Every finding on record at Pflugerville Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of 12 residents (Resident #1) reviewed for abuse and neglect. 1. The facility failed to prevent CMA A from mistreating Resident #1. CMA A threw a blanket on Resident #1's head and left the room without removing it from Resident #1's face who struggled to remove it herself. 2. The facility failed to ensure CMA A did not forcefully move Resident #1's jaw to administer medications while Resident #1 was not fully awake. These failures could place residents at risk for staff mistreatment. Findings include: Record review of Resident #1's care plan, dated 05/14/2026, reflected the problem: [Resident #1] is dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits with indicated interventions: all staff to converse with Resident #1 while providing care, and reflected the problem: The [Resident #1] has impaired cognitive function related to dementia with indicated interventions: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Provide the resident with necessary cues, reorient and supervise as needed. Record review of Resident #1's significant change in status MDS, dated [DATE], reflected a BIMS score of 2, which indicated severe cognitive impairment. Record Review of Resident #1 admission record, dated 07/02/2026, reflected an 86-years-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included atherosclerotic heart disease without angina pectoris (plaque buildup in heart arteries that reduces blood flow but doesn't cause chest pain), vascular dementia (damaged or blocked blood vessels restrict oxygen and nutrients to the brain which cases a decline in thinking skills), depression (a serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry and fear), and need for assistance with personal care. Record review of camera recording, dated 06/15/2026 at 7:08:45 a.m., revealed CMA A applied force to Resident #1's chin while pulling it down and administering medications to Resident #1. Record review of camera recording, dated 06/15/2026 at 7:09:17 a.m., revealed CMA A threw a blanket on Resident #1's head after she attempted to administer medications, walked away from Resident #1, and left Resident #1's room without checking on Resident #1 and adjusting the blanket which Resident #1 was able to remove from her head, but struggled to cover her legs. Record review of complaint's letter, dated 06/25/2026 and revised on 06/28/2026, reflected: [CMA A] that gave [Resident #1] her morning medicine on 6/15/2026, entered, raised her head portion of the bed, spoke to her about waking up. (note [Resident #1] was in a deep sleep at the time) [CMA A] began by pushing into her left axilla area (armpit), then tapping on her head with her fingers. Which caused Resident #1 to turn her head to the right with a facial look that implied discomfort and confusion. She shoved the cup of I assume medication to her lips. But by just being woken up from a deep sleep Resident #1 did not respond quickly enough. These first steps were a total of 46 seconds. Then because [Resident #1] did not respond as quickly as [CMA A] wanted; the [CMA A] forcefully used a technique that is used when trying to get a patient to swallow pills that are in their mouth, NOT a technique that is used to get someone to open their mouth. A technique that is softly used not in the abusive way she applied to [Resident #1]. After the force was applied, which could have caused severe injury to [Resident #1's] jaw, she shoves the cup back to her mouth to have her finish whatever was in the cup. Then she throws the blanket over [Resident #1's] head in a way that appears to be in an act to humiliation and out of agitation. Then the [CMA A] has a smirk on her face as she passed the camera and left the room. The [CMA A] left the bottom of the blanket up over [Resident #1's] head leaving her uncovered from the waist down and the bed inclined. During an interview on 07/02/2026 at 1:31 p.m., Resident #1's family member stated Resident #1 was at the facility just for a little longer than a month. She stated after reviewing the video recording, dated 06/15/2026, she saw Resident #1 was upset. She stated Resident #1 could not communicate and just could mumble. She stated she knew Resident #1 very well and it seemed to her she was depressed while she was at the facility, but she could not provide any examples of depressed behavior. She stated that Resident #1 seamed lethargic (a state of physical or mental sluggishness [no energy]) and she is more alert at other facility. Resident #1's RP stated she could really tell the difference between how Resident #1 was in this facility and the place she was now. She stated Resident #1's family visited her in the facility every day and did not notice any difference between behavior before and after the incident. She stated that Resident #1 did not display any fear towards any staff members. She stated she did not review a video recording every day and did not see the recording with a blanket incident, dated 06/15/2026, until 06/23/2026 night. She stated she contacted the DON on 06/24/2026 and the DON called her back, and they scheduled a meeting on 06/25/2026 where she presented the video recordings to the DON and ADM. She stated the facility initiated the investigation, and the DON told her they would put a one-on-one sitter to protect Resident #1 in the last few days she stayed at the facility. The observation of Resident #1was not completed due to Resident #1 was discharged from the facility on 06/26/2026. The interview with Resident #1 was not completed due to Resident #1 was not interviewable per Resident #1's MDS record review (BIMS score of 2, which indicated severe cognitive impairment) and interview with Resident #1's family member. During an interview on 07/02/2026 at 2:47 p.m., RN D stated she worked at the facility for 4 years and had ANE training last week. She was aware of reporting any signs of ANE to the ADM immediately. RN D stated she worked with Resident #1 in the memory unit on a regular basis. She stated she worked with Resident #1 on 06/15/2026 at 6 a.m. -6 p.m. She stated when she worked with Resident #1, she was always up in the dining room participating in activities. She stated nobody reported to her ANE and she did not see any signs of ANE with Resident #1 or other residents at the facility. During an interview on 07/02/2026 at 2:21 p.m., LVN E stated she had ANE in-services and learned to report immediately any types of abuse (verbal, physical, psychological, and financial). She stated she never observed or was notified that CMA A did not administer medications or abused residents in the memory unit or other floors in the facility. She assisted Resident #1 on occasions even though she was assigned to this resident as she was assigned to the other side of 100 hallway on the memory unit, but she observed her in the dining room without any signs of distress apparent to her. During an interview on 07/02/2026 at 3:21 p.m., LVN G stated she worked at the facility for a year and completed ANE training last week. She stated she learned about different types of abuse (verbal, physical, verbal, and mental) and the need for reporting any signs of ANE immediately to the ADM. She stated nobody reported to her ANE regarding Resident #1 or any other residents at the facility. LVN G stated she did not notice any apparent signs of distress in Resident #1 at the time of the incident or after it. She stated if she noticed staff threw a blanket on a resident's head or forcing medication to residents, she could consider it to be resident abuse and report it to the ADM immediately. During an interview on 07/02/2026 at 3:33 p.m., CMA B stated she worked with Resident #1 on the regular basis and did not see any difference in her behavior through her entire stay at the facility. She stated that she did not see any fear in her behavior or any other signs of ANE in Resident #1 or other residents at the facility. She stated she had regular training on ANE 2-3 days ago. She stated she learned if you see any ANE signs, report to ADM immediately, how to take care of residents with cognitive issues, how to administer medication when they were not awake, not forcing medications as residents had the right to refuse. If a blanket was thrown on a resident's face, it was an example of resident's abuse. If a resident was not able to take meds per their policy and training, they should wait, tell the nurse, and administer medication later or document that it was not administered. CMA B stated it was not acceptable to pull a resident's chin and force medication into the resident's mouth. During an interview on 07/02/2026 at 3:58 p.m., the DON stated she worked at the facility for 5 years, completed ANE training last week, and conducted ANE training along with the ADM to staff every two weeks on the pay day. She stated she learned and educated staff on different types of ANE: physical, verbal, financial, mental and reporting if noticed signs of ANE immediately to the ADM. She stated she learned about the ANE allegations for Resident #1 when her RPs came to the facility. She stated one of Resident #1's RPs presented the video recordings depicting Resident #1's abuse by CMA A. She stated CMA A was suspended pending investigation of ANE allegation immediately on 06/25/2026 and they terminated her after the investigation was concluded, a few days later. She stated when she reviewed the video footage depicting CMA A's forceful medication administration technique and throwing a blanket on Resident #1's head, it made her very upset. She stated this type of interaction with CMA A could negatively affect Resident #1's physical and mental state. She stated that Resident #1 was assessed when they found out of incident with CMA A and no physical or psychosocial distress was identified. She stated that observation of Resident #1 did not show any signs of distress as she did not demonstrate any fear or unusual behaviors. Record Review of MD report of Resident #1's History and Physical, dated 06/18/2026, which was two days after the incident, reflected: Dementia: no changes. No recent behavioral issues per staff. Continue current regiment. Continue hospice care. Depression: no changes. Continue current regiment. During an interview on 07/02/2026 at 4:10 p.m., the ADM stated that he worked at the facility for seven years and completed ANE training a few days ago. He stated that they provide ANE in-services to all staff every two months or after complaints or incident investigation. He stated that he educated staff on different types of ANE and the requirement of reporting to him any signs of ANE immediately. His phone as the ANE coordinator was posted in the building for all staff to call him any time. He stated that he received a complaint with allegation of abuse for Resident #1 on 06/25/2026. He stated that after the meeting with Resident #1's RPs and reviewing provided evidence including video footage from a camera located in Resident #1's room, he initiated the investigation immediately. He stated that Resident #1's RPs believed that CMA A used an abusive technique during medication administration. ADM stated that he saw the CMA A used a forceful technique during medication administration and threw a blanket on Resident #1's face. He stated that if staff used force during medication administration, the potential risk to residents could lead to different bodily injuries. The incident with throwing the blanket on Resident #1's head could lead to bad outcome to Resident #1: physical and psychological. He stated that the facility initiated ANE investigation immediately, Resident #1 was monitored, and assessed promptly. He stated that per nursing assessment, Resident #1 was not in physical or psychological distress. He stated that CMA A was employed at this facility for 10 years with no prior counseling or similar allegations. He stated that he interviewed other residents who received medications from CMA A and no report of similar interactions were made to him. He stated that, per interviews with other staff members, no reports were made regarding similar interactions between CMA A and residents at this facility. He stated that according to the facility's investigation they determined that the care provided by CMA A did not meet the facility's standards of care. Specifically, CMA A failed to use appropriate techniques while attempting to awaken a cognitively impaired resident medication administration. He stated that he provided an education of ANE immediately, continued monitoring of Resident #1's condition, and Resident #1's care plan was updated. He stated that safe surveys were done with residents and no other residents at the facility voiced concerns regarding ANE. He stated that they interviewed other staff members at the facility and nobody observed ANE or ANE behavior with CMA A. During an interview on 07/02/2026 at 5:13 p.m., CMA A stated she worked at the facility for 11 years. She stated she had ANE training every month. CMA A stated she learned about different types of abuse and neglect like physical, psychological, and verbal. She stated that she had never been involved in ANE before and after that incident. She stated Resident #1 could not communicate and sometimes did not want to take her medication. She stated she asked CNAs in the memory unit to get residents out of bed so she could administer medications to them while they were up and awake, but they frequently didn't do that. CMA A stated she was behind on medication pass that day and a lot of residents were still in bed sleeping, so she tried to wake Resident #1 and after Resident #1 did not wake up, she used a little more forceful technique than she intended pulling her chin down to swallow medication. She stated she felt burned out with so many residents on her case load and required time frame for medication administration. She stated sometimes she could not even go to the bathroom and could not provide quality care to residents with the work load she had. She stated she did not say anything about her frustration to nurses or administration as everybody was expected to complete their work and she just tried to do her work. She stated she could not believe she could do what she did (throw the blanket over Resident #1's head) as it was not her character as she cared about residents. Record review of the facility's policy on ANE, dated 08/15/2022, reflected It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury.intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of the facility's, undated, policy on Administering Medication to Sleeping or Confused Residents reflected the following techniques: Gentle awaking, use gentle stimulation, allow time, assess readiness, document and return. If resident is sleeping soundly and the medication is not time sensitive, it is often safer to let them sleep and after attempt to administer the dose later. Always document the refusal or delay according to facility protocol. Respect the right to refuse.

Based on, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure CMA A and CMA H accurately documented Resident #1's medications on 06/19/2026, 06/20/2026 and 06/21/2026. This failure could place residents at risk of medication error or not receiving the intended therapeutic benefit of their medication and delayed healing. Findings include: Record review of Resident #1's care plan, dated 05/14/2026, reflected the problem: [Resident #1] is dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits with indicated interventions: all staff to converse with [Resident #1] while providing care, and reflected the problem: The [Resident #1] has impaired cognitive function related to dementia with indicated interventions: use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Provide the resident with necessary cues, reorient and supervise as needed. Record Review of Resident #1 admission record, dated 07/02/2026, reflected an 86-years-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included atherosclerotic heart disease without angina pectoris (plaque buildup in heart arteries that reduces blood flow but doesn't cause chest pain), vascular dementia (damaged or blocked blood vessels restrict oxygen and nutrients to the brain which cases a decline in thinking skills), depression (a serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry and fear), and need for assistance with personal care. Record review of Resident #1's significant change in status MDS, dated [DATE], reflected a BIMS score of 2, which indicated severe cognitive impairment. Record review on Resident #1 family member's complaint, dated 06/25/2026 and revised on 06/28/2026, reflected: On these same mornings 19th, 20th and 21st, Resident #1 did not receive any morning medications in the room. On the 19th Med Tech came in and took her blood pressure shortly after 7 a.m. but never saw meds given. Record review of written statement of CMA H, dated 6/29/2026, reflected CMA H on June 21, 2026, at approximately 8:03 a.m., Resident #1 was in bed at the time of medication administration. I did not administer the medication while the resident was asleep or disturb the resident due to previous behavioral disruptions that have occurred when she has been awakened from sleep. Therefore, her medication is typically administered after she wakes up or at mealtimes. This information was not documented on Resident #1's MAR. Record review of an undated note from CMA A, reflected on 06/15/26 I went into the room to pass medication to Resident #1. When I arrived in the room, the resident was asleep. I tried to wake her by rubbing her shoulder and then gently patting her on the head. She was not fully awake. I then tried to open her mouth by pressing down on her chin. My intention was to wake her and give medication. Record review of nursing progress notes for Resident #1, dated 06/19/2026, 06/20/2026, and 06/21/2026 did not indicate that Resident #1 did not receiving medications on those days. Record review of Resident #1's Medication administration audit report, dated 07/02/2026, reflected Resident #1's medications scheduled for 7 a.m.: Sertraline HCl oral tablet 100 mg - give 1 tablet by mouth one time a day for depression, Docusate Sodium oral tablet 100 mg - give 1 tablet by mouth two time a day for constipation, omeprazole oral tablet delayed release 20 mg -give one table by mouth one time a day for GERD (gastroesophageal reflux disease - a chronic digestive disorder occurring when stomach acid repeatedly flows back up into the esophagus [the tube connecting your mouth and stomach]), Depakote Sprinkles oral capsule delayed release sprinkle 125 mg. Give 4 capsule by mouth three times a day for dementia behaviors. Carvedilol oral tablet 6.25 mg give 1 tablet by mouth two times a day for HTN (hypertension - high blood pressure). Polyethylene glycol 3350 oral powder 17 gm/scoop - give 1 scoop by mouth one time a day for constipation, and lorazepam oral tablet 0.5mg - give 1 tablet by mouth two times a day for restlessness were administered on 06/19/2026 at 07:07 a.m. and documented on 06/19/2026 at 7:09 a.m. by CMA A and on 06/20/2026 documented administration of same medications at 07:38 a.m. and documentation on 07:39 a.m. and on 06/21/2026 document administration on 08:03 a.m. and documentation at 08:03 a.m. by CMA H. Attempted interview with CMA H on 07.02.2026 at 2:43 p.m. was unsuccessful. During an interview on 07/02/2026 at 2:47 p.m., RN D stated she did not get any report during her shifts from CMAs about medications that were administered late or not administered to Resident #1 or any other residents. She stated per medication administration policy, medications should be administered first and not after documenting medication administration. During an interview on 07/02/2026 at 2:21 p.m., LVN E stated she assisted Resident #1 on occasions even though she was assigned to Resident #1 as she was assigned to the other side of 100 hallway on the memory unit, but she observed her in the dining room without any signs of distress apparent to her. She stated medication administration should be documented after medication administered to residents and not before. The negative effect of this to residents could be not accurate documentation and possible medication errors: not receiving medication if refused and administration of medication was already recorded. During an interview on 07/02/2026 at 3:21 p.m., LVN G stated no CMAs reported to her that medication was not administered to Resident #1. She stated according to facility medication administration policy, medication administration should be documented afterwards and not before. She stated CMAs were supposed to notify charge nurses regarding missed or delayed medication administration and charge nurses could attempt to administer medications to residents and notify the physician and RPs regarding missed medications. She stated that CMAs did not notify her about medications were administered later and documentation was done before administration of medications. During an interview on 07/02/2026 at 3:33 p.m., CMA B stated she worked at this facility for one year. She stated she had the medication administration training a few days ago. She stated CMAs and nurses should document the medication administration after administration and not before. CMA B stated if residents did not take medication, she should document it in their electronic medication administration records and notify the nurse. She stated she did not see any signs of ANE in Resident #1 and any other residents. She stated she gave medications to Resident #1 when she was up and awake. She stated that residents who were asleep needed to be awaken gently and not forced to take their medications. During an interview on 07/02/2026 at 3:58 p.m., the DON stated Resident #1's RP contacted her and informed her Resident #1 did not receive her medication on certain days. She stated she spoke to medication aides which included CMA A and they informed her she documented medication administration when she popped that medication, but she administered it to Resident #1 later when this resident got up and was taken to the dining room. The DON stated according to their policy on medication administration, ordered medication should be administered first and documented after it was administered to residents. During an interview on 07/02/2026 at 4:10 p.m., the ADM stated he worked at the facility for 7 years. He had training on medication administration sometimes during last year. He stated that it was not his area of expertise but he knew the administration of medications should be first and documentation afterwards. He stated the potential risk to residents could be not accurate administration of medication and documentation. ADM stated that per his interview with CMA A, the medications were administered to Resident #1. He stated that they did not have any witnesses to those administrations. During an interview on 07/02/2026 at 5:13 p.m., CMA A stated she worked at the facility for 11 years. She stated she was trained in medication administration policy and knew about proper medication administration post administration of medication to residents and not before. She stated she crushed routine ordered medications for Resident #1 and mixed them with ensure drink for Resident #1and sometimes she took some of medications but not all of them and she did not know what medications she took and what she didn't, so she documented all of them. Record review of Certified Medication Aide job description, reflected the certified medication aide will prepare, administer, and document prescribed medication per protocol. Administers prescribed medications and treatments as defined by state regulations in accordance with company policy and procedure. Reports to charge nurse and documents reasons prescribed drugs are not administered Record review of the facility's Medication administration policy, dated 10/24/2022, reflected: 14. Administer medication as ordered in accordance with manufacturer specification. 17. Sign medication administration record after medication administered. 19. Report and document any adverse side effects or refusals. Record review of camera recording, dated 06/19/2026, 06/20/2026, and 06/21/2026, did not show continuous recording of Resident #1, it was activated by movement. The time stamps between 06:00 a.m. and 9:00 a.m. on 06/19/2026, 06/20/2026, and 06/21/2026 did not reflect medication administration to Resident #1.

Based on observation, interview, and record review, the facility failed to make sure that drugs are stored in locked compartments and only authorized persons have access for 1 of 8 medication carts reviewed for pharmacy services. The facility failed to ensure one nursing medication cart was locked. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: Observation of hall 400 on 05/26/2026 at 6:01 a.m. revealed a nursing medication cart was along the wall unattended and unlocked. The nursing medication cart contained residents' prescription drugs, over the counter medications, narcotics in a locked box, and syringes and other supplies. There were no residents, visitors, or staff in the hallway or near the nurse's cart. All the residents in the 400 hallway had their doors closed. RN A was sitting at the nurse's station on the telephone. During an interview on 05/26/2026 at 6:10 a.m., RN A stated she had been trained in medication storage. RN A stated the policy for medication carts was that any time staff walked away from the cart, it should be locked. RN A stated the nurse was responsible for locking the medication cart. RN A stated if the medication cart was left unlocked and unattended, a resident could access the medication and ingest the wrong medications, which could cause the residents to get sick. RN A stated she was a charge nurse, and it was her responsibility to ensure medication carts were locked. RN A stated she left the medication cart unlocked because she was responding to doorbell to let the State surveyors in the building and calling leadership to inform them State had entered the building. RN A apologized to the State surveyor several times for leaving the cart unlocked and unattended. During an interview on 05/27/2026 at 1:15 p.m., the DON stated she had been trained in medication storage. The DON stated the policy for medication carts was that the carts should always be locked anytime the nurse or medication aides walked away. The DON stated whoever was in possession of the keys to the medication cards, was responsible for locking the medication carts. She said if the medication cart was left unlocked and unattended, a resident could get into the cart and take medications which could cause an allergic reaction, or overdose, or poke themselves with needles. The DON stated she and charge nurses monitored to ensure the carts were locked by doing observations during their rounds and had done in-service training. The DON stated that RN A told her she left the nurse medication cart unlocked and unattended when she answered the doorbell to let the State surveyors in the building. During an interview on 05/27/2026 at 1:23 p.m., the ADM stated he had been trained in medication storage. The ADM stated the policy for the medication carts was that the cart was to be locked when the nurses were not working on the carts. The ADM stated the nurse was primarily responsible for ensuring the medication cart was locked. The ADM stated if the medication cart was left unlocked and unattended it could cause residents to get medications that were not meant for them. The ADM stated the ADON and DON monitored to ensure the medication carts were locked during rounds. The ADM stated the RN A told him she left the nurse medication cart unlocked and unattended when she answered the doorbell to let the State surveyors in the building. Record review of facility's policy titled, Medication Carts and Supplies for Administering Meds dated 10/01/2019 reflected: ProcedureMed Carts.2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 67 of 105 (1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 ) residents reviewed for IDT meetings/ care plans in that:The facility failed to complete a quarterly assessment for Residents 1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 very 3 months (08/01/2025 through 12/012025).This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.Findings include:Record review of Residents 1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 MDS dated [DATE] revealed that 67 residents have not had an updated quarterly care plan for longer than 3 months.During an interview with the DON on 02/06/2026 at 12:15 p.m., the DON stated that she expected the IDT to complete a new care plan for every newly admitted resident within 14 days of admission to the facility. The DON stated she expects staff to reassess each resident on a quarterly basis. The DON stated the Social Worker was responsible for coordinating the quarterly care plan meetings. She stated that the facility does not have a Social Worker at this time and Residents #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 quarterly care plans have not been updated Since 8/2025.During an interview with the MDS Case Manager on 02/06/2026 at 12:47 p.m., the Case Manager confirmed the IDT Team was expected to meet on a quarterly basis to initiate and complete quarterly Care Plans assessments for each resident. The MDS Case Manager stated it was the responsibility of the facility's Social Worker to coordinate the quarterly care plan meetings. She revealed the facility has not had a social worker for most of 2025 and that the facility has hired a new Social Worker and that position will be filled soon.During an interview with the ADM on 02/06/2026 at 3:25 p.m., the ADM stated he expects the IDT to follow the RAI manual regarding the frequency of the Care Plan meetings. He stated the care plan meetings should be held on a quarterly basis.Record review of the CMS RAI Version 3.0 Manual, 4.7 The RAI and Care Planning As required at 42CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.Record review of CMS Appendix PP Issued: 11-22-17, Implementation: 11-28-17 Reveals: Note: The quarterly MDS does not require the completion of Care Area Assessments. However, the resident's care plan must be reviewed and revised by the interdisciplinary team after each assessment as required at 483.21(b)(2)(iii).

Based on interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation involve abuse and do not result in serious bodily injury for 1 of 3 residents (Resident #1) reviewed for abuse and neglect, in that: The facility failed to ensure that the DON reported allegations of abuse immediately, but no later than 2 hours to the ADM when Resident #1 reported she gave me a bruise to the DON on 06/12/2025. This failure could result in continued abuse or neglect of residents, injury, and/or psychosocial harm. Findings include: Review of Resident #1 face sheet reflected a year-old female admitted on [DATE] with diagnoses of major depressive disorder (serious mental illness characterized by sadness, loss of interest in activities and other symptoms that interfere with daily life), anxiety disorder (persistent worry and fear that can interfere with daily life), and impulse disorder (group of conditions where individuals struggles to resist strong urges or impulses leading to behaviors that can be harmful to themselves or others. Review of Resident #1's care plan dated 05/23/2021 reflected Resident #1 was at risk for skin impairment related to impaired cognition, anemia, impaired mobility and obesity. Interventions included to conduct skin inspections/examinations weekly and as needed. Review of Resident #1's care plan dated 11/28/2022 reflected Resident #1 was resistive to care and refused shower and hygiene at times. Interventions included to allow resident to make decisions about treatment regimen to provide sense of control and educate about possible outcome of non-compliance. Review of Resident #1's care plan dated 06/18/2025 reflected Resident #1 has potential to be physically aggressive with attempts to throw items at staff and punch staff. Interventions included that 2 staff members were present during showers. Review of Resident #1 quarterly MDS dated [DATE] reflected BIMS of 13 which indicated no cognitive impairment. Further review reflected Resident #1 had no physical symptoms directed towards others 7 days prior to assessment. Review of progress note dated 06/13/2025 at 2:48 PM reflected Resident #1 had hematoma on right forearm. Resident #1 reported she noticed after her shower the other day. NP was notified with no new orders made at that time. Review of progress note dated 06/17/2025 at 6:35 PM by RN B reflected call was received by RP for Resident #1, RP indicated Resident #1 reported she was pinched on her arm by CNA last week and wanted to report to the ADM. RN B wrote that reddish discoloration was noted to right forearm and redness noted under both breasts. NP notified. During an interview on 06/25/2025 at 10:43 AM, Resident #1 stated around 9:00 AM last week she had a shower and CNA C grabbed Resident #1's left arm and then pinched her right arm. Resident #1 stated this occurred about two weeks ago. Resident #1 stated about a week after the incident the ADM spoke with her about it and told Resident #1 this is the first I'm hearing about this. Resident #1 stated a day after the incident she reported to RN A and cannot recall if she reported it to anyone else. Resident #1 stated she spoke with her RP and her RP reported it to the ADM. Resident #1 stated she has not worked with CNA C since the incident and that she felt safe at the facility. Resident #1 stated her shower days are Monday, Wednesday and Friday and the shower occurred on a non-scheduled shower day. Observation on 06/25/2025 at 10:47 PM, revealed two small faded red marks about an inch apart on Resident #1's right forearm. The marks were not perfectly circular and had no coherent shape. Resident #1 stated that one spot (closer to elbow) happened about five days after the other and the other spot (closer to wrist) was from some other time. Resident #1 reported that the bruise from when CNA C pinched her was gone as of 06/25/2025. During an interview on 06/25/2025 at 12:55 PM, RN A stated she saw a mark on Resident #1's right arm a few weeks ago. RN A stated she asked Resident #1 what happened to her forearm and Resident #1 reported I got it from my shower yesterday. RN A stated Resident #1 reported oh it's nothing I just got this from the shower yesterday. RN A stated the mark was about the size of a penny and it was dark red and not purple. RN A stated Resident #1 did not report that anyone pinched her or any allegations of abuse. RN A stated she completed a head to toe assessment with Resident #1. RN A stated Resident #1 has fragile skin. RN A stated if Resident #1 reported that someone had pinched or held her down she would report that to the administrator as soon as the incident was discovered. RN A stated the ADM was the abuse coordinator. During an interview on 06/25/2025 at 1:16 PM, CNA D reported that she normally worked on Resident #1's hall. CNA D stated she worked on 06/13/2025 on Resident #1's hall. CNA D stated she does not usually work directly with Resident #1 as Resident #1 wasparticular and she usually just passes the breakfast and lunch trays to Resident #1. CNA D stated she waited until Resident #1 left her room to make up the bed and stated on 06/13/2025 Resident #1 asked CNA D to move some furniture or items in her room to a certain spot. CNA D stated Resident #1 refused her showers often and Resident #1 rarely showered. CNA D stated she tried to encourage Resident #1 to take a shower but Resident #1 usually said she did not want to. CNA D stated she did not provide a shower to Resident #1 on 06/13/2025. CNA D stated Resident #1 did not express any concerns on 06/13/2025 and Resident #1 did not report any abuse to CNA D. CNA D stated she checked all residents skin in the morning during her rounds and she did not notice any changes or issues in Resident #1's skin on 06/13/2025. CNA D stated any complaints regarding abuse should be reported to the ADM and nurse immediately. CNA D stated the abuse coordinator was the ADM. During an interview on 06/25/2025 at 1:32 PM, CNA C stated she assisted Resident #1 with her shower a few weeks ago but could not recall the exact day. CNA C stated CNA E also was present during the shower and when CNA C interacted with Resident #1. CNA C stated she gave Resident #1 a shower and CNA C stated she washed Resident #1's back for her, back of her legs and feet. CNA C stated Resident #1 washed the front of her upper body and her hair. CNA C stated she put shampoo and conditioner in Resident #1's hair but Resident #1 washed it herself. CNA C stated it was in the morning when she showered Resident #1. CNA C stated she did not hold Resident #1's arms down or pinch Resident #1. CNA C stated Resident #1 sprayed CNA C with the shower head. CNA C stated she did not spray Resident #1 with the shower head. CNA C stated her uniform was wet from the shower and she had to stand outside after to dry. CNA C stated she noticed green discoloration on Resident #1's neck from her jewelry that washed off. CNA C stated she had received in-services over abuse and neglect and any reports of abuse should be reported to the ADM within two hours. CNA C stated the ADM was the abuse coordinator. CNA C stated the ADM suspended her on 06/17/2025 after an allegation was reported from Resident #1. During an interview on 06/25/2025 at 1:41 PM, CNA E stated she and CNA C assisted Resident #1 to the shower. CNA E stated she sat on a bench in the shower room and only observed the shower and CNA C assisted Resident #1 during the shower. CNA E stated that CNA C washed Resident #1's back, hair, legs and put soap on a towel so Resident #1 could wash herself. CNA E stated Resident #1 sprayed CNA C with water. CNA E stated CNA C rinsed Resident #1's hair, back and legs and did not spray Resident #1 in the face. CNA E stated CNA C did not pinch or hold down Resident #1's arm during the shower. CNA E stated Resident #1's skin appeared at baseline during the shower. CNA E stated Resident #1 did not report any allegations of abuse nor that any one pinched her the remainder of the shift or since the shower. CNA E stated she was made aware of the allegation about a week later and was asked to write a statement. CNA E stated she received in-services on abuse and neglect and she had to report abuse to the abuse coordinator which was the ADM. During an interview on 06/25/2025 at 1:55 PM, the DON stated she checked in with Resident #1 after her shower and thanked Resident #1 for taking a shower. The DON stated Resident #1 stated look at this bruise she did it. The DON stated she did not observe any bruising on the resident and that Resident #1 wheeled off and said whatever. The DON stated this was after the shower and was between 10:30 - 11:00 am. The DON stated when Resident #1 stated look at this bruise Resident #1 did not report any names. The DON did not report this to the ADM and stated she thought he heard it as it was after morning meeting when the IDT was leaving the conference room. The DON stated it was reported to her about a week later by the ADM that there was an allegation of abuse. During an interview on 06/25/2025 at 2:16 PM, RN B stated she worked on Resident #1's hall on 06/17/2025. RN B stated she received a call from Resident #1's RP that Resident #1 reported someone pinched her. RN B stated she immediately reported to the ADM. RN B stated there were two spots, and they were about the size of a coin. RN B stated they were red, they were not blue or yellow and looked newer. RN B stated they appeared to look as if they occurred the night or day before. RN B stated the spots were close together. RN B stated she worked on Resident#1's hall on 06/14/2025 and that there were no skin alterations or impairments noted then. RN B stated she completed a head-to-toe assessment on 06/17/2025 and no other impairments were noted. RN B stated any suspicions of abuse would be reported to the ADM immediately. RN B stated that Resident #1 reported that a CNA pinched her about a week ago when asked during the head-to-toe assessment. During an interview on 06/25/2025 at 4:07 PM, the ADM stated he was made aware of the allegation of abuse on 06/17/2025 after he spoke with Resident #1's RP. The ADM stated RN B reported the allegation to him and he contacted Resident #1's RP. The ADM stated that it was reported that Resident #1 had a bruise on her arm and that she was pinched by a CNA. The ADM stated the CNA was identified as CNA C and she was immediately suspended after he spoke with Resident #1. The ADM stated she interviewed Resident #1, CNA C and CNA E and found the allegation was unconfirmed due to witnessed being present during Resident #1's shower. The ADM stated he did not observe or talk with Resident #1 after her shower. The ADM stated that usually Resident #1 reported any concerns to him and he spoke with her almost daily and she did not mention any allegations of abuse. The ADM stated if a resident reported to any staff that someone gave them a bruise, he expected it be reported to him immediately. The ADM stated he was not aware that Resident #1 reported to the DON that someone gave her bruise after her shower. The ADM stated if he was made aware he would have changed his course of action in that the investigation would have started at that point. During an interview on 06/25/2025 at 4:27 PM, the DON stated when an allegation of abuse or neglect was reported, it should be reported immediately. The DON stated depending on the type of abuse, a delay in reporting could allow for ongoing abuse. Review of PIR dated 06/19/2025 reflected on 06/17/2025 at 6:35 PM, RN received a call from Resident #1's RP that Resident #1 was pinched on her arm by CNA last week. Further review of PIR reflected On 06/12/2025 CNAs informed the DON that [Resident #1] had an unpleasant odor. Resident #1 was asked to shower by the DON due to her history of refusing. Further review reflected After the shower [Resident #1] was noted at the smoking area upset. The DON stated Thank you for taking the shower. Resident stated 'Look at this bruise, she did it'. PIR reviewed the DON saw no bruising on Resident #1's arms. Review of statement by the DON dated 06/18/2025 reflected the DON thanked Resident #1 for taking a shower and Resident #1 started look at this bruise, she did it. The DON wrote that she looked at both of Resident #1's arms and no bruising was noted. Review of in-service dated 06/18/2025 reflected in-service was conducted with all staff over topic of Abuse, Neglect, Exploitation, which facility policy titled Abuse, Neglect, and Exploitation was reviewed. Review of facility policy dated 08/15/2022 and titled Abuse, Neglect, and Exploitation reflected under reporting and response that reporting of all alleged violations to the Administrator was required immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or result in serious bodily injury. Further review reflected the facility will make all efforts to protect residents from physical and psychosocial harm, as well as additional abuse and included responding immediately to protect the alleged victim.

Based on observations, interviews, and record review the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of seven residents (Resident #67, Resident #18, and Resident #2) reviewed for ADL abilities. Resident #67 had dirty, jagged fingernails and flaky, dry skin on legs. Resident #18 had long, jagged fingernails. Resident #2 had long, jagged fingernails, chipped nail polish and unbrushed teeth. This deficient practice could place residents who required assistance at risk of or not receiving care and services to meet their needs and avoid ADL decline. Findings included: Resident #67 Review of Resident #67's face sheet, dated 04/02/2025, reflected an [AGE] year-old female admitted to the facility on . Her diagnosis was Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. Record review of Resident #67's quarterly MDS dated [DATE] reflected Resident #67 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS reflected Resident #67 needed extensive assistance with transfers and toileting. Review of Resident 67's facility care plan reflected: Problem: The resident has an ADL self-care performance deficit. Interventions: Personal Hygiene - The resident requires assistance by one staff with personal hygiene and oral care. In an interview and observation on 4/3/2025 at 8:40 AM, Resident #67 had jagged nails that were no longer than one quarter to one half inch in length. There was a black substance under one fingernail. Two fingers had dark, black bruises underneath and up the side of two nails. Resident #67 stated she had no clue how she had bruised her fingers. Resident #18 Review of Resident #18's face sheet, dated 4/3/2025, reflected a [AGE] year-old female readmitted to the facility on [DATE] and diagnosed with Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #18's incomplete quarterly MDS dated [DATE] reflected Resident #18 had a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident 18's facility care plan dated 3/7/2025 reflected: Problem: The resident has an ADL self-care deficit. Interventions: Personal Hygiene/Oral Care: The resident is totally dependent on one staff for personal hygiene and oral care. In an observation on 4/3/2025 at 8:55 AM, Resident #18 the resident had long, jagged nails. The nails varied in length from one quarter to one half inch. Resident #18 was unable to respond to questions. Resident #2 Review of Resident #2's face sheet, dated 04/2/2025, reflected a [AGE] year-old who female was admitted to the facility on [DATE] and diagnoses were Traumatic Brain Injury (injury to brain caused by an external force, that leads to impairment of cognitive, physical and psychosocial functions), and Cognitive Communication Deficit (difficulty in communication skills stemming from underlying cognitive impairments, such as attention, memory and problem solving). Record review of Resident #2's incomplete quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 12 which indicated intact cognition. Review of Resident #2's facility care plan dated 2/19/2025 reflected: Problem: The resident has an ADL self-care deficit related to Disease Process, Hemiplegia, Limited Mobility, Musculoskeletal Impairment, Pain. Interventions: Personal Hygiene/Oral Care: The resident is on one staff for personal hygiene and oral care. In an interview and observation on 3/31/2025 at 2:37 PM, Resident #2 had chipped nail polish and jagged nails. Her nails were no longer than one half inch. Her teeth were not brushed and had a buildup of food in between her teeth. Resident #2 said her nails were horrible and she needed a manicure. She said she relied on staff to help her with all hygiene needs and did not remember the last time her teeth were brushed. In an interview and observation on 4/3/2025 at 9:00 AM, Resident #2's nails were jagged and had chipped nail polish. She said staff had not done nail care that week. During an interview on 4/3/2025 at 10:45 AM, CNA B stated the CNAs were responsible for the residents' nail care. She said nail care included filing, clipping, cleaning underneath the nail with a wood stick, and putting lotion on their feet. She said, We tried to do it every day. During an interview on 4/3/2025 at 12:45 PM, the DON stated nail care included soaking the nails, clean underneath the nails with a wood stick, clipping and filing. She said the CNAs were responsible to provide nail care three times per week or as needed and oral care daily. She said the residents could have scratched themselves or had open scratches that introduced bacteria. During an interview on 4/3/2025 at 1:05 PM the ADM stated his expectation was that nail care was done on a regular basis or based on resident preference. He said germs could have gotten under the nails and became infected. He said nail care should have included cleaning, cleaning underneath the nails, filing, clipping, and painting. He said his expectation was that it should have been looked at, at least weekly. Review of the facility's policy titled Regency Integrated Health Services; Activities of Daily Living (ADLs) dated 5/26/2023 reflected: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 6. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred.

Based on observation, record review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one kitchen reviewed for pests. Cockroaches were seen in the kitchen near the garbage can located beside clean pots and pans and one located in the dining room near the large wall of cabinets. This failure could place residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:05 AM revealed a cock roach was beside a garbage can located by shelves full of pots and pans. Observation on 04/02/2025 at 6:08 AM, a cock roach was moving from underneath the garbage can located by the shelves of pots and pans into the dishwasher area. Observation on 04/02/2025 at 7:10 AM a cock roach was near the large cabinets against the wall in the dining room. Interview on 04/02/2025 at 6:35 AM The Dietary Manager stated anytime roaches, or any type of pest was observed in the kitchen she would report it to the Maintenance Supervisor. She stated the pest control company comes to the facility on ce a month and it was time for him to come this month (April). She stated there is a maintenance log where the staff documents any maintenance issues including pests. She stated if roaches were in the kitchen there was a possibility roaches may have contact with dishes or other food contact surfaces. The Dietary Manager stated she was not certain of what the roaches could spread to areas in the kitchen. Interview on 04/03/2025 at 12:25 The Administrator stated the pest control company came to the facility this week and sprayed in the kitchen. He stated the pest control company does come to the facility monthly. He stated if there were roaches in the kitchen there was a possibility it may make residents sick or uncomfortable with the pests. The Administrator stated if there were any pests in the facility, if they pest control need to make more than one visit per month to the facility, he would call the pest company and they will come out that day or the next day. Interview on 04/03/2025 at 1:05 PM the Maintenance Supervisor stated there was a book where the staff wrote any type of issues for maintenance to take care of and pest was one of those issues. He stated the pest control comes once a month and as needed. He stated whenever they call the pest company, they will come either that day or the next day. Record review of Program Specifications of pest control contract reflected the facility would receive service from pest control company once a month. All interior and exterior areas will be serviced during each service visit to ensure that a completed and total service was provided. The following programs will be implemented such as: interior crawling insect, interior rodent, interior large fly, exterior crawling insect, exterior rodent, exterior large fly bait (dumpster) and, fire ants. The following are the areas of service: 1. Dietary / dining 2. Central Nurse Station 3. Activities 4. Rehabilitation Services/ Physical therapy 5. Laundry / Housekeeping 6. Maintenance / Central stores 7. Clean/ Soiled Utility 8. Health and Beauty 9. Resident Halls/ Common Areas 10. Office/ Administrative 11. Employee Breakroom 12. Exterior Perimeter. Follow-up services, even low levels of pest activity are not tolerated. Therefore, the initial services is followed up with additional services performed at a frequency necessary to eliminate all pest infestation. Follow up services also provide a communication opportunity to ensure we are meeting the client's expectation.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for one of one kitchen 1. The facility failed to keep overflowing garbage away from an area where food was being prepared for resident meals. 2. The facility failed to keep garbage away from an area where clean cook ware was stored. These failures could place residents at risk for exposure of germs and diseases carried by vermin and rodents. Findings Included: Observation on 04/01/2025 at 2:30 PM revealed there was a garbage barrel with the lid off on half of the barrel. There was overflowing garbage with cans and boxes with food residue inside and outside of the cans, containers and, boxes located in the garbage barrel. The garbage barrel was located approximately three feet from the stove-oven, and less than two feet away from clean pans in the food prep area. Observation on 04/02/20255 at 6:05 AM revealed there was a garbage barrel with the lid not completely covering the top of the barrel. There were boxes, food, and a large can inside the garbage barrel. There was a roach moved from underneath the garbage barrel when barrel was moved. In an interview on 04/02/2025 at 6:10 AM the Dietary Aide/Cook in Training stated the garbage barrel was expected to be located next to the door that leads to outside. He stated he had been in-service not to leave garbage barrel in the kitchen area and to always keep the lid on it. He stated there was a possibility garbage in the kitchen area may cause bugs to come into the kitchen where food is prepped. The Dietary Aide/ [NAME] in training stated he knew the pests was not clean and may have some type of germs. He stated he did not like to talk about pests. In an interview on 04/02/2025 with the Dietary Manager at 6:35 AM she stated the garbage barrels was expected to be stored in the area near the back door to the outside area. She stated the garbage barrel was to be covered completely and not overflowing with garbage. She stated on 04/01/2025 the garbage barrel was overflowing with garbage and there was a possibility someone could accidentally touch the garbage and not change gloves and prep food when it was near the stove. She stated the garbage may attract roaches or any type of pest. She stated she did not recall at this time if she in-serviced staff on removing garbage. Facility Policy on Garbage Receptacles, revised on 06/01/2019, reflected the facility will maintain receptacles in a clean and sanitary manner to minimize the risk of food hazards. Indoor receptacles: 1. Trash cans will be kept with lid in place when not in use. 2. Refuse shall be removed from the premises when trash can is full or at a frequency that will minimize the development of objectional odors and attract insects and rodents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary [NAME] C, Dietary [NAME] D and Dietary Aide E used proper hand hygiene during food preparation. 2. The facility failed to ensure Dietary Aide E wear a hair net and Dietary Aide F wear a beard guard when standing over the oven and the food prep table. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 03/31/2025 at 9: 20 AM Dietary [NAME] C was wearing gloves in the kitchen. She was standing by the stove preparing lunch. Dietary [NAME] touched the right side of her shirt when she moved her right hand from her right side to the handle of the utility cart. She placed her right hand on the shredded cabbage located in a large plastic bag on the utility cart. Dietary [NAME] C touched the outside of the bag with her right hand prior to opening the plastic bag wider for her right hand to pick up purple shredded cabbage located in a small clear plastic bag inside the large plastic bag. Dietary [NAME] C did not change gloves prior to touching the shredded cabbage. Interview on 03/31/2025 at 9:25 AM Dietary [NAME] C stated the outside of the plastic bags was not contaminated and she was not required to change her gloves when she touched the utility cart or the outside of plastic bag of cabbage. She stated she did not recall if she touched her shirt. She stated it was a possibility, but she did not recall touching her shirt. Dietary [NAME] C stated the utility cart was not considered contaminated. She stated the only time she was required to change her gloves if she touched anything contaminated. She stated the dietary staff sprays disinfectant on all the clear plastic bags when the food is delivered and before they place the food in the refrigerator or freezer. She stated they did not sanitize the bags every time someone touched the bag. Dietary [NAME] C stated she did not document when she cleaned the plastic bags. She stated there should not be any holes in the plastic bags when asked if she checked the bags for any holes before she sprayed each plastic bag. She stated she had been in serviced on hand hygiene and she did not recall the date of the in-service. Interview on 03/31/2025 at 9:35 AM The Dietary Manager stated the dietary staff cleans and sanitizes all plastic bags with sanitizer before they place the clear plastic bags in the refrigerator or freezer. She stated all staff was expected to change their gloves if they touched anything contaminated. The Dietary Manager stated outside of a plastic bag came from outside source was not considered contaminated. She also stated the utility cart, and the cooks top was not considered to be contaminated. The Dietary Manager stated she did not document they sanitized the clear plastic bags of food or when the sanitized the utility cart. She stated it was not possible to document everything they did due to needing to cook and do other things to prepare for meals. She did not answer the question when asked what if there were holes in the plastic bags and when spraying it with disinfectant was there a possibility the disinfectant may be on the food. Observation on 04/01/2025 at 1:45 PM Dietary [NAME] D was preparing puree bread. She was not wearing gloves. She placed the puree bread in the oven and exited where the oven was located and enter the area of the kitchen near entrance into the dishwashing room. She picked up the mop and placed it in the mop water container. Dietary [NAME] D entered the area of the kitchen where the stove was located and she checked the food in the oven and opened the silver container with the pureed bread and her ring finger and middle finger from the knuckle to the edge of her fingers touched the pureed bread inside the silver container. She did not wash her hands after she touched the mop. Interviewed on 04/01/2025 at 2:00 PM Dietary [NAME] D was unable to understand English. Dietary [NAME] D stated she did not wash her hands and she did touch the mop and touched the pureed bread by accident. Dietary [NAME] D stated she was expected to wash her hands when she touched anything that was dirty. She stated the germs on her hands possible transfer to the food. She stated she had been in-service on hand hygiene. She did not recall the date or time. Observation on 04/02/2025 at 5:35 AM to 6:15 AM revealed the following: * Dietary Aide E was in the only dietary staff working at that time. He was wearing gloves. Dietary [NAME] E touched his cell phone, touched his shirt, and began to cook oatmeal on the stove. He picked up the large mixing spoon and touched the inside of the rounded part of the spoon and placed it in the oatmeal to stir. * Dietary Aide F did not have on a hair net. He was cooking eggs, oatmeal, and sausage without wearing a hair net. He also pureed sausage without wearing a hair net. Interview on 04/02/2025 at 6:00 AM, Dietary Aide E stated he did not change his gloves until now (6:00 AM). He stated he did touch his cell phone; his shirt and he touched inside the spoon before he placed it into the oatmeal cooking on the stove. He stated he was to change gloves after he touched his phone and shirt. He stated germs may transfer to the food from his hands. Dietary Aide E stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach problems such as vomiting. He stated he had been in-service on hand hygiene but did not remember the date of the in-service. Interview on 04/02/2025 at 6:10 AM Dietary Aide E stated his hair was short and he did not think he needed a hair net with his hair being short. He stated all dietary staff was expected to wear hair net when in the kitchen. Dietary Aide E stated it was a possibility hair may fall in the food while he was cooking. He stated hair was considered to have germs on it and the germs may get on the resident's food. He stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach issues such as vomiting. Dietary Aide E stated he had been in-service on wearing hair nets. He did not recall the date of the in-service. Observation on 04/02/2025 at 5:55 AM Dietary Aide entered the area where the food prep tables were located, and he had six to eight inches of growth on his face (around his chin and side of face). He was not wearing a beard guard when he was standing over the food prep table. Interview on 04/02/2025 at 6:12 AM Dietary Aide F stated he was required to wear a beard net when he entered any area of the kitchen. He stated there was a possibility hair may fall onto food or table where food is prepared. He stated hair may touch residents' food and contaminate the food. He stated he did not know if a resident may become ill if they ate any food with hair on it or where hair had been on the food. Dietary Aide F stated he had been in-service on wearing beard guards. He stated he did not recall the date of the in-service. Interview on 04/03/2025 at 8:30 Am the Dietary Manager stated the Dietary Aide E was expected to receive four straight days of training from her on how to be a cook. The Dietary Manager stated the Dietary Aide E did not know how to puree food. She stated the dietary aide E had not been trained on how to puree food. The Dietary Manager stated she did not have a recipe for the sausage patty the Dietary Aide E was pureeing.

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 and to help prevent the development and transmission of communicable disease and infection for 2 of 4 residents (Resident #35 and, Resident #68) reviewed for infection control: 1. The facility failed to ensure MA B sanitized the nasal spray before it was used in Resident #68's nostril and before storing it in the med cart after her use. 2. The facility failed to ensure CNA A was not using soiled gloves while handling clean items during peri care on Resident #35. These failures could place residents at-risk for infection due to improper care practices. Findings included: Review of Resident #35's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #35 had diagnoses of Alzheimer's disease, Anxiety disorder, Major depressive disorder, Age-related physical debility, Lack of coordination, Pain, Vitamin B12 deficiency and need for assistance with personal care. Review of Resident #35's annual MDS dated [DATE] reflected a BIMS score of 0 which indicated her cognition was severely impaired. Review of Resident #35's Care Plan dated 03/25/25 reflected she had bowel incontinence related to Dementia and relevant intervention was providing peri care after each incontinent episode. During an observation on 03/31/25 at 4:33pm CNA A was doing peri care on Resident #35. CNA A washed her hands, put on gloves, and performed the peri care on Resident #35. CNA A removed the brief soiled with urine and feces and cleaned the front, back and the perineal area (the area between the anus and the genitals) of the resident. CNA A then without changing the soiled gloves put on the new brief on the resident. After the completion of the procedure, using the same gloves, pulled up the blanket and adjusted the bed for Resident #35. During an interview on 03/31/25 at 4:50pm CNA A stated she thought she was doing it correctly. When the surveyor walked through the process, she was able to identify the mistake she made. CNA A stated she should have changed the gloves before handling the clean items like the new brief, bedlinen, and blanket. CNA A stated she was aware that handling materials with contaminated gloves could spread diseases. CNA A stated she received in services on peri care however did not remember exactly when it was. Review of Resident #68's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #68 had diagnoses of Hypertension, Age-related physical debility, Need for assistance with personal care, Type 2 diabetes, Dementia, Psychotic disturbance, Mood disturbance, Anxiety Chronic pain, Tobacco use, Unspecified asthma, Rhinitis (inflammation of the nasal lining) and COPD. Review of Resident #68 annual MDS dated [DATE] reflected a BIMS score of 05 which indicated her cognition was severely impaired. Review of Resident #68's Care Plan dated 03/14/25 had not reflected the management of rhinitis. Record review of Resident #68's March 2025 MAR reflected: Fluticasone Propionate Nasal Suspension 50 MCG (Fluticasone Propionate (Nasal)) 2 sprays in each nostril one time a day for Rhinitis. During an observation on 03/31/25 at 9:30 am MA B was administering medication in Hall 400. She had provided Resident #68's Fluticasone Propionate to her for self-administration, under her supervision. Resident #68 inserted the nozzle of the bottle into her nostrils and squeezed two times in each nostril. After the administration she returned the bottle to MA B. MA B then put the bottle back in the drawer of the med cart. MA B did not sanitize the Fluticasone Propionate bottle before and after the resident inserted it into her nostrils. During an interview on 03/31/25 at 9:55 am MA B stated she forgot to sanitize the nozzle of the bottle before and after the use. She stated this was necessary to minimize spreading germs of various diseases from residents. MA B stated she received training's and in services on infection control and aware of the importance of following infection control protocol however was nervous and forgot to implement it during administering the nasal spray. During an interview on 04/03/25 at 12:35pm the DON stated MA B expected to sanitize the nasal spray every time when it was used. She stated this was essential to limit the spread of various diseases at the facility. The DON stated the infection control in services were conducted frequently. She stated she had not remembered the exact days however the documentation of in services were available in the in-service folder. During an interview on 04/03/25 at 12:55pm the IP stated she was responsible for the supervision of the infection control management at the facility. She stated the expectation was, all staff at the facility would follow the facility's infection control policy. She stated she routinely observed if the staff followed the correct infection control procedures. IP stated staff were provided in service sessions and one to one in service if necessary. IP stated she observed wound care and peri care time to time, to make sure the staff followed the correct procedure as recommended in the infection control policy. Record review of facility policy Infection Prevention and Control Program dated 05/13/23 reflected: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . . 2. All staff are responsible for following all policies and procedures related to the program. . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE .

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen observed. The facility failed to provide a recipe for pureeing sausage which resulted in Dietary Aide E adding an unmeasured amount of water to the puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:12 AM Dietary Aide E placed 28 sausage patties into the puree blender. He had a pitcher of water and began pouring water without measuring. Interview on 04/02/2025 at 6:14 AM Dietary Aide E stated he had never puree food before and he was guessing how much water needed to be in the container with the sausage before he pureed the sausage. He did not know if he was to view the recipe prior to pureeing the sausage. He stated he had cooked by himself before, and he usually did puree at 6:25 AM or 6:30 AM without anyone assisting him. The Dietary Manager entered the kitchen, he stated Dietary Aide E had never puree food before and today would be his first time. Interview on 04/03/2025 at 8:30 Am the Dietary Manager stated the Dietary Aide E was expected to receive 4 straight days of training from her on how to be a cook. She stated the dietary aide/cook in training had not been trained on how to puree food. The Dietary Manager stated she did not have a recipe for the sausage patty the Dietary Aide E was pureeing. She stated her expectations was for him to receive the proper training on how to be a cook prior to him cooking without any supervision. The Dietary Manager stated, I knew he was at the facility to cook but I overslept and did not come in to supervise him until after 6:00 and he was almost finished with preparing breakfast when I arrived at the facility on 04/02/2025. She stated Dietary Aide E was required to follow the recipe for pureeing the sausage and the recipe was not available in the recipe book. She stated what was used the puree sausage was what was on the recipe to use. Record Review of Dietary Manager job description reflected she was responsible for daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. The Certified Dietary Manager provides leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactory met. 1. Interview, train, coach, and evaluate dietary staff. 2. Specify standards and procedures for preparing food. Food safety- Assure safe receiving, storage, preparation, and service of food. Signed by the Dietary Manager on 01/26/2023. The policy /protocol for pureeing food and the recipe for pureeing sausage was not provided at the time of exit.

Based on observation, interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to conduct the functions of the food and nutrition services for one of three kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. Dietary Aide E had not received onboarding training with the appropriate competencies and skills to conduct the functions of the food and nutrition services department and his food handler certificate was expired. This failure placed residents at risk of not having their nutritional needs met and placed them at risk of food borne illness. Findings included: Interview and observation on [DATE] at 5:35 AM Dietary Aide E introduced himself as the [NAME] for the day (he did not mention he was in training to be a cook). He stated he did not know when the Dietary Manager was coming in for the day. Dietary Aide E stated the Dietary Manager usually came to work between 7:30 AM and 8:00 AM. He was observed placing pots on the stove. Observation on [DATE] at 6:12 AM Dietary Aide E in training placed twenty-eight sausage patties into the puree blender. He had a pitcher of water and began pouring water without measuring or reviewing the recipe. Interview on [DATE] at 6: 14 AM Dietary Aide E stated he had never pureed food before and he was guessing how much water needed to be in the container with the sausage before he pureed the sausage. He did not know if he was to view the recipe prior to pureeing the sausage. He stated he had cooked by himself before, and he usually did puree at 6:25 AM or 6:30 AM without anyone assisting him. When the Dietary Manager entered the kitchen, he stated he had never pureed food before and today would be his first time. Interview on [DATE] at 6:18 AM the Dietary Manager stated Dietary Aide E was in training to be a cook. He had not finished his training and she was expected to be in the kitchen with him on [DATE], however, she overslept. She stated he was not to cook by himself he had not been trained to be a cook. The Dietary Manager stated he was not to puree food by himself or do any cooking by himself. Observation and interview on [DATE] at 6:45 AM the Dietary Aide E were by himself in the kitchen finishing cooking and preparing for breakfast. The Dietary Manager was in the dishwashing room washing dishes and was not with the Dietary [NAME] in Training. The Dietary Aide E placed eggs on the steam table and they were not fully cooked. He stated he was in training to be a cook. He stated when he introduced himself around 5: 30 AM he said he was the cook for the day and did not explain he was in training to be a cook. The Dietary Aide E stated he only had one day of training, and it was observing another cook. Interview /Observation on [DATE] at 6:48 AM The Dietary Manager stated she was needing to wash some dishes before breakfast. She stated she would stop and obtain the temperature of the food on the steam table. She entered the kitchen area where the steam table was located and began taking temperature of the oatmeal and then she pulled back the aluminum foil covering the uncooked eggs and she stated these eggs are not cooked and we cannot serve raw eggs. The Dietary Aide E came to the steam table and carried the eggs to the stove to re cook the eggs. The Dietary Aide E stated he thought they were cooked. Record review on [DATE] and [DATE] of Dietary Aide E personnel file reflected Dietary Aide E had a new position of [NAME] on [DATE] with effective date on [DATE]. There was not any documentation in his personnel file of him being trained as a Cook. He did have his food handler license, however, it expired on [DATE]. Reviewed his training and he was not trained on being a cook. Record review of the dietary staff training and Dietary Aide E only had one training related to the kitchen and it was on infection and hand hygiene. Interview on [DATE] at 8:30 Am the Dietary Manager stated she thought he had his food handler license and she stated she did not believe his license had expired. She stated his most current food handler license would be in his personnel file. She stated she did not have any thing documented on Dietary Aide E training. The Dietary Manager stated Dietary Aide E was expected to receive 4 straight days of training from her on how to be a cook. She stated he only got one day of training about 2 weeks ago and she did not document the training she provided to him. She stated she did not recall the training he received on that one day. The Dietary Manager stated the Dietary Aide E was not qualified to cook alone. She stated he needed to be with her when Dietary Aide E cooked. The Dietary Manager stated she should have called him and told him not to cook until she got to the facility. She stated the eggs Dietary Aide E placed on the food prep table was not cooked properly and it was a possibility if a resident had eaten raw eggs the residents would have developed some type of food borne illness. The Dietary Manager stated she did not have a recipe for that type of sausage the Dietary Aide E was pureeing. Record Review of Dietary Manager job description reflected she was responsible for daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. The Certified Dietary Manager provides leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactory met. 3. Interview, train, coach, and evaluate dietary staff. 4. Specify standards and procedures for preparing food. 5. Food safety- Assure safe receiving, storage, preparation, and service of food. Signed by the Dietary Manager on [DATE].

Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident , encouraging both independence and interaction in the community for one of five residents (Resident #15) reviewed for activities. The facility failed to provide Resident #15 in room activities during the months ofFebruary and March of 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings included: Review of Resident #15's Face sheet , dated 04/02/2025, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis: vascular dementia, unspecified severity, with mood disturbance ( a type of dementia caused by conditions that damage blood vessels in the brain, resulting in reduced blood flow, and can lead to changes in mood), muscle wasting ( thinning , and weakening of muscles), age-related physical debility (an aging-related syndrome characterized by symptoms including weakness, fatigue, multiple chronic health conditions that affect different organs in the body, and reduced tolerance to medical and surgical interventions), and repeated falls ( move downward, typically rapidly and freely without control, from a higher level to a lower level). Record review of Resident #15's Annual MDS Assessment, dated 08/02/2024, reflected Resident #15's activity preference was a place to lock personal belongings, listening to music, and spending time outdoors. Record review of Resident #15's Quarterly MDS, dated [DATE], reflected Resident #15 Resident #15 was unable to complete the BIMS. Resident #15 had poor short- and long-term memory recall. Resident #15's decision making ability was severely impaired (never/rarely make decisions). Resident was assessed to have repeated falls, impaired vision, unclear speech and, minimal difficulty with hearing (difficulty with hearing in some noisy environments. She rarely or never understood others or made self-understood. Record review of Resident #15's Comprehensive Care Plan, with a completion date of 02/14/2025, reflected the following care areas: *Resident #15 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits (may be present from birth or may result from environmental causes such as brain damage or mental illness) date initiated on 01/20/2022. Resident #15 activity preference appears to be nurturing her doll that she treats like an infant. Interventions: Resident #15 needed in room activities if unable to attend out of room events. *Resident #15 had a problem with communication. She spoke Korean. Resident #15's family would translate. Her family did attempt to translate, however, the family stated Resident #15 was confused and did not respond to communication or when she did speak unable to understand what she is trying to say. Interventions: Anticipate and meet needs. Resident #15 required assistance from family with communication. *Resident #15 had dementia with impaired thought processes. Interventions: Engage Resident #15 in simple, structured activities that avoid overly demanding tasks. Resident #15 had depression. Intervention: Monitor and document any signs or symptoms of depression including hopelessness, anxiety, sadness, and/or insomnia. Record review of Resident #15's Activity Initial Review Form, dated 08/09/2020, reflected the form was blank. Record review of Resident #15's last Activity Progress Note documented in the electronic medical record, dated 09/22/2022 reflected Resident #15 was currently in attendance to group activities; however, she was unable to participate due to diagnosis of Dementia and Alzheimer (a type of brain disorder that causes problems with memory, thinking, and behavior) disease. She used a wheelchair for mobility, one person to assist. She was unable to understand what was being said to her due to her diagnosis. There was also a language barrier, but the staff had used the language translator on their phone in attempt to communicated with her, but she did not appear to understand. Her family member had attempted to speak to her in her native language and has reported to staff the Resident #15 speaks, her response was not making sense. Staff will continue to provide sensory stimulation as mean of socialization and comfort. Signed by the Activity Director. Record review of Resident #15's Activity Participation Record from January, February and March of 2025 reflected Resident #15 was not provided in room activities, participated in group activities and/or received any type of activities. Observation on 03/31/25 at 11:39 AM, revealed Resident #15 was lying in bed staring at the ceiling and would move her eyes toward the wall beside her. Resident #15 had television in room. There was no stimulation in her room. The privacy curtain was pulled and she was unable to look out the door into hallway. Resident #15 did not have a radio in her room. Resident #15 did not speak. Observation on 03/31/2025 at 3:20 PM, revealed Resident #15 was lying in bed and staring toward ceiling. There was no stimulation in her room. The privacy curtain was pulled, and she was unable to look out the door leading from hall into her room. She did not have a doll in her room. Resident #15 found comfort holding a doll and enjoyed music. Resident #15 did not have any electronic device to listen to music except for the television. Resident #15 did not speak. Observation on 04/01/2025 at 8:20 AM, Resident #15 was in her room lying in bed. She was staring toward ceiling and toward the television. There was no stimulation in her room. The privacy curtain was pulled where she could not look out the door leading to the hallway. Where her bed was positioned, she was unable to look out the window. There was not a doll in her room or any type of electronic device for her to listen to music. Resident #15 did not speak. Observation on 04/01/2025 at 4:30 PM Resident #15 was in her room lying in bed. She was staring toward the ceiling and then would stare toward television in front of her. Resident #15 did not have a doll or any type of electronic device to listen to music. Resident #15 did not speak. Observation on 04/02/2025 at 9:05 AM Resident #15 was in her room lying in bed. She was staring toward the wall in front of her and would stare toward the ceiling. Resident #15 did not have any stimulation in her room. Resident #15's privacy curtain was pulled where she could not see out the door leading into the hallway, and she was unable to see out the window. She did not have a doll in her room. Observation on 04/02/2025 at 2:30 PM Resident #15 was in her room lying in bed. She was staring toward the ceiling and toward the wall beside her. Resident #15 did not have a doll in her room and did not have any electronic device to listen to music except for her television. Observation on 04/03/2025 at 8:40 AM Resident #15 was in her room lying in bed. She did not have any stimulation in her room. Resident #15 was staring at the ceiling and would stare at the wall in front of her. She did not have a doll in her room. The privacy curtain was pulled, and she could not view the door leading to the hallway. Resident #15 could not view the outside from the window in her room due to where her bed was positioned. Interview on 03/31/2025 at 3:30 PM the Activity Director stated she did not know how to print the participation records from the computer. She stated all her documentation for in room activity and group activities was on each resident's participation record in the electronic medical record. Interview on 04/03/2025 at 9:30 AM The Activity Director stated she did not have a list of Residents that required in room activities. She stated she remembered who needed the in-room activities. The Activity Director stated Resident #15 did come out of her room and received stimulation by watching other residents. She stated Resident #15 was not capable of participating in group activities. The Activity Director stated she was to follow the care plan on all the residents. She stated Resident #15 did enjoy holding a doll. She stated the doll brought comfort to Resident #15. She stated a doll was not left in Resident #15's room for her to hold all the time due to the dolls was very expensive. The Activity Director stated the doll would be difficult to replace if it was missing. She stated a family member of Resident #15 would probably bring her a doll if she contacted a family member. She stated she did not think about getting her another type of doll for her to hold that was not a life-like doll. The Activity Director stated if Resident #15's participation record was blank in the computer system she missed documenting on Resident #15. She stated she was expected to document on every resident of the type of activity they did during the day. She stated Resident #15 did enjoy music and she did not ask a family member if they knew Resident #15's favorite music. The Activity Director verified after looking on the electronic medical record there was no documentation on Resident #15's participation record. She stated if a resident was not receiving any type of activities there was a possibility a resident may become bored, depressed or have a decline in their mental status. She stated not receiving activities would affect their overall quality of life. The Activity Director stated she did not know how she forgot to not document on Resident #15. She stated she completed section F on the MDS. The Activity Director stated she did not know what section E was and she did not complete section E ( Mood and Behavior) of the MDS. Interview on 04/03/2025 at 12:25 PM the Administrator stated if Resident #15 was not receiving any type of activities there was a possibility Resident #15 may have some repercussions. He stated I am not sure of what type of repurcussions. The Administrator stated the activity care plan was expected to be followed. He stated if there was a doll intervention on Resident #15's care plan, the doll was expected to be provided and left in Resident #15's room. The Administrator stated the Activity Director was responsible to ensure all residents received the type of activities related to their cognition and culture. He stated he was the Activity Director's supervisor. The Administrator stated he did give an in-service with the Activity Director this week on in room activities. Record review of The Activity Director Job Description (this is considered the facilities policy for the Activity Department), dated 08/03/2022, reflected the following: The Activity Director will be responsible for planning, coordinating, and directing the resident's activity program and the maintenance of necessary documentation. 1. Organize both individual and group activities on the needs to the residents. 2. Ensure that multiple activities are occurring for both high and low functioning residents. 3. Develop the activities component of the Comprehensive Care Plan from the completed activity assessment. 4. Complete an annual assessment for each resident on the activity's component of the Resident Assessment. 5. Provide activities for residents that are bedfast and/or unable to participate in group activities (one to one) and documents in the appropriate record.

Based on observation, interview, and record review the facility failed to ensure medications and biological's were stored in locked compartments for one of seven (Hall 300 medication cart) medication carts reviewed for medication storage. The facility failed to ensure Hall 300 medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to medications, biological's, and needles. Findings included: Observation on 03/31/2025 at 3:30 PM revealed a unlocked medication cart on Hall 300; located near the entrance of the hallway, closest to the nurse's station. The back of the cart was against the wall with the drawers facing the hallway. The state surveyor observed the medication cart with the locking mechanism protruding outward. The state surveyor opened the drawers and captured photos. During an interview on 3/31/2025 at 3:40 PM, the RN said she thought she had locked the medication cart on Hall 300 before she walked away. She said she could not believe the cart was unlocked, as she had the only set of keys for that cart. She said if residents had accessed the medication cart they could have overdosed, taken the wrong medication, had an allergic reaction, could require hospital admission. She said she had previously been in-serviced on locking the medication carts and could not recall the specific date. She said she was aware the medication cart should have been locked. During an interview on 4/3/2025 at 12:45 PM, the DON said her expectation was the medication cart should have been locked. She said she had in-serviced staff multiple times and had reminded staff this morning to ensure the medication carts were locked. Review of the facility's undated policy titled, Medication Administration, Medication Carts and Supplies for Administering Meds reflected: Policy: The facility maintains equipment and supplies necessary for the preparation and administrations of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Med Carts: . 2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 (Resident #2) of 2 residents reviewed for blood glucose monitoring. RN A failed to perform hand hygiene and wear gloves while checking Resident #2's blood glucose. This failure place residents at risk of infections. Findings included: Review of Resident #2's face sheet dated 10/01/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, peripheral vascular disease, and dependence on renal dialysis. Review of Resident #2's care plan initiated 02/13//2024 reflected Resident #2 had an ADL self-care performance deficit related to right below the knee amputation, independent with all ADL's and driving. It was also reflected Resident #1 was at risk for fluid volume overload or potential fluid volume overload related to end stage kidney disease. Review of Resident #2's Nursing Home Quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #2's physician orders reflected: Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale subcutaneously before meals and at bedtime for DM dated 04/02/2024. During an observation on 10/01/2024 at about 12:02 pm, RN A walked into Resident #2's room to check his blood glucose for lunch, ungloved hands with a glucometer machine, test strip, a lancet, an alcohol pad, and a 2x2 gauze. RN A did not perform hand hygiene after entering the room, did not wear gloves, she took Resident #2's finger, and disinfected it with the alcohol pad. RN A then used her ungloved hands and dried Resident #2's finger, thereby disinfecting the finger. RN A then stuck Resident #2's finger with the lancet and put a blood sample on the test strip that was inserted in the glucometer. RN A then used the 2x2 gauze to wipe the blood off Resident #2's finger with her ungloved hands. RN A walked out Resident #2's room without hand hygiene, touching the doorknob. During an interview on 10/01/2024 at 12:10 pm Resident #2 stated the staff always checked his blood glucose without wearing gloves. Resident #2 also stated you don't know what the staff have touched, and they were touching you with ungloved hands. During an interview on 10/01/2024 at about 12:39 pm RN A stated, I didn't wear gloves, I was supposed to allow the alcohol to air dry. We wear gloves to protect the residents and the staff from infection. I do not want to transmit infection from the resident to me or from me to the resident. I do not know what to say, I know that was not right, he was my last resident to do accu check and I was hurrying to go to the dining hall. During an interview on 10/01/2024 at about 2:57 pm, the DON stated there was no excuse for what RNA did when checking Resident #2's blood glucose. The DON stated RN A should have knocked on the Resident #2's door, wash her hands, wore gloves, cleaned Resident #2's finger, allowed it to air dry, and took the blood sample. The DON stated gloves should be worn when coming in contact with Resident's bodily fluids, for infection control, protecting the resident, and the staff. The DON stated she expected the staff to follow the checkoff steps for checking blood glucose. The DON stated RN A told her what had happened, and she went ahead and in-serviced RN A on infection control and hand hygiene with return demonstration. Review of in-service dated 10/01/2024 titled Infection Control and hand hygiene presented by the DON, signed by RN A. Review of the facility's Glucometer/Fingerstick check off undated reflected: Procedure -- Did the nurse set up equipment prior to starting the procedure? --Clean the Glucometer before use? -- Did the nurse wash hands prior to putting on gloves? -- Identify Resident, ensure privacy, and explained the procedure to the resident? -- Place barrier down for equipment? -- Clean the finger of the patient with alcohol pad and allow the area to dry? -- Place test strip and lancet in sharps container after the procedure was performed. -- Disposed of gloves and washed hands before touching anything else and exiting the room. -- Re-glove and disinfect glucometer with germicidal (must remain wet for 2 minutes) and allowing it to air dry for the appropriate amount of time? -- After cleaning glucometer if placed on top of cart was the area cleaned with a POI wipe or was a barrier provided? --Disposed of gloves and rewashed hands? Review of the facility's policy titled Hand Hygiene dated 10/24/2022 reflected: (Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's policy titled Infection Prevention and Control Program dated 05/13/2023 reflected: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.

Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately but not later than 24 hours after the allegation was made for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident on the facility's van where the Van Driver failed to ensure Resident #1 was properly strapped in the facility's van on 09/23/2024. This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #1's face sheet dated 10/01/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, and encephalopathy (describe a disease that affects the brain structure or function. It causes altered mental status and confusion) unspecified. Review of Resident #1's care plan revised 02/28/2024 reflected Resident #1 had a communication problem related to speaks Spanish, required interpreter, understands English but speaks broken English increasing the risk for miscommunication; has potential for fluid volume overload related to requiring dialysis and on fluid restrictions; needed hemodialysis related to end stage renal disease. Review of Resident #1's incident report dated 09/23/2024 at 11:30 am reflected the following, Per charge nurse at approximately 10:30 am Van Driver called her that the Resident sustained hematoma on head due to chair tilting backward causing her head to bump on the grate in the van. Resident went to dialysis and C/O headache and dialysis sent Resident to hospital for CT scan. Resident stated, my chair went back on my way to dialysis and hit my head on the metal thing. Review of Resident #1's progress notes dated 09/23/2024 at 5:35 pm reflected, Resident went to dialysis for her treatment, later the dialysis center called the facility and spoke with nurse that the pt hit her head to an object in the van on her way coming to dialysis, the pt c/o headache at dialysis and they sent her from dialysis to ER, the nurse notified the NP in the facility and also, she notified the ADON, the daughter was also made aware of what is going on. she not back from ER up till now at 1739. Review of Resident #1's progress notes dated 09/23/2024 at reflected: Resident came back from hospital for CT, on stretcher via EMS accompanied by 2. Resident alert and oriented, denies pain and discomfort, scalp bruise on the right side of her head. No other skin issues at this time. WCTM. Review of Resident #1's CT scan (is an imaging test that uses x-rays and a computer to create detailed images of your bones and soft tissues of the head dated 09/23/2024 reflected, Right parietal scalp contusion (it occurs when there is bleeding under the scalp, but the skin is not broken. The affected area may have swelling) without fracture. Review of facility's investigation folder regarding the incident reflected the following statements: On 09/24/2024 at 10am administrator and myself went to talk to (Resident #1). I help him translate. We asked what happen. stated she had fallen backwards in the van, on her way to her dialysis and she wasn't strap properly. She said only was strap with one strap. She hit her head. She told dialysis nurses about it. MD at the clinic told them to send out since she told her head was hurting. She then was sent to the local hospital. Resident #1, was interviewed by the Administrator regarding the incident that occurred during transporting to Dialysis. The resident stated her chair tilted backward during transport. She stated that as the Van driver accelerated from tile stoplight, the wheelchair tilted backwards, and she bumped her head. I asked if she was properly secured in the van. She (Resident #1) stated she could not see the straps but [NAME] as though the chair could not have been secured correctly, however she was not sure. Signed by the administrator, undated. Review of facility's Van Driver personnel file reflected staff was taken off the van and suspended as of 09/26/2024 due to failure to report an incident and failing to meet job expectation. The following was also reflected and signed by the administrator and van driver, Official written reprimand for failure to perform the required functions of your job duties per instruction and training. On 9/23/24 there was an incident that took place on the van during resident transport to a recurring appointment. This incident of carelessness had the potential to cause harm. Review of Resident #1's skin assessment dated [DATE] reflected: Top of scalp knot to top of head from transfer related incident. Review of facility's in-services reflected the following: Post fall procedures dated 09/26/2024. Abuse and Neglect dated 09/26/2024 . Review of facility's record in TULIP reflected the incident was not reported to the State Agency. During an interview on 10/01/2024 at 11:01 am, the Van Driver stated she had been driving the facility's van for 2 years. She stated she was trained on how to operate the van prior to driving the van and was trained routinely. The Van Driver stated on 09/23/2024 at about 10:25 am while taking Resident #1 and 2 to dialysis, she had stopped at the red light, when the light changed green, the moment she put her foot on the gas she heard Resident #1 yelling saying she was moving back, and that she hit her head. The Van driver stated she looked over her shoulder and saw that Resident #1's wheelchair tilted back, she couldn't pull over right away because they were in the middle of the road, so she drove a little for safety and to pull to the side. The Van driver stated she parked the van, went to the back where both Residents were and positioned Resident #1 properly in the wheelchair. The Van Driver stated she observed a bump on Resident #1's head, she immediately called the facility, spoke with the Administrator, and 2 other nurses, and was told to take Resident #1 to dialysis. The Van Driver said she called the dialysis center, staff at the center spoke with Resident #1, and the dialysis center staff said to take Resident #1 to dialysis. The Van Driver stated when she got to the dialysis center, the staff were waiting outside for Resident #1, she was assessed before and after taking her in and she was told it was ok to leave. The Van Driver stated she strapped Resident #1 in but was not sure what happened. The Van Driver stated she hadn't driven the van since the incident, she was interviewed by the Administrator and suspended. During an observation and interview on 10/01/2024 at about 11:23 am of the facility's van with the Van Driver, the Van Driver demonstrated how to properly strap a resident in the van. It was observed that there were 4 straps, 1 for each wheel on the wheelchair, 2 seat belts to secure the resident. It was also observed that when a wheelchair was strapped properly, there was no way for the wheelchair observed to tilt or move. The Van Driver was then asked what did she see when she stopped the van and went to check the Resident? The Van Driver touching the right wheel of the wheelchair and stated it was not on proper and saying the wheelchair was strapped. The Van Driver stated she lifted Resident #1's wheelchair but her feet were not in the air. The Van Driver again stated she noted a bump on Resident #1's head that was when she called everyone. The Van driver stated it all happened so fast, she stated Resident #1 was still connected to straps and she didn't know what happened. During an interview on 10/01/2024 at 11:42 am Maintenance Director stated he checked the van monthly and asked the Van Driver to report if the tires and engine lights were on. The Maintenance Director stated they have not had problems with the van. He also stated trainings were done every 6 months on how to secure the wheelchair in the van. The Maintenance Director said he couldn't tell if Resident #1's wheelchair was properly strapped because he was not in the van at the time of the incident . During an interview on 10/01/2024 at about 11:50 am, Resident #2 stated he was in the facility's van on 09/23/2024 when the incident happened with Resident #1. Resident #2 stated he was put in the van first by the Van Driver, strapped and then Resident #1. Resident #2 stated they were at the light, when the Van Driver accelerated, he heard Resident #1 saying she was going back in her chair and that she had hit her head. Resident #2 stated when he turned, he saw Resident #1's feet in the air, her wheelchair was tilted over but he couldn't see Resident #1's head. Resident #2 stated he could help Resident #1 because he was strapped but the front 2 wheels of Resident #1's wheelchair was not strapped. Resident #2 stated the Van Driver couldn't park immediately because they were in the middle lane, other cars were coming on both ends. Resident #1 stated when they parked after the traffic had cleared, the Van Driver got down, had to pick Resident #1 up because her feet were in the air. Resident #2 stated that was the first time such an incident had happened. During an interview on 10/01/2024 at 12:24 pm, Resident #1 was sitting in her room, eating lunch. Resident #1 understood English and spoke a little with demonstration. When asked about the incident on the van, Resident #1 started to yell, saying she fell and hit her head. Resident #1 then started to demonstrate that her feet were in the air while saying it, touching the 2 front wheels of her wheelchair saying it was not hooked. Resident #1 then demonstrated while saying she had the belt strapped around her, her wheelchair went back, and she hit her head while pointing to where she hit her head. The State Surveyor observed a raised bruise area on right parietal head about the size of a nickel. Resident #1 also stated she was scared and that she went to the hospital when she went to dialysis. Resident stated she was not hurting and said, thank you Jesus. During an interview on 10/01/2024 at about 3:48 pm, the Administrator stated he was the abuse and neglect coordinator, and it was his expectation that staff reported any suspicion of abuse and neglect to him immediately. He also stated if there were allegations of abuse or neglect, he in-serviced the staff, investigated, and determined if it had to be reported to the state. He stated he was made aware of the incident with Resident #1, and he initiated an investigation. The Administrator stated according to what he was told, the Van Driver was taking Resident #1 to her routine dialysis, when she accelerated at the light, Resident #1 bumped the top rear of her head. The Administrator stated from the way it was explained to him, it appeared to be a very light bruise. The Administrator stated he took the Van Driver off the van pending investigation, the Resident was sent to the ER and the findings were negative, neurological assessments (exam consist of physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) were completed accordingly, family and MD/NP notified, safe survey with other residents who rode the van, abuse and neglect in-service with staff, and the Resident would be transported by commercial transport until the van was check out. He stated he asked the Van Driver to explain and show him what had happened. The Administrator stated, My finding is, there was no way possible, this would have happened if the resident was strapped properly, based on expectations and training. Staff were in-serviced on abuse and neglect. The Administrator stated, from the way the incident was explained to him, he did not think it was reportable. The Administrator stated the Van Driver was suspended because he didn't think the Van Driver was saying the truth. The Administrator stated he spoke with Resident #1 and Resident #2, but the Residents were not sure if the wheelchair was strapped properly. The Administrator stated suspicion of abuse and neglect with injury was reportable . Review of facility's policy titled Abuse, Neglect, and Exploitation dated 08/15/2022 reflected: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect, exploitation, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting/Response A The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation} involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to check Resident #1's glucose level or A1C for five months after he was admitted to the facility with a diagnosis of type II diabetes and was recently discontinued from Metformin and Trulicity (medications utilized to manage high blood glucose levels with individuals with type II diabetes) at the hospital. These failures could place residents at risk of not receiving necessary medical care, harm, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including type II diabetes, stroke, hypertension (high blood pressure), and vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain). Review of Resident #1's quarterly MDS assessment, dated 06/28/24, reflected a BIMS of 7, indicating a severe cognitive impairment. Section I (Active Diagnoses) reflected he had a diagnosis of diabetes. Review of Resident #1's quarterly care plan, dated 08/29/24, reflected he had Diabetes Mellitus with an intervention of fasting serum blood sugars as ordered by the doctor. Review of Resident #1's hospital discharge paperwork, dated from 02/29/24 - 03/23/24, reflected to stop taking the following medications: Metformin - 1 tablet twice a day by mouth, dulaglutide (Trulicity pen) - 0.75 Milligrams every week. Takes on Fridays. Last dose on 02/23/24. During his stay his BS readings were ranging 84 - 123. A1C: 5.4 (normal is below 5.7). Review of Resident #1's BS readings in his EMR, on 09/17/24, reflected his glucose level was never checked for the duration of his stay at the facility. Review of Resident #1's physician order, dated 04/08/24 and ordered by the MD, reflected the following: CBC w/Auto Diff | Comprehensive Metabolic Panel - one time only related to . Type II Diabetes with Mellitus with Unspecified Complications. Review of Resident #1's lab results, dated 04/10/24, reflected a high glucose level of 318 (Reference Range: 82-115 ). Review of Resident #1's physician orders, on 09/17/24, reflected no further lab work was requested after 04/08/24. During a telephone interview on 09/17/24 at 10:52 AM, Resident #1's NP stated if a resident was a diabetic, it would depend on the individual of how often their glucose level (if they were not being administered insulin or diabetic medication) should be checked. She stated the resident's A1C should be checked every three months. She stated labs such as a CBC or CMP tested the glucose level. She stated if there were lab results that showed a blood sugar of 318, she would have expected to have been notified and it should have been addressed. She stated she would have ordered follow-up labs. During a telephone interview on 09/17/24 at 11:34 AM, Resident #1's MD stated if a resident's A1C was normal, regular glucose checks were not necessary. He stated he was notified of Resident #1's glucose of 318 reading in April 2024, but he could have eaten a hamburger or candy bar before the labs were drawn. He stated he could have ordered a fasting glucose check, but his A1C would not have changed since he had been in the hospital. He stated an A1C should be checked every three months unless it was consistently low, then it could be stretched out to every six months. During an interview on 09/17/24 at 11:48 AM, the DON stated if a resident was diabetic and not on diabetic medication, labs (including A1C) should be done every 3-4 months. She stated she was not notified of Resident #1's high glucose reading in April (2024). She stated the nurses should have checked his blood sugar after receiving the results and should have notified the NP. She stated a negative outcome of not drawing appropriate labs in a timely manner could be hyperglycemia or a resident's blood sugar dropping too high or too low. She stated they did not have a policy on lab work or caring for a diabetic resident.

Based on interview and record review, the facility failed to ensure all residents were free from unnecessary drugs for 1 (Residents #63) of 3 residents reviewed for unnecessary drugs. -The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to update the diagnosis for Seroquel XR for resident #63. -The facility failed to develop policies and procedures to address the timeframes of the medication regimen review. This failure could place resident as risk of not having their pharmacy consultations reviewed or recommendations implemented. The findings included: Review of Resident #63's face sheet printed 02/16/24, reflected a [AGE] year-old female most recently admitted to the facility on [DATE]. Her diagnoses included Guillain-Barre syndrome (a disorder of the immune system that causes weakness and tingling in arms and legs), other chronic pain, major depressive disorder (a mood disorder with persistent feeling of sadness and loss of interest), post-traumatic stress disorder (a mental health condition that develops following a traumatic event), unspecified intellectual disabilities (a condition that affects the ability to learn, understand, and interact), insomnia (difficulty sleeping), morbid obesity, and generalized anxiety disorder (intense and excessive worry and fear). Review of Resident #63's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected resident required setup or clean-up assistance for eating and oral hygiene but required maximum assistance for all other ADLs. Section I (Active Diagnoses) reflected anxiety disorder, depression, and Post-Traumatic Stress Disorder. Review of Resident #63's physician's order dated 11/20/23, reflected, Seroquel XR oral tablet Extended Release 24 Hour 300mg (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to GENERALIZED ANXIETY DISORDER. DO NOT CRUSH . Review of Resident #63's pharmacist Recommendations Pending Response dated 12/14/23, reflected, Please provide a CMS approved diagnosis for the following antipsychotic medication Seroquel XR - anxiety is not a CMS approved diagnosis. Please refer to the very short list of approved diagnosis provided by CMS. If the patient does not fit into one of the approved diagnosis, please consider changing to a more appropriate medication . During an interview on 02/16/24 at 11:22 AM, the DON stated they did not have any written timeframes for following up on pharmacy recommendations. She stated after the paperwork was received from the pharmacist, usually within two to three days they gave the recommendations to the providers. She stated as soon as the providers responded, the facility implemented the changes. She stated one of the ADONs was responsible for the process. She stated she oversaw the process. She stated there was no formal monitoring or tracking. A policy regarding following up on pharmacy recommendations was requested. During an interview on 02/16/24 at 12:57 PM, the DON stated the provider had documented the previous dose reduction attempts and the necessity for the medication. She stated the provider must have overlooked the recommendation from 12/14/23 about an appropriate diagnosis. Review of the policy Medication Regimen Review implemented 11/28/22, reflected in part, . 7. Timelines and responsibilities for Medication Regimen Review: a. The consultant pharmacist shall schedule a least one monthly visit . b. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review F. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. 45830

Based on observation, interview and record review, the facility failed to ensure all resident who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 8 (Resident #210, Resident #213, and Resident #10) residents reviewed for activities of daily living. 1. The facility failed to ensure Resident #210 and Resident #213 received nail care. 2. The facility failed to ensure Resident #10 received help with eating. These failures placed residents at risk of poor hand hygiene, skin tears, infection, poor nutrition, and weight loss. Findings included: 1. A record review of Resident #210's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of hypertension (high blood pressure), dysphagia (difficulty swallowing), atherosclerotic heart disease of native coronary artery (narrowing of arteries), need for assistance with personal care, type 2 diabetes (uncontrolled blood sugar), end stage renal disease (kidney disease), stage 2 pressure ulcer of right and left buttock (bed sores), and dependence on renal dialysis (artificial kidney filtration of the blood). A record review of Resident #210's admissions MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated moderately impaired cognition. Section GG (Functional Abilities and Goals) was incomplete and did not reflect Resident #210's required assistance with ADLs. A record review of Resident #210's care plan last revised on 2/06/2024 reflected he had impaired skin integrity and interventions reflected keep fingernails short. Resident #210's care plan also reflected he had ADL self-care deficit related to weakness and was able to complete personal hygiene tasks with set up assistance. A record review of Resident #213's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of extradural and subdural abscess (intracranial infection), muscle weakness, need for assistance with personal care, type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high cholesterol), and muscle wasting and atrophy (muscle loss). A record review of Resident #213's discharge with return expected MDS assessment dated [DATE] did not reflect a BIMS score, which was a test to measure cognition. A record review of section GG (Functional Goals and Abilities) reflected Resident #213's MDS was coded as independent for most ADLs. A record review of Resident #213's BIMS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. A record review of Resident #213's care plan last revised on 2/14/2024 reflected she had potential/actual impairment to skin integrity and interventions were to keep fingernails short. Resident #213's care plan reflected she had ADL self-care performance deficit related to recent hospitalization with weakness, debility, poor balance, and unsteady gait. Resident #213's care plan reflected she required limited assistance by 1 staff with personal hygiene. During an observation and interview on 2/13/2024 at 9:26 a.m., Resident #213 was observed sitting in a wheelchair in her room. Resident #213's fingernails were observed to be long (whites of nails showing) and with a dark unidentifiable substance underneath. The interview was translated from Spanish to English using HHSC's translating services. Resident #213 stated her nails were dirty because she had been scratching herself. Resident #213 stated she preferred her fingernails to be short rather than long and said no one had offered to cut her fingernails. Resident #213 stated it had been a month since her nails were trimmed. During an observation and interview on 2/14/2024 at 3:12 p.m., Resident #210 was observed lying in bed in his room with long (whites of nails showing) fingernails with a dark, unidentifiable substance underneath. Resident #210 stated What do you think? when asked if he thought his nails were dirty. Resident #210 stated oh yeah it bothered him to have long and dirty nails. Resident #210 stated a staff member told him that morning that his nails needed to be done, but he could not remember their name. During an observation and interview on 2/14/2024 at 3:22 p.m., Resident #213 was observed in her wheelchair in the 400-hall. Resident #213 was being wheeled down the hall by her family member. Resident #213's fingernails were observed to be long with a dark unidentifiable substance underneath them. Resident #213's family member stated yes her nails were long and dirty. During an observation and interview on 2/15/2024 at 9:01 a.m., CNA K stated CNAs provided nail care on shower days three times a week. CNA K stated she did not know the last time Resident #210 received nail care but said she would do Resident #210's nails that day. CNA K entered Resident #210's room, observed his nails and said she saw some dirt. Resident #210's nails were observed to be long and still with dark unidentifiable substance underneath, however CNA K stated the length was a good size. During an observation and interview on 2/15/2024 at 9:27 a.m., CNA K was observed entering Resident #213's room. Observed Resident #213's nails to still be long with a dark unidentifiable substance underneath. During an interview translated by an HHSC surveyor, Resident #213 stated yes she wanted her fingernails trimmed. CNA K stated Resident #213's nails looked good but they needed to be cleaned. During an observation and interview on 2/15/2024 at 9:28 a.m., CNA J was observed entering Resident #213's room. CNA J stated a couple of Resident #213's nails needed trimmed. During an interview on 2/16/2024 at 12:30 p.m., the DON stated CNAs, activities and nurses provided nail care at least three times a week and as needed. The DON stated she would look to see how CNAs were trained on providing nail care, said it was part of their CNA training manual, and said she had not done any training on nail care. The DON then said she had done demonstrative training with CNAs on nail care and stated she had done in-services. The DON stated she worked with Resident #210 on Monday 2/12/2024 but had not noticed his nails. The DON stated she had not seen Resident #213's nails either. The DON stated charge nurses and herself monitored CNAs to ensure nail care was being done and her expectation was that residents received nail care during showers. The DON stated if residents had long, dirty fingernails, they could scratch themselves, their skin could open, and they could get an infection. During an interview on 2/16/2024 at 1:55 p.m., the Administrator stated residents received nail care during activities and from CNA. The Administrator stated once it's identified it should be done-in regard to nail care. The Administrator sated if residents with long fingernails did not receive nail care, they could cut themselves. A record review of the facility's in-services dated December 2022-February 2024 reflected no in-service training on nail care. 2. Record review of Resident #10's face sheet dated 02/15/24 revealed an [AGE] year-old female admitted [DATE] with a diagnoses of unspecified dementia-unspecified severity-without behavioral disturbance-psychotic disturbance-mood disturbance- and anxiety (group of symptoms that affects memory, thinking, and interferes with daily life), hyperlipidemia (abnormally high levels of any or all lipids or lipoprotein in the blood), acute kidney failure, age-related physical debility, hypothyroidism (underactive thyroid, when the thyroid fails to produce sufficient thyroid hormones), acute on chronic systolic (congestive) heart failure (long term condition that happens when the heart cant pump blood well enough to give the body a normal supply), and anxiety disorder (fear characterized by behavioral disturbances). The face sheet also revealed Resident #10 resided in the secure unit and was in hospice care. Record review of most recent quarterly MDS dated [DATE] revealed Resident# 10 BIMS assessment score was a 5 suggesting severe cognitive impairment. Resident# 10's functional abilities for eating was coded at a 5 meaning setup or cleanup assistance required. The MDS reflected Resident# 10 was in hospice care with a prognosis of a condition/chronic disease that may result in a life expectancy of less than 6 months. Record review of hospice care plan dated 2/06/24 revealed Resident# 10 required maximum assist/extensive assistance in ADL's for feeding. During an observation on 2/14/24 at 8:00 a.m. during breakfast in the secure unit, Resident# 10 was observed having difficulty eating breakfast. Resident# 10 was observed pouring a full glass of cranberry juice on her plate and then mixing it with a spoon in a confused manner and then attempting to eat it. When a CNA noticed what the resident was doing the CNA removed the plate of food floating in cranberry juice away from the resident and a new meal was not provided. During an interview on 2/16/24 at 12:10 p.m. the DON stated that Resident# 10's condition had recently declined where she now required more assistance with meals. The DON said that the facility was supposed to work with hospice and update their care plan when it was identified that a resident's condition had changed, and they now required more assistance with ADL's. She stated it was the responsibility of the CNAs to assist residents that require feeding assistance. She stated that it is her expectation that residents who are identified that require feeding assistance get the help they need during meals. During an interview on 2/16/24 at 01:50 p.m. with the Administrator, he stated that the CNAs were responsible for assisting residents that require feeding assistance. He stated that a negative outcome to not getting the help that they need would be potential weight loss. The Administrator said that after a change was identified where a resident requires maximum assistance in ADLs, it was expectation that the resident begins receiving that level of assistance immediately. A record review of the facility's policy titled Activities of Daily Living (ADLs) dated 5/26/2023 reflected the following: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 4. Eating to include meals and snacks; Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.71 % based on 3 errors out of 28 opportunities, which involved 2 of 4 residents (Resident #38 and Resident #44) reviewed for medication administration. 1. The facility failed to ensure MA H administered medication as ordered to Resident #38 by administering Ferrous Sulfate 325mg instead of Ferrous Fumarate 324mg. 2. The facility failed to ensure MA H administered medication as ordered to Resident #44 by administering Calcium 600mg instead of Calcium 600mg with Vitamin D3 5mcg and Aspirin 81mg chewable tablet instead of Aspirin 81mg Delayed Release tablet. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings included: Resident #38 Review of Resident #38's face sheet printed on 02/15/24 reflected an [AGE] year-old female admitted to the facility 11/20/22 and readmitted on [DATE]. Her diagnoses included infection of the skin and subcutaneous tissue, multiple fractures, metabolic encephalopathy (problems with metabolism cause brain dysfunction), acute and chronic respiratory failure (not enough oxygen in the blood), type 2 diabetes (a condition that affects the way the body processes blood sugar), and unspecified dementia. Review of Resident #38's admission MDS assessment, dated 01/22/24, Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required moderate to extensive assistance with ADLs. Review of Resident #38's physician's order dated 01/18/24 reflected, Ferrous Fumarate Oral Tablet 324 (106 Fe) MG (Ferrous Fumarate) Give 1 tablet by mouth one time a day for IRON DEF. An observation on 02/14/24 at 8:16 AM revealed, MA H prepared for administration medications ofr Resident #38. MA H retrieved a ferrous sulfate 325mg tablet and placed it in a medication cup. MA H prepared seven other oral medications and a transdermal patch then walked into Resident #38's room. MA H administered the medications to Resident #38. Resident #44 Review of Resident #44's face sheet printed on 02/14/24, reflected a 92-[NAME]-old female admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included unspecified dementia, transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve withing 24 hours), chronic heart failure (heart disease that affects pumping action of the heart muscles), major depressive disorder (a mood disorder with persistent feeling of sadness and loss of interest), osteoporosis (a condition when bone strength weakens and is susceptible to fracture), and gastroesophageal reflux disease (acid reflux or heartburn). Review of Resident #44's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 7 indicating severe cognitive impairment. Section GG (Functional Abilities) reflected she required supervision or touching assistance for most ADLs. Review of Resident #44's physician's orders dated 10/25/23, reflected, Aspirin 81 Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet my mouth one time a day for ANTICOAGULANT THERAPY and Calcium plus Vitamin D3 Oral Tablet 600-5 MG-MCG (Calcium Carbonate-Cholecalciferol) Give 1 tablet by mouth two times a day for vitamin deficiency. An observation on 02/14/24 at 8:35 AM revealed, MA H prepared for administration medications for Resident #44. MA H retrieved a Calcium 600mg tablet and an Aspirin 81mg chewable tablet and placed them in a medication cup. MA H prepared four other medications and placed them in the medication cup. She mixed a powdered medication in a cup of water then entered the room and administered the medications to Resident #44. During an interview on 02/14/24 at 2:37 PM with MA H, she stated she has been a med aide since 2021. She stated she realized she had given the wrong aspirin tablet, as soon as I did it. She stated she was supposed to have checked the label against the order three times when she prepared the medications. She stated if the order and the medication on hand did not match, she notified the nurse who then contacted the provider for clarification or held the orders. She stated she was the central supply person and she was responsible for ordering the over-the-counter medications for the facility. She stated she was aware that there were different types and doses of calcium and calcium with vitamin in stock. She stated if the wrong medication was given, the resident may not get the desired effect. During an interview on 02/14/24 at 2:42 PM with the DON, she stated it was her expectation that the nurse or med aide checked the label, ensured the right resident, the right dose, the right route, etc. every time. She stated not giving the right medication could cause side effects, like if the resident had stomach problems and got an instant release instead of a delayed release it could cause problems. She stated the resident may not get the desired or intended effect if the wrong medication is administered. During an interview on 02/16/24 at 1:54 PM, the Administrator stated he expected the facility to have a medication error rate less than 5%. Review of the policy titled Medication Administration implemented 10/24/22, reflected in part, 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 3 of 24 residents (Residents #91, 81, and 92) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #91 assaulted Resident #81 on 08/27/22 which resulted in Resident #91 assaulting and injuring Resident #92. On 11/30/22 at 5:30 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/04/22, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical and psychosocial injury, including serious injury or death. Findings included: Review of the undated face sheet for Resident #91 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia of unspecified severity without behavioral disturbance, psychotic disturbance and anxiety. Review of the admission MDS for Resident #91 dated 07/28/22 reflected a BIMS score of 00, indicating a severe cognitive impairment and indicated no presence of aggressive behaviors. Review of the quarterly MDS for Resident #91 dated 11/14/22 reflected a BIMS score of 4, indicating a severe cognitive impairment. Record indicated the behavior of verbal aggression occurred one to three days of the 14-day lookback period, but not physical aggression. Review of the care plan for Resident #91 dated 08/30/22 reflected the following: The resident is/has potential to be physically agressive (sic) r/t Dementia 8/27/22- PUSHED ANOTHER RESIDENT INTO WALL CAUSING INJURY. The resident will not harm self or others through the review date. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the physician orders for Resident #91 on 11/30/22 at 2:31 p.m. reflected no new orders entered that day. Review of the progress notes for Resident #91 reflected the following: -08/27/22 documented by LVN N Late Entry: Note Text: Resident pushed another resident causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident (Resident #81) Neither resident is able to recall incident. This resident family member was notified and informed she would need to come sit with resident. Family member verbalized agreement. (Family member) verbalize concern that was provoked and has never had this type of behavior. Advised family member to speak with admin on Monday. Family member verbalized agreement with changing resident room to provide separation. This resident room was changed from 115B to 116A. On call notified. Safety precautions in place. -11/30/22 documented by ADON A: Note Text: 0920am-Per CNA this resident (Resident #91) and another resident (Resident #81) had an altercation in the dining room. Went to assess (Resident #91) and no apparent injuries noted. VS 118/75, 76HR, 18R, 97.9, 96%RA. Asked patient what happened and patient states That guy had my jacket on, and I hit him. Patient unable to give this nurse any other description. Per staff, (Resident #91) walked up to (Resident #92) and thy began argue over (Resident #92)'s jacket. Then (Resident #91) punched (Resident #92) three times in the face. The staff pulled them both apart and separated them. Placed (Resident #91) on 1:1 for safety precautions. Police officer did come to evaluate situation. Notified DON, Administrator, NP, and RP. Review of an incident report completed for Resident #91 dated 08/27/22 reflected the following: Resident pushed another resident, causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident after (roommate) pushed him. Neither resident is able to recall incident. This resident wife was notified and informed she would need to come sit with resident. (Family member) verbalized agreement. Verbalized concerned that her husband was provoked and has never had this type of behavior. Advised wife to speak with admin on Monday. Wife verbalized agreement with changing resident room to provide separation. The resident room was changed from 1:15 PM to 116. On-call notified. Safety precautions in place. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of readmission MDS for Resident #81 dated 09/01/22 reflected a BIMS score of 9, indicating a moderate cognitive impairment. Review of an incident report completed for Resident #81 dated 08/27/22 reflected the following: Aid assisted resident to nurse station. Resident has blood draining from his head down his left side of neck and back of head. Resident is unable to recall what happened. Per resident he was hit in the head and need to stop the bleeding. This nurse with assistance of other nurses cleaned blood from resident. Noted a gash - 1/2 inch long, superficial, no need for further assessment. Cleansed and applied bandage. Another resident visiting family member witnessed the incident. Per witness, roommate of resident pushed this resident after he shoved him. And this resident fell into the wall hitting his head. NP notified and aware resident is on Plavix. Per NP monitor closely and continue neurochecks. Family member's notified and verbalized concerned with the incident. ADON & DON notified. Review of undated face sheet for Resident #92 reflected an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. Review of quarterly MDS for Resident #92 dated 11/11/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Review of the care plan for Resident #92 dated 8/15/22 reflected the following: The resident exhibits behaviors of verbally & physically aggressive with agitation towards staff during attempts of providing care/redirecting. Review of hospital records for Resident #91 dated 07/17/22 immediately prior to admission to the facility and found uploaded to the resident's chart on the facility EMR reflected the following: Patient is walking the halls with his (family member) He is currently pleasantly confused. No further aggressive behavior as of yet. Has sitter at bedside. Still waiting on placement. This patient presents with altered mental status. Patient is a [AGE] year-old male brought to the emergency department for evaluation of aggressive behavior in dementia. Patient has no medical need to be admitted and should have been placed from ED but was unable to be. Patient is awake and alert. He is not oriented to time and place. Although his vital signs are stable his labs are mostly within normal limits. He does not have any significant past medical history other than dementia. This change of behavior is relatively new in the last two weeks and after today, he tried to choke his wife, and family are concerned and brought him here. Case management has tried to admit patient directly to a safe facility unfortunately, considering his aggression and being weekend, replacement has not been established yet. Neuro exam is limited, considering patient is not oriented and does not follow commands. Continue 1 to 1 sitter. CT of his head on 7/16 neck for any acute findings. Dispo: patient is at his baseline functional status. Wife refuses to take a patient home due to his violent behavior so still just waiting on a bed at Cross Creek or oceans. Patient is cleared to discharge once bed available. Plan discussed with patient and wife, nurse. Addendum: seen and examined on rounds. Wife and sitter at bedside. D/W PA. Patient gets aggressive when he's told what to do, and wife not comfortable taking him home. While I was in room, he refused to say seated and got up. Not aggressive, but clearly was not planning to listen to anyone. Still awaiting a facility that will take him. Reviewed PA findings and jointly created plan as above and agree. Review of physician progress note for Resident #91 dated 07/27/22 reflected the following : Patient was seen in collaboration with the supervising physician. Discussed POC with MD. Patient was admitted as a LTC resident due to dementia with behavioral issues. Admin history reason for admission for this day: the patient is a [AGE] year-old Caucasian male with a past medical history of dementia, who was brought to the emergency department for evaluation of aggressive behavior. Over the past four years, the patient's dementia has been slowly progressing to the point where his wife had to stay home with him for 24 hour care. Over the past three days prior to admission, patient's wife stated that he had been acting very aggressively. She stated that the morning of admission, he tried to choke her and hit their son several times when they tried to redirect him to eat, and to not wander outside . initially, we tried to place the patient into a psychiatric facility from the emergency room ; however, we were unsuccessful as it was a weekend. As time progressed, the patient's wife did not want him placed in a psychiatric facility, and instead requested long-term care placement. Review of NP notes for Resident #91 dated 08/29/22 reflected the following: Patient was seen in the secure unit today. He is awake and alert, and oriented to his name only. He is ambulatory. Staff reported some behavioral issues where he had an altercation with another resident, which is unusual from his baseline since admission. Patient is afebrile, vital signs have been stable, will monitor closely. Assessment and plan. Dementia: dementia, aggressive behavior. Patient is awake and alert is not oriented shot time and place all the rest signs are stable. His labs are mostly within normal limits. He does not have any significant past medical history. Other than dementia. Neuro exam is limited considering patient is not oriented and does not follow commands. CT of his head on 7/16 negative for any acute findings. Patient will need a secure locked unit as he is at risk of wandering in elopement. Dementia continues to worsen and he is not oriented to place. Continue Namenda. Patient is back in the memory care unit due to exit seeking behavior. Staff reports that he had an altercation with another resident in the unit, able to redirect after the incident. Monitor closely. Interview on 11/30/22 at 11:25 a.m., the DON stated Resident #91 had punched Resident #92 in the dining room during breakfast that morning and as a result was on one-to-one supervision with a designated staff person. Observation and interview on 11/30/22 at 12:28 p.m. revealed CNA E seated in the hall adjacent to the dining area of the secure unit observing the area. She was 20 feet away from Resident #91 with three tables full of residents between them. She stated there were two CNAs assigned to the hall who were out in the main part of the facility retrieving their lunches. She stated she knew there had been an altercation between Resident #91 and #92, and she was made aware by the other CNAs. She said they told her Resident #91 was combative with another resident and to be wary of him. She stated the DON asked her to do one to one supervision of Resident #91. When asked what one to one supervision meant, she stated it meant to have him within her sight at all times. She stated there was not direction given about how close she needed to stand near the resident. She stated she had not communicated with the nurse who was currently on the hall about the incident or Resident #91's behavior. She stated LVN B told her about what happened. She stated LVN D was aware to keep eyes on everyone while on the secure unit. She stated technically, all the residents needed to be supervised, so Resident #91 did not need special supervision. She stated she was familiar with Resident #91 from when she picked up shifts, and she had never seen him exhibit any aggression. She stated she was not concerned about his behavior and that, besides some residents with high risks of falling, no one in the secure unit worried her for their safety or the safety of others. Observation and interview on 11/30/22 at 12:28 pm revealed Resident #91 seated at a table next to the back door of the secure unit dining area. Two female residents were seated at the table with him, and immediately behind him were three male residents seated at the neighboring table. There was a total of 24 residents sitting at tables in the dining area. Observation on 11/30/22 at 12:32 p.m. revealed LVN D standing at a medication cart in the nurse's station area adjacent to the dining room. The other two CNAs assigned to the hall returned with their lunch plates and went into a room off the nurse's station and closed the door. The CNAs were there for another ten minutes. Two visitors engaged CNA E in the nurse's station for a few minutes, and during this time, the residents in the dining room within, including Resident #91, were not in her line of sight. She also entered the room off the nurse's station where the other two CNAs were and closed the door behind her for a minute. Resident #91 did not have constant supervision during this period of time. Interview on 11/30/22 at 12:35 p.m., LVN D stated she had been back here about 30 minutes. She stated she had heard about an altercation, but she did not know offhand who the residents were, who were involved and had to look in her computer to determine them. She stated she was not given any instructions or guidance on what happened or what measures were in place. When asked if she knew of any measures, she stated her understanding was that the NP spoke to one of the ADONs, but she was not sure what the orders were. She looked in her computer and said no PRN anxiety medications were given for either resident. She said there was no one to one supervision currently needed or happening on the unit, to her knowledge. She said she had never seen Resident #91 be aggressive before, but she did not often work with him. She stated she usually found out about behaviors on a progress note or the 24-hour report. Interview on 11/30/22 at 12:48 p.m., CNA F stated she was present in the secure unit that morning (11/30/22) when Resident #91 assaulted Resident #92. She stated her back was turned helping two ladies eat, and she heard something, turned around, and saw them. She stated she worked with Resident #91 every day, and he had aggressive behaviors at times but was usually calm. When asked if she was aware of another incident of aggression by Resident #91, she first said no, but then when asked about the specific incident in August, she said she remembered. She stated it happened on the 2-10 p.m. shift, so she was not present when it occurred. She stated she believed that Resident #91 pushed Resident #81, and then Resident #91 was moved to a different room. She stated she did not think Resident #81 had any injuries after the incident. She stated she had not received any specific training or in-servicing after the incident. When asked what interventions she had been trained to use when Resident #91 exhibited aggressive behaviors toward another residents, she stated she would separate the residents. She could not think of any other interventions. When asked if she had access to view interventions in the resident care plan, she stated she did but could not remember how to access the care plans on her electronic documentation system. She stated she was updated on new incidents and resident behaviors each shift when they get a report from the outgoing CNAs or nurse. She stated she was not told that Resident #91 needed to be on one-to-one supervision after the incident with Resident #92 that morning, but she was keeping an eye on him. Interview on 11/30/22 at 12:55 p.m., CNA G stated she had been involved in the incident between Resident #91 and Resident #92 that morning. She stated they were eating breakfast and were just fine, and suddenly Resident #91 stood up and walked over to Resident #92 and began punching him. She stated it happened very quickly, but she got up immediately and got in between the two residents. She stated LVN B was also there and helped to intervene. She stated LVN B took Resident #91 down the hall, and they called the ADON to come assist. She stated Resident #92 was injured, and he was sent to the hospital, but she did not know the extent of his injuries. She stated no one had in-serviced her on the incident or what to do with Resident #91, but she and her colleagues knew to keep an eye on everyone. When asked about what to do when two residents had an altercation, she stated she was to separate them and call a nurse. Interview on 11/30/22 at 1:10 p.m., the SW stated Resident #91 had been aggressive in the facility (she had no further details), but not toward his family prior to admission. The SW stated she had just learned about his assault of Resident #92 a little while ago. The SW stated she usually goes to check on residents involved in such an incident, but she had been in care plan meetings that day. The SW stated she did not have a role in any care planning for aggression and that nursing handled that. Interview on 11/30/22 at 1:26 p.m., ADON A stated she had worked at the facility since October 2018. She stated she was in her office this morning around breakfast time, and the CNA came out and said Resident #91 and #92 got into it. She stated she went onto the secure unit and saw Resident #92's eye was bleeding. She stated the charge nurse for the unit, LVN B, was on a different hall, so ADON A stated she took care of it. She said she applied gauze and notified the NP, who wanted him sent to the hospital due to him being on Plavix. She stated she then talked to Resident #91, who was not able to tell her much. She stated staff told her that Resident #91 thought Resident #81 had his jacket on, and from there they started fighting. She stated the staff said the residents pushed each other, and Resident #91 initiated the punches. She stated they (she thought they was the DON) put him with a one-on-one staff, and she was not sure who they chose to do that job. She stated the definition of one-on-one supervision was the CNA should stay right by the resident. When asked how many feet there should be between the resident and the one-on-one supervisor, she stated the staff person should be able to see the resident at all times. She stated she did not know what the staff person assigned to provide one on one supervision was told about what that supervision should entail. She stated she told LVN B to assign someone back there to Resident #91. She stated she had heard of other times when Resident #91 was aggressive, but she had not seen him be aggressive. When asked what she knew about those events, she stated they moved him into another room after he was aggressive, and she believed it was aggression against Resident #81. She stated Resident #91 was not aggressive all the time but had his moments of aggression. She stated she was not aware of any history of aggression in Resident #91 before he came to the facility. She stated she was not sure what the interventions in place were to respond or react if Resident #91 exhibits aggression. She stated they were supposed to keep the residents safe, so separating them would be important. She stated she did conduct training and in-servicing for the staff if there was a particular problem they needed to address. She stated she had not trained staff about resident-to-resident abuse or aggressive behaviors. She stated the staff had computer-based training they were supposed to do, but she was not sure what all training had been offered to them related to aggression, behaviors, or Resident #91. Interview on 11/30/22 at 1:39 p.m., LVN B stated she was sitting in the corner of the dining room, heard a CNA yell stop and turned around and saw Resident #91 punch Resident #92 with a closed fist in the eye. She stated she and CNA G separated them. She stated she sat with Resident #91 until police showed up while ADON A assessed Resident #92. She stated once everything was calm, she was told by the DON to assign someone to one-on-one supervision, and Resident #91 had since been sitting in a chair in a dining area calm with residents. When asked what the definition of that one on one was, she stated the DON asked her to make sure the residents were safe and to keep an eye on Resident #91. She stated she assigned one on one supervision to CNA E, and her expectation was CNA E should have been right there with Resident #91. When asked if 20 feet away from the resident met the definition of one-on-one supervision, she stated, as long as Resident #91 did not appear agitated, the staff could be at a distance from him. When asked if Resident #91 was showing signs of agitation prior to assaulting Resident #92, she said he was not. She stated Resident #91 was eating his food one second and up the next. She stated the way they knew which residents had aggressive behaviors by looking at behavior notes and sometimes the 24-hour book. Interview on 11/30/22 at 1:46 pm, the DON stated a CNA came with ADON A to her that morning (11/30/22) during the breakfast hour and told her there had been an altercation. The DON said she went to the unit and saw Resident #92 with some redness around his eye, and the staff explained Resident #91 had hit him. The DON said she verified that the staff had told the ADM, who was the abuse coordinator, and she called the NP to make notification. The DON stated she stayed in the unit for 30 minutes and told LVN B to stay with Resident #91. The DON stated by the time EMS arrived, Resident #92 was walking around. The DON stated she told ADON A and LVN B to designate a third person in the secure unit so that someone could be assigned to Resident #91 to supervise one to one. The DON stated her expectation for one-to-one supervision was to have eyes on the resident the whole time. The DON said the staff should get up and follow the resident if s/he walked down that hall and stay with him or her. The DON stated one to one supervision could include being within reach of the resident, but close proximity was her expectation. The DON stated the NP decided to send Resident #92 to the hospital because he was on anti-platelet medication. The DON stated she did not know yet the extent of Resident #92's injury and was waiting to hear from the hospital. The DON stated for Resident #91, the NP just advised close monitoring. The DON stated she believed there was an order for CBC, TSH, CMP labs, but she did not know why the order had not been entered. The DON stated Resident #91 did not have any PRN medication for agitation, because he did not get agitated. She stated Resident #91 would be sitting and smiling one minute and then, all of a sudden, he was aggressive. The DON stated she learned the jacket Resident #92 was wearing looked similarly to one of Resident #91's favorite jacket, and she thought that triggered him. When asked if Resident #91 had ever assaulted anyone, DON stated she did not think he had but remembered the incident on 08/27/22 after checking the EMR. The DON stated she did not know that he had a history of aggression before being admitted to the facility. The DON looked at the hospital progress note and the MD's progress note after admission and stated she did not remember seeing that information . When asked how they ensure the admission referral was thoroughly read, DON stated she tried to read all the referrals. She stated the IDT was responsible for reading the entire admission packet, but she was not sure specifically who should be primarily responsible. The DON did not describe any formal process in place for reviewing admitting information. The DON stated Resident #91 was placed on the secure unit on admission, and that was because they assumed he would have some behaviors, but what they were aware of was wandering and exit seeking. The DON stated the secure unit has more staff supervising residents, and they have a lot of activities. The DON stated someone from activities was usually with them. The DON stated the first incident of aggression by Resident #91 was triggered when his roommate pushed him, and Resident #91 pushed back. The DON stated the roommate was injured. The DON stated in the immediate aftermath of this event, Resident #91's family member came to the facility and sat with him all day. She stated they did not put anything in place after the first incident except general closer monitoring. The DON stated they updated his care plan at that point, and she read the following interventions from his care plan, communication, cues, assisting verbalization, psych consult as indicated, when he becomes agitated intervene, engage calmly in conversation. The DON stated she thought they did not intervene more, because his roommate initiated the event. The DON stated he should have had a psych consult and did not know why that had not occurred. The DON stated it was the ADON's responsibility to oversee processes like that, but it was always also her responsibility. The DON stated there was no formal direction after the incident of that morning given by her to the staff. Interview on 11/30/22 at 2:05 p.m., the ADM stated he was aware of the incident of Resident #91 punching Resident #92. The ADM stated his understanding was that Resident #91 assumed the jacket Resident #92 was wearing was his own jacket. The ADM stated a CNA came to him and told him the incident had occurred. The ADM stated he went back there and saw that there was a bruise around Resident #92's eye. The ADM stated the NP sent Resident #92 out to the hospital to be assessed, and they put Resident #91 on one-on-one monitoring. The ADM stated the DON assigned the one-on-one supervision. The ADM stated at that point in the situation, there were four staff designated to the secure unit, and the one-on-one supervisor was a fifth. The ADM stated the one-on-one supervision was going to last until they deemed Resident #91 was not a danger to others. The ADM stated he could not presently say when that would be. The ADM stated they could deem him safe after constant supervision to see what his actions were. The ADM stated they could request the SW to speak with him to determine if he was safe, and they could get psychology involved. When asked what defines one on one supervision, ADM stated it depended on the situation. The ADM stated it would mean the one-on-one supervisor would stay in the general area of the resident. The ADM stated that on the secure unit, there was not a lot of room to maneuver, and they just had to have a straight line of sight of the resident being supervised. The ADM stated he did not know about Resident #91's history of aggressive behaviors. He was asked to read the hospital paperwork for Resident #91 in order to verify that the document included mention of recent aggressive behaviors, but he did not do so during the interview and did not remark on the content of this document or the facility physician progress note. The ADM stated he thought the incident on 08/27/22 to be an isolated incident. The ADM stated the facility procedure was to review the clinical information, and it was the job of the IDT to do so. The ADM stated they normally did not admit aggressive people or they had a plan to manage the behaviors. When asked what kind of plan they would enact, ADM stated they normally just would not admit anyone with a recent history of aggression. When asked if he would have admitted Resident #91 had they read the hospital referral paperwork, he stated it would depend and did not elaborate. Interview on 11/30/22 at 2:45 p.m., LVN N stated she vaguely remembered an incident when Resident #91 and Resident #81 had an altercation. LVN N stated Resident #81 was going through Resident #91's things and would not stay on his own side of the room. LVN N stated the witness who explained what happened was the family member of another resident, but she could not remember who was the aggressor in the situation. LVN N stated she did not recall what happened. She stated she did recall that Resident #91's family member came to the facility, and he changed rooms. LVN N stated she did not remember any in-servicing, directions from management, or new orders from that event. When asked what she should do if residents in her care had an altercation, LVN N stated she would split them up and get them each assessed. Review of facility policy dated September 2018 and titled Protection of Residents During Abuse Investigations reflected the following: Our facility will protect residents from harm during investigations of alleged abuse. During investigations of alleged abuse, residence will be protected from armed by the following measures: a. C. If the alleged abuse involves another resident, the accused residence representative and attending physician will be informed of the alleged abuse incident, and that there may be restrictions on the accused resident's ability to visit other residence, rooms, unattended. If necessary, the accused resident's family members may be required to help meet this requirement. This was determined to be an Immediate Jeopardy (IJ) on 11/30/22 at 5:30 p.m. The ADM was notified. The ADM was provided with the IJ template on 11/30/22 at 5:33 p.m. The following Plan of Removal submitted by the facility was accepted on 11/30/22 at 12:45 p.m.: Plan of Removal Issue: The facility failed to prevent Resident #91 from abuse, and neglect. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: On 11/30/22 there were 26 Residents with the potential to be affected by Resident #91. On 11/30/22, the Director of Nursing placed Resident #91 on 1:1 monitoring with a facility staff member remaining within 6 feet of the member while outside of the resident's room. Beginning 11/30/22 and on-going, the DON / designee will assign a staff member to do 1:1 continuous observation on all shifts and provide training requirements to the staff for the resident at the time of assignment. Upon assignment, The DON / designee will in-service the assigned staff member(s), they must be between the resident and the entryway into the resident's room while in resident's room alone. Staff providing the 1:1 monitoring will sign in on the schedule binder to show the coverage day and hours. Resident #91 will remain on 1:1 monitoring until he is sent to a psychiatric facility to be evaluated. The DON / designee will be responsible for ensuring this is carried out. On 11/30/22, Resident's Primary care Physician gave an order for (psychology provider) Psychology to evaluate and treat. (Psychology provider) will follow Resident #91 while resident in this facility. The DON will be responsible to ensure Resident #91 continues to be treated by (Psychology provider). Beginning 12/1/22, The Regional Nurse Consultant will monitor that Resident #91 remains on services per physician's orders by verifying that visits are taking place, one time per week for four weeks, then two times per month for two months. The Director of Nursing re-educated the licensed nurses that were on shift at that time, on the indications of usage of PRN Antianxiety medication. The remainder of facility Nurses that were not working at that time, were re-educated prior to working their next shift and / or via telephone. All Licensed Nurses were re-educated by 12/2/22 by the DON / designee. Beginning 12/2/22 and on-going, The DON / designee will monitor all facility residents care plans, to ensure they are updated with changes in the plan of care- three times per week for one month, then two times per week

Based on interview and record review the facility failed to thoroughly investigate and report allegations of sexual harassment by 1 of 6 residents (Resident #2) reviewed for abuse/neglect. -[AGE] year old female, Resident #2, alleged sexual harassment on or about 1/18/12, 1/25/12 and 2/1/12, by 2 male residents (# 3 and #4) one of which had a history of [REDACTED].#2 from further sexual harassment, failed to thoroughly investigate and report the allegations of sexual harassment. This deficient practice caused Resident #2 to experience fear, mental and emotional anguish resulting in a diminished quality of life. It has the potential to place an additional 73 female residents risk for abuse, neglect and fear and result in a diminished quality of life. An IJ was identified on 2/7/12 at 4:10 PM. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility was still implementing and monitoring the Plan of Removal. The findings include: In an interview on 2/7/12 at 10:15 AM Resident #2 stated on two occasions Resident #3 stopped her when she was going into the dining room and asked her for sex. She stated prior to those episodes Resident #3 would ask her for a kiss and tell her she was pretty but then became more verbally aggressive, demanding they have sex. She stated the last time he asked her he yelled it out and she was very embarrassed because everyone in the dining room could hear it. She stated the last time he asked he was more "verbally aggressive" and scared her. She stated on one occasion Resident #4 was sitting next to her in the dining room and put his hand on the inside of her knee and began to run his hand up between her legs. She stated she screamed out for CNA C to help her and when CNA C came over she said "Oh not you again" to Resident #3. Resident #2 stated she was scared at the time and very embarrassed because other people in the dining room were watching. She stated the dining room was full of people and named three residents who were close enough to know what had happened, two of which came to her later and asked if she was all right. Resident #2 stated she was afraid to go into the hall or dining room if staff were not close to her and that after they stopped monitoring her closely the staff were frequently busy and were not always where she could see them. Review of the admission face sheet dated 4/28/11 for Resident #2 reflected she was [AGE] years old, an admission date of [DATE] and the following Diagnoses: [REDACTED].#2 reflected these additional Diagnoses: [REDACTED]. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 1/18/12 'She discussed incident of a male resident asking for sex. Patient said this upset her and triggered some anxiety and depression. Patient indicated she had notified staff of this too.' 1/25/12 'She discussed another incident that occurred last week of a male resident touching her leg inappropriately. Patient said she informed staff of this. This is 2nd report within past week of a male resident being inappropriate towards her. Patient professed increased sadness: reported being triggered from recent events. Therapist will discuss in detail incident with supervisor and follow-up with staff.' In an interview on 2/6/12 at 2:45 PM Resident #2's son stated he called the police after his mother told him she was afraid to be alone in the facility because she was being sexually harassed. He further stated the police came to the facility on [DATE] and talked to him and Resident #2. Review of a Witness Statement dated 1/29/12 by ADON D reflected the following: '...Resident was informed to always use call light or yell out for assistance/help and to always report this information to staff so that we can intervene to ensure her safety. Resident spoke of one male resident on her hallway, sitting in the hall and she can't get by. I informed resident to call for help or if she doesn't see anyone to go to room and put call light on. A police officer entered room and asked to speak with resident. Police officer came to nursing station, spoke to writer, took information and reports that this was called in as sexual assault but it is a safety call/concern ...'. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 2/1/12 'She discussed making a police report against male resident who she alleged to being sexually inappropriate towards her. Patient reported nursing home has set a safety plan for her.' In an interview on 2/7/12 at 3:30 PM Resident #2 stated after the police came to talk to her the facility put her on a "close watch" and she felt better, however now that they are no longer watching as close she is afraid to go into the hall. She stated Resident #4 lives on the same hall as her and she is afraid when goes into the hall and does not see one of the facility staff close by. She stated when she goes into the dining room Resident #3 watches her and she is afraid he is waiting until she is not looking he is going to come up to her. Resident #2 stated she is afraid and knows both residents will "harass" her again because they cannot be watched all the time. She further stated she knows they have had similar problems with both of these residents because the staff told her things like this had happened in the past. Resident #2 stated "If they know somebody is like that they should warn people". In an interview on 2/7/12 at 2:05 PM the facility psychological counselor stated she had counseling sessions with Resident #2 on 1/18/12, 1/25/12 and 2/1/12. She stated at each of those sessions Resident #2 discussed with her the "incidents" with both residents. She stated Resident #2 reported the first incident with Resident #4 on 1/18/12, then reported the additional incident to her on 1/25/12 and on 2/1/12 she discussed both incidents. The counselor stated on 2/1/12 she notified the facility Social Worker. The counselor stated Resident #2 was alert, orient and cognitively intact. Review of the MDS dated [DATE] for Resident #2 reflected the following: Section E-Behavior [MEDICAL CONDITION]-none Physical or Verbal behavior directed toward others-Behavior not exhibited Other behavior symptoms not directed toward others-Behavior not exhibited Review of the BIMS Assessments dated 11/18/11 and 1/13/12 for Resident #2 reflected a summary score of 15 (highest possible score, indicating cognitively intact). Review of the CAM assessment dated [DATE] and 1/13/12 for Resident #2 reflected the following: Inattention-Behavior not present Disorganized thinking-Behavior not present Altered level of consciousness-Behavior not present Review of the NN dated 1/29/12 for Resident #2 reflected the following: 'Resident ' s RP asked about the reports the resident had made to the nurses on shift a few days ago regarding sexual harassment. RP stated he wanted to follow-up on incidents.' Review of the facility's Resident Accident or Incident Report form dated 1/29/12 for Resident #2 reflected the following: Nature of Accident or Incident: Residents RP approached me and asked if I could please follow-up on the incident the resident had reported to the nurse last week. RP stated resident has complained of sexual harassment by other residents in the dining room. Interventions: Behavior Monitoring Recommended In-services: Abuse Prohibition In-service Outcome of Investigation: Behavior Monitoring, separated residents involved. Review of a Witness Statement dated 1/30/12 by RN B reflected the following: Resident #2's 'RP came to the nursing station demanding for report (written) showing his Mother's complaints of sexual harassment by male residents. I then redirected him to go speak with the mom's nurse at the time. He did state that the mom is not feeling safe at this facility and even requested him and his friend to take turns watching over her (because she has been scared to even leave her room especially to go to the dining room).' A typed statement dated 2/9/12, which was received by the investigator on 2/10/12, after exit on 2/7/12, and signed by CNA C reflected the following: 'I gave the same statement to her (surveyor) as I did to my nursing supervisor on the night that Resident #2 voiced an issue to her son (1/29/12). It was that one evening I was taking a resident to get coffee and heard someone scream ... I then heard someone yell and I could see activity over by the main entrance to the dining room so I went over. I witnessed Resident #4 pushing away from the table that Resident #2 was sitting at and she said "he touched me". ... I told Resident #2 that it was okay and I would assist Resident #4 to another table and keep an eye on him, which I did. She did not tell me anything more and seemed ok after I moved him. I told the nurse checking on the trays what the screaming was about. Resident #2 did not appear anxious or nervous and remained at her table for the meal. However, in a telephone interview on 2/7/12 at 5:00 PM CNA C stated she was in the dining room assisting with the evening meal on an unknown date in mid-January when she heard a scream and someone call out "CNA C he is touching me" . She stated she did not know who had screamed out but saw Resident #4 backing away from a table at which Resident #2 was sitting. CNA C stated when she got to the table Resident #2 was visibly upset, shaking and crying. CNA C stated she reported the incident to LVN A and returned to Resident #2 who was still upset and shaking and attempted to reassure her. In an interview on 2/7/12 at 5:30 PM LVN A stated she had no memory of being informed there was an incident in the dining room. She stated there is always screaming in the dining room so she does not pay much attention to it. She further stated she was busy getting trays checked and does not remember being told by CNA C there was a problem with Resident #2. In confidential interviews on 2/7/12 alert, oriented residents stated they had witnessed inappropriate behavior toward Resident #2 by Resident #3 and Resident #4. Each stated there was an incident in the dining room one evening when Resident #2 screamed out and said "He's touching me". They saw Resident #4 next to Resident #2 at the table and Resident #2 was crying and shaking, asking the staff to keep Resident #3 away from her. They further stated they had heard Resident #3 ask Resident #2 for sex more than once when she was trying to get into the dining room. They further stated that Resident #2 appeared distressed and embarrassed when this happened and would hurry into the dining room to get away from Resident #3. In an interview on 2/7/12 at 10:30 AM Resident #3 stated "I am not going to talk to you or anyone else about any of this[***]. In an interview on 2/7/12 at 10:45 AM Resident #4 when asked by the surveyor if he remembered any of the events regarding Resident #2 he shook his head 'No'. Further attempts to interview Resident #4 were unsuccessful due to his diminished cognitive ability. Review of the clinical record for Resident #3 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #3 was alert, oriented and cognitively intact. Review of the current care plan for Resident #3 reflected plans of care for the following Problem/Need: a. 4/14/11- Resident exhibits verbal behavioral symptoms directed to other. b. 5/2/11 - Resident exhibits inappropriate behavioral symptoms directed toward others, inappropriate sexual acts/disrobes in public. Behaviors are exhibited 2-4 times a week. However, no documentation of behavior monitoring and interventions were available. Review of the clinical record for Resident #4 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #4 was alert, oriented with short term memory loss and moderately impaired decision making abilities. Review of the current as care plan for Resident #4 reflected no care plan for behaviors. Review of the clinical record for Resident #4 reflected no documentation of behaviors or behavior monitoring. In confidential interviews on 2/7/12 staff members stated Resident #3 has been verbally aggressive to them and to others. Each stated he touches staff inappropriately and makes sexually suggestive remarks to them. Each stated they had heard Resident #3 ask female residents for sex and for kisses. In an interview on 2/7/12 at 1:15 PM the Administrator and DON stated an investigation was conducted and it was determined it was not a reportable allegation. The Administrator and DON were not able to produce or submit evidence of their rational for determining reportablility of the incident. When asked for documentation of the investigation the Administrator and DON stated a report had not been completed however there were Abuse Prohibition in-services sign in sheets. The DON stated she had notes in her notebook however they were not in a formal investigation format and there was no documentation of interviews conducted with residents or staff. After repeated requests for additional information no father documentation or copies of notes were provided to the surveyor. The Administrator and DON stated after they were notified of the allegations, they in-serviced staff on abuse and neglect and placed Residents 2, 3, and 4 on 72 hour 'critical monitoring'. They further stated no other 'formal actions had been implemented'; however they were keeping a closer watch on the residents. The DON stated there would be times when Resident #2 was not in sight of a staff member since they had stopped the critical monitoring of the 3 residents on 2/2/12. Review of the facility's 8/11 policy titled Facility Abuse Prohibition Policy and Procedures reflected the following: Component V: Investigation The facility should use reasonable efforts to develop and implement a systematic process to investigate allegations of abuse, neglect and/or exploitation so that such events can be accurately and timely investigated and reported to proper authorities. ? Any alleged violation involving abuse, neglect or exploitation of a resident should be reported to the facility Administrator IMMEDIATELY. The facility Administrator or Designee should then notify the appropriate agencies of the allegations ? The facility management should then take the following steps to help facilitate the safety of all residents: 3. If the alleged perpetrator is another resident, separate the residents immediately .... Place the abusive resident under supervision ... If the abusive resident's behavior cannot be controlled thereby posing a threat to the harm of other residents or themselves, steps should be taken to discharge the abusive resident as promptly as possible under the circumstances. ? The facility charge nurse should complete a Resident Accident or Incident Report ... ? The facility Nurse Manager should, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. ? The facility Social Services and/or Activity Departments should conduct resident interviews regarding Staff treatment of [REDACTED]. ? All written statements, incident reports and investigative information should be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response ? The facility Administrator/Designee should report all allegations of abuse, neglect and exploitation to the Texas Department of Human Services (TDHS), and any other appropriate state or local agency IMMEDIATELY upon learning of the incident or allegations, consistent with TDHS Provider Letter #00-43. At this time the investigative process should begin. On 2/7/12 at 4:10 PM the Administrator and DON were notified that an IJ existed. On 2/7/12 at 7:30 PM the Administrator and DON submitted the following Plan of Removal for the IJ. Review of the Plan of Removal, dated 2/7/12 and accepted at 7:45 PM revealed: Pertaining to Abuse Prohibition 1. Investigation Measures 2. Training Measures 3. Immediate Protection Measures 4. Monitoring Investigation Measures ? Interview facility staff as to any knowledge or witnessing of sexual inappropriateness between residents. To be initiated 2/7/12 and completed 2/17/12. ? Interview facility residents as to any knowledge, witnessing of, or allegations of sexual inappropriateness, between residents. To be initiated 2/7/12 and completed 2/17/12. ? Audit of clinical records for any reference to sexually inappropriate activity or allegations of abuse between residents. To be initiated 2/7/12 and completed 2/17/12. ? Any identified allegations of abuse will be reported to DADS and investigated per policy and regulatory requirements. To be initiated 2/7/12 and ongoing. Training ? The Administrator will be in-serviced on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated 2/7/12 and completed 2/7/12. ? Any allegations of abuse will be reported to DADS and investigated according to our policy and regulatory requirements. ? Facility staff will be in-serviced immediately on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated immediately and ongoing, including New Hire Orientation. ? All residents that are oriented will be educated on reporting allegations of abuse to Administration and /facility staff initiated on 2/7/12. To be initiated by Social Services 2/7/12 and completed 2/7/12 and ongoing through Resident Council, facility ' s monthly newsletter and additional avenues of communication with residents in the facility. Immediate Protective Measures ? Each of the three residents named in the allegation (Resident #s 2, 3, and 4) will be placed on behavioral monitoring. Resident # 2 will be monitored until the threat has been removed and/or Resident #2 can clearly communicate that she is safe. ? Resident #3 will be placed on one to one monitoring for 72 hours starting 2/7/12 and ongoing with appropriate interventions being implemented. ? Implement discharge protocols with Resident #4 within regulatory guidelines. Includes providing a 30 day Notice of Discharge, however discharge will be implemented as soon as alternative placement is identified. Plan of Action Monitoring ? Administrator and Director of Nurses will review Plan of Removal and its components weekly for compliance. ? The QA Committee will review the plan of removal monthly for compliance and success. Additional intervention will be implemented as need arise. ? The Administrator and/or Director of Nurses will monitor education comprehension through random staff interview. Observations and interviews of residents and staff on 2/7/12 from 6:00 PM until 8:00 PM revealed facility had implemented the Plan of Removal. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility had not completed was continuing to implement and monitor the Plan of Removal. The Administrator provided the census of 118. The ADON provided the number of 73 female residents.

Based on interview and record review the facility failed to prohibit sexual abuse when 1 of 6 residents (Resident #2) reviewed for abuse/neglect was not provided the care and services to prevent emotional harm, mental anguish and fear. -[AGE] year old female, Resident #2, alleged sexual harassment on or about 1/18/12, 1/25/12 and 2/1/12, by 2 male residents (# 3 and #4) one of which had a history of [REDACTED]. The facility failed to adequately protect Resident #2 from further sexual harassment. This deficient practice caused Resident #2 to experience fear of coming out of her room, mental and emotional anguish resulting in a diminished quality of life. It has the potential to place an additional 73 female residents that reside in the facility at risk for abuse, neglect and fear and result in a diminished quality of life. An IJ was identified on 2/7/12 at 4:10 PM. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility was still implementing and monitoring the Plan of Removal. The findings include: In an interview on 2/7/12 at 10:15 AM Resident #2 stated on two occasions Resident #3 stopped her when she was going into the dining room and asked her for sex. She stated prior to those episodes Resident #3 would ask her for a kiss and tell her she was pretty but then became more verbally aggressive, demanding they have sex. She stated the last time he asked her he yelled it out and she was very embarrassed because everyone in the dining room could hear it. She stated the last time he asked he was more "verbally aggressive" and scared her. She stated on one occasion Resident #4 was sitting next to her in the dining room and put his hand on the inside of her knee and began to run his hand up between her legs. She stated she screamed out for CNA C to help her and when CNA C came over she said "Oh not you again" to Resident #3. Resident #2 stated she was scared at the time and very embarrassed because other people in the dining room were watching. She stated the dining room was full of people and named three residents who were close enough to know what had happened, two of which came to her later and asked if she was all right. Resident #2 stated she was afraid to go into the hall or dining room if staff were not close to her and that after they stopped monitoring her closely the staff were frequently busy and were not always where she could see them. Review of the admission face sheet dated 4/28/11 for Resident #2 reflected she was [AGE] years old, an admission date of [DATE] and the following Diagnoses: [REDACTED].#2 reflected these additional Diagnoses: [REDACTED]. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 1/18/12 'She discussed incident of a male resident asking for sex. Patient said this upset her and triggered some anxiety and depression. Patient indicated she had notified staff of this too.' 1/25/12 'She discussed another incident that occurred last week of a male resident touching her leg inappropriately. Patient said she informed staff of this. This is 2nd report within past week of a male resident being inappropriate towards her. Patient professed increased sadness: reported being triggered from recent events. Therapist will discuss in detail incident with supervisor and follow-up with staff.' In an interview on 2/6/12 at 2:45 PM Resident #2's son stated he called the police after his mother told him she was afraid to be alone in the facility because she was being sexually harassed. He further stated the police came to the facility on [DATE] and talked to him and Resident #2. Review of a Witness Statement dated 1/29/12 by ADON D reflected the following: '...Resident was informed to always use call light or yell out for assistance/help and to always report this information to staff so that we can intervene to ensure her safety. Resident spoke of one male resident on her hallway, sitting in the hall and she can't get by. I informed resident to call for help or if she doesn't see anyone to go to room and put call light on. A police officer entered room and asked to speak with resident. Police officer came to nursing station, spoke to writer, took information and reports that this was called in as sexual assault but it is a safety call/concern ...'. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 2/1/12 'She discussed making a police report against male resident who she alleged to being sexually inappropriate towards her. Patient reported nursing home has set a safety plan for her.' In an interview on 2/7/12 at 3:30 PM Resident #2 stated after the police came to talk to her the facility put her on a "close watch" and she felt better, however now that they are no longer watching as close she is afraid to go into the hall. She stated Resident #4 lives on the same hall as her and she is afraid when goes into the hall and does not see one of the facility staff close by. She stated when she goes into the dining room Resident #3 watches her and she is afraid he is waiting until she is not looking he is going to come up to her. Resident #2 stated she is afraid and knows both residents will "harass" her again because they cannot be watched all the time. She further stated she knows they have had similar problems with both of these residents because the staff told her things like this had happened in the past. Resident #2 stated "If they know somebody is like that they should warn people". In an interview on 2/7/12 at 2:05 PM the facility psychological counselor stated she had counseling sessions with Resident #2 on 1/18/12, 1/25/12 and 2/1/12. She stated at each of those sessions Resident #2 discussed with her the "incidents" with both residents. She stated Resident #2 reported the first incident with Resident #4 on 1/18/12, then reported the additional incident to her on 1/25/12 and on 2/1/12 she discussed both incidents. The counselor stated on 2/1/12 she notified the facility Social Worker. The counselor stated Resident #2 was alert, orient and cognitively intact. Review of the MDS dated [DATE] for Resident #2 reflected the following: Section E-Behavior [MEDICAL CONDITION]-none Physical or Verbal behavior directed toward others-Behavior not exhibited Other behavior symptoms not directed toward others-Behavior not exhibited Review of the BIMS Assessments dated 11/18/11 and 1/13/12 for Resident #2 reflected a summary score of 15 (highest possible score, indicating cognitively intact). Review of the CAM assessment dated [DATE] and 1/13/12 for Resident #2 reflected the following: Inattention-Behavior not present Disorganized thinking-Behavior not present Altered level of consciousness-Behavior not present Review of the NN dated 1/29/12 for Resident #2 reflected the following: 'Resident ' s RP asked about the reports the resident had made to the nurses on shift a few days ago regarding sexual harassment. RP stated he wanted to follow-up on incidents.' Review of the facility's Resident Accident or Incident Report form dated 1/29/12 for Resident #2 reflected the following: Nature of Accident or Incident: Residents RP approached me and asked if I could please follow-up on the incident the resident had reported to the nurse last week. RP stated resident has complained of sexual harassment by other residents in the dining room. Interventions: Behavior Monitoring Recommended In-services: Abuse Prohibition In-service Outcome of Investigation: Behavior Monitoring, separated residents involved. Review of a Witness Statement dated 1/30/12 by RN B reflected the following: Resident #2's 'RP came to the nursing station demanding for report (written) showing his Mother's complaints of sexual harassment by male residents. I then redirected him to go speak with the mom's nurse at the time. He did state that the mom is not feeling safe at this facility and even requested him and his friend to take turns watching over her (because she has been scared to even leave her room especially to go to the dining room).' A typed statement dated 2/9/12, which was received by the investigator on 2/10/12, after exit on 2/7/12, and signed by CNA C reflected the following: 'I gave the same statement to her (surveyor) as I did to my nursing supervisor on the night that Resident #2 voiced an issue to her son (1/29/12). It was that one evening I was taking a resident to get coffee and heard someone scream ... I then heard someone yell and I could see activity over by the main entrance to the dining room so I went over. I witnessed Resident #4 pushing away from the table that Resident #2 was sitting at and she said "he touched me". ... I told Resident #2 that it was okay and I would assist Resident #4 to another table and keep an eye on him, which I did. She did not tell me anything more and seemed ok after I moved him. I told the nurse checking on the trays what the screaming was about. Resident #2 did not appear anxious or nervous and remained at her table for the meal. However, in a telephone interview on 2/7/12 at 5:00 PM CNA C stated she was in the dining room assisting with the evening meal on an unknown date in mid-January when she heard a scream and someone call out "CNA C he is touching me" . She stated she did not know who had screamed out but saw Resident #4 backing away from a table at which Resident #2 was sitting. CNA C stated when she got to the table Resident #2 was visibly upset, shaking and crying. CNA C stated she reported the incident to LVN A and returned to Resident #2 who was still upset and shaking and attempted to reassure her. In an interview on 2/7/12 at 5:30 PM LVN A stated she had no memory of being informed there was an incident in the dining room. She stated there is always screaming in the dining room so she does not pay much attention to it. She further stated she was busy getting trays checked and does not remember being told by CNA C there was a problem with Resident #2. In confidential interviews on 2/7/12 alert, oriented residents stated they had witnessed inappropriate behavior toward Resident #2 by Resident #3 and Resident #4. Each stated there was an incident in the dining room one evening when Resident #2 screamed out and said "He's touching me". They saw Resident #4 next to Resident #2 at the table and Resident #2 was crying and shaking, asking the staff to keep Resident #3 away from her. They further stated they had heard Resident #3 ask Resident #2 for sex more than once when she was trying to get into the dining room. They further stated that Resident #2 appeared distressed and embarrassed when this happened and would hurry into the dining room to get away from Resident #3. In an interview on 2/7/12 at 10:30 AM Resident #3 stated "I am not going to talk to you or anyone else about any of this[***]. In an interview on 2/7/12 at 10:45 AM Resident #4 when asked by the surveyor if he remembered any of the events regarding Resident #2 he shook his head 'No'. Further attempts to interview Resident #4 were unsuccessful due to his diminished cognitive ability. Review of the clinical record for Resident #3 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #3 was alert, oriented and cognitively intact. Review of the current care plan for Resident #3 reflected plans of care for the following Problem/Need: a. 4/14/11- Resident exhibits verbal behavioral symptoms directed to other. b. 5/2/11 - Resident exhibits inappropriate behavioral symptoms directed toward others, inappropriate sexual acts/disrobes in public. Behaviors are exhibited 2-4 times a week. However, no documentation of behavior monitoring and interventions were available. Review of the clinical record for Resident #4 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #4 was alert, oriented with short term memory loss and moderately impaired decision making abilities. Review of the current as care plan for Resident #4 reflected no care plan for behaviors. Review of the clinical record for Resident #4 reflected no documentation of behaviors or behavior monitoring. In confidential interviews on 2/7/12 staff members stated Resident #3 has been verbally aggressive to them and to others. Each stated he touches staff inappropriately and makes sexually suggestive remarks to them. Each stated they had heard Resident #3 ask female residents for sex and for kisses. In an interview on 2/7/12 at 1:15 PM the Administrator and DON stated an investigation was conducted and it was determined it was not a reportable allegation. The Administrator and DON were not able to produce or submit evidence of their rational for determining reportablility of the incident. When asked for documentation of the investigation the Administrator and DON stated a report had not been completed however there were Abuse Prohibition in-services sign in sheets. The DON stated she had notes in her notebook however they were not in a formal investigation format and there was no documentation of interviews conducted with residents or staff. After repeated requests for additional information no father documentation or copies of notes were provided to the surveyor. The Administrator and DON stated after they were notified of the allegations, they in-serviced staff on abuse and neglect and placed Residents 2, 3, and 4 on 72 hour 'critical monitoring'. They further stated no other 'formal actions had been implemented'; however they were keeping a closer watch on the residents. The DON stated there would be times when Resident #2 was not in sight of a staff member since they had stopped the critical monitoring of the 3 residents on 2/2/12. Review of the facility's 8/11 policy titled Facility Abuse Prohibition Policy and Procedures reflected the following: Component V: Investigation The facility should use reasonable efforts to develop and implement a systematic process to investigate allegations of abuse, neglect and/or exploitation so that such events can be accurately and timely investigated and reported to proper authorities. ? Any alleged violation involving abuse, neglect or exploitation of a resident should be reported to the facility Administrator IMMEDIATELY. The facility Administrator or Designee should then notify the appropriate agencies of the allegations ? The facility management should then take the following steps to help facilitate the safety of all residents: 3. If the alleged perpetrator is another resident, separate the residents immediately .... Place the abusive resident under supervision ... If the abusive resident's behavior cannot be controlled thereby posing a threat to the harm of other residents or themselves, steps should be taken to discharge the abusive resident as promptly as possible under the circumstances. ? The facility charge nurse should complete a Resident Accident or Incident Report ... ? The facility Nurse Manager should, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. ? The facility Social Services and/or Activity Departments should conduct resident interviews regarding Staff treatment of [REDACTED]. ? All written statements, incident reports and investigative information should be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response ? The facility Administrator/Designee should report all allegations of abuse, neglect and exploitation to the Texas Department of Human Services (TDHS), and any other appropriate state or local agency IMMEDIATELY upon learning of the incident or allegations, consistent with TDHS Provider Letter #00-43. At this time the investigative process should begin. On 2/7/12 at 4:10 PM the Administrator and DON were notified that an IJ existed. On 2/7/12 at 7:30 PM the Administrator and DON submitted the following Plan of Removal for the IJ. Review of the Plan of Removal, dated 2/7/12 and accepted at 7:45 PM revealed: Pertaining to Abuse Prohibition 1. Investigation Measures 2. Training Measures 3. Immediate Protection Measures 4. Monitoring Investigation Measures ? Interview facility staff as to any knowledge or witnessing of sexual inappropriateness between residents. To be initiated 2/7/12 and completed 2/17/12. ? Interview facility residents as to any knowledge, witnessing of, or allegations of sexual inappropriateness, between residents. To be initiated 2/7/12 and completed 2/17/12. ? Audit of clinical records for any reference to sexually inappropriate activity or allegations of abuse between residents. To be initiated 2/7/12 and completed 2/17/12. ? Any identified allegations of abuse will be reported to DADS and investigated per policy and regulatory requirements. To be initiated 2/7/12 and ongoing. Training ? The Administrator will be in-serviced on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated 2/7/12 and completed 2/7/12. ? Any allegations of abuse will be reported to DADS and investigated according to our policy and regulatory requirements. ? Facility staff will be in-serviced immediately on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated immediately and ongoing, including New Hire Orientation. ? All residents that are oriented will be educated on reporting allegations of abuse to Administration and /facility staff initiated on 2/7/12. To be initiated by Social Services 2/7/12 and completed 2/7/12 and ongoing through Resident Council, facility ' s monthly newsletter and additional avenues of communication with residents in the facility. Immediate Protective Measures ? Each of the three residents named in the allegation (Resident #s 2, 3, and 4) will be placed on behavioral monitoring. Resident # 2 will be monitored until the threat has been removed and/or Resident #2 can clearly communicate that she is safe. ? Resident #3 will be placed on one to one monitoring for 72 hours starting 2/7/12 and ongoing with appropriate interventions being implemented. ? Implement discharge protocols with Resident #4 within regulatory guidelines. Includes providing a 30 day Notice of Discharge, however discharge will be implemented as soon as alternative placement is identified. Plan of Action Monitoring ? Administrator and Director of Nurses will review Plan of Removal and its components weekly for compliance. ? The QA Committee will review the plan of removal monthly for compliance and success. Additional intervention will be implemented as need arise. ? The Administrator and/or Director of Nurses will monitor education comprehension through random staff interview. Observations and interviews of residents and staff on 2/7/12 from 6:00 PM until 8:00 PM revealed facility had implemented the Plan of Removal. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility had not completed was continuing to implement and monitor the Plan of Removal. The Administrator provided the census of 118. The ADON provided the number of 73 female residents.

Based on interview and record review the facility failed to implement their written policy and procedure for abuse/neglect prohibition for investigation and reporting allegations of sexual harassment by for 1 of 6 residents (Resident #2) reviewed. -[AGE] year old female, Resident #2, alleged sexual harassment on or about 1/18/12, 1/25/12 and 2/1/12, by 2 male residents (# 3 and #4) one of which had a history of [REDACTED].#2, conduct a thorough investigation and failed to report the incidents. This deficient practice caused Resident #2 to experience fear, mental and emotional anguish resulting in a diminished quality of life. It has the potential to place the 73 femaile residents residing in the facility at risk for abuse, neglect and fear and result in a diminished quality of life. An IJ was identified on 2/7/12 at 4:10 PM. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility was still implementing and monitoring the Plan of Removal. The findings include: In an interview on 2/7/12 at 10:15 AM Resident #2 stated on two occasions Resident #3 stopped her when she was going into the dining room and asked her for sex. She stated prior to those episodes Resident #3 would ask her for a kiss and tell her she was pretty but then became more verbally aggressive, demanding they have sex. She stated the last time he asked her he yelled it out and she was very embarrassed because everyone in the dining room could hear it. She stated the last time he asked he was more "verbally aggressive" and scared her. She stated on one occasion Resident #4 was sitting next to her in the dining room and put his hand on the inside of her knee and began to run his hand up between her legs. She stated she screamed out for CNA C to help her and when CNA C came over she said "Oh not you again" to Resident #3. Resident #2 stated she was scared at the time and very embarrassed because other people in the dining room were watching. She stated the dining room was full of people and named three residents who were close enough to know what had happened, two of which came to her later and asked if she was all right. Resident #2 stated she was afraid to go into the hall or dining room if staff were not close to her and that after they stopped monitoring her closely the staff were frequently busy and were not always where she could see them. Review of the admission face sheet dated 4/28/11 for Resident #2 reflected she was [AGE] years old, an admission date of [DATE] and the following Diagnoses: [REDACTED].#2 reflected these additional Diagnoses: [REDACTED]. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 1/18/12 'She discussed incident of a male resident asking for sex. Patient said this upset her and triggered some anxiety and depression. Patient indicated she had notified staff of this too.' 1/25/12 'She discussed another incident that occurred last week of a male resident touching her leg inappropriately. Patient said she informed staff of this. This is 2nd report within past week of a male resident being inappropriate towards her. Patient professed increased sadness: reported being triggered from recent events. Therapist will discuss in detail incident with supervisor and follow-up with staff.' In an interview on 2/6/12 at 2:45 PM Resident #2's son stated he called the police after his mother told him she was afraid to be alone in the facility because she was being sexually harrassed. He further stated the police came to the facility on [DATE] and talked to him and Resident #2. Review of a Witness Statement dated 1/29/12 by ADON D reflected the following: '...Resident was informed to always use call light or yell out for assistance/help and to always report this information to staff so that we can intervene to ensure her safety. Resident spoke of one male resident on her hallway, sitting in the hall and she can't get by. I informed resident to call for help or if she doesn't see anyone to go to room and put call light on. A police officer entered room and asked to speak with resident. Police officer came to nursing station, spoke to writer, took information and reports that this was called in as sexual assault but it is a safety call/concern ...'. Review of the Progress Notes by the psychological services Providing Clinician reflected the following: 2/1/12 'She discussed making a police report against male resident who she alleged to being sexually inappropriate towards her. Patient reported nursing home has set a safety plan for her.' In an interview on 2/7/12 at 3:30 PM Resident #2 stated after the police came to talk to her the facility put her on a "close watch" and she felt better, however now that they are no longer watching as close she is afraid to go into the hall. She stated Resident #4 lives on the same hall as her and she is afraid when goes into the hall and does not see one of the facility staff close by. She stated when she goes into the dining room Resident #3 watches her and she is afraid he is waiting until she is not looking he is going to come up to her. Resident #2 stated she is afraid and knows both residents will "harass" her again because they cannot be watched all the time. She further stated she knows they have had similar problems with both of these residents because the staff told her things like this had happened in the past. Resident #2 stated "If they know somebody is like that they should warn people". In an interview on 2/7/12 at 2:05 PM the facility psychological counselor stated she had counseling sessions with Resident #2 on 1/18/12, 1/25/12 and 2/1/12. She stated at each of those sessions Resident #2 discussed with her the "incidents" with both residents. She stated Resident #2 reported the first incident with Resident #4 on 1/18/12, then reported the additional incident to her on 1/25/12 and on 2/1/12 she discussed both incidents. The counselor stated on 2/1/12 she notified the facility Social Worker. The counselor stated Resident #2 was alert, orient and cognitively intact. Review of the MDS dated [DATE] for Resident #2 reflected the following: Section E-Behavior [MEDICAL CONDITION]-none Physical or Verbal behavior directed toward others-Behavior not exhibited Other behavior symptoms not directed toward others-Behavior not exhibited Review of the BIMS Assessments dated 11/18/11 and 1/13/12 for Resident #2 reflected a summary score of 15 (highest possible score, indicating cognitively intact). Review of the CAM assessment dated [DATE] and 1/13/12 for Resident #2 reflected the following: Inattention-Behavior not present Disorganized thinking-Behavior not present Altered level of consciousness-Behavior not present Review of the NN dated 1/29/12 for Resident #2 reflected the following: 'Resident ' s RP asked about the reports the resident had made to the nurses on shift a few days ago regarding sexual harassment. RP stated he wanted to follow-up on incidents.' Review of the facility's Resident Accident or Incident Report form dated 1/29/12 for Resident #2 reflected the following: Nature of Accident or Incident: Residents RP approached me and asked if I could please follow-up on the incident the resident had reported to the nurse last week. RP stated resident has complained of sexual harassment by other residents in the dining room. Interventions: Behavior Monitoring Recommended In-services: Abuse Prohibition In-service Outcome of Investigation: Behavior Monitoring, separated residents involved. Review of a Witness Statement dated 1/30/12 by RN B reflected the following: Resident #2's 'RP came to the nursing station demanding for report (written) showing his Mother's complaints of sexual harassment by male residents. I then redirected him to go speak with the mom's nurse at the time. He did state that the mom is not feeling safe at this facility and even requested him and his friend to take turns watching over her (because she has been scared to even leave her room especially to go to the dining room).' A typed statement dated 2/9/12, which was received by the investigator on 2/10/12, after exit on 2/7/12, and signed by CNA C reflected the following: 'I gave the same statement to her (surveyor) as I did to my nursing supervisor on the night that Resident #2 voiced an issue to her son (1/29/12). It was that one evening I was taking a resident to get coffee and heard someone scream ... I then heard someone yell and I could see activity over by the main entrance to the dining room so I went over. I witnessed Resident #4 pushing away from the table that Resident #2 was sitting at and she said "he touched me". ... I told Resident #2 that it was okay and I would assist Resident #4 to another table and keep an eye on him, which I did. She did not tell me anything more and seemed ok after I moved him. I told the nurse checking on the trays what the screaming was about. Resident #2 did not appear anxious or nervous and remained at her table for the meal. However, in a telephone interview on 2/7/12 at 5:00 PM CNA C stated she was in the dining room assisting with the evening meal on an unknown date in mid-January when she heard a scream and someone call out "CNA C he is touching me" . She stated she did not know who had screamed out but saw Resident #4 backing away from a table at which Resident #2 was sitting. CNA C stated when she got to the table Resident #2 was visibly upset, shaking and crying. CNA C stated she reported the incident to LVN A and returned to Resident #2 who was still upset and shaking and attempted to reassure her. In an interview on 2/7/12 at 5:30 PM LVN A stated she had no memory of being informed there was an incident in the dining room. She stated there is always screaming in the dining room so she does not pay much attention to it. She further stated she was busy getting trays checked and does not remember being told by CNA C there was a problem with Resident #2. In confidential interviews on 2/7/12 alert, oriented residents stated they had witnessed inappropriate behavior toward Resident #2 by Resident #3 and Resident #4. Each stated there was an incident in the dining room one evening when Resident #2 screamed out and said "He's touching me". They saw Resident #4 next to Resident #2 at the table and Resident #2 was crying and shaking, asking the staff to keep Resident #3 away from her. They further stated they had heard Resident #3 ask Resident #2 for sex more than once when she was trying to get into the dining room. They further stated that Resident #2 appeared distressed and embarrassed when this happened and would hurry into the dining room to get away from Resident #3. In an interview on 2/7/12 at 10:30 AM Resident #3 stated "I am not going to talk to you or anyone else about any of this[***]. In an interview on 2/7/12 at 10:45 AM Resident #4 when asked by the surveyor if he remembered any of the events regarding Resident #2 he shook his head 'No'. Further attempts to interview Resident #4 were unsuccessful due to his diminished cognitive ability. Review of the clinical record for Resident #3 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #3 was alert, oriented and cognitively intact. Review of the current care plan for Resident #3 reflected plans of care for the following Problem/Need: a. 4/14/11- Resident exhibits verbal behavioral symptoms directed to other. b. 5/2/11 - Resident exhibits inappropriate behavioral symptoms directed toward others, inappropriate sexual acts/disrobes in public. Behaviors are exhibited 2-4 times a week. However, no documentation of behavior monitoring and interventions were available. Review of the clinical record for Resident #4 reflected an admission date of [DATE] and the following Diagnoses: [REDACTED]. Further review reflected Resident #4 was alert, oriented with short term memory loss and moderately impaired decision making abilities. Review of the current as care plan for Resident #4 reflected no care plan for behaviors. Review of the clinical record for Resident #4 reflected no documentation of behaviors or behavior monitoring. In confidential interviews on 2/7/12 staff members stated Resident #3 has been verbally aggressive to them and to others. Each stated he touches staff inappropriately and makes sexually suggestive remarks to them. Each stated they had heard Resident #3 ask female residents for sex and for kisses. In an interview on 2/7/12 at 1:15 PM the Administrator and DON stated an investigation was conducted and it was determined it was not a reportable allegation. The Administrator and DON were not able to produce or submit evidence of their rational for determining reportablility of the incident. When asked for documentation of the investigation the Administrator and DON stated a report had not been completed however there were Abuse Prohibition in-services sign in sheets. The DON stated she had notes in her notebook however they were not in a formal investigation format and there was no documentation of interviews conducted with residents or staff. After repeated requests for additional information no father documentation or copies of notes were provided to the surveyor. The Administrator and DON stated after they were notified of the allegations, they in-serviced staff on abuse and neglect and placed Residents 2, 3, and 4 on 72 hour 'critical monitoring'. They further stated no other 'formal actions had been implemented'; however they were keeping a closer watch on the residents. The DON stated there would be times when Resident #2 was not in sight of a staff member since they had stopped the critical monitoring of the 3 residents on 2/2/12. Review of the facility's 8/11 policy titled Facility Abuse Prohibition Policy and Procedures reflected the following: Component V: Investigation The facility should use reasonable efforts to develop and implement a systematic process to investigate allegations of abuse, neglect and/or exploitation so that such events can be accurately and timely investigated and reported to proper authorities. ? Any alleged violation involving abuse, neglect or exploitation of a resident should be reported to the facility Administrator IMMEDIATELY. The facility Administrator or Designee should then notify the appropriate agencies of the allegations ? The facility management should then take the following steps to help facilitate the safety of all residents: 3. If the alleged perpetrator is another resident, separate the residents immediately .... Place the abusive resident under supervision ... If the abusive resident's behavior cannot be controlled thereby posing a threat to the harm of other residents or themselves, steps should be taken to discharge the abusive resident as promptly as possible under the circumstances. ? The facility charge nurse should complete a Resident Accident or Incident Report ... ? The facility Nurse Manager should, to the extent warranted and necessary, obtain written statements from all parties involved in the incident, any witnesses to the incident and any family members who may add pertinent information to the investigation. ? The facility Social Services and/or Activity Departments should conduct resident interviews regarding Staff treatment of [REDACTED]. ? All written statements, incident reports and investigative information should be turned into the Administrator or Designee for summation and final disposition. Component VII: Reporting/Response ? The facility Administrator/Designee should report all allegations of abuse, neglect and exploitation to the Texas Department of Human Services (TDHS), and any other appropriate state or local agency IMMEDIATELY upon learning of the incident or allegations, consistent with TDHS Provider Letter #00-43. At this time the investigative process should begin. On 2/7/12 at 4:10 PM the Administrator and DON were notified that an IJ existed. On 2/7/12 at 7:30 PM the Administrator and DON submitted the following Plan of Removal for the IJ. Review of the Plan of Removal, dated 2/7/12 and accepted at 7:45 PM revealed: Pertaining to Abuse Prohibition 1. Investigation Measures 2. Training Measures 3. Immediate Protection Measures 4. Monitoring Investigation Measures ? Interview facility staff as to any knowledge or witnessing of sexual inappropriateness between residents. To be initiated 2/7/12 and completed 2/17/12. ? Interview facility residents as to any knowledge, witnessing of, or allegations of sexual inappropriateness, between residents. To be initiated 2/7/12 and completed 2/17/12. ? Audit of clinical records for any reference to sexually inappropriate activity or allegations of abuse between residents. To be initiated 2/7/12 and completed 2/17/12. ? Any identified allegations of abuse will be reported to DADS and investigated per policy and regulatory requirements. To be initiated 2/7/12 and ongoing. Training ? The Administrator will be in-serviced on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated 2/7/12 and completed 2/7/12. ? Any allegations of abuse will be reported to DADS and investigated according to our policy and regulatory requirements. ? Facility staff will be in-serviced immediately on regulations and organizational Policy and Procedures for identifying, reporting and investigating allegations of abuse. To be initiated immediately and ongoing, including New Hire Orientation. ? All residents that are oriented will be educated on reporting allegations of abuse to Administration and /facility staff initiated on 2/7/12. To be initiated by Social Services 2/7/12 and completed 2/7/12 and ongoing through Resident Council, facility ' s monthly newsletter and additional avenues of communication with residents in the facility. Immediate Protective Measures ? Each of the three residents named in the allegation (Resident #s 2, 3, and 4) will be placed on behavioral monitoring. Resident # 2 will be monitored until the threat has been removed and/or Resident #2 can clearly communicate that she is safe. ? Resident #3 will be placed on one to one monitoring for 72 hours starting 2/7/12 and ongoing with appropriate interventions being implemented. ? Implement discharge protocols with Resident #4 within regulatory guidelines. Includes providing a 30 day Notice of Discharge, however discharge will be implemented as soon as alternative placement is identified. Plan of Action Monitoring ? Administrator and Director of Nurses will review Plan of Removal and its components weekly for compliance. ? The QA Committee will review the plan of removal monthly for compliance and success. Additional intervention will be implemented as need arise. ? The Administrator and/or Director of Nurses will monitor education comprehension through random staff interview. Observations and interviews of residents and staff on 2/7/12 from 6:00 PM until 8:00 PM revealed facility had implemented the Plan of Removal. While the IJ was removed on 2/7/12, the facility remained out of compliance at a severity level of 'Actual harm that is not immediate jeopardy' and a scope of pattern because the facility had not completed was continuing to implement and monitor the Plan of Removal. The Administrator provided the census of 118. The ADON provided the number of 73 female residents.