she had an order for Novolog Flex Pen 5 u subcutaneously (inject into the fatty layer of the skin) before meals. Observation of the Short Hall medication cart on 03/072024 at 10:52 AM revealed the top drawer of the cart contained one vial of Novolog flex pen with Novolog Insulin Flex Pen. The pen was not labeled by the pharmacy with directions for use and dose, it was dated opened on 02/28/24 and had the last name of Resident #12 written on the pen in black permanent marker . Record review of Resident 11's face sheet revealed he was an 89 - year old male, admitted to the facility on [DATE] with a diagnoses of diabetes (high blood sugar) Record review of Resident # 11's active e orders dated 03/07/24 revealed the resident had Lispro Insulin 8 Units ordered subcutaneously ( in the fatty tissue) before meals. Observation of the Short Hall medication cart at 10:00 AM on 03/07/2024 revealed a vial labeled Lispro Insulin Inject 9 units subcutaneously before meals. Interview with LVN C at 10:52 AM on 03/07/24 revealed the insulin pen for Resident #12 came from the Emergency Box and that was why it was not properly labeled. She stated she would order the medication for Resident #12. She stated The Insulin for Resident #11 was not labeled correctly because the order had been changed and the nurse did not request a label change from the pharmacy and notify them of the order change. She stated it was the nurses responsibility to order medications when they were out and to monitor to see if the medications were labeled properly with the resident's name, dose, medication name and expiration date. She stated failure to do could result in the resident receiving the wrong medication or dosage. Interview with the Director of Nurses (DON) on 03/07/24 at 02:27 PM the DON's response was the nurses were responsible for checking the medication carts and medication rooms for expired medications on a routine basis. She stated they should check for medications needing label changes daily. She stated it was the nurse that took a new orders responsibility to notify the pharmacy of the medication change and a label change. She stated failure to do so could result in a med error. Record review of the facility policy Recommended Medication storage, undated, stated If the physicians directions for use change or the pharmacy types an error on the label and it is impractical to return the medication to the pharmacy for re-labeling, the nurses place a signal label on the container indicating there is a change in directions for use. When such a label appears on the container, the medication nurse checks the resident's current medication administration record or the physicians order for up-to-date information. If the directions for use change the provider pharmacy should be informed prior to the next refill. Record review of the Control Drug Card Count Sheets revealed the sheets were missing signatures on the following dates and shifts: December 2023 Cart All - Signatures missing: 12/01/2023 2 PM - 10 PM on coming and off going nurse signatures missing. 12/04/2023 6 AM - 2 PM off going nurse and 2 - 10 on coming and off going signatures missing. 2/06/2024 6 AM - 2 PM off [NAME] nurse signature and 2 PM - 10 PM off going shift nurse signature. 12/07/2023 6 AM - 2 PM off [NAME] nurse signature and 2 PM - 10 PM off going shift nurse signature; 12/08/2023 2 PM - 10 PM off going nurse signature and 10 PM - 6 AM on coming nurse signature. 12/11/2024 6 AM - 2 PM nurse on signature, 2 PM - 10 PM nurse off signature and nurse on signatures, and 10 PM - 6 AM nurse off signature. 12/12/2023 2PM - 10 PM nurse on signature and 10 PM - 6 AM nurse off signature. 12/13/2024 6 AM - 2 PM nurse on signature, and 2PM - 10 PM nurse off signature. 2/14/2023 2PM - 10 PM nurse off signature 10 PM - 6 AM nurse on signature. 12/15/2023, 2PM - 10PM nurse off, 2PM - 10PM nurse on, 10PM - 6AM nurse off. 12/16/2023 6AM - 2PM nurse on, 10PM - 6AM nurse off. 12/17/23 10PM - 6AM nurse off; 12/18/23 2PM -10PM nurse on, 10PM -6AM nurse off. 12/19/23 6AM - 2PM nurse on, 2PM - 10 PM nurse off. 12/20/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off; 12/22/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off, 12/22/23 10 PM -6AM nurse on: 12/23/23 6AM- 2PM nurse on. 12/25/23 6AM- 2PM nurse on, 2PM- 10 PM nurse on, 2pm - 10 PM nurse off 12/25/23 10PM - 6AM nurse off. 12/26/23 2PM- 10PM nurse on, 2PM- 10 PM nurse off. 12/27/23 6AM- 2PM nurse on, 2PM- 10 PM nurse off, 2PM - 10PM nurse on; 10PM - 6AM nurse off. 12/28/23 2PM- 10PM nurse on, 10PM- 6 AM nurse off. 12/29/23 6AM - 2PM nurse on, 2PM- 10PM nurse on, 2PM- 10 PM nurse off, 10PM -6AM nurse off. Cart All January 2024 Signatures Missing 01/05/2024 6 AM - 2PM nurse on, 2 PM - 10 PM nurse on, 2 PM- 10 PM nurse off, 10PM - 6 AM nurse off. 01/06/2024 10 PM - 6 AM nurse off. 01/09/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off. 01/10/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off. 01/09/2024 - 2 PM nurse on, 2 PM - 10 PM nurse off; 01/16/2024 6 AM - 2P M nurse on, 2 PM - 10 PM nurse off; 2 PM - 10 PM nurse on, 10 PM - 6 AM nurse off. 01/17/2024, 2 PM - 10 PM nurse on, 2 PM - 10 PM nurse off. 01/18/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 01/19/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 01/22/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 01/24/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 2PM -10PM nurse off, 10PM -6AM nurse off. 01/25/2024 6AM - 2 PM nurse on, 2 PM - 10 PM nurse off; 01/26/2024 2 PM - 10 PM nurse on, 10 PM -6 AM nurse on, 10 PM -6 AM nurse off. 01/27/2024 6 AM - 2 PM nurse off, 10 PM -6 AM nurse on. 01/28/2024 6 AM - 2 PM nurse off. 01/29/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse on, 2 PM -10 PM nurse off, 10 PM - 6 AM nurse off. 01/30/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse on, 2 PM -10 PM nurse off, 10 PM -6 AM nurse off. 01/31/2024 2 PM - 10 PM nurse on, 10 PM -6 AM nurse off. February 2024 Cart All Signatures missing: 02/01/2024 2 PM - 10 PM nurse on . 