Every finding on record at Pleasanton North Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 5 residents (Residents #1) reviewed for assessments: Resident #1's MDS dated [DATE] did not indicate she had a fall since her last MDS assessment. These failures could place residents at risk for inadequate care due to inaccurate assessments.Findings included: Record review of Resident #1's face sheet dated 06/24/2026 revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include unspecified dementia, unspecified severity, with other behavioral disturbances (cognitive decline), unsteadiness on feet and other abnormalities of the gait and mobility (impaired patterns of walking and movement that deviate from normal coordination, balance or rhythm). Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 0 out of 15 indicating the resident's cognition was severely impaired. Further review of the MDS under Section J - Health Conditions revealed the assessment indicated Residet #1 had zero falls' in section J1800. Any falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS), whichever is more recent. Record review of Resident #1's care plan provided on 06/24/2026 revealed a focus area for the following: Falls: . had an actual fall r/t unsteadiness on feet initiated on 05/11/2026. Record review of Resident #1's progress note dated 05/11/2025 revealed Resident #1 had a fall on 05/11/2026. During an interview on 06/26/2026 at 12:57 p.m., MDS A stated they failed to enter that the resident had a fall after her last assessment. MDS A confirmed Resident #1 had a fall on 05/11/2026 and that it should have been reflected on Resident #1's MDS assessment dated [DATE]. MDS A stated the risk to an inaccurate MDS could be that the fall would not be recorded on the facility's quality measures report. During an interview on 06/26/2026 at 1:06 p.m., the DON confirmed Resident #1 had a fall on 05/11/2026. The DON stated the MDS dated [DATE] should have accurately reflected that Resident #1 had a fall. The DON stated the risk of an inaccurate MDS could be their log of falls could become inaccurate as well. Review of the facility's policy titled, MDS 3.0 Completion, with no date, revealed: Policy Explanation and Compliance Guidelines: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional compacity, using the RAI specified by the state.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 residents (Resident #1 and #2) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to accurately reflect Resident #1's fall prevention interventions, including low bed, anti-skid socks (socks with rubber on soles to stop slipping), and anti-skid tape on the floor (tape with a gritty type substance to reduce slipping), but did reflect hipsters (which she did not wear) in her comprehensive person-centered care plan. The facility failed to accurately reflect Resident #2's fall prevention interventions, including low bed, anti-skid socks, anti-tip devices on wheelchair, and anti-skid tape on the floor in his comprehensive person-centered care plan. This deficient practice affects residents at risk for falls and could result in injury r/t inaccurate or missed interventions.The findings included: Record review of Resident #1's electronic face sheet dated 01/14/2026 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (encompasses a group of lung diseases that block airflow and make it difficult to breathe), hypoxemia (low levels of oxygen in the blood causing difficult breathing and fatigue), dementia (loss of cognitive functioning that interferes with daily life and activities), adult failure to thrive (overall physical and functional decline), fatigue (extreme tiredness)and falls (move from a higher to a lower level without control). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected that she scored 1 of 15 on her BIMS which indicated her cognitive status was severely impaired. She required extensive assistance with her ADLs. Resident #1 used a wheelchair for locomotion and had a history of falls. Record review of Resident #1's comprehensive person-centered care plan dated 11/24/2025 reflected Focus, had an actual fall, interventions, hipsters (padded briefs that protect the hips) are to be worn while resident is up to help prevent injuries from falls, dated initiated, 11/18/2025. The comprehensive care plan for Resident #1 did not reflect that she wore anti-skid stockings, had a low bed and anti-skid tape on the floor next to her bed. Record review of Resident #1's FRA dated 11/24/2025 reflected Resident #1 had recent multiple falls, was unable to independently come to a standing position, and exhibited loss of balance while standing and required direct assistance to move from place to place. She scored 28 on her FRA which indicated she was at high risk for falls. Observation of Resident #1 on 01/14/2026 at 10:45 am revealed she was sitting in a wheelchair being taken to her room for her teeth to be examined by the dentist and she did not have hipsters. Observation of Resident #1 on 01/15/2026 at 09:20 am in her room revealed she was lying on a low bed, call light within reach, and there was anti-skid tape on the floor beside her bed. She wore non-skid socks. 2. Record review of Resident #2's electronic face sheet dated 01/14/2026 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), difficulty in walking (refers to a condition where an individual struggles to maintain a normal gait), vascular dementia (major cognitive impairment), and insomnia (sleep disorder that makes it difficult to fall or stay asleep). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he scored 1 of 15 on his BIMS which indicated his cognitive status was severely impaired. He required extensive assistance with his ADLs and had a history of falls. Record review of Resident #2's comprehensive person-centered care plan dated 11/21/2025 reflected Focus, falls, and did not include the interventions of: antiskid strips on floor, antiskid socks, anti-tip devices on wheelchair or low bed. Record review of Resident #2's FRA dated 10/09/2025 reflected he scored 23 which signified he was at high risk for falls. He exhibited loss of balance while standing and required direct assistance to move from place to place. Observation of Resident #2 on 01/14/2026 at 10:50 am revealed he was sitting in a wheelchair in the common area of the facility and had anti-tip devices on his wheelchair. Observation of Resident #2 on 01/15/2026 at 08:00 am revealed he was lying in bed in his room. The bed was in the low position; he had antiskid socks on and there was antiskid tape on the floor next to where he would get out of bed. During an interview on 01/15/2026 at 11:00 am with RN B, who performed Resident #1's FRA dated 11/24/2025 and frequently took care of the resident, she stated the resident wore non-skid socks, had a low bed and anti-skid tape on the floor next to her bed. She stated they tried hipsters and Resident #1 called them stupid and would take them off. She stated she could not recall the last time she had the hipsters. She stated the care plan accuracy was important because the CNAs could pull up her Kardex (form with resident's specific care requirements) which was created for them to know things about her care such as low bed, or non-skid socks. She stated Resident #2 had anti-tip devices on his wheelchair. During an interview on 01/15/2026 at 11:36 am with CNA C, who cared for Resident #1, she stated that Resident #1 did not wear hipsters, had a low bed, non-skid socks, and anti-skid tape on the floor. She stated CNA's have access to a Kardex, which is created by the residents' care plan. She stated it was important for the resident's care plan to be accurate, for the Kardex to be accurate, so care would not be missed. She stated Resident #2 had antiskid socks, tape on the floor, low bed, and anti-tip devices on his wheelchair. During an interview on 01/15/2026 at 12:30 pm with night nurse LVN D, she stated that Resident #1 did not use hipsters, and staff tried to keep her near the nurse's station in front to be able to monitor her. She stated Resident #1 had a low bed and wore anti-skid socks. She stated Resident #2 had a low bed, anti-skid tape on the floor and wore anti-skid socks. She stated Resident #2 had antiskid socks, tape on the floor, low bed, and anti-tip devices on his wheelchair. During an interview on 01/15/2026 at 3:25 pm CNA E stated Resident #1 was at high risk for falls, did not wear hipsters, had a low bed, and wore anti-skid socks. She stated the resident no longer used a walker and was now in a wheelchair. She stated Resident #2 had a low bed, antiskid socks, tape on the floor, and anti-tip devices on his wheelchair. During an interview on 01/16/2026 at 10:55 a.m., RN A, who had only worked at the facility for 2 months, stated she did the MDS assessments and participated in the care plan development and updates. She stated Resident #1's hipsters needed to be removed since they were not a physician's order, and she did not wear or want them, and her nonskid socks, low bed and anti-skid tape needed to be added to the care plan, so care would not be missed. She stated Resident #2's fall prevention interventions needed to be put into his care plan. During an interview on 01/16/2026 at 11:20 am, the DON stated the care plan process is a team effort and the interventions missing on Resident #1's care plan must have been overlooked. She stated Resident #1's hipsters needed to be taken off the care plan, and the low bed, anti-skid socks and tape needed to be put into the care plan and Resident #2's fall prevention interventions. She stated she was accountable for nursing care at the facility and did not want care to be provided wrong or to be missed. Record review of the facility policy and procedure titled Comprehensive Care Plans dated 2025 reflected, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 (Resident #1) reviewed for care plans.Facility staff failed to follow the fall interventions in Resident #1's care plan that included keeping Resident #1's bed in the lowest position. Resident #1's was observed lying in bed and the bed was not at the lowest position on 11/06/2025. This deficient practice could place residents with the potential for falls at risk for injury to themselves or others. The findings included:Record review of Resident #1's undated face sheet revealed Resident #1 was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's MDS assessment, dated 10/04/2025, revealed a BIMS score of 3, indicating severe cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on both sides of Resident #1's upper and lower extremities and was dependent on staff for bed mobility and transfers. Record review of Resident #1 physician's order summary report, dated 11/07/2025, revealed an order, low bed every shift for fall precautions, dated 11/29/2022 and fall precautions at all times every shift, dated 11/03/2025. Record review of Resident #1 undated comprehensive care plan revealed a care plan, [Resident #1] had an actual fall with subdural hematoma (bleeding near the brain), dated 10/31/2025 and revised 11/03/2025. An intervention revealed, low bed, dated 10/23/2025. Resident #1 had a care plan that revealed, [Resident #1] is a high risk for falls related to senile degeneration of brain, poor insight to deficits, and poor safety awareness. [Resident #1] is in a low bed and has a fall mat in place, dated 02/10/2022 and revised 10/23/2025. During an observation of Resident #1 and an interview, 11/06/2025 at 9:14 a.m., Resident #1 was observed lying in her bed with the bed in a standard knee height position and not lowered to the lowest level. Resident #1 had a fall mat beside the bed. A sign was observed on Resident #1's bulletin board at the foot of Resident #1's bed that revealed, low bed and fall mat. A bed remote was observed hanging on the outside of Resident #1's quarter rail and Resident #1 stated she did not use the remote to change the level of Resident #1's bed. During an interview with RN B, 11/06/2025 at 9:20 a.m., RN B observed Resident #1's bed and stated Resident #1 was supposed to have her bed lowered to the lowest position and stated Resident #1's bed was not in the lowest position. RN B stated she was the nurse assigned to Resident #1 and RN B stated all staff were responsible for ensuring Resident #1's bed was in the lowest position. RN B stated she had received training on keeping resident beds in the position for residents at risk for falls as a preventive measure to prevent falls. RN B stated Resident #1 was a fall risk and stated if Resident #1's bed was not in the low position, if she fell, the injuries could be worse because she is falling from a higher position than if the bed was in a low position. During an interview with the DON, 11/07/2025 at 11:00 a.m., the DON stated staff had received training on fall prevention to include keeping resident beds in a low position if the resident was at risk for falls. The DON stated all staff were responsible for keeping beds in the low position and stated staff could identify residents at risk for falls by the sign posted in a resident room that read, low bed. The DON stated it was important for beds to be in the low position for a resident at risk for falls because, they could fall and be injured. Record review of a facility policy titled, Comprehensive Care Plans (Copyright 2025), revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #5) reviewed for accuracy of records as evidenced by: The facility failed to ensure Resident #5's MDS assessment accurately recorded the number of days that insulin injections were received during the last 7 days prior to the assessment. This failure could place residents at risk of missing treatments or medications leading to a decline in health or overall well-being.Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #5) reviewed for accuracy of records as evidenced by: The facility failed to ensure Resident #5's MDS assessment accurately recorded the number of days that insulin injections were received during the last 7 days prior to the assessment. This failure could place residents at risk of missing treatments or medications leading to a decline in health or overall well-being. The findings included: Record review of Resident #5's admission sheet, dated 5/25/25, showed a [AGE] year-old female resident with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD) (a progressive lung disease that makes it difficult to breathe), Hypertension (high blood pressure), Hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slowdown in metabolism and anxiety disorder. Review of Resident #5's quarterly MDS assessment, dated 6/27/25, documented the resident with a BIMS of 9, indicating moderate cognitive impairment and a diagnosis of Diabetes Mellitus in Section I - Active Diagnoses. Further review of the MDS assessment Section N - Medications N0350 Insulin noted an answer of 0 to the statement Insulin injections - record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. Review of Resident #5's most recent care plan, dated 5/28/25, documented the resident was monitored for complications related to Diabetes Mellitus with interventions including Document any beginning stages of breakdown, notify wound consultant/nurse and MD; Encourage ambulation if not contraindicated; Encourage good nutritional and oral fluid intake. Review of Resident #5's order summary included an order active as of 5/29/25 for NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 150 = 0 Units Hold insulin; 151 - 200 = 2 units Administer subcutaneously; 201 - 250 = 4 units Administer subcutaneously; 251 - 300 = 6 units Administer subcutaneously; 301 - 350 = 8 units Administer subcutaneously; 351 - 400 = 10 units Administer subcutaneously; anything over 400 call MD., subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65). Review of Resident #5's June 2025 Medication Administration Record (MAR) documented the resident received insulin injections on 25 of 26 days preceding the date of the MDS assessment on 6/27/25. During an interview with the MDS Coordinator on 7/17/2025 at 12:34 PM, the MDS Coordinator stated she opens the MDS assessment, and lets the team know so each member can do their part. When everyone is finished, the MDS Coordinator stated she puts all the information in and closes the assessment and submits it. For insulin data, the MDS Coordinator stated she runs the administration report, looks at the time frame, sees if a resident was under the parameter or refused medication, and then enters the number of days the insulin was given into the system. When asked why it is important for the MDS assessment to contain accurate data, the MDS Coordinator stated it is important for the MDS to be accurate because it paints the picture of what the resident is receiving. Record review of the facility's policy titled Conducting an Accurate Resident Assessment, with a copyright date of 2025, noted Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The policy further noted The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identities resident strengths to maintain or improve medial status, functional abilities, and psychosocial status.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be treated with respect and dignity for 1 (Resident #14) of 8 residents reviewed, in that: Resident #14 was referred to as a feeder in the assisted dining room. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity. The findings were: Record review of Resident #14's face sheet, dated 07/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: altered mental status, dysphagia oral phase (difficulty swallowing), and unspecified dementia (difficulty with memory). Record review of Resident #14's quarterly MDS assessment, dated 06/21/2025, revealed a BIMS score of 00 which indicated severe cognitive impairment. Further review revealed Resident #14 required assistance to complete activities of daily living, including eating. Record review of Resident #14's care plan, edited 06/09/2025, revealed, [Resident #14] is at risk for nutritional impairment [related to] receiving therapeutic diet . [Resident #14] requires a divided plate and queuing with meals. Further review revealed, Cognitive loss/ dementia or alteration in thought processes . Promote dignity. Converse with resident and ensure privacy while providing care. An observation on 7/15/25 at 11:26 AM revealed LVN B in the assisted dining room, verifying diets on trays before CNAs pass trays out. LVN B noted that Residents sitting in that table the assisted dining table as feeders. During an interview with LVN B on 7/15/25 at 11:50 AM, it was revealed she used a poor choice of words when she used the word Feeder and should of used assisted dining table. During an interview with the DON on 07/15/2025 at 1:14 p.m., the DON I stated it was unacceptable to refer to residents who require assistance with dining as feeders, and that she expected staff members not to do so. Record review of the facility policy, Quality of Life - Dignity, Revised August 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1.Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on Observations, Interviews, and Record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 6 residents (Resident #12 & Resident # 31) reviewed for call light. The facility failed to ensure Resident #12 and # 31's call light was within reach. This failure could place residents at risk of not being able to call for assistance when needed. Findings include: 1.Record review of Resident # 12's face sheet dated 7/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident # 12 had a diagnosis that included: Hemiparesis on the left side (refers to weakness on the left side of the body), anxiety disorder (group of mental health conditions that cause fear, dread) and Muscle weakness (refers to a reduced ability of one or more muscles to generate force). Record review of Resident # 12's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderate cognitive impairment. Review of Resident #12's Quarterly MDS assessment, dated 6/13/25, reflected under section G, G0300, option # 3, which stated that the patient was unsteady on their feet, and required assistance X 2 for ADL care. Record review of Resident # 12's Quarterly care plan, revised 8/1/2024, revealed a care plan with interventions ensure the call light is within reach. Observation and interview on 7/15/25 in Resident # 12's room at 10:30 AM revealed that the call light was found on the floor under the bed. Resident # 12 stated they did not know how the call light ended on the floor and did not know what he would do if he needed assistance today. Record review of Resident # 31's face sheet dated 7/15/25, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident # 31 had diagnoses that included: Parkinson's disease (is a progressive neurodegenerative disorder that primarily affects movement), bipolar disorder (is a mental illness that causes unusual shifts in mood, energy) and anxiety disorder (involve more than occasional worry or fear). 2.Record review of Resident # 31's Quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated moderate cognitive impairment. Review of Resident #31's Quarterly MDS assessment, dated 5/12/25, reflected under section G, G0300, option # 3, which stated that the patient was unsteady on their feet, and required assistance X 2 for ADL care. Record review of Resident # 31's Quarterly care plan, revised 7/1/2024, revealed a care plan with interventions ensure the call light is within reach. Observation and Interview on 7/15/25 in Resident #31's room at 10:33 AM revealed that the call light was found under the mattress. Resident # 31 stated she did not know where her call light was and would hope and pray that someone would come in and check in on her today. During an interview on 07/15/25 at 10:40 AM, CNA C stated that she was the assigned nursing assistant for Resident # 12 and Resident # 31. She mentioned that he did not know how Resident #12s and Residents # 31's call light ended up on the floor, but she picked it up and clipped it to Resident #12's and Residents # 31's bedspread. she also noted that if both Resident's lacked access to the call light, it could potentially lead to a fall if they needed assistance. During an interview with the DON on 7/15/25, at 1:00 PM, she emphasized the importance of ensuring that the call light is accessible to all residents. She stated that the lack of accessibility to a call light for any resident could lead to a potential negative outcome if assistance is needed. The DON also mentioned that charge nurses currently monitor this task during their daily morning rounds, and she oversees this process. Record review of facility policy Call Light/Accessibility and Timely Response, dated 2024, revealed Staff will ensure the call light is within reach of Resident and secured, as needed .

Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program for residents with newly evident or possible severe mental illness for 2 of 4 residents (Resident #4 and Resident #15) reviewed for PASRR services. The facility failed to identify Resident #4 and Resident #15 as having diagnoses of mental illness including Major Depressive Disorder (MDD) on the PASRR Level I screening which would require a PASRR Level II assessment. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized PASRR services.The findings included: 1.Record review of the face sheet for Resident #4, dated 7/15/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder (MDD) (a serious mental health condition characterized by persistent feelings of sadness and loss of interest in activities) , Diabetes mellitus (is a group of metabolic disorders characterized by high blood sugar levels) and Left-sided hemiplegia (is a form of paralysis or severe weakness affecting the entire left side of the body). Record review of the quarterly MDS assessment for Resident #4, dated 2/3/2025, revealed a BIMS score 13, indicating intact cognition. Record review of the quarterly MDS assessment for Resident #4, dated 2/6/25, revealed section 1, Active diagnoses: Psychiatric Mood Disorder. Record review of Resident #4's physician's monthly orders dated July 15, 2025, revealed no medications for diagnoses of Major depressive disorder. Record review of Resident #4's PASRR Level 1 dated 8/2/24 revealed Section C was marked 0 under Mental Illness which indicated Resident #4 did not have any evidence or an indicator for Mental Illness. Interview with Resident #4 on 7/16/25 at 12:45 PM revealed he had had a diagnosis of some form of depressive disorder since he was a young man, and could not recall the diagnosis date, but recalled taking medication for it at times. 2. Review of Resident #15’s admission sheet with an admission date of 4/6/18 and a readmission date of 9/28/20 noted the resident had diagnoses including MDD (4/6/18), heart disease (4/6/18), anxiety disorder (12/12/18), Type 2 Diabetes Mellitus (9/28/20), Vascular Dementia (9/28/20), and Gastro Esophageal Reflux Disease (GERD) (10/29/21). Review of Resident #15’s quarterly MDS assessment, dated 6/2/25, noted the resident had a BIMS of 0, indicating severe cognitive impairment and required total dependence for mobility and self-care. Review of Resident #15’s order summary indicated the resident received monitoring for “depressive symptomology, cyclical and rapid mood shifts (tearfulness, sadness, hopelessness, loss of interest or pleasure, weight loss/gain, reduced/increased appetite, worthlessness, guilt, concentration and/or sleeping difficulties, thoughts of being better off dead, suicidal ideations, etc.” Review of Resident #15’s most recent care plan, dated 7/9/24, documented the resident had a diagnosis of depression with interventions including “out of room daily, encourage participation in activities, facilitate verbalization of fears/frustrations, medications as ordered.” Review of Resident #15’s PASRR Level I screening, dated 4/5/18, documented in section C0100. Mental Illness an answer of “0 (No)” to the question “Is there evidence or an indicator this is an individual that has a Mental Illness?” In section C0200. Intellectual Disability the PASRR Level I screening documented an answer of “0 (No)” to the question “Is there evidence or an indicator this is an individual that has an Intellectual Disability?” In section C0300. Developmental Disability the PASRR Level I screening documented an answer of “0 (No)” to the question “Is there evidence or indicators that this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g. Autism, Cerebral Palsy, Spina Bifida)?” During an interview with the MDS Coordinator on 07/16/25 at 10:50 AM, the MDS coordinator stated she was responsible for referring and screening all residents for re-evaluations of level I PASARR screening if they had a mental illness to the local health authority. She stated she was unaware Resident #4 and Resident #15 had a mental illness, as she had not had time to review all residents' active diagnoses. She further stated that not referring residents with a mental illness for a Level 2 evaluation could result in residents not benefiting from resources. During an interview with the DON on 7/16/25 at 3:34 PM it was revealed the MDS coordinator should have referred Resident #4 and Resident #15 to the local health authority for evaluation. The DON stated that she expected the MDS coordinator to follow facility policy regarding PASARR 2 screenings to ensure that all residents with mental health conditions receive all possible assistance. Review of the facility policy titled admission Criteria, with a copyright date of 2001, documented “All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.” The policy further documents The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.”

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards and provide assistive devices to each president to prevent avoidable accidents 1 of 2 residents (Resident #12), reviewed for accidents and hazards: The facility failed to ensure Resident #12 had fall mats in place These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Record review of Resident # 12's face sheet dated 7/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident # 12 had a diagnosis that included: Hemiparesis on the left side (refers to weakness on the left side of the body), anxiety disorder (group of mental health conditions that cause fear, dread) and Muscle weakness (refers to a reduced ability of one or more muscles to generate force). Record review of Resident # 12's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderate cognitive impairment. Review of Resident #12's Quarterly MDS assessment, dated 6/13/25, reflected under section G, G0300, option # 3, which stated that the patient was unsteady on their feet, and required assistance X 2. Record review of Resident # 12's care plan, 6/12/25 revealed interventions to use fall mats on floor when in bed. During an observation and interview on 7/15/25 at 10:15 a.m., Resident #12 was in bed with the fall mat located on the foot of bed not on floor. Resident # 12 stated the fall mat was to cushion his fall in case he ever fell from bed as he forgets at times he cannot walk. During an observation and interview on 7/15/25 at 10:40 a.m., CNA C stated the evening shift on 7/14/25 must have forgotten to place the fall mat when they placed Resident # 12 in bed. She was aware Resident # 12 was supposed to have fall mats in place when in bed but she had not had a chance to do proper rounds today and that by her not placing fall mat for Resident # 12, he risked possible injury if she would have fallen from bed.During an interview on 7/15/25 at 11:40 a.m., the DON stated, Resident #12 had a high BIMS score and was alert and oriented. However, it was her expectation that all staff use fall mats for all high risk fall Residents when in bed. She would reeducate all staff on the process as not using fall mats on high fall risk Residents could lead to an injury. Record review of the facility policy and procedure titled, Fall Prevention Program, 2024, revealed in part, .Policy: Provide additional interventions as directed by the resident's assessment, including but not limited to assistive devices.

Based on interview and record review, the facility failed to ensure a system of record of the disposition of all controlled drugs to enable accurate reconciliation for 1 of 5 residents (Resident #31) reviewed for pharmacy services.The facility failed to ensure Resident #31's medication reconciliation log for the Schedule II medication (substances with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) Norco 5/325 accurately reflected the number of doses administered.This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain, and a decreased quality of life. The findings included:Record review of Resident #31's admission sheet dated 11/28/24 documented a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, anxiety disorder, hypertension (high blood pressure), recurrent depressive disorders, hyperlipidemia (high cholesterol), and pseudobulbar affect (a condition that is characterized by episodes of sudden uncontrollable and inappropriate laughing or crying.) Record review of Resident #31's most recent quarterly MDS assessment dated [DATE] documented the resident was moderately cognitively impaired for daily decision-making skills and had received scheduled and as needed pain medication regimen in the last five days.Record review of Resident #31's comprehensive care plan dated 5/28/25 documented the resident needs pain management and monitoring for chronic pain syndrome with goals of maintaining adequate level of comfort, not experiencing a decline in function related to pain, and achieving acceptable pain level goal daily.Record review of Resident #31's MAR (Medication Administration Record) for July 2025 included the following:-Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for chronic pain. Further review of the MAR noted the resident received the morning dose of pain medication administered by the Medication Aide on 7/17/25 at 7:35 AM with 16 doses remaining.Record review of the controlled medication reconciliation log for Resident #31's Norco 5/325 located on the medication aide cart, noted 17 doses available of Resident #31's Norco 5/325, however only 16 doses were observed in the blister pack of medication. During an interview with the Medication Aide on 7/17/25 at 7:35 AM, when asked why it was important to deduct a controlled medication on the reconciliation log immediately after administering a dose, the Medication Aide stated, if you don't sign a medication out right away, you could forget to do it later causing the count to be off. Record review of the facility policy titled Controlled Substance Administration & Accountability, with a copyright date of 2025, noted All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. The policy further documented, In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form.Record review of the facility's policy titled Medication Administration with a copyright date of 2025, noted Policy Explanation and Compliance Guidelines: 21. If medication is a controlled substance, sign narcotic book.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for one of two medication carts (nurse medication cart) and one of one medication rooms observed for drug storage and labeling, as evidenced by:1. The facility failed to ensure the medication room contained no unexpired supplies.2. The facility failed to ensure all insulin pens located inside the nurse medication cart were properly labeled with opened dates.These failures could place residents at risk of receiving inadequate treatments or false results. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for one of two medication carts (nurse medication cart) and one of one medication rooms observed for drug storage and labeling, as evidenced by:1. The facility failed to ensure the medication room contained no unexpired supplies.2. The facility failed to ensure all insulin pens located inside the nurse medication cart were properly labeled with opened dates.These failures could place residents at risk of receiving inadequate treatments or false results. The findings included: During an observation on [DATE] at 7:45 AM of the nurse medication cart with LVN A, it was discovered that one of five insulin pens did not have an opened date documented anywhere on the pen. During an interview with LVN A on [DATE] at 7:45 AM, when asked why it was important to make sure the insulin pens were dated, LVN A stated if insulin pens were not dated, it would not be known how long they had been in use, and the medication could be expired. During an observation of the medication room on [DATE] at 8:35 AM with the DON, it was discovered that one package of flu collection swabs (4/2025) and one package of specimen collection kits (2024) were expired. During an interview with the DON on [DATE] at 8:35 AM, when asked what could happen if expired supplies were used to obtain specimens for testing, the DON stated the supplies might not work properly or provide inaccurate results and the expectation is that staff using the medication room clean out expired supplies upon discovery.Review of the facility's policy titled Labeling of Medications and Biologicals with a copyright date of 2025, noted Labels for individual drug containers must include: h. The expiration date when applicable.Review of the facility's policy titled Medication Administration with a copyright date of 2025, noted Policy Explanation and Compliance Guidelines: 13. Identify expiration date. If expired, notify nurse manager.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #3) reviewed for care plan revision/timing. The facility failed to ensure Resident #3's care plan was revised in a timely manner to reflect falls on (4) occasions. This deficient practice could affect residents' care/services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #3's admission Record, dated 5/30/25, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to: Unsteadiness on Feet and Dementia (General term for memory loss, language, and problem-solving severe enough to interfere with daily living). Record review of Resident #3's quarterly MDS assessment, dated 5/14/25, revealed the resident had a BIMS score of 03, suggesting severely impaired cognition. Further review of the assessment revealed Resident #3 was independent when walking 10-50 feet and required supervision or touching assistance when walking 150 feet. The assessment also revealed Resident #3 had two falls since admission/entry or reentry or prior assessment. Record review of the facility's incident log, received 5/29/25, revealed Resident #3 had falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. Record review of Resident #3's Progress Note (IDT Event Review), dated 4/8/25, revealed .New interventions suggested following current IDT review: Hipster (positioning device) in place will update care plan . Author: [DON] . Record review of Resident #3's Progress Note (IDT Event Review), dated 4/21/25, revealed .New interventions suggested following current IDT review: Assess for use appropriate footwear while ambulating and multi-modal cues for frequent rest breaks to reduce risk of further falls . Author: [DON] . Record review of Resident #3's Progress Note (IDT Event Review), dated 4/30/25, revealed .New interventions suggested following current IDT review: Recommendation to assess patient for proper footwear to accommodate foot size and width. RP was called by Activities Director to advise of updates and will provide recommendations for footwear options .[family member] will buy proper shoes for resident . Author: [DON] . Record review of Resident #3's Progress Note (Therapy), dated 4/30/25, revealed .Recommendation to assess patient for proper footwear to accommodate foot size and width. RP was called by Activities Director to advise of [sic] updates and will provide recommendations for footwear options. Author: [DOR] . Record review of Resident #3's Care Plan, initiated 5/20/25 and revised 5/28/25, revealed: [Resident #3] had an unwitnessed fall related to unsteady gait and improper shoes. Interventions initiated 5/28/25 included: Assess and encourage [Resident #3] on proper non-skid shoes. Assure that lighting is adequate. Call light within easy reach and answer timely. Encourage to use call light for staff assistance. Refer to physical/occupational therapy for strengthening exercises, gait training to increase mobility, need for adaptive equipment. Further review of the care plan revealed the document did not include resident falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. During an interview on 5/30/25 at 3:09 pm, CNA A said interventions in place for Resident #3 to help reduce/prevent falls included her shoes (which she thought were special made for the resident), leaving the restroom door open so that she was able to find it at night to avoid accidents and falls, supervision while Resident #3 used the restroom and was out of bed, and asking every two hours if she needed to use the restroom. Observation on 5/30/25 at 3:33 pm revealed Resident #3 walking to the dining room independently. Resident #3 refused an interview with the state investigator. Resident #3 was observed wearing black sport shoes with white rubber soles, the resident was supervised by a staff who provided touch assistance to the resident's right shoulder. During an interview on 5/30/25 at 3:41 pm, the DOR said ultimately the administrator was responsible for ensuring care plans were updated. The DOR said RN B updated care plans, but she was not at the facility full time, so management assisted with updating the care plans. The DOR further stated the IDT met every morning and reviewed any changes including falls. The DOR said Resident #3 was at a high risk for falls r/t to safety awareness and did not know when she needed rest. The DOR further stated Resident #3 needed lots of cues to take rest breaks, adding this was being implemented. The DOR said the staff ensured Resident #3's environment was well lit and free of clutter. The DOR said the facility bought a device to measure Resident #3's feet to get accurate measurements for the family. The DOR further stated Resident #3 did receive new shoes from her family after the fall on 430/25 because she had wide feet and a deformity. The DOR said Resident #3 was constantly supervised to ensure she was wearing her shoes. The DOR said Resident #3 pulled off the hipster and so they were discontinued. The DOR said the care plans were updated as a team, the interventions were individualized, and RN B was responsible for updating the care plan along with herself (DOR) and the DON when RN B was not at the facility. The DOR further stated the care plans should be updated after the risk management meetings, which were held every morning. The DOR said it was important that care plans be updated to reflect the residents' performance at that time because their needs fluctuate and to provide instruction for staff on the needs of the resident. The DOR said if care plans were not updated the residents' may not receive the care they needed or can receive care that was no longer recommended by their provider or healthcare team. During the interview, the DOR updated Resident #3's care plan. Review of the care plan revised 5/30/25 revealed: .Family has provided new, appropriate width and sized shoe to reduce risk of falls .Encourage frequent rest breaks, including assisting patient to seated position, to reduce risk of falls . Further review of the care plan revealed the document did not include resident falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. During an interview on 5/30/25 at 4:13 pm, RN B said staff, which included: the Administrator, DON, therapy department, and herself if she was at the facility, had meetings to discuss interventions that can help reduce or prevent falls. RN B further stated resident care plans were updated with any new interventions and staff were made aware of what the new interventions were. RN B said resident care plans were updated after every fall. RN B said any member of the IDT could update care plans and she was responsible for ensuring comprehensive care plans were accurate. RN B further stated there were no audits per se, but she audited care plans after the comprehensive assessments were completed. RN B said it was important that care plans were updated so everyone knew what interventions were in place for the residents' safety and wellbeing. RN B said she did know why Resident #3's care plan was not updated after the falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. RN B further stated she was only at the facility two days a week (Tuesdays and Thursdays) and that was probably why Resident #3's care plan was not updated after the falls. During an interview on 5/30/25 at 4:34 pm, the Administrator said new interventions to help reduce/prevent falls were reviewed during the daily meetings. The Administrator further stated, most of the time, care plans were updated during the meeting and other times RN B updated them when she was at the facility. The Administrator said she expected care plans be updated within the week the fall happened. The Administrator further stated RN B pulled the interventions from the IDT meeting when she was at the facility to update the care plans. The Administrator said usually RN B was responsible for updating care plans, but any nurse could update them. The Administrator said most of time care plans were audited by the IDT after an incident occurred for accuracy. The Administrator further stated the DON was responsible for ensuring care plans were updated and accurate. The Administrator said it was important to update care plans in a timely manner for continuity of care and so that staff knew what the residents' needs were. During an interview on 6/4/25 at 9:32 am, the DON said resident care plans were supposed to be updated after every fall. The DON further stated falls were discussed during morning meeting and the care plans updated afterward. The DON said she notified RN B (MDS nurse) after the meetings so that she could update the care plans and when RN B was not at the facility, she updated the care plans herself. The DON said RN B was responsible for updating resident care plans and she (DON) was responsible for ensuring RN B updated care plans as needed. The DON said that herself, the ADON, and RN B audited care plans monthly for accuracy. The DON said it was important that care plans were updated for the residents' safety to ensure staff knew what interventions were in place for the residents and were implemented. The DON further stated, for example, if staff did not know Resident #3 needed special shoes and they were not worn she could have had additional falls. The DON said she did not review Resident #3's care plan to ensure the recommended interventions were added to the care plan. The DON further stated she was sure it was the facility's policy to update care plans after falls. Record review of facility's policy, titled Fall Prevention Program dated 2024, revealed: .9. When a resident experiences a fall, the facility will .e. Review the resident's care plan and update as indicated . Record review of facility's policy, titled Comprehensive Care Plans dated 2025, revealed: .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Abuse, in that: The facility did not report an allegation of Abuse to the State Survey Agency (HHSC) within 24 hours of Resident #1 falling off the bed. This deficient practice could affect any resident and could contribute to further neglect. The findings were: Review of Resident's # 1 face sheet dated 4/16/ 2025, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: schizoaffective disorder ( mental disorder that changes how people think, feel and act, major depressive disorder ( mental state characterized by persistent loss of interest in activities), and Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). Record review of resident #1's quarterly MDS assessment dated [DATE] revealed a blank BIMS score, indicating the resident could not complete the interview. Record review of Resident # 1's care plan dated 4/17/24 revealed that the [resident's name] is at risk for falls; the goal is not to have a fall with injury. Record review of the facility incident report dated 2/4/25 for Resident # 1 revealed he fell from bed at 8:45 A.M unwitnessed . Record review of Texas Unified Licensure Information Portal (TULIP) on 4/18/25 at 11:41 A.M. revealed that no self-reported incidents regarding allegations of Abuse were reported for Resident # 1 on 2/4/25 . Interview with RN A on 4/16/25 at 9:55 A.M. revealed that she notified DON of the fall on 2/4/25, approximately 30 minutes after it occurred. RN A stated she did not note any injuries to the resident at the time of her assessment. Interview with the DON on 4/18/25 at 11:25 A.M revealed the administrator was responsible for reporting allegations of abuse to HHSC; however she stated her understanding was allegations of Abuse should be reported within 2 hours. Interview with the Administrator on 4/18/25, at 12:18 P.M. revealed she did not report the fall involving Resident #1, as there were no injuries. However, upon reviewing the abuse guidelines from HHSC, she acknowledged that she should have reported the fall within two hours of having knowledge that Resident # 1 required hospitalization. Record review of facility policy titled, Abuse, Neglect, and Exploitation, dated 2021, reflected, 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.

Based on observations, interviews, and record reviews the facility failed to a comprehensive person-centered care plan for each resident, consistent with the resident rights and includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 ( Resident #3) residents in that: Resident #3's care plan for his pacemaker was not complete with name, serial number and when he last seen the cardiac physician. This failure could affect residents by placing them at risk of not receiving necessary services and care. The Findings were: Record review of Resident #3's admission record dated 4/15/2025 indicated an admission date of 10/18/24 and readmission date of 3/25/2025. Resident #3 had a diagnosis of cardiac pacemaker. Record review of Resident #3's significant change MDS dated [DATE] revealed he had a BIMS score of 15/15 (cognitively intact) and had a cardiac pacemaker. Record review of Resident #3's consolidated physicians orders for April 2024 documented a diagnosis was a pacemaker. Further review reveled the cardiac pacemaker serial number and how to care for the device was not addressed. Record review of Resident #3's MAR for April 2025 did not address how to care for his cardiac pacemaker. Record review of Resident #3's care plan dated 3/7/2025, initiated on 11/13/2024 revealed he had a cardiac pacemaker, interventions were to avoid electro mechanical interference. The care plan did not include the name, serial number of the pacemaker. The care plan did not indicate a recent cardiac MD appointment to check the status of the cardiac pacemaker. The care plan did include what signs and symptoms to report to the MD immediately. No appointment for cardiac MD in Resident #4's chart. Observation and interview on 4/18/2025 at 1:05 PM Resident #3 laid in bed and stated he had a cardiac pacemaker., RN A stated Resident #3 did have a cardiac pacemaker. Interview on 4/18/25, at 12:18 P.M. with the ADM and DON had no reply when discussed Resident #3's pacemaker did not have information about Resident #4's pacemaker, such as serial # and etc. and his most recent cardiac appointment. They did not respond. Record review of policy on Comprehensive Care plans dated 2025 was documented: Policy: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for which resident, consistent with resident rights, that includes measurables objectives and timeframe to meet a resident medical nursing, and mental psychosocial needs and all services that are identified i the resident comprehensive assessment and meet professional standards of quality . 3.The compressive care plan will describe, at a minimum, the following a. the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being.

Based on, interviews, and record reviews the facility failed to ensure each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; and the health of individuals in the facility would otherwise be endangered for 1 of 3 (Resident #4) reviewed for discharge. Resident #4 was transferred to the hospital for a psychological evaluation on 3/25/2025 and was not allowed to return to the facility. The facility failed to document the bases of Resident #4's discharge. This could affect all residents and could result in residents not having the opportunity to appeal the discharge from the facility. The Finding were: Record review of Resident #4's admission record dated 4/15/2025 was documented he was admitted on [DATE] and re-admitted on [DATE] with diagnoses of Dementia, paranoid schizophrenia, major depressive disorder, legal blindness, and anxiety. The admission record was documented dated of discharge was 3/26/2025 at 7:19 PM (19:19) to acute hospital. Record review of Resident #4's consolidated orders revealed he had orders for observations for behaviors, schizophrenia monitor for characteristics of schizophrenia paranoid tendencies Olanzapine 5 mg, give 1 tablet by mouth two times a day for agitation, and Uzedy subcutaneous suspension prefilled syringe 200mg/0.56 ml (Risperidone) inject 200 mg subcutaneously one time a day every 2 months starting on the 12tj for 1 day for psychosis. Record review of Resident #4's discharge MDS dated [DATE] revealed his Cognition for daily decision making was moderately impaired and for Behavior symptoms was physical, verbal, and other behaviors directed toward others occurred 4-6 days and rejected care. Resident #3's return was not anticipated. Record review of Resident #4's care plan was documented he had impaired physical functioning related to deficit, cognition, impairment, and impaired vision, had a potential for mood problem or altercation in mood related to disease process. risk for behaviors related to demonstrate physically abusive behaviors towards staff and himself, at risk for violence, directed at self/others related to diagnosis of schizoaffective disorder, auditory hallucinations have been reported, has history of wanting to self-harm, and had disturbed sensory perception related to glaucoma, legally blind. offer verbal cuing and redirections as needed. Resident #4's care plan was documented as cancelled in front of each Focus/problem and all the care plans were resolved on 4/2/2025. Record review of Resident #4's progress notes, dated 3/26/2025 at 7:18 PM was documented Resident sent out 911 for aggressive behavior combative to staff breaking window in bedroom. Centric physicians notified orders to send to ER for eval/TX. Brother notified. Resident sent to hospital. Resident #4's progress note dated on 3/26/25 at 2:35 was documented resident #4 banging on walls, yelling for his probation officer. direct care staff assisting with redirecting resident, hollering, cursing, banging on walls. Record review of Resident #4's psychological note dated 1/17/25 was documented Record review of Resident #4's chart from 10/17/2024 to 3/26/2025 revealed no discharge summary report. Record review of Resident #4's psychological note dated 1/17/2025 was documented Pt seen today for psychiatric follow up evaluation for medication management. Also seen to follow up on recent psychotropic. medication adjustments. Pt seen today in bed. His privacy is maintained. His exam is limited secondary to his psychiatric and cognitive impairment. Denies depression or anxiety today. Continues to have labile moods. Has ongoing outbursts and agitation. His Ativan was recently switched to Clonazepam earlier this week by Dr. [NAME]. His PRN Ativan has not been effective per staff. He cannot be redirected with non pharmacological interventions per nurse. He reports eating and sleeping well. He has not been exhibiting any suicidal threats or gestures. Continues to have paranoia and delusions. His Latuda was recently changed to Zyprexa as staff report having better effect with medication when recently being used as PRN. No adverse effects reported at this time. Denies recent tobacco, and cannabis use reported. He has been refusing medication when upset. Pt encouraged to take medications as ordered today. Psychiatric follow up evaluation for medication management. Follow up on recent psychotropic medication adjustments Psychiatric diagnoses include Schizoaffective Disorder, GAD, Cognitive Impairment, Tobacco Dependence. In Remission, Hx of Substance Abuse. Pt seen for complex psychiatric issues that require continued monitoring, evaluation, medication review and treatment dx-Pt seen today for psychiatric follow up evaluation for medication management. Also seen to follow up on recent psychotropic medication adjustments. Pt seen today in bed. His privacy is maintained. His exam is limited secondary to his psychiatric and cognitive impairment. Denies depression or anxiety today. Continues to have labile moods. Has ongoing outbursts and agitation. His Ativan was recently switched to Clonazepam earlier this week by Dr. [NAME]. His PRN Ativan has not been effective per staff. He cannot be redirected with non-pharmacological interventions per nurse. He reports eating and sleeping well. He has not been exhibiting any suicidal threats or gestures. Continues to have paranoia and delusions. His Latuda was recently changed to Zyprexa as staff report having better effect with medication when recently being used as PRN. No adverse effects reported at this time. Denies recent tobacco, and cannabis use reported. He has been refusing medication when upset. Pt encouraged to take medications as ordered today. Record review of emergency department notes indicated the following: by complainant. * On1/20/2025 at 9 PM revealed spoke to ADM of facility who stated Resident #4 was not allowed back at the facility despite. patient being cleared medically and psychiatrically during stay. *On 1/31/2025 at 9:35 AM notified this nurse that the Resident #4 had been discharged out of the system and no longer lived at the facility. Record review of Resident #4's progress note dated 3/26/2025 at 7 :18 - PM Resident sent out 911 for aggressive behavior combative to staff breaking window in bedroom. [company]physicians notified orders to send to ER for eval/TX . [family] notified. Resident sent to hospital. Record review of email contact with complainant on 4/16/25 at 1:12 PM stated she spoke to the ADM prior to reporting to the STATE and she got absolutely no where. The Hospital complainant concerns where that Resident #4 was not allowed to come back to the facility after his evaluation discharge from the hospital. Interview on 4/16/2025 at 2 PM with the ADM stated Resident #4 was going to be sent back to facility after an evaluation, then he went to psych hospital. The ADM stated Resident #4 had been back to facility hmm2x , this last time the hospital sent him back right away without an evaluation. The ADM stated when he was at hospital- [company] found him group home. The ADM stated Resident #4 has not been back to facility, since first hospital visit. The ADM stated Resident#4 had behaviors that made other residents not safe. The ADM stated Resident #4 was not discharged . Interview on 4/17/2025 at 12:10 PM Resident #4's family stated he felt like Resident #4 was shipped off to psych hospital and was told by facility they would not take Resident #4 back. Family of Resident #4 stated the ADM let him know Resident was not allowed back to facility due to his behaviors. Family of Resident #4 stated the facility was aware of his behavior when he was admitted . Record review of policy dated 2025 Transfer and Discharge, was documented Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all resident regardless of their payment source . 3. The facility's transfer/discharge notice will be provided to the resident and residents representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided., 10. Emergency Transfers to Acute Care . i. The resident will be permitted to return to the facility upon discharge from the acute care setting. j. not permitting a resident to return following hospitalization constitutes a discharge.

Based on the interview and record review, the facility failed to ensure that 1 of 12 residents (Resident #2) reviewed for medication errors was free of any significant medication errors. The facility failed to administer medication (Glargine, a drug to lower blood sugar) as prescribed for Resident #2. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health. The findings included: Record review of admission face sheet, dated 4/16/2005, revealed Resident # 2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included vascular dementia ( occurs when there is damage to regions in the brain, affecting memory ), Type two diabetes ( condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and major depressive disorder ( persistent feeling of sadness and loss of interest). Record review of the quarterly MDS assessment, dated 3/3/2025, revealed Resident # 2 had a BIMS score of 06, which indicated moderate to severe cognitive impairment. Record review of the care plan for Resident # 2, dated 7/26/22, revealed a problem area: Resident # 2 has hyperglycemia related to diabetes with anticipated approaches of: administer medications as ordered. Record review of physician orders for the month of April 2025 revealed that Resident # 2 had the following orders: *Insulin Glargine 100 Units / ML, Inject 15 units subcutaneously every morning. Record review of the medication Insulin administration record for Resident # 2 from 2/4/25 to 3/8/25 revealed missed insulin doses documented as (held per M.D orders) on: 2/4/25, 2/13/25, 2/18/25, and 3/8/25. Record review of Resident #2's physician's monthly orders for February 2025 and March 2025 did not reveal any orders to hold insulin per M.D orders. Interview on 4/16/2025 at 11:35 A.M., Resident # 2's family member stated that she had been informed by the Department of Veterans Affairs case manager that the nursing facility nurse held insulin glargine without an M.D. order, which could cause elevated spikes in blood sugar. Interview was attempted with the Department of Veterans Affairs case manager on 4/16/24 at 12:30 PM, and the case manager did not return the phone call. Interview with RN A on 4/17/25 at 8:30 A.M. revealed she held the Insulin Glargine for Resident # 2 on 2/4/25, 2/13/25, 2/18/25, and 3/8/25 without an M.D. order because she was concerned Resident # 2 would go hypoglycemic as he did not want to eat breakfast and she forgot to document her reasoning in progress notes. RN A stated she was now aware that Insulin Glargine was a long-acting insulin and not rapid, therefore there was no need to hold insulin. RN A noted by holding insulin Glargine without an M.D order, Resident # 2 risked unpredictable spikes in blood sugar. An interview with the DON on 4/18/25 at 9:45 A.M. revealed she expected licensed nurses to follow M.D. orders regarding insulin, as failure could cause unexpectedly elevated blood sugars. The DON stated licensed nurses were responsible for their own practice, but she would monitor all licensed nurses in the facility at random for compliance with M.D. orders. Record review of a facility licensed nurse job description, revised 05/2019, revealed that the job requires the ability to perform duties promptly and within prescribed sequences and schedules.

Based on observations, interviews, and record reviews the facility failed to ensure residents received treatment and care based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 (Resident #3) resident in that: Resident #3's care plan for his pacemaker was not his last cardiac physician appointment. This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. The Findings were: Record review of Resident #3's admission record dated 4/15/2025 with admission date of 10/18/24 and readmission date of 3/25/2025. Resident #3 had a diagnosis of cardiac pacemaker. Record review of Resident #3's consolidated physicians orders for April 2024 was documented in his diagnosis was a pacemaker, but not as an order for cardiac pacemaker serial # and how to care for the device. Record review of Resident #3's MAR for April 2025 revealed not care for his cardiac pacemaker. Record review of Resident #3's significant change MDS dated [DATE] revealed he had a BIMS score was 15/15 (cognitively intact) and had a cardiac pacemaker. Record review of Resident #3's care plan dated 3/7/2025 was documented, iniated on 11/13/2024 he had a cardiac pacemaker and did not include the name, serial number and etc, or if he had a recent cardiac MD appointment to check the status of the cardiac pacemaker. The care plan did include report signs and symptoms to MD immediately. Observation on 4/18/2025 at 1:05 PM with Resident #3 lying in bed, RN A confirmed he had a cardiac pacemaker. Interview on 4/18/2025 at 1:05 PM with RN A confirmed Resident #3 had a cardiac pacemaker. Interview on 4/18/2025 at 1:06 PM with Resident # 3 stated he had a cardiac pacemaker. Interview on 4/18/25, at 12:18 P.M. with the ADM and DON had no reply when discussed Resident #3's pacemaker with no cardiac appointment. Asked for a pacemaker policy. Record review of policy on Comprehensive Care pans dated 2025 was documented: Policy: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for which resident, consistent with resident rights, that includes measurables objectives and timeframe to meet a resident medical nursing, and mental psychosocial needs and all services that are identified i the resident comprehensive assessment and meet professional standards of quality. 3.The compressive care plan will describe, at a minimum, the following a. the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Meat products were stored above other food items in the facility kitchen freezer. These deficient practices could place 34 residents who ate food from the kitchen at risk for foodborne illness. The findings were: During an observation of the facility kitchen, on 04/03/2025 at 9:45 a.m., the freezer was observed to have the following items, slabbed bacon 18/2 count box, 2-2 lb bags of diced turkey, 2-3 lb honey hams, 10 lb box of chicken, 50 portion box of beef fritters, 10 lb box of chicken sausage, stored above a box of 300 count bread rolls, a box of cookie dough, package of sweet potato fries, and a box of individual size pizzas. During an interview with the Dietary Manager, on 04/03/2025 at 10:00 a.m., the Dietary Manager stated she was responsible for storing the food in the freezer and ensuring the food was stored safely. The Dietary Manager stated meat should be stored below other food items to prevent the meat from dripping onto the other food items and stated, if the freezer breaks and starts to thaw, we would have blood all over the place and on the food it is not supposed to be on. The Dietary Manager stated she had provided education to her staff about storage, but stated she was the person who stored the food in the freezer incorrectly. The Dietary Manager stated she had a hard time lifting some of the boxes and felt like the freezer was too small. During an interview with the Dietician, on 04/03/2025 at 10:33 a.m., the Dietician stated she had not provided training to the staff specifically regarding food storage in the freezer but stated, there is an order for it and normally meat is stored on the bottom. The Dietician said it was important to store meat at the bottom because if it happens to thaw, you don't want the meat to drip and get onto the other food. The Dietician stated the Dietary Manager was responsible for ensuring the food was stored correctly. During an interview with the Administrator, on 04/04/2025 at 12:58 p.m., the Administrator stated meat should be stored at the lowest level of the freezer to prevent dripping on other products and it should be in a drip pan. The Administrator stated the facility had a policy and procedure for food storage and dietary staff received training on food storage on 04/03/2025. The Administrator stated improper food storage could cause the food to become contaminated and make the residents sick. Record review of a facility in-service titled Safe Storage of Foods, on 04/03/2025 at 11:30 a.m., presented by the Administrator had 3 employee names on the sign in list including the Dietary Manager. Record review of a facility policy titled Food Receiving and Storage revealed the policy statement Foods shall be received and stored in a manner that complies with safe food handling practices. Listed under the section, Policy Interpretation and Implementation, read .13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat food.

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #4) reviewed for accuracy of medical records. Resident #4 had a physician's order and care plan for hospice services on his medical record after he was discharged from hospice services. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension with ulcer of left lower leg (high blood pressure in the legs), chronic kidney disease (gradual loss of kidney function), and hemiplegia (unable to move one side of the body). Record review of Resident #4's quarterly MDS assessment, dated 02/03/2025, revealed a BIMS score of 13, indicating no cognitive impairment. Section E - Behavioral Symptoms revealed Resident #4 displayed physical, verbal, and other behavioral symptoms toward others daily during the assessment period and was resistive to care 4-6 days. Section GG- Functional Abilities revealed Resident #4 was dependent on staff for all ADL's, transfers, bed mobility, and bathing. Section H- Bladder and Bowel revealed Resident #4 was incontinent of bowel and bladder function. Section M- Skin Conditions revealed Resident #4 had a venous ulcer present. Record review of Resident #4's physician order summary, on 04/02/2025 at 12:20 p.m., revealed Resident #4 had an order that read, Call hospice 24/7 for falls, wounds, change in condition, dated 10/21/2024. Resident #4 had an order that read, Hospice MD to sign death certificate, Hospice RN to pronounce Hospice to contact PD, ME, FH at TDD, dated 10/21/2024. Resident #4 had an additional order that read, Resident was admitted to [Hospice company name] with a dx of atherosclerotic heart disease, dated 12/04/2024. Record review of Resident #4's comprehensive care plan revealed , Needs hospice care from [hospice company name] due to terminal diagnosis of Atherosclerotic heart disease, date initiated 10/18/2024 and revised 12/04/2024. Record review of a [Hospice Company Name] Document titled, Notice of Medicare Non-Coverage, listed Resident #4's name and read, The effective date of coverage of your current services will end: 03/25/2025. The document said, patient refused to sign on the signature of patient or representative line and was dated 03/21/2025. Record review of a Hospice visit note report by Hospice RN K, dated 03/21/2025, revealed RN K met with Resident #4 to discuss discharge planning from hospice and revealed, patient was not open to discussing any type of education. Patient asked me to leave his room. Record review of a facility document titled, SNF/NF to Hospital Transfer Form, dated 03/24/2025, revealed Resident #4 was transferred to the hospital due to a DVT (blood clot) in his left leg. Record review of a form titled, Texas Medicaid Hospice Program Individual Election/Cancellation/Update, Listed the form type as cancelled and dated 03/24/2025. During an interview with LVN A, on 04/02/2025 at 12:00 p.m., LVN A stated Resident #4 was on [Hospice company name] services and LVN A would obtain any new orders for care from the hospice company. During an interview with the DON, on 04/02/2025 at 12:11 p.m., the DON stated Resident #4 was discharged from hospice services for not following their plan of care. The DON stated [hospice company name] discharged Resident #4 last week from their services and Resident #4 had been on multiple hospice services in the past and would fire them. The DON stated in this insistence, [hospice company name] gave Resident #4 a 5-day discharge notice for refusing care and treatment and not following the plan of care. The DON stated Resident #4's clinical record, including the physician orders and care plan should have been updated to reflect Resident #4 was no longer on hospice services at the time he was discharged from services. The DON stated the Charge Nurses were responsible for updating the orders and the MDS Coordinator was responsible for updating the care plan. The DON stated the inaccuracy of a resident's medical record could cause the facility to give the wrong medications, treatments, or care. During an interview with Resident #4, on 04/03/2025 at 9:10 a.m., Resident #4 stated he was no longer on hospice because they kicked me out because I was calling other hospices and because I was calling 911 too much. When the state surveyor attempted to ask more questions, Resident #4 told the state surveyor to get out of the room and stop asking questions. During an interview with LVN E, on 04/03/2025 at 10:42 a.m., LVN E stated Resident #4 was no longer on hospice services and stated Resident #4 had made the comment to LVN E that he no longer wanted to be on hospice services. LVN E stated the facility staff provide basically the same care that hospice provides but stated it was important for the physician order and care plan in the clinical record to be accurate because he is no longer receiving the hospice services and we would need to get orders elsewhere for him. During an interview with CNA C, on 04/03/2025 at 12:39 p.m., CNA C stated Resident #4 was no longer on hospice services because Resident #4 was refusing all care and treatment from hospice and the facility staff were responsible for providing care. During an interview with CNA F, on 04/03/2025 at 1:00 p.m., CNA F stated Resident #4 was no longer on hospice services and CNA F stated Resident #4 refused care from hospice and facility staff. During an interview with the Hospice Director of Clinical Services, on 04/04/2025 at 9:30 a.m., the Director stated Resident #4 was issued a 5-day discharge notice on 3/21/2025 with an effective date of 03/25/2025. The Director stated Resident #4 was admitted to the hospital on 03/24/2025, so Resident #4's hospice coverage was terminated on 03/24/2025 due to hospice not being able to follow Resident #4 in the hospital. During an interview with the MDS Coordinator, on 04/04/2025 at 10:52 a.m., the MDS Coordinator stated a resident's care plan should be updated at the time the resident experienced a change in medication, orders, behaviors, or diet. The MDS Coordinator stated she was only at the facility 2 days a week and was updated on resident changes in their plan of care through reviewing the 24-hour report and running an order listing report. The MDS Coordinator stated all nurse managers had access to update a resident care plan when the MDS Coordinator was not in the facility. The MDS coordinator stated Resident #4's clinical record should have been updated on the date he was discharged from hospice by updating the care plan and physician orders to reflect that Resident #4 was no longer receiving hospice services. During an interview with the facility Administrator, on 04/04/2025 at 12:58 p.m., the Administrator stated care plans and physician orders should be updated as the resident needs changed and stated all nursing staff was responsible for updating the clinical record. The Administrator stated the accuracy of the clinical record was important so we can make sure we are meeting the needs of the resident and so we know everything we need to know about them and stated an inaccurate clinical record could mean that a resident would not have their needs met or doctor's orders followed correctly. Record review of a facility policy titled, Maintenance of Electronic Clinical Records (Copyright 2024 The Compliance Store, LLC.), revealed under the section, Policy Explanation and compliance Guidelines, 1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on observations, interviews, 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 diseases and infections for 1 of 5 residents (Resident #4) reviewed for infection control. Resident #4 had an order for enhanced barrier precautions related to a wound and did not have a sign on his door identifying a need for enhanced barrier precautions for Resident #4. This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension with ulcer of left lower leg (high blood pressure in the legs), chronic kidney disease (gradual loss of kidney function), and hemiplegia (unable to move one side of the body). Record review of Resident #4's quarterly MDS assessment, dated 02/03/2025, revealed a BIMS score of 13, indicating no cognitive impairment. Section E - Behavioral Symptoms revealed Resident #4 displayed physical, verbal, and other behavioral symptoms toward others daily during the assessment period and was resistive to care 4-6 days. Section GG- Functional Abilities revealed Resident #4 was dependent on staff for all ADL's, transfers, bed mobility, and bathing. Section H- Bladder and Bowel revealed Resident #4 was incontinent of bowel and bladder function. Section M- Skin Conditions revealed Resident #4 had a venous ulcer present. Record review of Resident #4's physician order summary, 04/02/2025 at 12:20 p.m., revealed Resident #4 had an order that read, enhanced barrier precautions every shift: left calf venous stasis and chronic venous ulcer to left heel with a start date of 01/16/2025. Record review of Resident #4's comprehensive care plan revealed , [Resident #4] is on enhanced barrier precautions r/t chronic wound, date initiated 11/14/2024 and revised 01/11/2025. The care plan interventions included, [NAME] gown and gloves during high contact personal care activities. During an observation, on 04/02/2025 at 9:00 a.m., Resident #4 was observed in a room without an orange enhanced barrier precaution sign on the door indicating staff were to wear PPE when providing direct care to Resident #4. During an observation, on 04/03/2025 at 2:26 p.m., Resident #4's room did not have an enhanced barrier precaution sign on the room door. During an interview with Resident #4, on 04/02/2025 at 10:35 a.m., Resident #4 stated he had wounds on his left leg. When the state surveyor attempted to ask if staff wore PPE when providing care, Resident #4 stated he was not sure, became agitated, and told the state surveyor to stop asking so many questions. During an interview with LVN A, on 04/02/2025 at 12:00 p.m., LVN A stated Resident #4 was on enhanced barrier precautions and staff wore gloves and gowns when providing treatments or care. LVN A stated residents on enhanced barrier precautions had signs on their door indicating they were on enhanced barrier precautions. During an interview with CNA C, on 04/03/2025 at 12:39 p.m., CNA C stated residents on enhanced barrier precautions had a sign on the outside of their door. CNA C stated the DON was responsible for placing the sign on the door and stated Resident #4 had a sign on his door and was on enhanced barrier precautions. CNA C stated it was important for residents on enhanced barrier precautions to have a sign indicating enhanced barrier precautions so staff know what the precautions are when we go change him and because of his wound, so it does not get infected. During an interview with CNA F, on 04/03/2025 at 1:00 p.m., CNA F stated residents on enhanced barrier precautions had an orange sign on their door that was placed on the door by the DON. CNA F stated Resident #4 had a sign on his door and stated when a resident had an orange sign on their door, CNA F would put on a gown, gloves, and a mask when providing care. CNA F stated it was important for residents on enhanced barrier precautions to have a sign identifying the need for precautions, so we know who is on it so we can help prevent them from getting infections. During an interview with CNA B, on 04/03/2025 at 1:44 p.m., CNA B said the residents on enhanced barrier precautions were identified by having a sign on their door that indicated the resident was on enhanced barrier precautions. CNA B stated Resident #4 was on enhanced barrier precautions and CNA B said she thought Resident #4 had a sign on his door. CNA B stated it was important to have the enhanced barrier precaution sign on the door so everyone that goes into that room knows what to do. CNA B stated staff should wear gloves and a gown when providing care to any resident on enhanced barrier precautions. During an interview with the DON, on 04/4/2025 at 12:30 p.m., the DON stated residents on enhanced barrier precautions were identified with a sign on the door that read enhanced barrier precautions and listed what equipment was needed to provide care. The DON stated any resident with a wound, foley catheter, feeding tube, or antibiotics should be on enhanced barrier precautions and stated there was not a designated person responsible for placing the sign on a resident door. The DON stated she was planning to add it to the manager room rounds so managers can validate the signs were on the residents' doors when making rounds daily. The DON stated Resident #4 was on enhanced barrier precautions due to his wound and the enhanced barrier precaution sign was placed on his door on the morning of 04/04/2025. The DON said the importance of having the enhanced barrier sign on the door of residents who required enhanced barrier precautions was for their protection, we don't want to bring anything like infections to the resident due to their open areas. During an interview with the facility Administrator, on 04/04/2025 at 12:58 p.m., the Administrator stated residents on enhanced barrier precautions were identified by having a sign placed on their door indicating the resident was on enhanced barrier precautions and listed PPE equipment required to provide care. The Administrator said residents with foley catheters, feed tubes, wounds, or any openings on their body were required to be on enhanced barrier precautions. The Administrator stated the DON or the ADON was responsible for placing the enhanced barrier precaution sign on the residents' doors. The Administrator stated Resident #4 was on enhance barrier precautions and a sign was placed on his door last night. The Administrator said the importance of identifying residents on enhanced barrier precautions was so the resident can be protected for infection and making sure we have a barrier of PPE between ourselves and the residents, so we don't transfer anything to them. During an observation, on 04/04/2025 at 9:01 a.m., Resident #4 had an orange sign outside of Resident #4's room door that had a stop sign on it and said, Enhanced Barrier Precautions and indicated providers and staff should wear gloves and a gown when providing high contact direct care activities like dressing, bathing, transferring, changing linens, providing hygiene or toileting/brief changes. The sign also included a gown and gloves must be worn for device care or use for central lines, urinary catheters, feeding tubes, tracheostomy, and any wound care with a skin opening that required a dressing. Record review of a facility in-service titled, Enhanced Barrier Precautions, dated 03/28/2025, revealed the in-service was presented by the Administrator and the DON and had 17 employee signatures. Record review of a facility policy titled, Enhanced Barrier Precautions 2001 MED-PASS, Inc., revealed a policy statement that read, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employees targeted gown and glove use during high contact resident care activities. The section, Policy Interpretation and Implementation, read, .11. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required.

Based on observation, interviews, and record review the facility failed to provide a safe, functional, and comfortable environment for residents for 1 of 5 residents (Resident #4) reviewed for environment. Resident #4's footrest on the electric bed was in an elevated position and reported to Maintenance on 03/29/2025. Resident #4's bed was not repaired until 04/03/2025. This deficient practice could place residents at risk of being uncomfortable and at risk of injury from equipment that was not functioning properly. The findings were: Record review of Resident #4's undated face sheet revealed Resident #4 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a buildup of fat in the artery walls), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension with ulcer of left lower leg (high blood pressure in the legs), chronic kidney disease (gradual loss of kidney function), and hemiplegia (unable to move one side of the body). Record review of Resident #4's quarterly MDS assessment, dated 02/03/2025, revealed a BIMS score of 13, indicating no cognitive impairment. Section E - Behavioral Symptoms revealed Resident #4 displayed physical, verbal, and other behavioral symptoms toward others daily during the assessment period and was resistive to care 4-6 days. Section GG- Functional Abilities revealed Resident #4 was dependent on staff for all ADL's, transfers, bed mobility, and bathing. Section H- Bladder and Bowel revealed Resident #4 was incontinent of bowel and bladder function. Section M- Skin Conditions revealed Resident #4 had a venous ulcer present. Record review of Resident #4's comprehensive care plan revealed a care plan, date initiated 11/13/2024, that read [Resident #4] has impaired physical functioning r/t SPECIFY: (left side hemiplegia, weakness, impaired mobility and transfers. The care plan interventions revealed Resident #4 was dependent on staff for bed mobility. Record review of a facility document titled, Work Order #550, created on 03/29/2025 at 3:24 a.m. by CNA B revealed, [Resident #4] bed not working footrest not going down. The document revealed the work order was assigned to the Maintenance Director and revealed an updated status, set to completed on 04/04/2025 at 9:13 a.m. Record review of a facility document titled, Work Order #553, created on 04/01/2025 at 1:30 p.m. by the ADON revealed, remote to bed is not working. The room number listed was [Resident #4 room number]. The document revealed the work order was assigned to the Maintenance Director and revealed an updated status, set to completed on 04/04/2025 at 9:13 a.m. During an observation, on 04/02/2025 at 10:35 a.m., Resident #4 was observed lying in bed with the foot of the bed slightly elevated underneath Resident #4's lower legs and feet. During an interview with CNA B, on 04/03/2025 at 1:44 p.m., CNA B stated she had been trained to enter maintenance work orders into the electronic [company name] work order system. CNA B stated Resident #4 had complained about the foot of his bed being elevated and the bed remote not working last week while CNA B was working the night shift. CNA B stated she entered the concern into the maintenance electronic system and CNA B stated the bed was still broken last night and she was not sure why the bed had not been fixed yet. During an interview with Resident #4, on 04/03/2025 at 2:15 p.m., Resident #4 stated his bed was fixed on the morning on 04/03/2025. Resident #4 stated he was not hurt but the elevated footrest and stated it was just uncomfortable at times. Resident #4's foot of bed was observed in a flat position with no elevation. During an interview with CNA F, on 04/03/2025 at 2:20 p.m., CNA F stated Resident #4 had not complained about his bed being uncomfortable and had not mentioned his remote or bed not functioning properly to CNA F. During an interview with MA D, on 04/03/2025 at 2:23 p.m., MA D stated Resident #4 had not reported a concern with his bed not functioning properly and MA D stated she would have reported it to the Maintenance Director and entered it into the [company name] work order system. During an interview with the ADON, on 04/04/2025 at 11:29 a.m., the ADON stated she placed a work order in the maintenance system for Resident #4 on 04/01/2025 due to Resident #4 stating his bed remote was not working. The ADON stated she did not notice the foot of the bed being elevated and stated Resident #4 was agitated and just said it was not working. During an interview with the Maintenance Director, on 04/04/2025 at 11:45 a.m., the Maintenance Director stated all staff were trained to enter maintenance work orders for malfunctioning or broken equipment into the [company name] electronic work order system. The Maintenance Director stated once the work order was entered into the system, the Maintenance Director would receive a message on his work phone and on his computer notifying him of the maintenance request. The Maintenance Director stated Resident #4 was transferred from a hospice provided bed to the current bed on 03/27/2025 and the Maintenance Director stated he inspected the bed at that time and the remote and foot of the bed was operating correctly. The Maintenance Director stated the ADON notified him of Resident #4's bed not working properly on 04/01/2025 and stated he repaired the bed on 04/03/2025 around 1:15 p.m. The Maintenance Director stated the expectation was resident equipment would be fixed the same day as the work order was entered. The Maintenance Director looked through his phone during the interview and stated the first time he was notified of Resident #4's bed not working was 03/29/2025. The Maintenance Director stated the repair log revealed the work order was completed on 04/04/2025 at 9:13 a.m. because that was when he updated the work order. The Maintenance Director stated it was important to repair essential resident equipment so there are no further issues and so the patient is comfortable and does not have any pain or harm. During an interview with the facility Administrator, on 04/04/2025 at 12:58 p.m., the Administrator stated all staff members had access to [company name] maintenance work order system and once a maintenance request was entered, the Maintenance Director was responsible for prioritizing the importance of the request and updating the system when the work order had been completed. The Administrator stated the facility expectation was resident equipment would be repaired as soon as possible, I would say the same day. The Administrator stated a resident could be harmed or caused discomfort if malfunctioning resident equipment was not fixed timely. Record review of a facility policy titled, Maintenance Inspection (2005 The Compliance Store, LLC.), revealed 3. all opportunities will be corrected immediately by maintenance personnel.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #11) reviewed for abuse. The facility failed to ensure CNA A was suspended pending an allegation of abuse or neglect when Resident #11 became combative with care. CNA A did not discontinue care or call for help when Resident #11 became combative. Resident #11 sustained skin tears to his hands, bruising to hands, skin tears to his forearms, and a left-hand fracture. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/7/24 at 09:15 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy 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 continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record Review of Resident #11's Admission record revealed an [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses to include neurogenerative disorder with Lewy bodies (It is characterized by the presence of Lewy bodies-abnormal protein deposits-in the brain. These deposits affect brain chemicals, leading to problems with thinking, movement, behavior, mood, and other bodily functions), dementia (loss of thinking, remembering, and reasoning skills) without behaviors, and atherosclerotic heart disease (Plaque build-up in the arteries). Record Review of Resident #11's care plan, last updated 4/4/24, stated [Resident #11] has behaviors which include taking the linens off of his bed. He will put them on the chair at the end of his bed and cover himself with items such as the pink pad or other items that are not linens. He also puts his call light on the floor or behind his bed. He can also become combative with care at times. He does not always understand what you are trying to do. [Resident #11] will have 2 people assist them at all times. The interventions included administer medications as doctor has ordered, attempt intervention before resident behavior begins by checking frequently, fall mat at bedside while in bed, make sure resident is not in pain or uncomfortable, [Resident #11] will have two CNAs assisting him at all time, and please tell residents what you are going to do before you begin. 5/2/24 [Resident #11] has potential to demonstrate physical behaviors related to dementia. [Resident #11] can be argumentative, become agitated/ combative with care at times. With interventions to analyze key times, places, circumstance, triggers, and what escalates behavior and document, Assess and anticipate resident needs: move, thirst, toileting needs, comfort level, body positioning, pain ETC., 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 staff member when agitated, Modify environment: reduce noise, dim light, place familiar objects in room, monitor/document/ report to MD/ hospice/ VA of danger to self or others. 3/32/23 [Resident #11] has impaired cognitive function/ dementia or impaired thought process related to diagnosis of Lewy body dementia. With interventions to ask yes/ no questions in order to determine the residence needs, communication: use the resident preferred name, identify yourself at each interaction, face the revenant in speaking and make eye contact, reduce any distractions- turn off TV, radio, closed door ETC, the resident understands consistent, simple, directive sentences, Provide the resident with necessary cues-stop and return if agitated, cue, reorient and supervise as needed. Record Review of Resident #11's quarterly MDS assessment, dated 5/16/24, reflected Resident #11 had a severely impaired cognition for daily decision making. The MDS indicated Resident #11 did not exhibit rejection of care or physical or verbal behaviors towards others such as hitting or screaming. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS indicated he was dependent for ADLS including oral hygiene, toileting hygiene, shower or bathe, dressing, and personal hygiene. The MDS indicated the resident needed substantial assistance (the helper does more than half the effort) to sit to lying, lying to sit, sit to stand, and did not attempt to walk due to medical condition or safety concerns. Record review of nursing progress notes, dated 3/28/24 through 4/4/24, for Resident #11's stated the following: - 3/28/24 at 10:38 p.m. patient not cooperating with aide during brief change, patient gave himself a skin tear to right lower forearm, top of left hand, left 4th finger cleaned with wound cleanser, and covered with [bandage]. Written by LVN B. - 3/29/24 at 9:45 a.m. Skin tear top of LT (left) hand, ST (skin tear) LT (left) 4th index finger, ST to RT (right) FA (forearm), bruising to Lt hand 1st finger and pinky-finger, swelling to Rt hand .Assessed areas, limited ROM to Rt hand, X-ray ordered to hand/wrist pending X-ray, Patients description of event: unable to verbalize . written by LVN C -3/30/24 at 1:58 p.m.X-Ray to rt. hand done on 3/29/24. Tx (treatment) to all skin issues as ordered. Xray results: No acute fx (fracture/break). Or dislocation seen. mild interphalangeal (finger joints) arthrosis (degenerative arthritis that causes the breakdown of the joints) shown by small degenerative spurring (growth) . written by LVN R - 3/31/24 at 3:57 p.m. Rt hand/wrist swelling, multiple skin tears RFA, top of L hand, Lt 4TH finger .applied steri-strips (Wound closure strips are porous surgical tape strips which can be used to close small wounds. They are applied across the laceration in a manner which pulls the skin on either side of the wound together.) to all skin tears - 4ss (steri-strips) to top Lt hand and 7ss to RT FA . written by LVN C. - 4/1/24 at 2:00 p.m. Late Entry . [Hospice]RN is here with [hospice company] and ordered an x-ray to [Resident #11]'s left hand. I heard her notify [Hospice doctor], [RP], and call in the x-ray. She noted swelling and bruising to [Resident #11]'s hand. Written by the DON. - 4/2/24 at 11:50 a.m. resident presents with discoloration to both upper bilateral extremities and scratched . written by LVN S. - 4/2/24 at 4:30 p.m. Late Entry .I overheard [hospice RN] on the phone with [Hospice Doctor] and then [Medical Director] and she stated that both physicians declined to get further diagnostics. She stated that {Hospice Doctor] told her that the treatment would be the same meaning the hand splint. Written by the DON - 4/2/24 at 7:07 p.m.FX to left hand . Hospice ordered splint stabilizer for left hand fx . written by LVN S - 4/2/24 at 11:06 p.m.left hand fx with splint; multiple skin tears left hand; right hand edema . written by LVN T. -4/3/24 at 9:13 a.m. selling and bruising to the left hand. THERE IS NO CONFIRMED FRACTURE . written by the DON. Record review of x-ray results, dated 4/2/24, stated .Impression: The bones are osteoporotic (a condition where bones become thin and lose their strength, resulting in increased fragility and a higher risk of fractures.). The distal (farthest away from the center) radial (a long bone that extends from the lateral (outside) side of the elbow to the thumb side of the wrist) diametaphyseal (specific region of a long bone or wrist area) irregularity is visualized, the focal (point of) tender (where it was hurting on the resident) correlation (was the same area) and follow up are recommended to exclude a fracture. The moderate wrist and hand osteoarthritis (disorder of the joints characterized by progressive deterioration of cartilage or of the entire joint) is visualized. Record review of the NP's notes, dated 4/3/24, stated Resident #11 was seen for follow up on change in condition to his left wrist for swelling and redness. The note stated .aggressive/combative with care last week, caused some skin tears to left-hand, left-hand X-ray ordered by Hospice for swelling . X-ray resulted- cannot rule out distal radius fracture (distal radius fracture versus chronic osteoarthritis), [Hospice Dr.] Ordered splint . swelling and redness noted to left wrist. The NP ordered 500 mg of cephalexin three times a day for 10 days for cellulitis (bacterial skin infection) to the left upper arm. The medical director reviewed the notes and agreed on 4/24/24. On 6/4/24 at 4:51 p.m. LVN B was attempted by phone an interview and did not answer. On 6/5/24 at 12:00 p.m. LVN T was attempted by phone for an interview and did not answer. On 6/6/24 at 2:00 p.m. The Administrator stated LVN S no longer worked for the facility and was a disgruntled employee. During an interview on 6/5/24 at 11:02 a.m. the DON stated she became aware of the incident the morning of 3/29/24 where Resident #11 became combative during care with CNA A. She stated CNA A was interviewed by phone on 4/3/24 at 4:11 p.m. and told her the resident was combative during care and beat her up, she continued with care because he was naked. CNA A noticed the skin tears after, and reported it the charge nurse or LVN B. The DON stated the other staff working did not witness the incident and the resident was non-interviewable. The DON stated they ordered an x-ray of his right hand on 3/29/24 because most of the swelling and injuries were to his right hand. The DON stated the resident had a history of being combative with care and staff was instructed to just stop care if a resident became combative. The DON stated CNA A did not stop care and finished changing him. The DON stated CNA A still worked at the facility. The DON stated it was treated more like an injury of unknown origin than abuse and neglect because the resident had a history of arthritis and she did not think the CNA A did anything to the resident. The DON stated on 4/2/24 they did an x-ray to his left hand due to new onset swelling and it showed a possible fracture, they reported it to the state on 4/2/24. During an interview on 6/5/24 at 3:59 p.m. CNA A described Resident #11's recent behavior with care as okay after the incident on 3/28/24. CNA A stated she continued to work with Resident #11 at the nursing facility after the incident but mostly worked on the woman's side now. CNA A stated she began working for the facility in March of 2024 and Resident #11 was really combative with care but since then was more familiar with her. CNA A stated on 3/28/24 she was providing incontinent care to Resident #11. CNA A stated this resident's bed was against the wall. CNA A stated she told Resident #11 what she was about to do for care and stated, I went to turn him and put on his brief he did not want to me to change him he kept getting out of the bed. CNA A stated Resident #11 was upset that she was providing peri care and she had to keep him in the bed. CNA A stated Resident #11 let her remove his pants but when she went to put on the clean brief it went on from there. CNA A stated Resident #11 got out of the bed, grabbed her scrub top, ripped her top, and pulled her hair. The CNA A stated she kept helping Resident #11 put his legs back in the bed. She stated, I would explain to him about putting his legs back in the bed. CNA A stated she never left or called for help because she usually could get them to calm down on her own. CNA A stated the resident had no injuries after the incident. CNA A stated she did not know how the resident had injuries to his hands or arms. CNA A stated she was not suspended pending an investigation. CNA A stated she did not know why she would be suspended because that would make it sound like she did something to the resident. CNA A stated she did not have specific training after this incident for handling combative residents. She stated she had recent training after another incident at the facility not related to this resident or her. She stated they also had annual training for abuse and neglect. CNA A stated she should have called for help to have a witness for the resident's safety and her safety. During an interview on 6/5/24 at 3:10 pm. the Administrator stated the DON reported this incident, but she was aware of it. She stated they concluded that because CNA A told them Resident #11 was combative during care, she concluded he hit his hand on the wall possibly causing a fracture. The Administrator stated she could not recall if she saw the resident's injuries but if she did it was nothing she would suspect was abuse or neglect. The Administrator stated they made a police report on 4/2/24 to rule out any potential abuse. The Administrator stated they did not feel there was any abuse and there had never been any other allegation made against CNA A so she continued to work for the facility. The Administrator stated staff should take a break if a resident was resistant to care and call for help. Record review of a police report, dated 4/2/24, stated on April 2nd 2024 I officer . was dispatched . for a information report. Upon arrival I made contact with [the DON] who's stated [Resident #11] was injured sometime in the last couple of days. The [DON] when stated on the 28th staff was dealing with [Resident #11] when he suffered multiple skin tears. The [DON] stated that on this said day X-rays were taken. Results showed that [Resident #11] had a possible fractured left hand. I attempted to speak with [Resident #11], due to [Resident #11's] diagnosis I wasn't able to get side of the story. I photographed [Resident #11]'s injuries which were later uploaded to the . evidence server. The [DON] could not confirm if an assault occurred. The [DON] stated she would conduct an interview over the next few days. due to the [DON] still having to investigate the incident report is for information purposes only pending follow up by the reporting party. Record review CNA A's employee records did not contain any disciplinary forms, suspension, misconduct, or coaching forms. Record review of a document titled in service-abuse, dated 4/2/24, did not contain CNA A or LVN B's signature. Record review of the facility's policy, titled Facility Responsibilities for Reporting Allegations, dated 9/22, stated The following addresses facility responsibilities for reporting allegations/occurrences involving staff-to-resident abuse; resident-to-resident altercations; injuries of unknown source; and misappropriation of resident property/exploitation. Reporting Staff-to-Resident Abuse All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator who serves as the facility abuse coordinator and to other officials, including the State Survey Agency and adult protective services, where state law provides for jurisdiction in nursing homes [see S 483.12(c)]. This includes, but is not limited to: All allegations/occurrences of physical, sexual, mental, and verbal abuse, including deprivation of goods and services by staff, and involuntary seclusion perpetrated by staff (See F600 and F603 for examples of types of abuse); Staff taking or distributing demeaning or humiliating photographs or recordings of residents through social media or multimedia messaging; and All reports from residents of abuse perpetrated by staff; allegations must not be dismissed on the basis of a resident's cognitive impairment(s). Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues July 10,2019, reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. An Immediate Jeopardy (IJ) was identified on 6/5/24 at 7:15 p.m. and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 6/6/24 at 2:45 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 6/5/2024 an investigation on a self-report was initiated at [Nursing Facility and address]. On 6/5/2024 at 7:15 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F600 Freedom from Abuse. The Facility neglected to put measures in place to prevent Resident #1 from abuse. IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On June 5, 2024, at approximately 6:00pm the following actions were initiated upon facility identification of concern: Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times. IDT team reviewed and updated patient #1 Care plan on 6/5/2024 to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors. On 6/5/24 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place. DON/designee completed psychosocial assessment on resident #1, on 6/5/2024, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this. CNA A contract terminated on 6/5/2024. IDENTIFICATION OF OTHER AFFECTED: DON/Designee completed an audit of all residents on 6/5/202 through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/designee will provide education to all staff regarding identifying types of abuse by 6/6/2024. Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect by 6/6/2024. The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia by 6/6/2024. All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors. On 6/5/2024, the Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation. Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Ad hoc QAPl meeting held on 6/5/2024 905 PM with IDT team and MD to review findings for immediate jeopardy. TRACKING AND MONITORING: Administrator/Designee will conduct audits of all residents for 7 days, beginning 6/5/2024 to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination. Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring. Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse. Challenging behavior care and interventions for individuals experiencing dementia. Monitoring will occur every shift for 7 days, beginning 6/5/2024, to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors. The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 6/19/2024 then monthly and as needed thereafter to identify trends and sustainability, If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable. Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Administrator The POR verification was accepted on 6/7/24 at 4:15 p.m. as follows: Record review of an in service dated 6/6/24 revealed 42 of 43 staff signed the in-service. LVN T had not completed the inservice because she was returning to work that night and would complete it before her shift per the Administrator. Interview on 06/07/2024 at 9:30 a.m., the Activity Director stated she received an in-service yesterday evening delivered by the ADM related to different types of abuse, the protocol of who to report to, and example of potential abuse and neglect. The Activity Director stated examples included suspicious bruising and noticing aggressive residents the expected protocol when that occurs. The Activity director affirmed understanding of the content. Interview on 06/07/2024 at 9:33 a.m., LVN F stated she received an in-service by the DON in-person yesterday that described who the ANE coordinator was, what example of abuse include, and the expected protocol when noticing potential abuse and neglect. She stated she had received training related to this same content a week prior but was trained on it frequently. She confirmed she understood the training. Interview on 06/07/2024 at 9:39 a.m., PTA J stated he received an in-service by the ADON in-person yesterday regarding abuse, resident rights, and combative residents. He stated the in-service included types of abuse and what to observe for in potential abuse allegations. He stated suspicious bruising was described as a potential concern to inform the ANE coordinator. He stated they also described the expected protocol when providing services to a combative resident was to walk away and come back with help. PTA J stated he understood the in-service. Interview on 06/07/2024 at 9:41 a.m., LVN C stated she received an in-service on abuse and types of abuse from the DON in-person. LVN C stated the in-service included types of abuse, what to look for, and expected protocol when a combative resident requires care. LVN C stated suspicious bruising was a sign to look for and to notify the ADM about. LVN C stated she understood the in-service. Interview on 06/07/2024 at 9:46 a.m., CNA K stated she was an agency CNA who had not worked at the facility in several months but stated she did receive an in-service today. CNA K stated the in-service was provided to her by the DON and discussed protocols when working with residents with behaviors. CNA K stated she was described the expected protocol was to walk away and potentially attempt care again with another staff but first to ensure the resident was safe prior to leaving. CNA K stated she understood the training. Interview on 06/07/2024 at 10:01 a.m., NA L stated she started at the facility two weeks ago but was in-serviced this morning by the DON and ADM regarding abuse, combative residents, and protocols when attempting care with these residents. NA L stated the in-service included the expected protocol to walk away during a combative episode and ensure an additional staff member was present to bear witness in the instance the resident was hurt to confirm what occurred. Interview on 06/07/2024 at 10:24 a.m., CNA H stated she received an in-service today and also last Sunday regarding abuse and neglect, but also regarding protocols when providing care to aggressive or combative residents. CNA H stated the in-service described walking away from the resident and coming back later with another staff member to provide assistance. CNA H stated the in-service also discussed example of abuse and what the expected protocol was when noticing suspicious bruising. Interview on 06/07/2024 at 10:49 a.m., COTA M stated she received an in-service this morning regarding abuse and neglect, as well as expected protocol when providing care to a resident with combative behaviors. COTA M stated she felt confident on the training and stated she received a similar training last month as well. COTA M stated the in-service gave specific description on not attempting care when a resident was aggressive and to return with another staff such as her OT at the facility. COTA M stated she had provided care to aggressive residents as recently as today and stated her action was to inform the DOR and the charge nurse of the aggressive resident so it could be monitored. Interview on 6/7/24 at 12:23 p.m. LVN G stated she received the in service on 6/6/24. She stated they went over signs of abuse, resident right, and if a resident is having an issue with staff she would go into the room to help and report anything that happened to the Administrator. Interview on 06/07/2024 at 12:27 p.m., PTA N stated she received an in-service yesterday related to abuse and neglect, and protocols when providing care to aggressive or combative residents. PTA N stated the in-service included content on the types of abuse, what action to take when noticing potential signs of abuse and neglect, and what expected protocol was when a resident begins to respond physically. PTA N stated the described practice was to attempt to redirect the resident and to return at a later time with another staff member. Interview on 6/7/24 at 12:35 p.m. CNA O stated they received the Inservice on 6/7/24. They talked to her about abuse and neglect, resident rights, and who to report abuse and neglect to. Reports it to Admin. Give the resident space if they get combative and talk to them in a low voice. Interview with LVN P at 12:45 p.m. stated she received the in service on 6/7/24. She stated she only worked at the facility about once a week and was agency. She stated they went over the types of abuse and signs of abuse. She stated they also went over resident rights. She stated when they encounter a combative resident they will try to deescalate and if that does not work then they would take a break and get a second staff. She stated because she does not have an established rapport with all the residents, she will normally get a 2nd person at all times to help. Interview on 06/07/2024 at 12:57 p.m., LVN Q, stated she worked as an agency LVN at the facility for the last two nights during the 6PM - 6AM shift and stated yesterday at the end of her shift she received an in-service regarding abuse and neglect along with protocols while providing care to residents with behaviors. LVN Q stated she understood the content of the in-service and stated she felt it was a sufficient time to discuss the content, in addition to discussing examples of non-explicit resident abuse or neglect that would require reporting to the abuse and neglect coordinator. Interview on 6/7/24 at 1:22 p.m. CNA E stated they had one Inservice over abuse and neglect her last in service was a couple days ago. While giving care to a resident if they are refusing stop your care, make sure they are safe, notify your nurse, and have a second aide with you. She would report abuse and neglect to her nurse and the Admin. Interview on 6/7/24 at 1:06 p.m. the SW stated she completed the in-service on 6/5/24. She stated the admin was the abuse coordinator and report any concerns or incidents to her. If someone was combative, we make sure they are safe and we go get help from a charge nurse. Interview on 06/07/2024 at 1:17 PM, the ADON, the ADM completed an in-service with her on the types of abuse, what the expected protocols when providing care with combative residents, ensure safety, and then to go redirect and get someone else to assist in the care. She stated the general types of abuse but included examples of potential abuse like restraints and chemical restraints. Interview with the DON on 6/7/24 at 1:26 p.m. the in-service she received was over abuse and neglect, resident rights, challenging behaviors, reporting, and investigating. If she sees or suspect any abuse to report it to the Administrator and get more details on her risk management assessments. They covered training and in servicing staff. Also, in service on the provider letter for reportable, and not reportable. For example, if the injuries are bruises, if we were not there watching it, then it's reportable. We covered distraction techniques, offering snacks, if a resident is combative make sure you leave them in a safe position and let them be, report it to the charge nurse, and try to go back at another time. It depends on what the resident was doing if they go back alone and they are fine then that was ok, or they have a resident who will not eat but will for someone else, so try different people. She will make sure everyone was in serviced before they start their shifts, and we keep asking them what they do if someone was refusing care, she was documenting the interviews or in service with staff. If she has staff involved in an incident, she will immediately suspend them pending investigation. The DON stated they canceled CNA A's contract. Interview with the Administrator 6/7/24 1:59 p.m. she did receive the services they went over resident rights, abuse, and neglect, and caring for challenging residents with behaviors. Residents have the right to be free from abuse and neglect. This was the resident's home, and we need to treat this like this is their home. The types of abuse and listed examples like physical or chemical restraints. If they do not want, you in the room or are having behaviors you make sure they are safe and step away. The clinical nurse went over reporting with them if the resident cannot tell them what happened, and we did not see and if there was an injury, they should report it. If staff is involved in an incident they will suspend them, have a verbal suspension, and they have a suspension form they can use. They plan on using a form to document if someone gets suspended now. After an allegation they will do a 1 to 1 in-service with the staff member over what the allegation was and training and document it with their signature. She will continue with knowledge checks, rounds to assess residents for abuse, and interviews of the resident for abuse and neglect. She has a couple of residents she can interview, and she also physically look at them [TRUNCATED]

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for of 8 residents (Resident #1) reviewed for neglect and abuse, in that; The facility failed to implement its abuse policy and procedures when Resident #11 obtained skin tears, brusising to hands, skin tears to his forearms, and a left-hand fracture after peri-care with CNA A. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on 6/7/24, While the IJ was removed on 6/7/24 at 09:15 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy 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 continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the facility's policy, titled Facility Responsibilities for Reporting Allegations, dated 9/22, stated The following addresses facility responsibilities for reporting allegations/occurrences involving staff-to-resident abuse; resident-to-resident altercations; injuries of unknown source; and misappropriation of resident property/exploitation. Reporting Staff-to-Resident Abuse All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator who serves as the facility abuse coordinator and to other officials, including the State Survey Agency and adult protective services, where state law provides for jurisdiction in nursing homes [see S 483.12(c)]. This includes, but is not limited to: All allegations/occurrences of physical, sexual, mental, and verbal abuse, including deprivation of goods and services by staff, and involuntary seclusion perpetrated by staff (See F600 and F603 for examples of types of abuse); Staff taking or distributing demeaning or humiliating photographs or recordings of residents through social media or multimedia messaging; and All reports from residents of abuse perpetrated by staff; allegations must not be dismissed on the basis of a resident's cognitive impairment(s). Record Review of Resident #11's Admission record revealed an [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses to include neurogenerative disorder with Lewy bodies (It is characterized by the presence of Lewy bodies-abnormal protein deposits-in the brain. These deposits affect brain chemicals, leading to problems with thinking, movement, behavior, mood, and other bodily functions), dementia (loss of thinking, remembering, and reasoning skills) without behaviors, and atherosclerotic heart disease (Plaque build-up in the arteries). Record Review of Resident #11's care plan, last updated 4/4/24, stated [Resident #11] has behaviors which include taking the linens off of his bed. He will put them on the chair at the end of his bed and cover himself with items such as the pink pad or other items that are not linens. He also puts his call light on the floor or behind his bed. He can also become combative with care at times. He does not always understand what you are trying to do. [Resident #11] will have 2 people assist them at all times. The interventions included administer medications as doctor has ordered, attempt intervention before resident behavior begins by checking frequently, fall mat at bedside while in bed, make sure resident is not in pain or uncomfortable, [Resident #11] will have two CNAs assisting him at all time, and please tell residents what you are going to do before you begin. 5/2/24 [Resident #11] has potential to demonstrate physical behaviors related to dementia. [Resident #11] can be argumentative, become agitated/ combative with care at times. With interventions to analyze key times, places, circumstance, triggers, and what escalates behavior and document, Assess and anticipate resident needs: move, thirst, toileting needs, comfort level, body positioning, pain ETC., 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 staff member when agitated, Modify environment: reduce noise, dim light, place familiar objects in room, monitor/document/ report to MD/ hospice/ VA of danger to self or others. 3/32/23 [Resident #11] has impaired cognitive function/ dementia or impaired thought process related to diagnosis of Lewy body dementia. With interventions to ask yes/ no questions in order to determine the residence needs, communication: use the resident preferred name, identify yourself at each interaction, face the revenant in speaking and make eye contact, reduce any distractions- turn off TV, radio, closed door ETC, the resident understands consistent, simple, directive sentences, Provide the resident with necessary cues-stop and return if agitated, cue, reorient and supervise as needed. Record Review of Resident #11's quarterly MDS assessment, dated 5/16/24, reflected Resident #11 had a severely impaired cognition for daily decision making. The MDS indicated Resident #11 did not exhibit rejection of care or physical or verbal behaviors towards others such as hitting or screaming. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS indicated he was dependent for ADLS including oral hygiene, toileting hygiene, shower or bathe, dressing, and personal hygiene. The MDS indicated the resident needed substantial assistance (the helper does more than half the effort) to sit to lying, lying to sit, sit to stand, and did not attempt to walk due to medical condition or safety concerns. Record review of nursing progress notes, dated 3/28/24 through 4/4/24, for Resident #11's stated the following: - 3/28/24 at 10:38 p.m. patient not cooperating with aide during brief change, patient gave himself a skin tear to right lower forearm, top of left hand, left 4th finger cleaned with wound cleanser, and covered with [bandage]. Written by LVN B. - 3/29/24 at 9:45 a.m. Skin tear top of LT (left) hand, ST (skin tear) LT (left) 4th index finger, ST to RT (right) FA (forearm), bruising to Lt hand 1st finger and pinky-finger, swelling to Rt hand .Assessed areas, limited ROM to Rt hand, X-ray ordered to hand/wrist pending X-ray, Patients description of event: unable to verbalize . written by LVN C -3/30/24 at 1:58 p.m.X-Ray to rt. hand done on 3/29/24. Tx (treatment) to all skin issues as ordered. Xray results: No acute fx (fracture/break). Or dislocation seen. mild interphalangeal (finger joints) arthrosis (degenerative arthritis that causes the breakdown of the joints) shown by small degenerative spurring (growth) . written by LVN R - 3/31/24 at 3:57 p.m. Rt hand/wrist swelling, multiple skin tears RFA, top of L hand, Lt 4TH finger .applied steri-strips (Wound closure strips are porous surgical tape strips which can be used to close small wounds. They are applied across the laceration in a manner which pulls the skin on either side of the wound together.) to all skin tears - 4ss (steri-strips) to top Lt hand and 7ss to RT FA . written by LVN C. - 4/1/24 at 2:00 p.m. Late Entry . [Hospice]RN is here with [hospice company] and ordered an x-ray to [Resident #11]'s left hand. I heard her notify [Hospice doctor], [RP], and call in the x-ray. She noted swelling and bruising to [Resident #11]'s hand. Written by the DON. - 4/2/24 at 11:50 a.m. resident presents with discoloration to both upper bilateral extremities and scratched . written by LVN S. - 4/2/24 at 4:30 p.m. Late Entry .I overheard [hospice RN] on the phone with [Hospice Doctor] and then [Medical Director] and she stated that both physicians declined to get further diagnostics. She stated that {Hospice Doctor] told her that the treatment would be the same meaning the hand splint. Written by the DON - 4/2/24 at 7:07 p.m.FX to left hand . Hospice ordered splint stabilizer for left hand fx . written by LVN S - 4/2/24 at 11:06 p.m.left hand fx with splint; multiple skin tears left hand; right hand edema . written by LVN T. -4/3/24 at 9:13 a.m. selling and bruising to the left hand. THERE IS NO CONFIRMED FRACTURE . written by the DON. Record review of x-ray results, dated 4/2/24, stated .Impression: The bones are osteoporotic (a condition where bones become thin and lose their strength, resulting in increased fragility and a higher risk of fractures.). The distal (farthest away from the center) radial (a long bone that extends from the lateral (outside) side of the elbow to the thumb side of the wrist) diametaphyseal (specific region of a long bone or wrist area) irregularity is visualized, the focal (point of) tender (where it was hurting on the resident) correlation (was the same area) and follow up are recommended to exclude a fracture. The moderate wrist and hand osteoarthritis (disorder of the joints characterized by progressive deterioration of cartilage or of the entire joint) is visualized. Record review of the NP's notes, dated 4/3/24, stated Resident #11 was seen for follow up on change in condition to his left wrist for swelling and redness. The note stated .aggressive/combative with care last week, caused some skin tears to left-hand, left-hand X-ray ordered by Hospice for swelling . X-ray resulted- cannot rule out distal radius fracture (distal radius fracture versus chronic osteoarthritis), [Hospice Dr.] Ordered splint . swelling and redness noted to left wrist. The NP ordered 500 mg of cephalexin three times a day for 10 days for cellulitis (bacterial skin infection) to the left upper arm. The medical director reviewed the notes and agreed on 4/24/24. On 6/4/24 at 4:51 p.m. LVN B was attempted by phone an interview and did not answer. On 6/5/24 at 12:00 p.m. LVN T was attempted by phone for an interview and did not answer. On 6/6/24 at 2:00 p.m. The Administrator stated LVN S no longer worked for the facility and was a disgruntled employee. During an interview on 6/5/24 at 11:02 a.m. the DON stated she became aware of the incident the morning of 3/29/24 where Resident #11 became combative during care with CNA A. She stated CNA A was interviewed by phone on 4/3/24 at 4:11 p.m. and told her the resident was combative during care and beat her up, she continued with care because he was naked. CNA A noticed the skin tears after, and reported it the charge nurse or LVN B. The DON stated the other staff working did not witness the incident and the resident was non-interviewable. The DON stated they ordered an x-ray of his right hand on 3/29/24 because most of the swelling and injuries were to his right hand. The DON stated the resident had a history of being combative with care and staff was instructed to just stop care if a resident became combative. The DON stated CNA A did not stop care and finished changing him. The DON stated CNA A still worked at the facility. The DON stated it was treated more like an injury of unknown origin than abuse and neglect because the resident had a history of arthritis and she did not think the CNA A did anything to the resident. The DON stated on 4/2/24 they did an x-ray to his left hand due to new onset swelling and it showed a possible fracture, they reported it to the state on 4/2/24. During an interview on 6/5/24 at 3:59 p.m. CNA A described Resident #11's recent behavior with care as okay after the incident on 3/28/24. CNA A stated she continued to work with Resident #11 at the nursing facility after the incident but mostly worked on the woman's side now. CNA A stated she began working for the facility in March of 2024 and Resident #11 was really combative with care but since then was more familiar with her. CNA A stated on 3/28/24 she was providing incontinent care to Resident #11. CNA A stated this resident's bed was against the wall. CNA A stated she told Resident #11 what she was about to do for care and stated, I went to turn him and put on his brief he did not want to me to change him he kept getting out of the bed. CNA A stated Resident #11 was upset that she was providing peri care and she had to keep him in the bed. CNA A stated Resident #11 let her remove his pants but when she went to put on the clean brief it went on from there. CNA A stated Resident #11 got out of the bed, grabbed her scrub top, ripped her top, and pulled her hair. The CNA A stated she kept helping Resident #11 put his legs back in the bed. She stated, I would explain to him about putting his legs back in the bed. CNA A stated she never left or called for help because she usually could get them to calm down on her own. CNA A stated the resident had no injuries after the incident. CNA A stated she did not know how the resident had injuries to his hands or arms. CNA A stated she was not suspended pending an investigation. CNA A stated she did not know why she would be suspended because that would make it sound like she did something to the resident. CNA A stated she did not have specific training after this incident for handling combative residents. She stated she had recent training after another incident at the facility not related to this resident or her. She stated they also had annual training for abuse and neglect. CNA A stated she should have called for help to have a witness for the resident's safety and her safety. During an interview on 6/5/24 at 3:10 pm. the Administrator stated the DON reported this incident, but she was aware of it. She stated they concluded that because CNA A told them Resident #11 was combative during care, she concluded he hit his hand on the wall possibly causing a fracture. The Administrator stated she could not recall if she saw the resident's injuries but if she did it was nothing she would suspect was abuse or neglect. The Administrator stated they made a police report on 4/2/24 to rule out any potential abuse. The Administrator stated they did not feel there was any abuse and there had never been any other allegation made against CNA A so she continued to work for the facility. The Administrator stated staff should take a break if a resident was resistant to care and call for help. Record review of a police report, dated 4/2/24, stated on April 2nd 2024 I officer . was dispatched . for a information report. Upon arrival I made contact with [the DON] who's stated [Resident #11] was injured sometime in the last couple of days. The [DON] when stated on the 28th staff was dealing with [Resident #11] when he suffered multiple skin tears. The [DON] stated that on this said day X-rays were taken. Results showed that [Resident #11] had a possible fractured left hand. I attempted to speak with [Resident #11], due to [Resident #11's] diagnosis I wasn't able to get side of the story. I photographed [Resident #11]'s injuries which were later uploaded to the . evidence server. The [DON] could not confirm if an assault occurred. The [DON] stated she would conduct an interview over the next few days. due to the [DON] still having to investigate the incident report is for information purposes only pending follow up by the reporting party. Record review CNA A's employee records did not contain any disciplinary forms, suspension, misconduct, or coaching forms. Record review of a document titled in service-abuse, dated 4/2/24, did not contain CNA A or LVN B's signature. Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues July 10,2019, reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. An Immediate Jeopardy (IJ) was identified on 6/5/24 at 7:15 p.m. and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 6/6/24 at 2:45 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 6/5/2024 an investigation on a self-report was initiated at [Nursing Facility and address]. On 6/5/2024 at 7:15 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F600 Freedom from Abuse. The Facility neglected to put measures in place to prevent Resident #1 from abuse. IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On June 5, 2024, at approximately 6:00pm the following actions were initiated upon facility identification of concern: Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times. IDT team reviewed and updated patient #1 Care plan on 6/5/2024 to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors. On 6/5/24 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place. DON/designee completed psychosocial assessment on resident #1, on 6/5/2024, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this. CNA A contract terminated on 6/5/2024. IDENTIFICATION OF OTHER AFFECTED: DON/Designee completed an audit of all residents on 6/5/202 through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/designee will provide education to all staff regarding identifying types of abuse by 6/6/2024. Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect by 6/6/2024. The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia by 6/6/2024. All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors. On 6/5/2024, the Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation. Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Ad hoc QAPl meeting held on 6/5/2024 905 PM with IDT team and MD to review findings for immediate jeopardy. TRACKING AND MONITORING: Administrator/Designee will conduct audits of all residents for 7 days, beginning 6/5/2024 to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination. Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring. Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse. Challenging behavior care and interventions for individuals experiencing dementia. Monitoring will occur every shift for 7 days, beginning 6/5/2024, to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors. The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 6/19/2024 then monthly and as needed thereafter to identify trends and sustainability, If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable. Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Administrator The POR verification was accepted on 6/7/24 at 4:15 p.m. as follows: Record review of an in service dated 6/6/24 revealed 42 of 43 staff signed the in-service. LVN T had not completed the inservice because she was returning to work that night and would complete it before her shift per the Administrator. Interview on 06/07/2024 at 9:30 a.m., the Activity Director stated she received an in-service yesterday evening delivered by the ADM related to different types of abuse, the protocol of who to report to, and example of potential abuse and neglect. The Activity Director stated examples included suspicious bruising and noticing aggressive residents the expected protocol when that occurs. The Activity director affirmed understanding of the content. Interview on 06/07/2024 at 9:33 a.m., LVN F stated she received an in-service by the DON in-person yesterday that described who the ANE coordinator was, what example of abuse include, and the expected protocol when noticing potential abuse and neglect. She stated she had received training related to this same content a week prior but was trained on it frequently. She confirmed she understood the training. Interview on 06/07/2024 at 9:39 a.m., PTA J stated he received an in-service by the ADON in-person yesterday regarding abuse, resident rights, and combative residents. He stated the in-service included types of abuse and what to observe for in potential abuse allegations. He stated suspicious bruising was described as a potential concern to inform the ANE coordinator. He stated they also described the expected protocol when providing services to a combative resident was to walk away and come back with help. PTA J stated he understood the in-service. Interview on 06/07/2024 at 9:41 a.m., LVN C stated she received an in-service on abuse and types of abuse from the DON in-person. LVN C stated the in-service included types of abuse, what to look for, and expected protocol when a combative resident requires care. LVN C stated suspicious bruising was a sign to look for and to notify the ADM about. LVN C stated she understood the in-service. Interview on 06/07/2024 at 9:46 a.m., CNA K stated she was an agency CNA who had not worked at the facility in several months but stated she did receive an in-service today. CNA K stated the in-service was provided to her by the DON and discussed protocols when working with residents with behaviors. CNA K stated she was described the expected protocol was to walk away and potentially attempt care again with another staff but first to ensure the resident was safe prior to leaving. CNA K stated she understood the training. Interview on 06/07/2024 at 10:01 a.m., NA L stated she started at the facility two weeks ago but was in-serviced this morning by the DON and ADM regarding abuse, combative residents, and protocols when attempting care with these residents. NA L stated the in-service included the expected protocol to walk away during a combative episode and ensure an additional staff member was present to bear witness in the instance the resident was hurt to confirm what occurred. Interview on 06/07/2024 at 10:24 a.m., CNA H stated she received an in-service today and also last Sunday regarding abuse and neglect, but also regarding protocols when providing care to aggressive or combative residents. CNA H stated the in-service described walking away from the resident and coming back later with another staff member to provide assistance. CNA H stated the in-service also discussed example of abuse and what the expected protocol was when noticing suspicious bruising. Interview on 06/07/2024 at 10:49 a.m., COTA M stated she received an in-service this morning regarding abuse and neglect, as well as expected protocol when providing care to a resident with combative behaviors. COTA M stated she felt confident on the training and stated she received a similar training last month as well. COTA M stated the in-service gave specific description on not attempting care when a resident was aggressive and to return with another staff such as her OT at the facility. COTA M stated she had provided care to aggressive residents as recently as today and stated her action was to inform the DOR and the charge nurse of the aggressive resident so it could be monitored. Interview on 6/7/24 at 12:23 p.m. LVN G stated she received the in service on 6/6/24. She stated they went over signs of abuse, resident right, and if a resident is having an issue with staff she would go into the room to help and report anything that happened to the Administrator. Interview on 06/07/2024 at 12:27 p.m., PTA N stated she received an in-service yesterday related to abuse and neglect, and protocols when providing care to aggressive or combative residents. PTA N stated the in-service included content on the types of abuse, what action to take when noticing potential signs of abuse and neglect, and what expected protocol was when a resident begins to respond physically. PTA N stated the described practice was to attempt to redirect the resident and to return at a later time with another staff member. Interview on 6/7/24 at 12:35 p.m. CNA O stated they received the Inservice on 6/7/24. They talked to her about abuse and neglect, resident rights, and who to report abuse and neglect to. Reports it to Admin. Give the resident space if they get combative and talk to them in a low voice. Interview with LVN P at 12:45 p.m. stated she received the in service on 6/7/24. She stated she only worked at the facility about once a week and was agency. She stated they went over the types of abuse and signs of abuse. She stated they also went over resident rights. She stated when they encounter a combative resident they will try to deescalate and if that does not work then they would take a break and get a second staff. She stated because she does not have an established rapport with all the residents, she will normally get a 2nd person at all times to help. Interview on 06/07/2024 at 12:57 p.m., LVN Q, stated she worked as an agency LVN at the facility for the last two nights during the 6PM - 6AM shift and stated yesterday at the end of her shift she received an in-service regarding abuse and neglect along with protocols while providing care to residents with behaviors. LVN Q stated she understood the content of the in-service and stated she felt it was a sufficient time to discuss the content, in addition to discussing examples of non-explicit resident abuse or neglect that would require reporting to the abuse and neglect coordinator. Interview on 6/7/24 at 1:22 p.m. CNA E stated they had one Inservice over abuse and neglect her last in service was a couple days ago. While giving care to a resident if they are refusing stop your care, make sure they are safe, notify your nurse, and have a second aide with you. She would report abuse and neglect to her nurse and the Admin. Interview on 6/7/24 at 1:06 p.m. the SW stated she completed the in-service on 6/5/24. She stated the admin was the abuse coordinator and report any concerns or incidents to her. If someone was combative, we make sure they are safe and we go get help from a charge nurse. Interview on 06/07/2024 at 1:17 PM, the ADON, the ADM completed an in-service with her on the types of abuse, what the expected protocols when providing care with combative residents, ensure safety, and then to go redirect and get someone else to assist in the care. She stated the general types of abuse but included examples of potential abuse like restraints and chemical restraints. Interview with the DON on 6/7/24 at 1:26 p.m. the in-service she received was over abuse and neglect, resident rights, challenging behaviors, reporting, and investigating. If she sees or suspect any abuse to report it to the Administrator and get more details on her risk management assessments. They covered training and in servicing staff. Also, in service on the provider letter for reportable, and not reportable. For example, if the injuries are bruises, if we were not there watching it, then it's reportable. We covered distraction techniques, offering snacks, if a resident is combative make sure you leave them in a safe position and let them be, report it to the charge nurse, and try to go back at another time. It depends on what the resident was doing if they go back alone and they are fine then that was ok, or they have a resident who will not eat but will for someone else, so try different people. She will make sure everyone was in serviced before they start their shifts, and we keep asking them what they do if someone was refusing care, she was documenting the interviews or in service with staff. If she has staff involved in an incident, she will immediately suspend them pending investigation. The DON stated they canceled CNA A's contract. Interview with the Administrator 6/7/24 1:59 p.m. she did receive the services they went over resident rights, abuse, and neglect, and caring for challenging residents with behaviors. Residents have the right to be free from abuse and neglect. This was the resident's home, and we need to treat this like this is their home. The types of abuse and listed examples like physical or chemical restraints. If they do not want, you in the room or are having behaviors you make sure they are safe and step away. The clinical nurse went over reporting with them if the resident cannot tell them what happened, and we did not see and if there was an injury, they should report it. If staff is involved in an incident they will suspend them, have a verbal suspension, and they have a suspension form they can use. They plan on using a form to document if someone gets suspended now. After an allegation they will do a 1 to 1 in-service with the staff member over what the allegation was and training and document it with their signature. She will continue with knowledge checks, rounds to assess residents for abuse, and interviews of the resident for abuse and neglect. She has a couple of residents she can interview, and she also physically look at them. She will assess if they are at their baseline if they are not able to be in [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are required to treat the resident's medical symptoms for 1 of 8 (Resident #1) residents reviewed for restraint, in that; The facility failed to ensure that Resident #1 was free from restraint when RN A and NA H tied Resident #1 to a wheelchair with a gait belt wrapped around his abdomen and secured behind the resident out of reach and by using furniture to block his movement while in the wheelchair on multiple occasions from 10/082023-03/01/2024. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. This failure could affect residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. The findings included: 1. Record review of Form 3613-A, Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA alleged RN A used a gait belt to keep a resident in the wheelchair. The report indicated Resident #1 was the victim. Record review of a photocopy of text conversation between the DON and RN A (undated) revealed the DON sent a text to RN A that indicated she had been trying to reach RN A by phone to let her know she was suspended pending investigation because it was reported she used a gait belt to restrain Resident #1 . The DON indicated she had to report it to state. RN A responded by asking if she should go to work on Monday and Tuesday. RN A stated, I did use a gait belt .sorry about the belt but I was just trying to keep him from falling. The DON responded by telling RN A not to go to work Monday or Tuesday. This document was signed by the DON. Record review of a handwritten document dated 3/01/2024 and signed by the DON revealed agency CNA B called her (the DON) and told her RN A on the night shift was using a gait belt to restrain Resident #1 in his wheelchair at night. The document indicated CNA B could not give specific dates or times. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA D stated she had witnessed RN A use a gait belt to restrain Resident #1 in his wheelchair. The document indicated CNA D could not remember exact dates and times and stated CNA did not report it because she was scared of retaliation from RN A. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA N stated she had witnessed RN A use a gait belt to restrain Resident #1 at night. She stated she did not report it because she was afraid of retaliation and could not remember exact dates and times. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an observation/interview on 4/15/2024 at 10:16 p.m. revealed there were no residents in the main common area or near the nurse's station. The facility lights were low, and the atmosphere was calm/quiet. CNA B was observed near the nurse's station in the hallway. CNA B stated Resident #1 had returned from the hospital today and had been confused and combative with staff which she described as normal behavior for the resident. CNA B stated Resident #1 kept wandering to different hallways saying he was going to beat someone up. She stated she approached him in a calm way, redirected him and just talked to him which was how she was trained to respond. She stated although he was confused, she eventually got him to bed. During an observation on 4/15/2024 at 10:19 p.m., Resident #1 was observed on a low bed, with fall mat in place. The resident was sleeping and had the covers pulled up over his head. During an observation on 4/15/2024 at 10:45 p.m., Resident #1 remained asleep in his bed. During an observation/interview on 4/16/2024 at 3:26 p.m., Resident #1 was observed seated in his wheelchair in the main front living/dining area nearest the nurse's station. Resident #1 moved almost constantly and kept scooting up toward the edge of his wheelchair where he was redirected calmly by staff. Resident #1 was alert and smiled when spoken to but did not respond when questions were asked. Resident #1 did not have any obvious injuries. During an observation on evening shift at 4/16/2024 at 8:22 p.m., Resident #1 was observed asleep in his bed with the covers over his head, low bed with fall mat in place. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she was the facility ADON until 1/01/2024 when she became the DON. She stated Resident #1 had a fall history and had run out of new interventions to try. She stated after every fall she updated Resident #1's care plan. She stated the most effective intervention was to keep Resident #1 within eyesight. She stated on 4/04/2024 she put a goal for him to be up in his wheelchair out of his room when awake to prevent Resident #1 from ambulating unassisted. The DON stated there was no pattern of time for the falls because they happened on every shift. She stated the falls were not happening with one particular staff person. She stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. The DON stated she did have enough staff to care for him. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it, she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team, and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 2-3 times, but she was very vague. During an interview on 4/17/2024 at 3:17 p.m., the DON stated none of the residents in the facility were reliable for an interview due to dementia. She stated all residents in the facility had a diagnosis of dementia with memory issues. She stated some of the residents also had hallucinations/delusions and would not be able to give a reliable interview regarding restraint/abuse. The DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A, CNA C and CNA D. The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation, they let her go. The DON stated there would have been a bigger investigation had she denied the allegations. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. She stated she interviewed CNA E who worked for an agency, but she denied seeing abuse and the other regular staff member (unknown name) said she didn't see it either. The DON stated on 3/01/2024 when she received the allegations of abuse, she had approximately 31 staff. She stated she in-serviced 19 of those staff on abuse and neglect. The DON stated when she called the meeting for the in-service CNA F (night shift) had worked the whole week and she did her a favor by picking up extra shifts, so she excused CNA F from the in-service and the other person (CNA E) from night shift was an agency person. The DON stated agency staff had their own in-services through their agency. She stated if the agency staff are in the building when the meeting was called, they would attend. The DON stated she did not in-service night shift staff because she does not see the night shift people because they occur during the daytime. The DON stated as part of the abuse investigation she completed a skin assessment of Resident #1 and found no new skin conditions. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated she worked for a staffing agency and first began working at the facility in August 2023. CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNAs to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. She stated CNA E took RN A a gait belt and gave it to her but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like she did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON; it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down and the CNAs were down the halls working. She stated, these were not one day events. No one had wanted to report it. She stated CNA E and CNA K both had talked about the abuse, and both had information. CNA B stated she wrote a witness statement. She stated a lot of staff wrote witness statements to the DON. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which is what she did. CNA B stated after this event there was a training. She stated they were told to read and sign something, but she could not remember what it was about. During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she was regular full-time staff at the facility. She stated she did not work with RN A often. CNA D stated RN A was loud, and she was rude, but she never saw abuse. CNA D stated the handwritten statement written by the DON was not accurate. CNA D stated when the DON called her and asked her about the gait belt on Resident #1, she told the DON, no. CNA D stated she thought the DON misunderstood her. CNA D stated RN A did ask her to put a gait belt on as a restraint on Resident #1 but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates. CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., CNA E stated she worked with an agency and had worked at the facility regularly for 3-4 months, mostly on the weekends with RN A. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H. She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen, and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON; RN A made her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON She (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). CNA E stated She stated she was trained to report abuse to her agency. She stated her agency was a data base and she entered it into the data base but could not remember when this occurred, she stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (3/01/2024). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated she told all of this to management. CNA N stated Resident #1 did not seem upset because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated she did not see any injuries to Resident #1. She stated management responded by saying there would be a state investigation. CNA N stated she was not asked to write a witness statement from facility management. She stated she would be willing to write out her version on a piece of paper in front of this surveyor for proof. During an interview on 4/17/2024 at 6:10 p.m., the ADON was presented as a witness by the DON. The ADON stated CNA D told her she did see RN A strap Resident #1 to a chair with a gait belt but because RN A was a registered nurse, she did not report it because Who are they going to believe a RN or a CNA? The ADON stated CNA D stated she actually witnessed it and told the ADON approximately one month ago. The ADON stated she was a charge nurse when this occurred and did not become the ADON until 3/01/2024. The ADON stated the first time she knew anything about the situation was when all the chatter started about it when the facility reported it to state (3/01/2024). She stated she heard NA H and CNA C talk about it, but this was after it was already reported. The ADON stated she never heard any residents complain and did not see any change in any resident behaviors. The ADON stated restraint was abuse. The ADON stated she has come to assist night shift before when they needed help but did not know where that was. She stated it was to do extra work. She stated she was new to the job and was still training. The ADON stated there had never been a discussion between management staff about monitoring night shift. The ADON stated she was not responsible for training any of the staff. During an observation/interview on 4/17/2024 at 6:35 p.m., the Maintenance Director measured the opening of the main living area to be 93 inches and the couch in the main living area was 74 inches. When placed in the middle of the doorway there was a 4.5 inch opening on each side of the couch which was too small for wither a wheelchair or a person to be able to walk through. The Maintenance Director stated there used to be two couches in the main living area, but one was thrown away on an unknown date. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she was regular full-time staff at the facility and worked many extra shifts. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not cream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F denied knowledge of any other resident abuse. CNA F stated RN A was a really good nurse. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated they normally work with one nurse and two aides at night. She stated they would all take turns watching the residents. She stated some of the residents do not sleep at night and there had been some chaotic nights. She stated on the chaotic nights they still made sure the residents needs were met. CAN F stated she did not complete the abuse training in-service after the incident and still had not completed it as of this interview. She stated worked to help the DON out by working an extra shift and the DON gave her permission to be excluded from the abuse class. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal and sexual abuse immediately to the Administrator. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated there were two-night shift nurses. She was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. She stated she was trained to report abuse, including restraint to the Administrator immediately. During an interview on 4/17/2024 at 7:19 p.m., CNA K stated she worked for an agency. She stated she had worked with RN A. CNA K stated RN A was a little rude and did not move much. She stated RN A passed meds and then would just sit at the desk. CNA K stated RN A never asked her to put a restraint or use a gait belt on a resident. She stated she never saw one put on a resident but did hear RN A state she was going to have to put a gait belt on Resident #1 to keep him in his wheelchair so he would not fall. CNA K stated she tried to just keep to herself and not pay attention. She stated she really did not have any knowledge and for the most part RN A was alright with her. She stated she could not really remember working at the facility when asked if she had reported it. She replied I don't remember to all further questions about details and training and declined further interview. During an interview on 4/17/2024 at 7:24 p.m., CNA G stated she was full time staff at the facility. She stated the very first time she worked nights at the facility, a Saturday night (2/10/2024-2/11/2024), RN A asked NA H to put a gait belt around Resident #1. CNA G stated NA H physically put the gait belt around the resident clasping it in the back. CNA G stated she asked NA H what she was doing it and NA H stated she was restraining Resident #1. CNA G stated had asked RN A if there were doctor's order and she said no, it was just the way she did it so he would not have any falls. CNA G stated she told NA H she had to take it off Resident #1 because there were no doctor's orders and NA H said no. CNA G stated she knew it was against the law to restrain residents in the state of Texas. She stated CNA E and RN A got in an argument over it. CNA G stated it just did not sit right with her and felt like the DON would have told her if they were supposed to restrain Resident #1. CNA G stated CNA E said it had happened before and that she had reported it to her agency. CNA G stated RN A got really upset with her when she told her to take it off. CNA G stated she asked CNA E to help her take it off Resident #1. She stated RN A told her and CNA E if we touched Resident #1, we would get in trouble. CNA G stated CNA E and RN A got in a screaming match and a lot of abuse things were said by both parties. She stated both CNA E and RN A were calling the DON trying to resolve it. CNA G stated she told the DON about the gait belt. She stated she was not able to hear the DON's response. She stated while CNA E was talking to the DON on the phone RN A continued yelling at CNA E. CNA G stated she did hear CNA E tell the DON that RN A placed a gait belt around Resident #1 and that she told NA H to do it to. CNA G stated she heard CNA E tell the DON that she (CNA G) had taken it off. CNA G stated she does not know what was said after that point because CNA E had to go outside to continue the conversation because RN A was yelling. CNA G stated after this happened everything calmed down and she took Resident #1 to bed. CNA G stated when she came back to work on Sunday (date unknown) RN A tried to do it again. She stated RN A told NA H to do it and this time NA H refused. CNA G stated RN A said if ya'll are not going to do it then she was going to do it. CNA G stated she told RN A no and told her she was just going to lay Resident #1 down in bed. CNA G stated RN A stated if he stays in bed then that is perfect. CNA G stated she never witnessed RN A physically put the gait belt on Resident #1 but she did witness her tell NA H to do it. She stated those were the only two days she worked with RN A. She stated she told the DON she was not going to work with RN A anymore because of it and moved to working day shift. CNA G stated this occurred on Super Bowl weekend 2/11/2024. She stated she worked both 2/10/2024 and 2/11/2024. CNA G stated after CNA E reported the restraint to the DON, RN A stayed at the facility and worked the whole shift. She stated no one went home. She stated the DON never came to the facility that night. CNA G stated she was new to the facility at the time and did not have anyone's phone numbers to report it but she knew CNA E reported it. She stated CNA E showed her where she had reported it (to her agency) multiple times, 3 times in total on the portal. She stated after this occurred the facility eventually put phone numbers up to report abuse. CNA G stated RN A continued to work in at the facility until sometimes in March (date unknown). CNA G denied knowledge of abuse or restraint of any other resident. She stated it was just Resident #1. She stated Resident #1 looked really confused by the restraint and he was trying to fight it. She stated he did not know why he could not get up. She stated it was tied around him like a seat belt. She stated he was trying to get up and stand up which was causing the wheelchair to move forward with him. She stated it was almost making the wheelchair fall over while he was trying to stand up. CNA G stated it looked really weird [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 2 of 8 residents (Residents #1 and Resident #5) reviewed for abuse, in that: 1. The facility failed to ensure Resident #1 was free from physical abuse when RN A and NA H restrained the resident using a gait belt wrapped around the resident's abdomen from 10/08/2023 to 3/01/2024 and secured to his wheelchair behind the resident to prevent the resident from standing, used furniture to prevent movement by Resident #1 in his wheelchair and emotional abuse from RN A. 2. The facility failed to ensure Resident's #1 and #5 were free from verbal abuse when RN A used derogatory language and profanity directed at the residents. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2024 at 5:27 p.m. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. These failures could place residents at risk of physical, mental and emotional decline, psychosocial harm and physical injury and could result in a decline in isolation and withdrawal and result in a decline in health. The findings included: 1. Record review of Form 3613 -A, Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA (unidentified) alleged RN A used a gait belt to keep a resident in the wheelchair and used profanity when she spoke to a resident. The report indicated Resident #1 was the victim. The report also indicated RN A told Resident #5 to shut the f%&$ up but Resident #5 was unable to recall foul language. Record review of a photocopy of text conversation (undated) between the DON and RN A revealed the DON sent a text to RN A that indicated she had been trying to reach RN A by phone to let her know she was suspended pending investigation because it was reported she used a gait belt to restrain Resident #1 and profanity when speaking to Resident #5. The DON indicated in the text she had to report it to state. RN A responded by asking if she should go to work on Monday and Tuesday. RN A stated, I did use a gait belt, but I don't recall using profanity with any resident .sorry about the belt but I was just trying to keep him from falling. The DON responded by telling RN A not to go to work Monday or Tuesday. This document was signed by the DON. Record review of a handwritten document dated 3/01/2024 and signed by the DON revealed agency CNA B called her (the DON) and told her RN A on the night shift was using a gait belt to restrain Resident #1 in his wheelchair at night. The document indicated CNA B could not give specific dates or times. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA D stated she had witnessed RN A use a gait belt to restrain Resident #1 in his wheelchair. The document indicated CNA D could not remember exact dates and times and stated CNA D did not report it because she was scared of retaliation from RN A. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA N stated she had witnessed RN A use a gait belt to restrain Resident #1 at night. She stated she did not report it because she was afraid of retaliation and could not remember exact dates and times. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an observation/interview on 4/15/2024 at 10:16 p.m. revealed there were no residents in the main common area or near the nurse's station. The facility lights were low, and the atmosphere was calm/quiet. CNA B was observed near the nurse's station in the hallway. CNA B stated Resident #1 had returned from the hospital today and had been confused and combative with staff which she described as normal behavior for the resident. CNA B stated Resident #1 kept wandering to different hallways saying he was going to beat someone up. She stated she approached him in a calm way, redirected him and just talked to him which was how she was trained to respond. She stated although he was confused, she eventually got him to bed. During an observation on 4/15/2024 at 10:19 p.m., Resident #1 was observed on a low bed, with fall mat in place. The resident was sleeping and had the covers pulled up over his head. During an observation on 4/15/2024 at 10:45 p.m., Resident #1 remained asleep in his bed. During an observation/interview on 4/16/2024 at 3:26 p.m., Resident #1 was observed seated in his wheelchair in the main front living/dining area nearest the nurse's station. Resident #1 moved almost constantly and kept scooting up toward the edge of his wheelchair where he was redirected calmly by staff . Resident #1 was alert and smiled when spoken to but did not respond when questions were asked. Resident #1 did not have any obvious injuries. During an observation on evening shift at 4/16/2024 at 8:22 p.m., Resident #1 was observed asleep in his bed with the covers over his head, low bed with fall mat in place. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she was the facility ADON until 1/01/2024 when she became the DON. She stated Resident #1 had a fall history and had run out of new interventions to try. She stated after every fall she updated Resident #1's care plan. She stated the most effective intervention was to keep Resident #1 within eyesight. She stated on 4/04/2024 she put a goal for him to be up in his wheelchair out of his room when awake to prevent Resident #1 from ambulating unassisted. The DON stated there was no pattern of time for the falls because they happened on every shift. She stated the falls were not happening with one particular staff person. She stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. The DON stated she did have enough staff to care for him. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team, and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 2-3 times, but she was very vague. 2. Record review of Resident #5's face sheet dated 4/18/2024 revealed an admitted [DATE] with diagnoses which included: Alzheimer's disease, psychotic disorder with delusions due to known physiological condition and recurrent major depressive disorder. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 which indicated a severe cognitive impairment. Record review of Resident #5's annual MDS assessment dated [DATE] revealed a BIMS score was not assessed. Record review of Resident #5's Care Plan dated last revised on 3/27/2023 revealed Resident #5 sometimes had behaviors which included shouting with interventions which included: attempt interventions before behavior escalates, make sure resident not in pain or uncomfortable. Record review of Resident #5's psychosocial assessment dated [DATE] revealed Resident #5's memory recall included staff faces and names and that he was in a facility. The assessment indicated the resident understand his surroundings and had severely impaired decision-making skills and socially inappropriate behaviors with a note anxiety, yells, prefers to be alone in room The assessment revealed Resident denies that anyone has told him anything to upset him. During on observation on 4/15/2024 at 10:25 p.m., Resident #5 was observed sleeping in bed, low bed, fall mat in place. During an interview on 4/17/2024 at 3:17 p.m., the DON stated none of the residents in the facility were reliable for an interview due to dementia. She stated all residents in the facility had a diagnosis of dementia with memory issues. She stated some of the residents also had hallucinations/delusions and would not be able to give a reliable interview regarding restraint/abuse. The DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A, CNA C and CNA D . The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation , they let her go. The DON stated there would have been a bigger investigation had she denied the allegations. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. The DON stated she interviewed Resident #5 about the verbal abuse , and he said everyone was nice to him, but he could not remember, and he had no complaints from other residents. She stated she interviewed CNA E who worked for an agency, but she denied seeing abuse and the other regular staff member (unknown name) said she didn't see it either. The DON stated on 3/01/2024 when she received the allegations of abuse, she had approximately 31 staff. She stated she in-serviced 19 of those staff on abuse and neglect. The DON stated when she called the meeting for the in-service CNA F (night shift) had worked the whole week and she did her a favor by picking up extra shifts, so she excused CNA F from the in-service and the other person (CNA E) from night shift was an agency person. The DON stated agency staff had their own in-services through their agency. She stated if the agency staff are in the building when the meeting was called, they would attend. The DON stated she did not in-service night shift staff because she does not see the night shift people because they occur during the daytime . The DON stated as part of the abuse investigation she completed a skin assessment of Resident #1 and found no new skin conditions . During an observation/interview on 4/17/2024 at 3:30 p.m., Resident #5 was seated on his bed with his clothes thrown on the floor beside him. There were no visible injuries noted. Resident #5 stated he was fine. He stated he had lived at the facility for [AGE] years (which showed confusion) and was stated he did not know who any of the people were in the numerous personal photos posted near his bed on the wall. Resident #5 had a childlike demeanor. He was unable to answer detailed interview questions and did not have memory recall of answer questions about past events. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated she worked for a staffing agency and first began working at the facility in August 2023. CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNA's to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. CNA B stated CNA E took RN A a gait belt and gave it to her (RN A) but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like RN A did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down and the CNA's were down the halls working. CNA B stated one day, (date unknown) Resident #1 was having a good day and was in a good mood. He looked at RN A and stated, I love you and RN A looked right at him and stated, I hate you. CNA B stated it really broke her heart. She stated she told RN A wow and just walked off. CNA B stated Resident #1 did not say anything, but he knew. She stated she could see it in his eyes that he knew. CNA B stated one night (date unknown) Resident #5 could smell her dinner when she was warming it up and he yelled he wanted a cheeseburger. CNA B stated RN A yelled Shut the fuck up. CNA B stated Resident #5 was in his room and got quiet. CNA B stated after she reported it to the DON a lot of other staff started talking. These were not one day events. No one had wanted to report it. She stated CNA E and CNA K both had talked about the abuse, and both had information. CNA B stated she wrote a witness statement. She stated a lot of staff wrote witness statements to the DON. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which was what she did. CNA B stated after this event there was a training. She stated they were told to read and sign something, but she could not remember what it was about. During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she was regular full-time staff at the facility. She stated she did not work with RN A often. CNA D stated RN A was loud, and she was rude, but she never saw abuse. CNA D stated the handwritten statement written by the DON was not accurate. CNA D stated when the DON called her and asked her about the gait belt on Resident #1, she told the DON, no. CNA D stated she thought the DON misunderstood her. CNA D stated RN A did ask her to put a gait belt on as a restraint on Resident #1, but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates. CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. She stated RN A was just rude and loud. She would tell the residents things like it's enough already. CNA D stated it was not the way she personally would talk to the residents, but it was not abusive. She stated she never heard RN A cuss at a resident. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., CNA E stated she worked with an agency and had worked at the facility regularly for 3-4 months, mostly on the weekends with RN A. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H . She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON, RN A makes her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON she (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). CNA E stated RN A was verbally abusive to residents as well. She stated she was nasty and unkind to Resident #5. CNA E stated RN A would say shut up and fuck off to the residents. She stated or RN A would tell them they smell, or they were not loved. CNA E stated she told the DON she would never work with RN A again. CNA E stated She stated she was trained to report abuse to her agency. She stated her agency was a data base and she entered it into the data base but could not remember when this occurred, she stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint and then was mean to the residents telling them to shut up and called them stupid. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no, and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (date unknown). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. CNA N stated RN A was not verbally the nicest, but more like she was inconvenienced by the residents rather than abusive towards them. CNA N stated she never heard name called. She stated RN A did use profanity but not directed towards the residents. CNA N stated the first time she told anyone about it was that Friday 3/01/2024. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated RN A was slamming drawers on the med carts around the residents. She stated she told all of this to management. CNA N stated Resident #1 did not seem up set because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated she did not see any injuries to Resident #1. She stated management responded by saying there would be a state investigation. CNA N stated she was not asked to write a witness statement from facility management. She stated she would be willing to write out her version on a piece of paper in front of this surveyor for proof. During an interview on 4/17/2024 at 6:10 p.m., the ADON was presented as a witness by the DON. The ADON stated CNA D told her she did see RN A strap Resident #1 to a chair with a gait belt but because RN A was a registered nurse, she did not report it because Who are they going to believe a RN or a CNA? The ADON stated CNA D stated she actually witnessed it and told the ADON approximately one month ago. The ADON stated she was a charge nurse when this occurred and did not become the ADON until 3/01/2024. The ADON stated the first time she knew anything about the situation was when all the chatter started about it when the facility reported it to state (3/01/2024). She stated she hard NA H and CNA C talk about it, but this was after it was already reported. The ADON stated she never heard any residents complain and did not see any change in any resident behaviors. The ADON stated restraint was abuse. The ADON stated she heard RN A state things like go over there or leave that alone in a loud voice but never heard her cuss or call a resident a name. She stated she never heard RN A raise her voice at a resident, she just used a loud voice. The ADON stated she has come to assist night shift before when they needed help but did not know where that was. She stated it was to do extra work. She stated she was new to the job and was still training. The ADON stated there had never been a discussion between management staff about monitoring night shift. The ADON stated she was not responsible for training any of the staff. During an observation and interview on 4/17/2024 at 6:35 p.m., the Maintenance Director measured the opening of the main living area to be 93 inches and the couch in the main living area was 74 inches. When placed in the middle of the doorway there was a 4.5 inch opening on each side of the couch which was too small for wither a wheelchair or a person to be able to walk through. The Maintenance Director stated there used to be two couches in the main living area, but one was thrown away on an unknown date. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she was regular full-time staff at the facility and worked many extra shifts. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not scream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F denied knowledge of any other resident abuse. She denied knowledge of verbal/emotional abuse. CNA F stated RN A had a very hard deep voice, a very strong voice. She stated when RN A spoke at the nurses station, she could be heard all the way down at the end of the hall but it was not in a disrespectful way. CNA F stated RN A was a really good nurse. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated they normally work with one nurse and two aides at night. She stated they would all take turns watching the residents. She stated some of the residents do not sleep at night and there had been some chaotic nights. She stated on the chaotic nights they still made sure the residents needs were met. CNA F stated she did not complete the abuse training in-service after the incident and still had not completed it as of this interview. She stated she worked to help the DON out by working an extra shift and the DON gave her permission to be excluded from the abuse class. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal and sexual abuse immediately to the Administrator. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated there were two-night shift nurses. She was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. She stated she was trained to report abuse, including restraint to the Administrator immedi [TRUNCATED]

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for 1 of 8 residents (Resident #1) reviewed for restraint and abuse, in that; The facility failed to develop and implement and abuse policy that clearly defines restraint as abuse and ensure staff had the knowledge of how and where to report allegations of restraint and abuse. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. This failure could place all residents at risk for potential abuse due to restraint due to unreported restraint and abuse and result in continued abuse, physical harm, psychosocial harm and a decline in health and potential for injury. The findings included: Record review of a facility policy titled Abuse and Neglect-Clinical Protocol dated 2022 revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. The policy did not identify or define restraint as a form of abuse. Record review of a facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect undated revealed To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services Immediately. This policy contradicts other evidence including an interview with the Administrator who identified herself as the abuse coordinator. Record review of Form 3613-A Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA alleged RN A used a gait belt to keep a resident in the wheelchair and used profanity when she spoke to a resident. The report indicated Resident #1 was the victim. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment, and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it, she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 two to three times, but she was very vague. During an interview on 4/17/2024 at 3:17 p.m., the DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A were CNA C and CNA D. The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation, they let her go. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNAs to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. She stated CNA E took RN A a gait belt and gave it to her, but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like she did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON; it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down, and the CNAs were down the halls working. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which is what she did (to the DON). During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated RN A did ask her to put a gait belt on as a restraint on Resident #1 but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., agency CNA E stated she was trained to report abuse to her agency. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H. She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen, and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON; RN A makes her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON she (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). She stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated she reported the restraint of Resident #1 on Friday 3/01/2024 to the DON and Administrator together after having knowledge of it for several days. She stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint and then was mean to the residents telling them to shut up and called them stupid. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (3/01/2024). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. CNA N stated RN A was not verbally the nicest, but more like she was inconvenienced by the residents rather than abusive towards them. CNA N stated she never heard name called. She stated RN A did use profanity but not directed towards the residents. CNA N stated the first time she told anyone about it was that Friday 3/01/2024. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated RN A was slamming drawers on the med carts around the residents. She stated she told all of this to management. CNA N stated Resident #1 did not seem upset because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated management responded by saying there would be a state investigation. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal, and sexual abuse immediately to the Administrator. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not cream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated she knows she should have reported it. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated she was trained to report abuse, including restraint to the Administrator immediately. She stated was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. During an interview on 4/17/2024 at 7:19 p.m., CNA K stated RN A never asked her to put a restraint or use a gait belt on a resident. She stated she never saw one put on a resident but did hear RN A state she was going to have to put a gait belt on Resident #1 to keep him in his wheelchair so he would not fall. CNA K stated she tried to just keep to herself and not pay attention. She stated she could not really remember working at the facility when asked if she had reported it. She replied I don't remember to all further questions about details and training and declined further interview. During an interview on 4/17/2024 at 7:24 p.m., CNA G stated restraint was considered abuse and was supposed to be reported to the Administrator immediately. She stated the very first time she worked nights at the facility, a Saturday night (2/10/2024-2/11/2024), RN A asked NA H to put a gait belt around Resident #1. CNA G stated NA H physically put the gait belt around the resident clasping it in the back. CNA G stated she asked NA H what she was doing it and NA H stated she was restraining Resident #1. CNA G stated had asked RN A if there were doctor's order and she said no, it was just the way she did it so he would not have any falls. CNA G stated she told NA H she had to take it off Resident #1 because there were no doctor's orders and NA H said no. CNA G stated she knew it was against the law to restrain residents in the state of Texas. She stated CNA E and RN A got in an argument over it. CNA G stated it just did not sit right with her and felt like the DON would have told her if they were supposed to restrain Resident #1. CNA G stated CNA E said it had happened before and that she had reported it to her agency. CNA G stated RN A got really upset with her when she told her to take it off. CNA G stated she asked CNA E to help her take it off Resident #1. She stated RN A told her and CNA E if we touched Resident #1, we would get in trouble. CNA G stated CNA E and RN A got in a screaming match and a lot of abuse things were said by both parties. She stated both CNA E and RN A were calling the DON trying to resolve it. CNA G stated she told the DON about the gait belt. She stated she was not able to hear the DON's response. She stated while CNA E was talking to the DON on the phone RN A continued yelling at CNA E. CNA G stated she did hear CNA E tell the DON that RN A placed a gait belt around Resident #1 and that she told NA H to do it to. CNA G stated she heard CNA E tell the DON that she (CNA G) had taken it off. CNA G stated she does not know what was said after that point because CNA E had to go outside to continue the conversation because RN A was yelling. CNA G stated after this happened everything calmed down and she took Resident #1 to bed. CNA G stated when she came back to work on Sunday (date unknown) RN A tried to do it again. She stated RN A told NA H to do it and this time NA H refused. CNA G stated RN A said if ya'll are not going to do it then she was going to do it. CNA G stated she told RN A no and told her she was just going to lay Resident #1 down in bed. CNA G stated RN A stated if he stays in bed then that is perfect. CNA G stated she never witnessed RN A physically put the gait belt on Resident #1 but she did witness her tell NA H to do it. She stated those were the only two days she worked with RN A. She stated she told the DON she was not going to work with RN A anymore because of it and moved to working day shift. CNA G stated this occurred on Super Bowl weekend 2/11/2024. She stated she worked both 2/10/2024 and 2/11/2024. CNA G stated after CNA E reported the restraint to the DON, RN A stayed at the facility and worked the whole shift. She stated no one went home. She stated the DON never came to the facility that night. CNA G stated she was new to the facility at the time and did not have anyone's phone numbers to report it but she knew CNA E reported it. She stated CNA E showed her where she had reported it (to her agency) multiple times, 3 times in total on the portal. She stated after this occurred the facility eventually put phone numbers up to report abuse. CNA G stated RN A continued to work in at the facility until sometimes in March (date unknown). CNA G denied knowledge of abuse or restraint of any other resident. She stated it was just Resident #1. She stated Resident #1 looked really confused by the restraint and he was trying to fight it. She stated he did not know why he could not get up. She stated it was tied around him like a seat belt. She stated he was trying to get up and stand up which was causing the wheelchair to move forward with him. She stated it was almost making the wheelchair fall over while he was trying to stand up. CNA G stated it looked really weird. She stated RN A then placed Resident #1 in the corner of the main living room area with a table in front of him blocking his wheelchair with furniture so he could not move. She stated he still had the gait belt around his abdomen at the time. She stated the gait belt was on tight and she was not able to get her fingers under the belt. CNA G stated she could not tell if Resident #1 was in any pain. She stated he just looked frustrated and confused. She stated Resident #1 could not really express his feelings because of the dementia. She stated he was unable to talk. CNA G stated on one of the days she was unsure how long Resident #1 had been in the restraint. She stated he was already in it when she saw it around 8:00 p.m. She stated she heard RN A tell NA H to put it on his but she did not see it occur. She stated she just heard RN A yell at NA H. She stated the words she heard were get the gait belt and NA H went and did it. CNA G stated she had always been taught they could not prevent a resident from moving by placement of furniture because that in of itself was considered restraint. She stated she was also told that the facility does not use restraints except by doctor order and we could not use objects as restraint. CNA G stated it was important that the residents have the right to be free and they don't deserve to be restrained or abused. During an interview on 4/17/2024 at 7:51 p.m., agency CNA M stated she was trained to notify the DON for any problems at the facility. She stated she only worked one night at the facility with RN A. She stated she had problems with RN A and did have to call the DON for interventions. She stated she refused to return to work at the facility after that one night due to issues with RN A. CNA M stated she had no knowledge of restraint or abuse. During an interview on 4/17/2024 at 7:53 p.m., agency CNA P stated she was trained to report abuse to her agency and to the Administrator. She stated she was trained they were not supposed to restrain people and she would report as abuse. She stated she had no knowledge of abuse or neglect at the facility. During an interview on 4/17/2024 at 8:09 p.m., the DON stated she first learned issues involving abuse/restraint regarding on evening/night shift when CNA B called her on 3/01/2024. She stated after she talked to CNA B, she also spoke with CNA E. The DON stated she did not obtain a statement of what happened from CNA E because her and RN A had argued on the shift, and she knew they were not getting along. The DON stated she wanted to only consider facts. The DON stated the argument between RN A and CNA E occurred sometime in February. She estimated it to be 2/27/2024 or 2/28/2024. She stated it was shortly before CNA B told her about the gait belt. The DON stated she did not bring CNA E back to work for approximately two weeks because she thought she was the problem. The DON stated what was reported to her in February was that RN A was rude and disrespectful. There was nothing about a gait belt. The DON stated after she talked to CNA E on the phone in February, RN A called her and told her CNA E was lazy and did not want to work with her. The DON stated she asked what she meant by that, and RN A wanted CNA E to do vital signs, but CNA E was giving showers. The DON stated she told RN A that the nurse typically obtains vital signs, but RN A did not like that answer. The DON stated she did not come to the facility during that shift to assess the situation. She stated they both agreed to get along and she (DON) felt the situation was okay. The DON stated she also talked to other staff but could not remember who she talked to. She stated the other staff told her RN A was rude. DON stated both RN A and CNA E were shouting but both agreed they could finish the shift. She stated no one told her about a gait belt restraint and she did not know how it impacted the residents. The DON stated she did not believe she received any notification about restraint or abuse or the use of a gait belt on 2/11/2024. She stated night shift nurse should report abuse to her. She stated she was certain no one told her about a gait belt as a restraint. She stated the staff only told her about it when she specifically asked questions about it. The DON stated RN A told her the gait belt restraint was to keep Resident #1 from falling. The DON stated no one had told her anyone was using furniture to block Resident #1. She stated that would be violating the rights of the resident and they could be injured. She stated their resident population, due to dementia just do not understand. She stated the resident's do not even understand something you do not want them to do. The DON stated the charge nurse was responsible for ensuring the safety of residents, for ensuring they were free from abuse and restraint on night shift. The DON stated she was responsible for monitoring the charge nurses. She stated she monitored the charge nurses by having a ton of in-services. She stated she had periodically dropped in at night to deliver supplies, to start an IV or just to peek in a window. She stated both the charge nurses and her were responsible for monitoring agency staff. The DON stated the agency was responsible for ensuring their staff had their own training. The DON stated the facility ensured residents were safe and free from harm by constant in-services and weekly skin assessments and observations. The DON stated does and does not consider restraint abuse, depending on the circumstances. The DON stated for Resident #1 his own family member wanted him to have a seat belt on his wheelchair. She stated she does not think in this case it would be considered abuse because he would not even realize he had one on. The DON stated she knows they are not supposed to use a gait belt as a restraint, but it was a hard one to consider and she didn't know if she would consider it abuse. The DON stated a restraint for Resident #1 did not pass legal because they are a restraint free facility. The DON stated her only question was if RN A was at that point of needing to use a gait belt as a restraint, why did she not call and tell anyone. The DON stated she does consider furniture placement as abuse because it prevents movement. She stated Resident #1 had to have some way to burn his energy and if he cannot stand, he wants to move. She stated he used his feet to self-propel in the wheelchair around the facility. The DON stated their policy indicated the facility was restraint free. She stated they could not block their vision or impede residents from getting out of bed. She stated the abuse policy did indicate restraint was abuse to her knowledge. During an interview on 4/18/2024 at 9:16 a.m., the Medical Director (MD) stated he had not been made aware of abuse/restraints in the facility. He stated he thought restraints were wrong. The MD stated he typically communicated with the facility and heard about situations like this from a call from the DON, the Administrator, or the NP. He stated he would tell them he did not agree with the restraint, but that had not happened, no one had communicated with him. He stated he communicated with the DON when he came to the facility and during QAPI meetings to discuss incidents to try to make things better. The MD stated the last QAPI was a few weeks ago and restrains was not part of the discussion. During an interview on 4/18/2024 at 10:56 a.m., the Administrator stated she was the abuse coordinator. She stated she expected the staff to notify her regardless of time immediately for any suspected abuse. She stated her phone numb [TRUNCATED]