02/02/2024 6 AM - 2 PM nurse off signature missing, 2 PM - 10 PM nurse off, 2 PM - 10 PM nurse on. 02/16/2024 6 AM - 2 PM nurse on, 2 PM - 10 PM nurse off, 10 PM - 6 AM nurse off. 02/25/2024 6 AM - 2 PM nurse on, 6 AM - 2 PM nurse off, 2 PM - 10 PM nurse off, 2 PM - 10 PM nurse on, 10 PM -6AM nurse off. 02/28/2024 6AM - 2 PM nurse on, 2 PM - 10 PM nurse off. During an interview on 03/07/24 at 11:01 AM LVN B, stated staff should be signing in and out on the Control Drug Card Count Sheets when taking possession of the medication cart to indicate that the count was correct and has been counted by the oncoming and off going nurses at the change of each shift. She said it was the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. During an interview with LVN C on 03/07/24 at 11: 05 AM, she stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. She stated failure to do so could result in a drug diversion. During an interview with the DON on 03/07/2024 at 12:30 PM, verified that the signatures were missing for the Control Drug Card Count Sheets for December 2023, January 2024, and February 2024 She stated she was a new DON that had been employed at the facility since 09/2023 and she did not know that the narcotics should be counted and signed for on the facility form titled Controlled Drugs Audit Record until she was told this needed to be documented by her pharmacy consultant. She stated she had instructed all nursing staff regarding counting and signing the count sheets stating that all narcotics were counted and reconciled at the beginning and end of the shift by the nurse coming on duty and the off going nurse. She said that staff should be signing the sign in and out narcotic log (Control Card Count) when they take possession of the cart. She stated the DON and ADON should be monitoring to see that it was done. She stated failure to count narcotics, could result in a drug diversion. During an interview with the ADON on 03/07/24 at 12:41 PM she stated she had not been aware of the procedure for counting narcotics at the end of each shift. She stated she was new to long term care nursing and this facility, and the failure had occurred due to lack of familiarity with state, local and federal laws, and regulations. She stated she was not aware of the facilities policy and procedure. Review of facilities Policy titled: Controlled Drug Audit and Accountability revealed the following in part: The change of shift audit sheets is where nursing staff will sign to indicate that the controlled drugs were audited and that the responsibility of accountability of the controlled drugs is being changed to a different nursing staff. This form has columns to indicate the total number of controlled drug audit sheets present at each shift change.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed kitchen sanitization. 1. The facility failed to ensure the floors were not soiled with food particles beneath the appliances and stainless-steel shelf units throughout the kitchen and dry storage area. 2. The facility failed to ensure two of two refrigerators did not have what appeared to be dried liquids, and food crumbs on the bottom floor of the refrigerator. These failures could place residents at risk for foodborne illness and a decline in health status. The findings included: Observations on 03/05/2024 at 9:40 AM, during the initial tour of the facility kitchen, revealed the following: - the floor was soiled with food debris and grease beneath shelves and appliances throughout the kitchen. - 2 of 2 refrigerators had what appeared to be spilled milk, dried liquids, and food crumbs on the bottom shelf. Observations on 03/05/2024 at 9:50 AM revealed daily cleaning logs, dated March 2024, used for all the kitchen cleaning duties revealed all cleaning duties for the morning had been completed and initialed by the kitchen staff who completed the cleaning. In an interview on 03/05/2024 at 10:40 a.m. with the Dietary Manager stated, her kitchen staff followed a cleaning schedule, but someone must have opened a box, and it spilled in the freezer and was not cleaned. She further stated, it's important that the kitchen counters, refrigerators, freezers, and equipment be clean to prevent foodborne illness. In an interview on 03/05/2024 at 3:35 p.m. the DON stated, her expectation was for the dietary department to follow the dietary department cleaning policy. In an interview on 03/06/2024 at 3:40 p.m. the Facility Administrator stated, her expectation was for the dietary department to follow their cleaning schedule per dietary department policy. Record review of the facility's Policy titled Refrigerators, Coolers and Freezers dated, October 1, 2018, revealed [in-part]: The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers, and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed .

Based on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4(Resident #16, Resident #19, Resident #24 and Resident #20) of 19 residents in dining room reviewed for infection control techniques in that: 1. The facility failed to ensure CNA washed or sanitized her hands in between feeding resident #20 and resident #24. 2. The facility failed to ensure the Hospitality Aide-A washed or sanitized her hands between feeding resident #16 and resident #19. These failures could place residents at risk of infections. The findings included: 1. Record review of Resident #16's face sheet, dated 3/6/2024, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included other Alzheimer's disease (impaired ability to remember, think or make decisions) and moderate protein-calorie malnutrition (lack of enough protein and calorie in food intake). Record review of Resident #16's MDS assessment dated [DATE] revealed the following: Section GG revealed the resident dependent with meals (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). 2. Record review of Resident #19's face sheet, dated 3/6/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of which included dementia (impaired ability to remember, think or make decisions) and hypertension (high blood pressure). Record review of Resident #19's MDS annual assessment dated [DATE] revealed the following: Section GG revealed the resident dependent with meals (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). 3 Record review of Resident #20's face sheet, dated 3/6/2024, revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (impaired ability to remember, think or make decisions) and dysphagia (difficulty swallowing). Record review of Resident #20's MDS dated [DATE] revealed the following: Section GG Supervision or touching assistance with meals (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). 4. Record review of Resident #24's face sheet, dated 3/6/2024, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (impaired ability to remember, think or make decisions) and generalized muscle weakness. Record review of Resident #24's MDS assessment, dated 2/22/2024, revealed the following: Section C revealed a staff assessment of the BIMS score of 01, which indicated severe cognitive impairment. Section GG revealed the resident required supervision or touching assistance with meals (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as residents completes activity. Assistance may be provided throughout the activity or intermittently). Observation on 03/05/24 12:11 PM of CNA-A and Hospitality aide-A revealed both at a table with four residents (Residents #16, #19, #20, #24). CNA A and Hospitality Aide were each feeding two residents at same time, touching top of their glasses, using utensils to feed, not sanitizing hands between alternating residents. Hospitality aide cleaned spoon of Resident #16 then picked up Resident #24 cup and gave drink, then fed Resident #24, then picked up glass & spoon of Resident #16 and fed her. CNA A was feeding Residents #19 and Resident #20, using utensils and beverage containers alternating between the two residents, feeding each resident, and giving them hydration without using hand sanitizer between each instance. Observation on 03/05/24 12:22 PM revealed the Administrator entered dining room, instructed CNA A and hospitality to feed one resident at a time or to sanitize between each resident. Both CNA A and the hospitality aide at table then got hand sanitizer out of scrubs to begin using it. Observation on 03/05/24 12:26 PM revealed Resident #19 digging in pants, CNA A touched and redirected his arm, then held his hand to move it back to table, then picked up glass of Resident #20 for hydration, then picked up fork of Resident #20 and fed him without sanitizing hands. Interview on 3/5/2024 at 12:48 PM with CNA A revealed that she has been a CNA for [AGE] years and employed with this company [AGE] years. She stated that she usually always feeds two residents at the same times and to use hand sanitizer between the two. She stated the possible effect of lack of hand hygiene while feeding she stated, it could cause infection, spread disease or if one resident is sick and we don't know it then the other resident could get sick too. Interview on 3/5/2024 at 12:53 PM with the Hospitality Aide revealed that she has been employed with this facility since December 2023 and was previously certified in another stated, her certification just hasn't transferred yet. Hospitality aide -A stated she always works with another CNA, mostly CNA -A. She stated hand hygiene was performed after I mess with any resident, after feeding we normally wash hands, after picking up trays or after picking up things from the floor. She stated, I just forgot earlier. when I was feeding the residents in the dining room. She stated not performing proper hand hygiene she stated that cross contamination could happen. Interview on 3/6/2024 at 3:45 PM with DON revealed that her expectation was use of gel sanitizer when feeding two residents. Interview on 3/7/2024 at 1:30 PM, the Administrator stated proper hand hygiene is my expectation. When I noticed I immediately reminded them to use hand sanitizer. Review on 3/7/24 @ 9:30 AM of Infection Control Policy and Procedure Manual updated 3/2023, was found to state the following: Preventing Spread of Infection: The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Intent: Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination.