Every finding on record at Rose Haven Retreat

Based on observation, interview, and record review, the facility failed to maintain all essential mechanical and electrical equipment in safe operating condition, for 1 of 1 commercial gas range and oven in the kitchen reviewed for food service in that:The facility did not ensure the commercial gas range and oven were in proper working order: Two of ten gas stove burners (far right front and back) did not light automatically, when the knobs were turned on. Eight of ten gas burners had carbon buildup. One (right oven) of two ovens did not heat properly.These failures could place residents who ate food from the kitchen at risk for under-cooked food and foodborne illness.Findings included:During an observation and interview on 6/15/26 beginning at 9:07 AM, initial tour of the kitchen revealed there was carbon buildup on eight of the ten burners on the commercial gas range. DA E said all of their equipment was in good working order except for the right-side oven. DA E said it often did not cook at the proper temperature, and it had been going on for quite a while. DA E said they would work on it to fix it, and it would maybe work right for two weeks and then it would go back to not heating correctly.During an observation and interview on 6/16/26 beginning at 10:00 AM to observe preparation of purees (smooth, lump-free food with a pudding consistency) followed by food temperatures, at 10:35 AM, [NAME] F removed a pan of Teriyaki chicken from the oven on the right side of the stove and placed a thermometer in the chicken. The thermometer read 140 degrees. The right-side oven was set at 350 degrees. During observation, [NAME] F did not open the right side of the oven between 10:00 AM and 10:35 AM. [NAME] F said the chicken had been in the oven since before 9:00 AM and it still was not hot enough. [NAME] F placed the pan of chicken over two burners on the top of the stove. [NAME] F said the right-side oven had issues and she often had to take food out and place it on the stove burners to heat the food to the right temperatures. [NAME] F said it was a frequent occurrence that the food was not cooked in the right-side oven. [NAME] F said often she would think the food would be done because it had been in the oven for the required amount of time or more, but then when she pulled the food out of the oven, it would not be done. [NAME] F had to frequently stir the chicken as the liquid in the pan was boiling. [NAME] F said she had to watch it closely to not burn or scorch it while trying to cook the chicken to the appropriate temperature to serve to the residents. [NAME] F said it would often put her behind and she had to rush to heat the food on the stove top to get the residents' meals served on time. There continued to be carbon build up to eight of ten burners on top of stove.During an interview on 6/17/26 at 9:15 AM, DA E said she had worked at the facility for over thirteen years, and the stove was there long before she came to work there. DA E said the burners on the right side of the stove had not worked since the last time the vent-a-hood cleaning service came around the end of May 2026. DA E said they reported the burners not working to the Maintenance Supervisor verbally, about two weeks ago.During an observation and interview on 6/17/26 at 9:30 AM, [NAME] F said she had worked at the facility for four years this time. [NAME] F said she had come in around 5:15 AM and turned the right oven on at 350 degrees. [NAME] F said she was cooking hamburger patties in both ovens for the lunch meal and started them early to ensure she had time, if they were not cooked all the way. [NAME] F said she was going to check the hamburger patties at that time. Using an infrared thermometer, the right-side oven temperature was 230 degrees when the oven door was opened, and the oven was set at 350 degrees. The left-side oven temperature was 382 degrees when the oven door was opened, and it was set at 400 degrees. [NAME] F said the two burners on the far right-side of the stove top would not light automatically. [NAME] F said she had to use a lighter to light it, so she usually did not use them. [NAME] F turned both knobs on of the two far right-side burners, and they did not light automatically. [NAME] F said if someone accidentally did not turn off the two far right-side burners that did not automatically light, if could let gas out and could be a fire hazard. [NAME] F said they tried to clean the stove top burners with oven cleaner, but it did not do anything to remove the carbon buildup or grease. [NAME] F said the Maintenance Supervisor had to take them outside to pressure wash them when they got real bad. [NAME] F said they did not have a schedule to take them out to clean them, but the Maintenance Supervisor normally would clean them when they asked her to, when she had time. [NAME] F said the carbon buildup on the stove top was real bad now and it could catch on fire. [NAME] F said Maintenance Supervisor said she was going to come clean them about 2 weeks ago, but she had not had a chance to do it yet. [NAME] F said they also told the Maintenance Supervisor when they had issues with the stove/oven and had told the Maintenance Supervisor over a month ago that the right oven was not heating right again and told her about the two burners not lighting about two weeks ago. [NAME] F said the right-side oven not heating properly was more of an inconvenient issue for the cooks, because as the cooks, they would make sure to heat the food to the appropriate temperatures before serving the food, so there would not be a risk to the residents. During an interview on 6/17/26 at 10:10 AM, the Maintenance Supervisor said she had worked at the facility for about 18 years. The Maintenance Supervisor said either the staff members would let her know if there is an issue with equipment or they would write it in her maintenance book. The Maintenance Supervisor said there was something with the stove oven. The Maintenance Supervisor said they knew that one side heats really good and the other side heats but did not get as hot. The Maintenance Supervisor said she knew there was a problem and they would have to replace a small part in it every so often and it may need to be replaced again. The Maintenance Supervisor said she did not know about the burners, not lighting. The Maintenance Supervisor said if they verbally told her about the burners, she gets told so much that she may have forgotten. The Maintenance Supervisor said if staff forgot to turn off the burners that did not light, the gas detectors would let them know or they could smell it if they were left on. The Maintenance Supervisor said she did not have a schedule to clean the stove top burners/grills, but she needed to get the grills on the stove cleaned now. The Maintenance Supervisor said she cleaned them at least every two months or sooner if needed. During an interview on 6/17/26 at 10:38 AM, the Maintenance Director said he was over this facility and one other facility. The Maintenance Director said if staff do not write things in the maintenance log, then he does not know when issues happen. The Maintenance Director said both ovens had been worked on previously. The Maintenance Director said during the past Thanksgivings, they tried to say a thick pan of dressing would not cook in the oven, but he felt the pan of dressing was too big and thick and that was why it did not cook. The Maintenance Director said he could call the repair people that worked on that type of equipment. The Maintenance Director said if the burners would not light automatically and the knob was left on accidently; it could let gas out. The Maintenance Director said they only cleaned the burners as needed and they did not have a scheduled cleaning time. The Maintenance Director said he really did not know what the risk of having the carbon build up on the top of the stove would be. The Maintenance Director said staff should have written any issues with the stove/oven in the maintenance log at the nurse's station, or notified the Maintenance Supervisor or himself, and they all had his number. Documentation related to any maintenance or repairs of the stove/oven was requested.During an observation and interview on 6/17/26 at 12:37 PM, the Maintenance Director said the staff that worked with the equipment would be responsible for ensuring the Maintenance Department, himself or the Maintenance Supervisor, were notified if something was not working properly. The Maintenance Director said staff should be writing in the maintenance log and letting them know, so they could get issues addressed. The maintenance log was reviewed with the Maintenance Director and there were no work orders related to the stove/oven or burners not working.On 6/17/26 at 1:50 PM, the Maintenance Director provided documentation of the last time a technician came to work on the stove/oven, it was dated 11/13/25 and said they came out and adjusted the thermometer on the right-side oven.Record review of the facility's policy titled Maintenance Service dated revised December 2009 revealed . Maintenance Service shall be provided to all areas of the building, grounds, and equipment . the Maintenance Department was responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times . the Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment were maintained in a safe and operable manner .

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for incontinent care. (Resident #7)The facility failed to ensure CNA A changed her gloves and sanitized her hands after providing incontinent care to Resident #7 prior to touching Resident #7's clean fabric incontinent pad, her bare leg and shoulder, and her bedding.This failure could place residents and staff at risk for cross-contamination and the spread of infection.Findings included:Record review of Resident #7's face sheet dated 6/16/26 indicated she was an [AGE] year-old female and she admitted to the facility initially on 11/13/19 and re-admitted on [DATE]. Resident #7 had diagnoses including dementia (decline in mental ability), diarrhea (loose, watery stools) and hypertension (high blood pressure).Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated she was understood and understood others. The MDS indicated she had a BIMS score of 6 which indicated she had severe cognitive impairment. The MDS indicated Resident #7 required substantial assistance of staff in performing most activities of daily living. The MDS indicated Resident #7 was always incontinent of bowel and bladder.Record review of Resident #7's undated care plan indicated she had the potential for urinary tract infections related to a history of urinary tract infections with interventions to ensure meticulous personal hygiene, especially after elimination, to provide perineal (private areas) care as soon as possible after an incontinent episode per the facility policy and use principles of infection control.During an observation on 6/16/26 beginning at 1:10 PM, CNA A assisted by CNA B provided incontinent care for Resident #7. CNA A and CNA B washed their hands and put on clean gloves. CNA A and CNA B positioned themselves one on each side of Resident #7's bed. CNA B assisted with turning Resident #7 and CNA A performed the incontinent care. CNA A and CNA B positioned Resident #7's covers to expose her front perineal area. CNA A removed her gloves, sanitized her hands, and put on clean gloves. CNA A used a multi-folded washcloth to cleanse Resident #7's front perineal area appropriately and then discarded the washcloth. CNA A removed her soiled gloves, sanitized her hands and put on a clean pair of gloves. CNA A and CNA B rolled Resident #7 toward the wall and CNA B held the resident on her side. CNA A then used a clean multi-folded washcloth to cleanse bowel movement off Resident #7's back perineal area appropriately and then she took a towel and dried the resident's back perineal area. CNA A then got a clean fabric incontinent pad from a bag on the bedside table, rolled it 1/2 way and pushed it under the resident's bottom half of her body wearing the same gloves she used to clean bowel movement off of Resident #7's back perineal area. CNA A assisted Resident #7 onto her back. CNA A then put the same gloved hands used to clean bowel movement off Resident #7's back perineal area, onto Resident #7's bare left leg and shoulder and pulled the resident toward herself. CNA B pulled the other 1/2 of the fabric incontinent pad from under the resident and smoothed it out on the bed, and then the resident was allowed to roll back onto her back. CNA A and CNA B pulled the covers up over resident. CNA A then removed her gloves that were used to cleanse bowel movement from Resident #7's back perineal area and sanitized her hands. CNA A and CNA B then pulled Resident #7 up in bed and positioned her for comfort.During an interview on 6/16/26 at 1:25 PM, CNA A said she had worked at the facility since February 2026. CNA A said she was nervous during the incontinent care on Resident #7, and she should have changed her gloves and sanitized her hands after she cleaned the bowel movement off the resident and before she handled Resident #7's clean linens, bedding, or Resident #7. CNA A said she cross-contaminated and whatever was on her gloves could have gotten on anything she touched with those gloves. CNA A said the resident could get an infection and could get sick from her not changing her gloves or sanitizing her hands after cleaning bowel movement during incontinent care and then touching clean items on the resident's bed. CNA A said she had been trained to change her gloves and sanitize her hands after cleaning bowel movement from the resident and prior to touching clean items, but she was nervous and must have forgotten to.During an interview on 6/16/26 at 1:28 PM, CNA B said she had worked at the facility for about 2 years as a CNA. CNA B said staff should change their gloves after cleaning the front perineal area and after cleaning the back perineal area. CNA B said staff should change their gloves before touching anything clean such as the resident's bedding or the resident. CNA B said CNA A did not change her gloves or sanitize her hands after cleaning bowel movement off Resident #7's back perineal area and before touching her clean pad, turning her, or touching Resident #7's bedding. CNA B said staff were not supposed to touch anything clean after providing incontinent care because it was dirty and cross-contaminated anything that was touched with the soiled gloves. CNA B said the resident could get sick from the cross-contamination.During an interview on 6/17/26 at 10:01 AM, CNA C said he was the CNA Supervisor. CNA C said staff should change their gloves and sanitize their hands after performing incontinent care to the resident's front perineal area. CNA C said then they would do the back perineal area. CNA C said staff should then change their gloves and sanitize their hands and remove the privacy blanket and then pull the resident's covers up. CNA C said by CNA A not changing her gloves after cleaning bowel movement off the resident's back perineal area and touching the incontinent pad and her covers was cross-contamination. CNA C said not changing her gloves after cleaning bowel movement off the resident's back perineal area, could spread infection and germs.During an interview on 6/17/26 at 12:52 PM, the DON said staff should be removing their gloves and sanitizing their hands after providing incontinent care to the resident. The DON said staff should not be touching any of the resident's clean linens, bedding, call lights or anything clean wearing the same gloves that were used to clean bowel movement or provide incontinent care to the resident. The DON said the staff know what they should do, but they get nervous and forget what they are doing. The DON said she would expect the staff to change gloves before touching other items in the resident's room after performing incontinent care. The DON said by not changing gloves after incontinent care and touching items on the resident's bed, it placed the resident at risk for the spread of infection.During an interview on 6/17/26 at 1:06 PM, the ADM said staff contaminated whatever the CNA touched, when she did not change her gloves after cleaning bowel movement from the resident while performing incontinent care. The ADM said the resident could get an infection from the CNA not changing her gloves and not performing hand hygiene after cleaning bowel movement from the resident and then touching clean linen and the resident, and it was just nasty and could be a dignity issue. The ADM said she would expect staff to follow the facility policies while performing incontinent care.Record review of the facility's policy titled Perineal Care dated revised October 2010 revealed . the purpose of this procedure is to provide cleanliness and comfort to the resident, preventing infections and skin irritation . Steps in the Procedure . 2. Wash and dry your hands . 7. put on gloves . 9. For female resident . 9b. wash perineal area, wiping from front to back . 9c. Instruct or assist the resident to turn on her side . 9e. Wash rectal area thoroughly . g. Dry area thoroughly . 11. Discard disposable items into designated containers . 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly . 13. Reposition bed covers. Make resident comfortable .Record review of the facility's policy titled Infection Control Guidelines for All Nursing Procedures dated revised August 2012 revealed . Purpose . To provide guidelines for general infection control while caring for residents . 3. Employees must wash their hands for ten to fifteen seconds using . soap and water under the following conditions . c. after contact with blood, body fluids, secretions, mucous membranes . d. After removing gloves . e. After handling items potentially contaminated with blood, body fluids, or secretions . 4. In most situations, the preferred method of hand hygiene was with an alcohol-based hand rub . for all the following situations . a. Before and after direct contact with residents . f. Before moving from a contaminated body site to a clean body site during resident care . j. After removing gloves .

Based on interview and record review, the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident that were complete and accurately documented for 2 of 4 residents (Resident #27 and Resident #61) reviewed for accuracy of medical records. 1. The facility failed to ensure Resident #27 and Resident #61's baseline care plans were dated. 2. The facility failed to ensure Resident #27's baseline care plan had the accurate family member listed as informed and delivered. 3. The facility failed to ensure LVN D's signature on Resident #27's baseline care plan was valid and accurate. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: 1. Record review of the face sheet, dated 06/17/26, reflected Resident #27 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia without behaviors (decline in cognitive abilities severe enough to interfere with daily life). Record review of the admission MDS assessment, dated 06/04/26, reflected Resident #27 had clear speech, was understood by others, and was able to understand others. Resident #27 had a BIMS score of 6, which indicated severe cognitive impairment. She had no behaviors or refusal of care. Record review of Resident #27's baseline care plan reflected there was no date to indicate the day the baseline care plan was completed. The section titled Written Summary of Baseline Care Plan was not filled out. Another resident's family member was written in the blank as being informed and delivered in person, with no date. LVN D's signature of her last name was misspelled. 2. Record review of the face sheet, dated 06/17/26, reflected Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, with agitation-sundowner syndrome (a person with dementia whose specific type is not clearly identified, but who exhibits agitation and sundowning - a pattern of mood and behavioral symptoms that worsen in the late afternoon, evening, or night). Record review of the MDS assessment list, accessed on 06/17/26, reflected Resident #61's MDS assessment was In progress. It had not been completed. Record review of Resident #61's baseline care plan reflected there was no date to indicate the day the baseline care plan was completed. The section titled Written Summary of Baseline Care Plan was not filled out. During an interview on 06/16/26 at 3:44 p.m., LVN D stated the DON brought her the baseline care plan for Resident #27 earlier in the day (06/16/26) and asked her to fill it out because the state surveyor was asking for it. LVN D stated she was not the admitting nurse for Resident #27 but knew the resident pretty well because she had been at the facility for a few weeks. LVN D stated she checked off the boxes for Resident #27's baseline care plan but did not sign the document. LVN D was shown the paper copy of the baseline care plan and stated that it was not her signature. She stated the last name was spelled wrong. She stated she did not complete Resident #61's baseline care plan. During an interview on 06/17/26 at 9:58 a.m., Tthe DON stated she expected the baseline care plans to be completed fully and accurately. The DON stated she was unable to find Resident #27 and Resident #61's baseline care plans so both baseline care plans were completed on 06/16/26 when the state surveyor asked for them. The date was not filled out. She stated Resident #27's family member was not the one listed on the baseline care plan. She stated that it was inaccurate documentation. The DON said she was unsure who signed LVN D's name on Resident #27's baseline care plan. She said she was unsure why anyone would sign someone else's signature. She said it was important to ensure the baseline care plan documentation was completed fully and accurately to ensure each residents received the appropriate care and services. During an interview on 06/17/26 at 10:12 a.m., the Administrator stated she expected baseline care plans to have been completed accurately and completely. The Administrator stated the nurse was responsible for completing the baseline care plans accurately and fully. The Administrator stated she was unsure who would have signed LVN D's signature. The Administrator stated it was important to ensure records were completed accurately and fully so the facility staff had the information they needed and access to the care needed for each resident. Record review of the Charting and Documentation policy, dated July 2017, reflected .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: .a. the date and time of the procedure/treatment was provided; the name and title of the individual who provided the care. the signature and title of the individual documenting.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and provide the resident and their representative with a summary of the baseline care plan for 2 of 4 (Resident #27 and Resident #61) residents reviewed for baseline care plans. 1. The facility did not ensure Resident #27 and Resident #61's baseline care plan was developed within 48 hours of admitting to the facility. 2. The facility did not ensure Resident #27, Resident #61, or their representatives were provided with a summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: 1. Record review of the face sheet, dated 06/17/26, reflected Resident #27 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia without behaviors (decline in cognitive abilities severe enough to interfere with daily life). Record review of the admission MDS assessment, dated 06/04/26, reflected Resident #27 had clear speech, was understood by others, and was able to understand others. Resident #27 had a BIMS score of 6, which indicated severe cognitive impairment. She had no behaviors or refusal of care. Record review of Resident #27's baseline care plan reflected there was no date to indicate the day the baseline care plan was completed. The section titled Written Summary of Baseline Care Plan was not filled out. Another resident's family member was written in the blank as being informed and delivered in person, with no date. During an observation and interview on 06/15/26 at 10:04 a.m., Resident #27 was walking down the hallway using her rolling walker. The conversation with Resident #27 was confused and she was unable to remember admitting to the facility. 2. Record review of the face sheet, dated 06/17/26, reflected Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, with agitation-sundowner syndrome (a person with dementia whose specific type is not clearly identified, but who exhibits agitation and sundowning - a pattern of mood or behavioral that worsen in the late afternoon, evening, or night). Record review of the MDS assessment list, accessed on 06/17/26, reflected Resident #61's MDS assessment was In progress. It had not been completed. Record review of Resident #61's baseline care plan reflected there was no date to indicate the day the baseline care plan was completed. The section titled Written Summary of Baseline Care Plan was not filled out. There was no indication that the resident or resident representative was informed. During an observation and interview on 06/15/26 at 11:25 a.m., Resident #61 was wheeling himself around in his wheelchair. The conversation with Resident #61 was confused. Resident #61 stated he needed to call his wife to come pick him up. He believed he was at a diner for free coffee. During an attempted telephone interview on 06/15/26 at 2:33 p.m., Resident #61's family member did not answer the phone. A brief message was left with a call back number that was not returned upon exit from the facility. During an attempted telephone interview on 06/15/26 at 2:41 p.m., Resident #27's family member did not answer the phone. A brief message was left with a call back number that was not returned upon exit from the facility. During an interview on 06/16/26 at 3:44 p.m., LVN D stated the admitting nurse was responsible for completing the baseline care plan. She stated the baseline care plan was a form that was included in the admission packet that was provided by the management team. LVN D stated the admitting nurse was the one who initiated the baseline care plan. LVN D stated the baseline care plan was usually checked off but she did not go over the baseline care plan with the families. She stated the DON brought her the baseline care plan for Resident #27 earlier in the day (06/16/26) and asked her to fill it out because the state surveyor was asking for it. LVN D stated she was not the admitting nurse for Resident #27 but knew the resident pretty well because she had been at the facility for a few weeks. LVN D stated she was the admitting nurse for Resident #61 and believed she had mistaken the baseline care plan for the elopement care plan. LVN D stated she did not complete Resident #61's baseline care plan. LVN D stated it was important to ensure baseline care plans were completed within 48 hours, so residents received accurate and consistent care. During an interview on 06/17/26 at 9:58 a.m., the DON stated baseline care plans were part of the admission packet. The DON stated the charge nurse was responsible for completing them on admission, then they were placed in the chart. She stated the interdisciplinary team reviewed the baseline care plans at the first care plan meeting after admission. The DON stated she was unable to find Resident #27 and Resident #61's baseline care plans so both baseline care plans were completed on 06/16/26 when the state surveyor asked for them. She stated the facility staff went over the care provided to each resident with the representatives, but they did not go over the baseline care plan form specifically. She said it was important to ensure the baseline care plans were completed timely and discussed with the family to ensure the correct care was being provided to the resident. During an interview on 06/17/26 at 10:12 a.m., the Administrator stated she expected baseline care plans to have been completed upon admission or at least within 24 hours after admission. The Administrator stated the nurse was responsible for completing the baseline care plans and going over them with the resident and their family. The Administrator stated it was important to ensure baseline care plans were completed timely and discussed with the family to ensure the correct care was being provided to the resident. Record review of the Care Plans - Baseline policy, dated December 2016, reflected 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.the resident and their representative will be provided a summary of the baseline care plan.

Based on interview and record review the facility failed to provide notice to residents when changes in coverage were made to items and services covered by Medicare as soon as is reasonably possible to 2 of 3 residents (Resident #6 and Resident #10) who were provided skilled Medicare services, were discharged from services, and remained in the facility in that: 1. The facility failed to notify Resident #6 and Resident #10 at least 2 days before the end of Medicare Part A coverage. 2. The facility failed to notify Resident #6 and Resident #10 with a complete Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form before the end of Medicare Part A coverage. These failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services.The findings were:1. Record review of a face sheet, dated 06/16/26, revealed Resident #6 was admitted on [DATE] with diagnoses including dementia, diabetes, and anxiety disorder.Record review of a quarterly MDS dated [DATE], revealed Resident #6 had a BIMS of 7 which indicated severely impaired cognition. The MDS indicated Resident #6 required supervision or touch assistance with ADLs.Record review of a SNF (skilled nursing facility) Beneficiary Notification Review form indicated Resident #6's last day of coverage of Part A Service was 01/04/26. The form indicated Resident #6 had been provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form and Notice of Medicare Non-Coverage form.Record review of a Notice of Medicare Non-Coverage form revealed Part A (Skilled) coverage for Resident #6 ended on 01/05/26. The form was signed by Resident #6 on 01/05/26.Record review of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form for Resident #6 reflected it was incomplete. There was no date indicating the date coverage would end and care the resident had received during the Inpatient Skilled Nursing Facility stay was not completed. The estimated cost of services per day/item was completed. The form was signed by the resident on 01/04/26. 2. Record Review of a face sheet, dated 06/16/26, revealed Resident #10 was initially admitted on [DATE] with diagnoses including chronic obstructive pulmonary diseases (chronic lung disease), nasal congestion, and pain.Record Review of a quarterly MDS for Resident #10, dated 04/13/26, revealed a BIMS of 12 indicating moderate cognitive impairment. The MDS indicated Resident #10 required supervision to touching assistance with ADLs.Record review of a SNF (skilled nursing facility) Beneficiary Notification Review form indicated Resident #10's last day of coverage of Part A Service was 02/04/26. The form indicated Resident #10 had refused to sign a Beneficiary Notice task did not reveal a Notice of Medicare Non-Coverage form.Record review of documentation provided by the facility between 06/15/26 - 06/17/26 for the Beneficiary Notice task did not reveal a Notice of Medicare Non-Coverage form for Resident #10.Record review of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form for Resident #10 reflected it was incomplete. There was no date indicating the date coverage would end and care the resident had received during the Inpatient Skilled Nursing Facility stay was not completed. The estimated cost of services per day/item was completed. The form was signed by the resident on 02/05/26.During an interview on 06/17/26 at 10:16 a.m., the Social Worker said the Beneficiary Notices were her responsibility, but she was not very familiar with the process. She said the Business Office Manager helped her. She said not being familiar with the process said was the reason the forms were not complete and the residents were not being notified in a timely manner.During an interview on 06/17/26 at 10:20 a.m., the Business Office Manager said the Social Worker was new to the Beneficiary Notice process, and she had been helping her. She said she did not know that the residents had to be notified at least 2 days before the last day of Part A Service coverage. She said Resident #10 had refused to sign a Notice of Medicare Non-Coverage form. She said she was not very familiar with the forms and that was why they were not completed accurately.During an interview on 06/17/26 at 12:17 p.m., the DON said Beneficiary notices were supposed to be given at least 48 hours in advance. She said she expected the notices to be complete and in the correct time frame. She said it was important for residents to be aware of the changes, if they want to appeal, and have their needs met.During an interview on 06/17/26 at 12:40 p.m., the Administrator said she expected for Beneficiary Notices to be done properly, completely, and timely. She said this was important because they do not want to surprise bill someone. She said residents need notice in case they need to make other arrangements and so they know what to expect.Record review of a Medicare Advanced Beneficiary Notice facility policy dated April 2021 indicated, .Residents are informed in advance when changes will occur in their bills.The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial.The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility.If the resident's Medicare P A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage (CMS form 10123) to the resident at least two calendar days before Medicare covered services end (for coverage reasons).

Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #1)The facility failed keep Resident #1 free of misappropriation of property when staff discovered a missing card of 60 Hydrocodone-acetaminophen 10/325 milligrams (a Schedule II controlled substance used for pain management).This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.Findings included:Record review of face sheet dated 05/11/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of dementia, diabetes, and spinal stenosis (the narrowing of spaces within the spine, placing pressure on the spinal cord and nerves, usually causing pain, numbness, or weakness in the lower back or neck).Record review of active physician's orders dated 05/11/26 for Resident #1 indicated an order for hydrocodone-acetaminophen (a Schedule II controlled substance used for pain management) 10/325 milligrams, 1 tablet every 6 hours at 12:00 a.m., 06:00 a.m., 12:00 p.m. and 06:00 p.m.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS of 07 which indicated severe cognitive impairment. The MDS indicated Resident #1 received a scheduled pain management regimen. The MDS indicated Resident #1 was taking an opioid.Record review of a care plan last revised on 03/16/26 for Resident #1 required pain management. There was an intervention to assist with ADLs and provide comfort measure as needed. The care plan indicated Resident #1 had potential for complaints of chronic pain related to spinal stenosis, chronic pain syndrome, and diabetes with poor circulation and neuropathy (damage to the nerves outside the brain and spinal cord, often causing weakness, numbness, and pain, typically in the hands and feet).Record review of a Medication Error Report dated 04/23/26 for Resident #1 indicated an error was discovered on 04/23/26 at 9:54 a.m. The report indicated the order was for Hydrocodone 10/325 milligrams 1 tablet by mouth every 6 hours routine. The report indicated alternate medication was available to manage pain. The report indicated the medication count sheet and card of medication was unaccounted for.Record review of a Nurse's Notes dated 04/23/26 signed by the DON indicated the following:*At 10:30 a.m. for Resident #1 indicated, .Norco (Hydrocodone) refill requested.not delivered to facility at this time.pharmacy called (and) reported med was last delivered on 4-1-26 to facility. Request was to soon.med error report done. (Physician) made aware.medication inventory audit completed.Pharmacy contacted R/T (related to) delivery (and) quantity. Resident denies any changes in pain.*At 12:15 p.m. indicated, .resident Norco will be delivered today (and) given when arrives. Resident states, I'm alright, it's no big deal.* At 4:12 p.m. indicated, Resident continues to get up in electric scooter & go outside for smoke breaks. No nonverbal indications of pain, also denies pain. (pain) 0/10 at that time.*At 5:30 p.m. indicated, Norco arrived from pharmacy.Record review of MAR for Resident #1 for 04/01/26 - 04/23/26 indicated and order for Hydrocodone-acetaminophen tablet, 10/325 milligrams, amount to administer was 1 tablet every 6 hours with a start date of 01/15/26. The MAR indicated the resident did not miss any doses of Hydrocodone.Record review of a police report dated 04/24/26 indicated the police department received a call regarding missing narcotics at the facility. The report indicated that the DON reported that on 04/01/26 the pharmacy delivered two blister packs of Hydrocodone, each containing 60 pills. However, only one pack could be accounted for and was currently in their possession. The DON stated it was possible the second pack was never delivered or that the discrepancy resulted from a pharmacy error. The report indicated the DON stated that such errors had occurred previously, though they were uncommon. The DON advised that the delivery driver stated he followed protocol by stapling the narcotics inside a brown bag before delivery. The report indicated the DON had contacted the pharmacy and requested a review of their surveillance footage. The report indicated that no error occurred during the medication transfer. The report indicated the officer had nothing further to report. Record review of a packing slip provided by the Pharmacy Manager dated 04/01/26 indicated a delivery was made to the facility for Resident #1. The packing slip indicated there were 2 cards of Hydrocodone-Acetaminophen 10/325 milligrams and each card contained 60 tablets each. There was a handwritten check mark by each card. The packing slip was signed at the bottom by RN C and the Delivery Driver on 04/01/26 at 7:15 p.m.During an interview on 05/11/26 at 10:09 a.m., Resident #1 said he had no issues with his pain medication. He said he had never missed any doses. He said the medication must be working because he was no longer in pain.During an interview on 05/11/26 at 11:35 a.m., Pharmacist D said after the medication for Resident #1 was discovered missing they watched the cameras. She said they could see on camera that the pharmacy technician placed the correct amount of medication in the bag on 04/01/26. She said the bag did not get opened again until it was at the facility. She said RN C checked the bag at the facility and signed saying the correct amount was delivered. She said the process for packaging medications was that a pharmacist filled each card. Then another pharmacist inspected the cards for accuracy. She said then the medications were carried to the back where they were scanned in and placed in the bag. She said the bag was then stapled shut with a packing slip in the bag and a packing slip on the outside of each bag.During an interview on 05/11/26 at 11:50 a.m., RN A said she was the one that discovered the missing Hydrocodone for Resident #1. She said Resident #1 was almost out of the medication. She said the sticker for the medication was missing, indicating it had already been ordered. She said one card of a 60 count of hydrocodone was missing. She said she counted the cart the medication was on in the morning with the night shift and then handed it over to the Medication Aide later in the morning. She said Resident #1 never went without his pain medication. She said she had counted on her shift on from 04/01/2026 - 04/23/2026 and the count had not been off. She said whatever was in the drawer was what had been in the book with two nurses counting. She said there were always two nurses counting. She said when she started her shift, herself and the night shift nurse counted all three carts. She said in the month of April she did not remember any discrepancies.During an interview on 05/11/26 at 12:49 p.m., RN B said she had counted the medications a few days before the card was found missing. She said Resident #1 only had a few left at that time. She said she questioned it and was told it had already been ordered by the day shift. Then she found out another card had already come in and there should be another card of 60 available. She said she could not ever remember there being a second full card of 60. She said when she came in at night, she counted with the 2 p.m. to 10 p.m. nurse. She said she felt the medication aide was already gone. She said they count all carts, the narcotics in the medication room and the emergency supply. She said Resident #1 received hydrocodone every 6 hours. She said there were no discrepancies in the month of April. She said they had to call the DON to report any and she has not had to do that. She said she was not sure at what point the cards were delivered. She said if two cards were delivered, there would have been a narcotic sheet for each card. She said there was no system in place to show how many cards there were on hand. She said if the sheet and the card were missing, you would not even realize it was gone. She said if you were not there at the time it was delivered, you would not know it had been there. She said some facilities had a system to keep an on-going count of how many cards were in the drawer.During an interview on 05/11/26 at 1:09 p.m. the Pharmacy Manager said cameras did record inside of the delivery vehicles. She said the cameras inside of the Delivery Driver's vehicle were not reviewed because they saw on camera that the technician placing both cards in the bag. She said RN C at the facility, then signed for the medications and placed check marks beside each that she had received them. She said she really thought this had all been resolved because the DON had told one of their pharmacist that someone at the facility had sticky fingers. During an interview on 05/11/26 at 1:43 p.m. RN C said anytime a delivery driver made a delivery she went over all of the medications with the driver. She said she counted with the driver. She said she always did this. She said she did it the same way every time. She said Resident #1 did have two cards of Hydrocodone delivered to the facility on [DATE]. She said the Delivery Driver did not sign the packing slip until after she had counted all of the medications in front of him. She said when a delivery was made, if something was not there she wrote on the sheet if something was missing and then she would call the pharmacy. She said the Delivery Driver that signed with her on 04/01/26 was a pharmacy technician. She said the bag was stapled and had not been tampered with. She said there were two cards in the bag. She said there were two cards of hydrocodone. She said after she checked the medications, she would hand them off to the medication aide to place the medication on the cart. She said if the medication aide was not available, she locked up the medication until they were available. She said she thought the medication aide on 4/01/26 was Medication Aide E. She said that the Medication Aide E then placed the cards on the medication cart.During an interview on 05/11/26 at 1:56 p.m. the Delivery Driver said he was the person that delivered Resident #1's medications on 04/01/26. He said he was not the technician that placed the medication in the bag. He said the bag was stapled shut the entire time he had the bag in his possession. He said medications were placed in a bag with a packing slip and any narcotic count sheets. He said then they were stapled closed with a packing slip on the outside. He said when he got to the facility, all medications were counted along with RN C. He said all medications were there. He said there were 2 cards of Hydrocodone and 2 narcotic count sheets in the bag. He said he always counted medications with RN C, especially the narcotics. During an interview on 05/11/26 at 2:10 p.m., Medication Aide E said she did take the medications from RN C on 04/01/26. She said she did count the medications for Resident #1 and there were two cards of hydrocodone and a bottle of Linzess (medication used for chronic constipation). She said she placed both cards of Hydrocodone in the locked narcotic box, placed the sheets in the count notebook, and placed the Linzess on the cart. She said she did not hear anything else about it until on 04/23/26 when they were looking for the card. She said she had requested for a refill on 04/20/26 and that was when the card was discovered missing. She said she did not have any idea who may have taken it. She said they had never had a problem with missing medicine.During an interview on 05/11/26 at 2:23 p.m., the DON said this they had missing medications before with the pharmacy. She said the pharmacy would say medications were delivered and they were not. She said when she interviewed RN C she could not tell with certainty that she had counted the medication but had signed for it. She said the Delivery Driver's signature was on the form. She said Medication Aide E was the medication aide that would have put the medication on the cart. She said Medication Aide E could not tell her if the medications were delivered. She said on 04/12/26, Medication Aide E told her that she submitted a refill request for Hydrocodone for Resident #1. She said that told her there was not another card on the cart at that time. She said if there had been another card she would not have submitted the requested. She said they were working on coming up with a different system with a form that tells them how many cards and count sheets they had on hand. She said now they were going by the delivery manifest to determine what they have. She said she had implemented that two nurses were to count and sign off on each medication delivery. She said she has never determined what happened to the card. She said this was the fourth time she has gone through this with this pharmacy. She said it was important to know how much medication they had on hand to make sure there was none missing and the residents receive the medications that they need.During an interview on 05/11/26 at 2:45 p.m., the Administrator said as soon as she found out about the missing medication, everyone that had access to the medication was drug tested. She said all test were negative. She said the DON put in place that two people sign off with the pharmacy staff when medications were delivered. She said all of this would then be compared with another slip to make sure they were receiving the medications from the pharmacy. She said it is important to know how much medication they have for a resident to make sure that they are getting accurate doses at the accurate time and to make sure the medications were being used properly.Record review of a Controlled Substances facility last revised 12/2012 indicated, .The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances.Controlled substances must be counted upon delivery. The nurse receiving the medication, along with person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record.Record review of an Abuse Policy last updated 05/2017 indicated, Purpose: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion and misappropriation of resident's belongings or money.Each resident has the right to be free from mistreatment, neglect and misappropriation of property.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure food items were not stored on the floor of the dry pantry. 2. The facility failed to ensure food items in the dry pantry were labeled and dated. 3. The facility failed to ensure plastic bags of what appeared to be hamburger patties, chicken tender strips, sausage patties, onions/green/red peppers, and French fries were labeled and dated in the large freezer. 4. The facility failed to ensure a plastic bag containing an unknown meat was labeled and dated in the white freezer. 5. The facility failed to ensure the white freezer did not have melted and refrozen substance in the bottom of freezer. 6. The facility failed to ensure a silver metal container in the refrigerator/cooler with what appeared to be chicken noodle soup covered with plastic wrap, was labeled and dated. 7. The facility failed to ensure a large plastic zippered bag of what appeared to be ,d+[DATE] sandwiches with resident names on individual plastic bags were labeled or dated. 8. The facility failed to ensure a partial bag of what appeared to be biscuits was not labeled or dated. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations and interviews of the kitchen on [DATE] beginning at 8:25 AM, and accompanied by [NAME] A, revealed: The dry Pantry had: * A box on the floor with 6 large cans of mixed greens and they were not dated. * A partial box (3 of 6) large cans of vegetables for stew were stored on top of the mixed greens and they were not dated. * A partial box of chips with 3 large clear bags of chips was on the floor and they were not dated. * An unopened box of individual bagged coffee was on the floor. * A box of large cans of tropical fruit salad was on the floor. * A box of large cans of peas and diced carrots was on the floor and was not dated. The large Freezer had: * A plastic bag of what appeared to be hamburger patties, and they were not labeled or dated. * A plastic bag of what appeared to be chicken tender strips, and they were not labeled or dated. * Two partial plastic bags of what appeared to be chicken tender strips, and they were not labeled or dated and there was no opened date. * A partial bag of what appeared to be sausage patties, and they were not labeled or dated and there was no opened date. * A plastic zippered bag with what appeared to be chopped onion, red/green bell peppers and they were not labeled or dated. * Three bags of what appeared to be French fries and they were not labeled or dated. White freezer had: * Two plastic zippered bags with an unknown meat that was not labeled or dated. * The white freezer had what looked like it had defrosted something in the bottom of the freezer, and it refroze. The Refrigerator/Cooler had: * A silver metal container with what appeared to be chicken noodle soup covered with plastic wrap and it was not labeled or dated. * A large plastic zippered bag of what appeared to be ,d+[DATE] sandwiches with resident names on individual plastic bags and they were not labeled or dated. * A partial bag of what appeared to be biscuits, and they were not labeled or dated and there was no opened date. During an interview on [DATE] at 8:45 AM, [NAME] A said all food items should be labeled and dated when they were placed in the freezer or cooler. [NAME] A said food items should be labeled and dated to know when it was placed in there and to know if or when it would go bad. [NAME] A said if food that was not labeled or dated was served to the residents, it could be expired, and residents could get sick. [NAME] A said food should not be stored on the floor of the dry goods pantry because it could cause accidents. [NAME] A said they were short staffed in the kitchen and there were only two people on each shift, and they tried to get to things as they could and since the dishwasher had not been working and they had to handwash everything, it took extra time. [NAME] A said they had someone who came in on the days of the truck deliveries to put up the stock, she said she was not sure why the delivery items were not put up from Friday ([DATE]). [NAME] A said the DM had been in the hospital since Friday ([DATE]). [NAME] A said the sandwiches were probably made yesterday for evening shift snacks, but she just assumed and was not for sure, but they only made sandwiches daily and they were used daily for the residents' snacks. During an interview on [DATE] at 8:55 AM, Dishwasher B said the dishwasher had been out for about two weeks and they tried to repair it, but the machine was old, and they could not get parts, so they had a new one ordered. Dishwasher B said food items should be labeled and dated when placed in the freezers or cooler. Dishwasher B said if the item was not labeled or dated, it should be thrown away and not served to the residents because you would not know when it was made. Dishwasher B said she threw anything away that was not labeled or dated and would not serve it to residents because it could make them sick. During an interview on [DATE] at 8:30 AM, the DM said she expected staff to put food delivery stock up and label and date everything when it was delivered on Tuesdays and Fridays. The DM said they had a specific person to put stock up when it came in, Dietary Stocker C. The DM said she did not know why the stock person did not put the stock up. The DM said food items should be labeled and dated when placed in the freezer and if the package had been opened then it should have an opened date on it. The DM said it was important to label and date the food items when placed in the freezer to know what it was, and to ensure the food item was still good to use. The DM said if the food item was out of date and was served to the residents it could make them sick. During an interview on [DATE] at 12:53 PM, Dietary Stocker C said she was a stocker and only worked on Tuesdays. Dietary Stocker C said she put up the food truck deliveries and rotates the groceries. Dietary Stocker C said she dated the dry goods and placed on the shelf. Dietary Stocker C said they got food delivery trucks every Tuesday and sometimes on Fridays depending on the menus. Dietary Stocker C said she did not think they got a truck on last Friday ([DATE]). Dietary Stocker C said if there was a box or a bag, everything should be labeled and dated. Dietary Stocker C said sometimes she used the sticky labels on items in the freezer and sometimes they would come off. Dietary Stocker C said she did not usually have anything to do with putting partial bags of items in the freezer. Dietary Stocker C said if there were boxes of food items on the floor, she would ensure they were stored properly before leaving. Dietary Stocker C said items should be put up so it could be rotated, so the oldest items were used first, and it helped her with the rotating stock. Dietary Stocker C said if they were not labeled or dated, it could spoil and make someone sick. Dietary Stocker C said everyone gave a helping hand in the kitchen and someone else would help put things up if they received a food truck delivery when she was not working. During an interview on [DATE] at 1:24 PM, the ADM said boxes of food items should not be left on the floor. The ADM said when food items were delivered, the staff should inspect the items for damage, date the item with date delivered and put up for proper storage. The ADM said leaving food items stored on the floor contributed to pests and could be a food contamination issue. The ADM said she would expect staff to follow the facility's policy of labeling, dating, and storing food, even when the DM was not there. The ADM said there could be an infection control issue, cross contamination, and food spoilage if the food items were not labeled or dated. The ADM said it could also potentially make the resident sick or could be something the resident was allergic to if an item was not labeled or dated. The ADM said the DM would be the first one responsible for ensuring food was labeled, dated, and stored appropriately and then the ADM would be ultimately responsible. Record review of the facility's policy titled Food Receiving and Storage, dated revised [DATE], indicated . foods shall be received and stored in a manner that complies with safe food handling practices . food services, or other designated staff, will maintain clean food storage areas at all times . food in designated dry storage areas shall be kept off the floor (at least 18 inches) . all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . all foods belonging to residents must be labeled with the resident's name, the item and the use by date . other opened containers must be dated and sealed or covered during storage Record review of the facility's policy titled Food Preparation and Service, dated revised [DATE], indicated . food service employees shall prepare and serve food in a manner that complies with safe food handling practices . food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness

Based on observation, interview, and record review the facility failed to follow their own established smoking policy for the facility's only smoking area and 1 of 1 facility smoking area reviewed for smoking policies. The facility failed to ensure the smoking area had no cigarette butts on the ground and the red metal can was free of trash on 05/05/25. This failure could place residents at risk of an unsafe smoking environment. The findings included: During an observation on 05/05/25 beginning at 10:57 AM, there were 2 red-tipped cigarette butts on the sidewalk near the door. There was a sign on the door that stated, Do not throw cigarette butts on the ground. There was a used white tissue in the red metal can. During an interview on 05/07/25 beginning at 12:49 PM, The Social Services Director stated she was the staff member responsible for the 11:00 AM smoke break. The Social Services Director stated she did not notice the used white tissues in the red metal can or the used, red-tipped cigarette butts on ground during the smoke break on 05/05/25. The Social Services Director stated the Maintenance Assistant and housekeeping staff were responsible for making sure the red metal can had no trash and cigarette butts were kept off the ground. The Social Services Director stated when she noticed trash in the red metal can or cigarette butts on the ground, she should have let someone know or fixed it herself. The Social Services Director stated it was important toe ensure cigarette butts were kept off the ground and trash was kept out of the red metal can to prevent fires. During an interview on 05/07/25 beginning at 12:53 PM, the Housekeeping Supervisor stated the Maintenance Assistant was responsible for picking up the cigarette butts every morning. The Housekeeping Supervisor stated if anyone noticed cigarette butts on the ground, they should have picked them up. The Housekeeping Supervisor stated she worked together with the Maintenance Assistant to keep trash out of the red metal trashcan and cigarette butts off the ground. The Housekeeping Supervisor stated she believed the residents throw trash in the red metal can without thinking about it. The Housekeeping Supervisor stated it was important to ensure trash was kept out of the red metal can and cigarette butts were kept off the ground to prevent fires. During an interview on 05/07/25 beginning at 1:24 PM, the Maintenance Assistant stated she was responsible for picking up the cigarette butts and making sure the trash was kept out of the red metal can. The Maintenance Assistant stated she kept sand in the red can and recently added more. The Maintenance Assistant stated she had educated the staff who take the residents out to smoke about making sure the residents did not throw their cigarette butts on the ground. The Maintenance Assistant stated the staff should have been checking the red metal can for trash. The Maintenance Assistant stated if it was noticed they should have notified her or removed it. The Maintenance Assistant stated it was important to ensure cigarette butts were kept off the ground and trash was kept out of the red metal can to prevent fires. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected the facility staff to ensure residents were putting their cigarettes butts in the red metal can or ashtrays. The Administrator stated the Maintenance Assistant or housekeeping staff were responsible for monitoring to ensure the cigarette butts were kept off the ground and trash was kept out of the red metal can. The Administrator stated it was important for fire safety. Record review of the Smoking Policy - Residents, revised July 2017, reflected .this facility shall establish and maintain safe resident smoking practices .ashtrays are emptied only into designated receptacles .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment allowing the resident to use his or her personal belongings to the extent possible for 1 of 5 residents (Resident #33) reviewed for cleanliness of the physical environment. The facility failed to ensure Resident #33's bed sheets were clean and free of stains. This failure could place residents at risk for a decreased quality of life and an unsanitary environment. The findings included: Record review of the face sheet, dated 05/07/25, reflected Resident #33 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of unspecified dementia without behaviors (memory loss) and Schizophrenia (chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges). Record review of the quarterly MDS assessment, dated 04/07/25, reflected Resident #33 had clear speech and was understood by others. The MDS reflected Resident #33 was able to understand others. The MDS reflected Resident #33 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #33 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #33 required supervision or touching assistance with most ADLs. Record review of the comprehensive care plan, dated 03/15/25, reflected Resident #33 required supervision or touching assistance with most ADLs. The care plan reflected Resident #33 required one staff assistance with showers two times a week with complete bed baths on alternating days. During an observation on 05/05/25 beginning at 9:14 AM, Resident #33 was lying in the bed with her sheets pulled up to her face. The top sheet had numerous brown stains with a crusty yellow substance. During an observation and interview on 05/06/25 beginning at 11:09 AM, Resident #33 was lying in her bed with her top sheet pulled up near her face. The top sheet had numerous brown stains with a crusty yellow substance. Resident #33 stated the facility staff usually changed her sheets on her shower days. Resident #33 stated her shower days were on Monday, Wednesday, and Friday. Resident #33 stated she received her shower on 05/05/25 but the facility staff did not change her sheets. Resident #33 stated it bothered her the staff did not change her sheets. Resident #33 stated she felt nasty and gritty. During an interview on 05/07/25 beginning at 1:00 PM, NA D stated linens should have been changed every shower day. NA D stated the CNAs were responsible for changing the linens. NA D stated Resident #33 received showers on Monday, Wednesday, and Friday. NA D stated she was unsure if Resident #33's linens were changed on Monday because she did not work. NA D stated if Resident #33's sheets had noticeable stains or crusty substances they should have been changed even if it wasn't her shower day. NA D stated she noticed clean bed sheets coming from laundry were not in the best condition and often had stains. NA D stated she had not reported the condition of the bed sheets. NA D stated it was important to ensure linens were changed and in good condition to maintain a homelike and comfortable environment and prevent the growth of bacteria. During an interview on 05/07/25 beginning at 1:03 PM, the Housekeeping Supervisor stated the laundry staff were trained to look at the condition of the bed sheets. The Housekeeping Supervisor stated if she noticed a bedsheet was torn or stained, they placed them into a bag or threw them away. The Housekeeping Supervisor stated it was hard to miss sheets that were heavily stained. The Housekeeping Supervisor stated if the sheets became stained or needed to be changed the CNAs were responsible for completing that. The Housekeeping Supervisor stated it was important to ensure sheets were changed and in good condition to prevent infection. The Housekeeping Supervisor stated it was also important to maintain a homelike and comfortable environment. During an interview on 05/07/25 beginning at 1:06 PM, the CNA Supervisor stated bed sheets should have been changed as needed and every shower day. The CNA Supervisor stated Resident #33's sheets should have been changed on Monday, Wednesday, and Friday. The CNA Supervisor was unsure why Resident #33's bed sheets would not have been changed. The CNA Supervisor stated it was important to ensure bed sheets were changed and in good condition to maintain infection control and a homelike environment. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated she expected bed sheets to have been changed on shower days and as needed. The DON stated the CNAs and charge nurses should have ensured the bed sheets were changed. The DON stated Resident #33 was non-complaint at times with certain things. The DON stated she was unsure if Resident #33 refused to have her bedsheets changed. The DON stated general rounds were completed but there was no system in place for monitoring bed linens. The DON stated it was important to ensure bedsheets were changed to maintain good skin integrity, to control odors, to ensure residents were bathed properly, to maintain a comfortable environment, and maintain pest control. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected the staff to change the bed linens on shower days and as needed. The Administrator stated Resident #33 refused care at times but was unsure if she refused this week. The Administrator stated she expected staff to at least attempt to change the bed linens. The Administrator stated it was important to ensure bedsheets were changed for hygiene purposes and to maintain a comfortable environment. Record review of the Quality of Life - Homelike Environment policy, revised May 2017, reflected the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: .clean bed and bath linens that are in good condition .

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental services to meet the needs of 1 of 1 (Resident #33) residents reviewed for dental services. The facility failed to ensure Resident #33 received dental services when she had a broken tooth that caused her discomfort. This failure could place residents at risk of not receiving needed dental care and a decreased quality of life. The findings included: Record review of the face sheet, dated 05/07/25, reflected Resident #33 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of unspecified dementia without behaviors (memory loss) and Schizophrenia (chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges). Record review of the quarterly MDS assessment, dated 04/07/25, reflected Resident #33 had clear speech and was understood by others. The MDS reflected Resident #33 was able to understand others. The MDS reflected Resident #33 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #33 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #33 required supervision or touching assistance with oral hygiene that included ability to use suitable items to clean teeth. The MDS reflected Resident #33 had no broken or loosely fitting full or partial denture or mouth or facial pain, discomfort, or difficulty with chewing. Record review of the comprehensive care plan, dated 03/15/25, reflected Resident #33 required supervision or touching assistance with most ADLs. The care plan reflected Resident #33 required one staff assistance with oral care two times a day and as needed. The care plan did not address any dental issues. During an observation and interview on 05/05/25 beginning at 9:14 AM, Resident #33 was lying in the bed with the sheets pulled up around her face. Resident #33 stated her tooth was broken and had been giving her problems and she felt that the facility staff had not addressed it. Resident #33 stated she was having a hard time eating but had not lost any weight. Resident #33 denied constant pain or hurting. Resident #33 stated she had slight discomfort only while eating. Resident #33 opened her mouth to show the state surveyor her teeth. Resident #33 had her natural teeth, and no obvious broken teeth were observed. During an interview on 05/07/25 beginning at 9:36 AM, the Social Services Director stated she was aware Resident #33 had a dental concern. The Social Services Director stated she had attempted to reach out to the mobile dentistry used by the facility, but they would not see Resident #33 because she had an outstanding balance at the facility. The Social Services Director stated she attempted to reach out to several places in the community, but they would not accept Resident #33's medical insurance plan. The Social Services Director provided the documentation from a soft file in her office. Record review of the social progress notes, signed and dated 04/23/25, reflected On today [Resident #33] told this [Social Services Director] that her tooth cracked and is causing her a little pain and discomfort. This [Social Services Director] checking on [mobile dentistry] for resident and encouraged her to tell her nurse when it bothers her and maybe she can give resident [over the counter] pain reliver. Resident stated that she would. Will continue to monitor Record review of the social progress notes, signed and dated 04/24/25, reflected Resident [#33] has a past due balance and [the mobile dentistry] will only see residents whose bill is up to date. This [Social Service Director] trying to find an alternative for Resident #33. Will continue to monitor . There were no further notes to address the Resident #33's dental pain or discomfort. During an interview on 05/07/25 beginning at 9:44 AM, the Social Services Director was unable to answer any questions about the specifics of Resident #33's outstanding balance. The Social Services Director stated the BOM was responsible for handling Resident #33's finances. The Social Services Director stated she was unsure if there were any community resources that could have helped Resident #33 with her outstanding balance or dental concerns. During an interview on 05/07/25 beginning at 9:48 AM, the BOM stated Resident #33 had an outstanding balance at the facility. The BOM stated she had attempted to reach out to Resident #33's family member on numerous occasions to attempt to collect the balance. The BOM stated Resident #33's family member did not answer the phone or return her phone calls to the facility. The BOM stated Resident #33 complained of dental issues since admitting to the facility. The BOM stated Resident #33's family member mentioned he would have taken Resident #33 to the dentist in the past. The BOM stated she told the Social Services Director to reach out to places in the community that would have seen her. The BOM stated the facility has had problems with the mobile dentistry services for other residents. During an interview on 05/07/25 beginning at 10:02 AM, the BOM stated she provided a couple of phone numbers to dentist offices in the area to the Social Services Director. The BOM stated she attempted to call Resident #33's family member with no response. During an attempted telephone interview on 05/07/25 beginning at 10:15 AM, Resident #33's family member did not answer the phone. A brief message was left with a call back number, but the call was not returned upon exit of the facility. During an interview on 05/07/25 beginning at 11:11 AM, the Corporate Clinical Nurse stated Resident #33 was currently at the dentist and the facility was going to cover the cost. During an interview on 05/07/25 beginning at 12:10 PM, the Social Services Director stated she was unsure if she spoke with Resident #33's family member about her dental concerns when he was contacted on 04/25/25. The Social Services Director stated Resident #33 had just returned from a dental appointment. The Social Services Director stated when she attempted to reach out to other dentists in the area it was not for Resident #33. The Social Services Director stated when a resident complained of dental concerns, she looked to see if they had any dental insurance. She said if the residents had no dental insurance, then she attempted to set them up with the mobile dentistry service that came to the facility. The Social Services Director stated if everything checked out with the mobile dentistry service then they were scheduled. If the mobile dentistry was unable to see the resident, then they would find a place in the community and the resident would have to pay for it out of pocket. The Social Services Director stated she should have notified the nursing staff about Resident #33's dental concerns but the only person she notified was the BOM. The Social Services Director stated Resident #33 should have been seen by the dentist sooner. The Social Services Director stated she was fairly new to the position and was still learning the specifics of her job duties. The Social Services Director stated it was important to ensure dental services were provided to residents who had dental concerns to minimize pain, prevent infection, and prevent appetite changes. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated she had not been informed of Resident #33's dental concerns or any pain or discomfort. The DON stated she expected to be notified if a resident had any dental issues or concerns. The DON stated the facility staff usually talked about things like that during the morning stand-up meetings. The DON stated Resident #33's teeth were not discussed that she was able to recall. The DON stated it was important to ensure dental issues were followed up on to make sure care was provided, pain was controlled, and no secondary illness developed as a result of untreated dental issues. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she expected a process to have been followed for residents with dental pain. The Administrator stated the process included notifying nursing staff and herself as soon as the dental concerns were discovered. The Administrator she was notified on 05/05/25 regarding Resident #33's dental concerns and was following up to see where they were at in the clinical process. The Administrator stated she should have been notified sooner. The Administrator stated it was important to ensure dental issues were addressed to prevent infections and pain. Record review of the Dental Services policy, revised December 2016, reflected Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .routine dental services are provided to our resident through: a contract agreement .referral to the resident's personal dentist .referral to community dentists .referral to other health care organizations that provide dental services .residents have the right to select dentists of their choice when dental care or services are needed .social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Cart 4) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN E locked Cart 4 on the secured unit nurse medication cart, when it was not in use on 05/06/2025. 2. The facility failed to ensure two Albuterol Sulfate Inhalation Solution (inhalation solution used to open the airways for breathing) on Cart 4 was dated when opened. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings include: During an observation and interview on 05/06/2025 starting at 09:32 AM, revealed LVN E entered the resident's room and did not lock her medication cart. While in the room, LVN E was not able to visualize her medication cart because she had the privacy curtain pulled. The nurse had a conversation with the resident for approximately 10 minutes before returning to her medication cart. LVN E said she guessed she got distracted and did not realize she did not lock it. LVN E said the nurse should ensure the medication cart was locked when not in use. LVN E said it was important for the medication cart to be locked because they had dementia patients, and someone could go and inject themselves or someone could take stuff. LVN E said it was super dangerous for the medication cart to be left unlocke with narcotics on the cart During an observation and interview on 05/07/2025 at 08:35 AM, two Albuterol Sulfate Inhalation Solutions on Cart 4 were not dated when opened. LVN E said she did not know who opened them, so she did not know why they had not put an open date on them. LVN E said the person who opened a medication was responsible for putting the open date on it. LVN E said it was important to label and date the medications when opened to ensure the medications were effective and therapeutic for the residents. During an interview on 05/07/2025 at 1:11 PM, the DON said the medication cart needed to be locked at all times when not in use. The DON said she conducted rounds daily to check to ensure the medication carts were locked. The DON said the nurses were responsible for ensuring the medication carts were locked. The DON said if the medication cart was left unlocked somebody could access the medications or treatments in it. The DON said she did random weekly audits on the medication carts to ensure the medications were labeled and dated correctly. The DON said it was important for all breathing inhalations to have an open date to ensure the residents did not receive expired medications. The DON said all medications should be stored and labeled per the manufacturer's instructions. During an interview on 05/07/2025 at 1:30 PM, the Administrator said she expected for the medication carts to be locked anytime the nurses were not in front of them. The Administrator said if the medication cart was left unlocked a resident could get into the medication cart. The Administrator said the nurses should be making sure they dated medications when opened. The Administrator said there was a system in place to check the medication carts. This system included the clinic staff and the pharmacy consult checking the medication carts to ensure everything was dated. The Administrator said it was important to date medications as opened to ensure efficiency of the medication. Record review of the facility's policy, titled, Security of Medication Cart, revised April 2007, indicated, 4. Medication carts must be securely locked at all times when out of the nurse's view. Record review of the facility's policy, titled Labeling of Medication Containers, revised on April 2007, indicated, 5. The date drug dispensed; The expiration date when applicable

Based on observation, interview and record review the facility failed provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #36) reviewed for medication administration. The facility failed to ensure Resident #36 rinsed and spit after administration of an inhalation medication (Budesonide) for a diagnosis of COPD. This failure could place residents at an risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings include: Record review of Resident #36's face sheet, dated 05/07/2025, revealed Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #36 had a diagnosis which included COPD - chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report, dated 05/07/2025, revealed Resident #36 had an order, which started on 02/14/2025, for Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation twice a day for a diagnosis of COPD with special instruction to rinse mouth and spit after each use. Record review of the MAR, dated 05/06/2025, indicated Resident #36 received Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. Record review of the Annual MDS assessment, dated 04/14/2025, indicated Resident #36 had clear speech and was understood by staff. Resident #36 was able to understand others. Resident #36 had a BIMS of 15, which indicated intact cognition. Record review of the comprehensive care plan, initiated on 07/19/2024, indicated Resident #36 had a diagnosis of COPD and took medication. The interventions included: administer medication per orders. During an observation on 05/06/2025 at 8:45 AM, revealed LVN F prepared Resident #36's medication for administration. LVN F obtained a bottle of multivitamin with minerals and placed one, round, pale pink tablet in the cup. LVN F finished preparing the remainder of Resident #36's morning medication, which included the Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. LVN F obtained a plastic glass of water and went into Resident #36's room. LVN F gave Resident #36's his medication cup, which included the multivitamin with minerals, and Resident #36 swallowed the medication. LVN F then administered Resident #36's Budesonide 0.5 milligram/2 milliliter suspension for nebulization, I ampule inhalation. LVN F gave Resident #36 a glass of water after administration of the medication but did not instruct Resident #36 to rinse and spit after the use of his nebulizer inhalation treatment. During an interview on 05/06/2025 at 09:10 AM, LVN F stated medication should have been administered per the physician orders. LVN F stated special instructions should have been followed during medication administration. LVN F stated she should have instructed Resident #36 to rinse and spit after administration of his nebulizer inhalation treatment, but she did not think to look at the label on the box. LVN F stated she should have verified the order and the medication bottle prior to administering the medication to Resident #36. LVN F stated it was important to ensure medication was administered per the physician orders to prevent adverse effects such as cavities. During an interview on 05/07/2025 at 01:10 PM, the DON stated she expected medications to be given as ordered by the physician. The DON stated LVN F should have instructed Resident #36 to rinse and spit after administration of his nebulizer inhalation treatment. The DON stated the EMAR , and the medication label should be verified at least 3 times prior to medication administration. The DON stated it was important to ensure special instructions were followed and the correct medications were administered to prevent adverse reactions to the resident . The DON said the resident should rinse per the medication guidelines and orders to prevent any side effects from the nebulizer such as cavities. During an interview on 05/07/2025 at 01:30 PM, the Administrator stated she expected medication to be administered per the physician order. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to administer medications according to the physician order to ensure the safety and well-being of the residents. Record review of the Administering Medications policy, revised on 12/2012, indicated 3. Medications must be administered in accordance with the orders, and by manufactures guidelines.

Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident (Resident #28) reviewed for trauma-informed care. The facility failed to ensure Resident #28 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #28 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 05/06/25, reflected Resident #28 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the annual MDS assessment, dated 03/13/25, reflected Resident #28 had clear speech and was understood by others. The MDS reflected Resident #28 was able to understand others. The MDS reflected Resident #28 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #28 had no behaviors or refusal of care. The MDS reflected Resident #28 had an active diagnosis of PTSD. Record review of the comprehensive care plan, dated 03/25/2024, reflected Resident #28 had a history of being fearful and easily annoyed related to PTSD. The goal was to use effective coping mechanisms to manage PTSD and have no fearful episodes during the next 90 days. Record review of Resident #28's initial social service history, dated 03/19/24, reflected no screening questions to indicate a history of trauma. Record review of the Resident #28's Make Me Feel Important form, undated, reflected the sections titled Five things to NEVER do with/around me: and Five things to ALWAYS do with/around me: were not filled out or answered. During an interview on 05/06/25 beginning at 3:49 PM, the Social Services Director stated she was responsible for completing the initial social history assessment on admission. The Social Services Director stated quarterly assessments and progress notes were completed each time a care plan meeting was conducted. The Social Services Director stated the initial social history assessment had no screening questions related to trauma. The Social Services Director stated she communicated with the DON for psychiatric referrals for residents who confided in her about their traumatic histories. The Social Services Director stated there was no trauma screening completed on admission that she was aware of. The Social Services Director stated if someone admitted to the facility with a diagnosis of PTSD, the facility attempted to obtained counseling services. The Social Services Director was unaware of any services being provided for Resident #28. The Social Services Director stated it was important to ensure residents were screened for a history of trauma and potential triggers were identified to maintain the correct environment to prevent triggers that could have caused re-traumatization. The Social Services Director stated it would have been important to know the potential triggers to prevent aggravation, frustration, or other behaviors. During an observation and interview on 05/06/25 beginning at 4:02 PM, Resident #28 was sitting up in the dining room watching videos on his laptop. Resident #28 did not want to leave the dining room, unable to complete the interview regarding his PTSD diagnosis. During an interview on 05/07/25 beginning at 1:12 PM, the DON stated the only part of trauma informed care that she participated in was during the new admission referral process. The DON stated she reviewed the clinical record for psychotropic medication and behaviors. The DON stated she reviewed the diagnosis to ensure the referral was appropriate for admission to the facility. During an interview on 05/07/25 beginning at 1:41 PM, the Administrator stated she reviewed the clinical documentation of new admission referrals to try and identify a possible history of trauma or any diagnosis related to trauma. The Administrator stated the Social Services Director was responsible for completing the initial social history assessment, which included trauma screening questions. The Administrator stated she was unaware the initial social services history assessment did not include the trauma screening questions. The Administrator stated the Activity Director, and the CNA Supervisor completed the Make Me Feel Important form, which was used to identify specific triggers and de-escalation interventions. The Administrator was unaware Resident #28's Make Me Feel Important form was not filled out. The Administrator stated she recently started working on developing a system for trauma informed care and had not completed it. The Administrator stated it was important to ensure residents were assessed for a history of trauma and potential triggers were identified to prevent re-traumatizing and maintain the safety of the residents and staff. Record review of the Trauma Informed Care policy, dated 2024, reflected .a tool for screening new residents for trauma will be developed and implemented as part of the admissions process if a resident demonstrations signs of past trauma (either one-time or on-going), additional screening will take place .

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 16 residents (Resident #3) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #3's active diagnoses to not include a diagnosis of schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) on her 4/23/25 MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #3's face sheet, dated 5/06/25, indicated she was [AGE] years old and admitted to the facility on originally on 7/13/21 and readmitted on [DATE]. Resident #3 had diagnoses which included dementia (progressive or persistent loss of intellectual functioning including impairment of memory, thinking, and personality changes due to disease of the brain) with psychotic disturbance (mental disorder characterized by a disconnection from reality with symptoms of delusions-false belief of reality; hallucinations-seen, heard, touched, tasted, or smelled something that was not really there; talking incoherently; and agitation), neurosyphilis (infection that can occur in people with syphilis-sexually transmitted disease, especially if left untreated, that affects the coverings of the brain, the brain itself, or the spinal cord), and depressive episodes (feelings of sadness, tearfulness, angry outbursts, irritability or frustration even over small matters). Record review of Resident #3's annual MDS assessment, dated 4/23/25, indicated Resident #3 had a BIMS of 3, which indicated she had severe cognitive impairment. The MDS indicated Resident #3 had an active diagnosis of schizophrenia. Record review of Resident #3's undated care plan indicated she received an antidepressant and antipsychotic medication related to anxiety, paranoid delusional thinking, and depression auditory (hearing) and visual hallucinations, paranoid that people were out to get her and that she was being poisoned. Resident #3 had memory problems related to dementia. Resident #3 had physical behavioral symptoms toward others had history of hitting other residents. Resident #3 had auditory and visual hallucinations, talking to people and animals that were not present with diagnosis of schizophrenia with primary diagnosis of dementia. Record review of Resident 3's Physician Order Report, dated 4/07/25 - 5/07/25, indicated Resident #3 did not have a diagnosis of schizophrenia. During an interview on 5/07/25 at 8:10 AM, the Regional Nurse said the MDS Coordinator investigated Resident #3's chart and concluded the schizophrenia diagnosis was marked in error or was marked on the wrong resident with the same last name because she was the MDS Coordinator for two buildings/facilities. During an interview on 5/07/25 at 10:21 AM, the MDS Coordinator said she was the MDS Coordinator for two buildings/facilities and she did not know what happened but Resident #3's MDS was just miscoded. The MDS Coordinator said she had been the MDS Coordinator since 1999. The MDS Coordinator said she had been doing both buildings/facilities for a couple of years. The MDS Coordinator said she primarily did the MDSs remotely and received information from the DON, SW, therapy, and all other care areas. The MDS Coordinator said she was in the process of submitting MDS corrections in Resident #3's chart. The MDS Coordinator said there was no pertinent information to justify the diagnosis of schizophrenia being coded on Resident #3's MDS. The MDS Coordinator said the MDS should reflect an accurate picture of the resident to guide the resident's care. The MDS Coordinator said the resident was at risk of not receiving the services that they needed if the MDS was not coded accurately. The MDS Coordinator said she followed the RAI manual and looked things up if she had any questions. The MDS Coordinator said she saw Resident #3's MDS included schizophrenia was first coded in May of 2024 and apparently was carried over from assessment to assessment. The MDS Coordinator said she just really did not have a good answer for why it was coded. The MDS Coordinator said she was currently auditing all of the diagnoses and assessments in the facility. During an interview on 5/07/25 at 1:24 PM, the ADM said she would expect the MDS to be coded accurately. The ADM said the MDS was a medical record, it affected what care was provided and/or services the resident received. The ADM said if the MDS was not coded accurately, the resident may not get medications or services that they needed or they may get medications or services they did not need. The ADM said the MDS Coordinator, and the DON were responsible for ensuring the MDS was coded accurately. Record review of the facility's undated policy titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy indicated . the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who were familiar with his/her physical, mental, and psychosocial well-being . Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require . the assessment accurately reflect the resident's status

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 staff (Laundry Aide G) reviewed for infection control practices. The facility failed to ensure that Laundry Aide G covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings: During an observation and interview on 05/05/2025 at 09:10 am., Laundry Aide G was seen in hall 2 pushing an uncovered laundry cart that had clean clothes exposed. Laundry Aide G said she covered the laundry cart while she transported it from the laundry building outside, but once she entered the facility, she was not required to cover the laundry cart while she delivered to the residents. During an interview 05/07/2025 at 1:10 PM., the DON said dirty and soiled laundry should not be transported out in the open due to the risk of infection and cross contamination. The DON said she expected the clean linens and residents' clothing to be distributed per the proper protocol per housekeeping, which is covered in and outside the building. The DON said and she expected all staff to ensure infection preventives were utilized daily to protect the residents' health and wellbeing by proper handwashing, bagging and transporting soiled linen in closed containers, using PPE appropriately and properly. During an interview on 05/07/2025 at 1:15 PM, the Housekeeping Supervisor said she was responsible for and had educated the laundry aides and expected the staff to keep the clean laundry covered while transported it from the laundry building outside and required to cover the laundry cart of clean clothing while delivered to the residents to prevent cross contamination. During an interview on 05/07/2025 at 1:30 PM, the Administrator said she expected for all staff to be responsible for infection control precaution. The Administrator stated the facility had purchased a covered cart strictly for the delivery of clean linens and expected staff to utilize the cart for linen delivery to prevent cross contamination while inside and outside of the building. Record review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen, updated January 2014, indicated, . 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contaminations, such as covering clean linen carts.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 18 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to prevent Resident #1 from eloping (leaving the facility property) from the secured unit on 02/10/25. The noncompliance was identified as PNC. The IJ began on 02/10/25 and ended on 02/10/25. The facility had corrected the noncompliance before the survey began. This failure could place the residents at risk for serious injury, serious harm, serious impairment, or death. The findings included: Record review of the face sheet, undated, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia (memory loss), anxiety disorder (intense feelings of anxiety and fear that can interfere with daily activities), restlessness and agitation, delusional disorder (type of psychotic disorder that involves having unshakable belief in something not true), and unspecified convulsions (seizures). Record review of the quarterly MDS assessment, dated 01/22/25, reflected Resident #1 had clear speech and was understood by others. The MDS reflected Resident #1 was able to understand others. The MDS reflected Resident #1 had a BIMS score of 6, which indicated severely impaired cognition. The MDS reflected Resident #1 had inattention and disorganized thinking that was continuously present and did not fluctuate. The MDS reflected Resident #1 had no behaviors. The MDS reflected Resident #1 was independent with indoor mobility that included ambulation (walking) and used no assistive devices. Record review of the comprehensive care plan, updated on 02/10/25, reflected Resident #1 was at risk for elopement and exhibited wandering behaviors. The interventions included: one-to-one observations that started on 02/10/25 and resolved on 02/15/25; and provide comfort measures for basic needs if Resident #1 begins to wander, such as pain, hunger, toileting, too hot/cold. Record review of the physician order report, dated 01/25/25 to 02/25/25, reflected Resident #1 had an order which started on 01/20/2025 for Resident #1 to admit to the facility on the secured unit related to elopement risk. Record review of the elopement risk assessment, dated 08/28/24, reflected Resident #1 had a score of 24. The scoring criteria stated if a resident had a score of 10 or more, the resident was at risk for elopement. Record review of the skilled daily nurses note, dated 02/10/25, reflected Resident #1 exhibited wandering behaviors on the evening shift. The narrative, timed at 4:40 PM, stated [RN A] came from front when stopped by [BOM] asking where resident is. Resident had eloped and went outside down the road and fell . EMS called for evaluation - taken to ER. Resident awake and alert, oriented to baseline at time of incident. DON notified, RP notified, Administrator notified. The narrative timed at 8:45 PM, stated Resident returns to locked unit via facility van accompanied with staff. Ambulatory, alert to baseline. Contusion to right forehead and 2 scabs on right ear. No new orders per ER doctor. Add: Abrasion on right forehead, 2 scabs with bruising on right ear. Small bruise on right upper extremity, small scabbed over abrasion on left knee. Record review of the incident report, dated 02/10/25, reflected Resident #1 was found outside the facility and had an unwitnessed fall. The incident report reflected Resident #1 was alert and had head involved contusions/hematomas. The narrative stated [RN A] was getting blood sugar levels from front residents. [CNA B] in shower with another resident. Received a call from [BOM] stating resident had eloped. Resident returned to facility. EMS here to assess resident, sent to ER for evaluation and treatment. Record review of CNA B's witness statement, dated 02/10/25, reflected I was giving a shower during time of incident - I wasn't aware of incident. I did give him [Resident #1] a snack and orange juice in the dining room at 4:30 PM. Watching television. Record review of RN A's witness statement, dated 02/10/25, reflected This resident last seen by this nurse approximately 3 PM - 3:30 PM while getting vital signs. This nurse had to leave secured unit to go check blood sugars on other residents under this nurse's care. Arrived back on secured unit to [BOM] asking if I had seen resident. Resident found outside, doctor states to send resident to ER. Record review of Sitter C's witness statement, dated 02/10/25, reflected I didn't see what happened. The last time I saw him [Resident #1] was when I came in at 2 PM. I've been doing one-on-one with [another resident]. Record review of the provider investigation report, signed 02/17/25, reflected the facility immediately returned Resident #1 to the facility and assessed for injury. Resident #1 was sent to the ER for evaluation and treatment. The facility immediately performed a head count, and all other residents were accounted for. The facility checked all alarms and exit-doors to ensure they were functioning properly. The facility performed a psycho-social assessment on Resident #1 and resident safe surveys. The facility provided in-service education on abuse, neglect, and exploitation, elopement, alarms, door codes, and using exit doors on the secured unit. Record review of Resident #1's ER paperwork, dated 02/10/25, reflected Resident #1 was seen in the emergency department for an abrasion on forehead after a fall. No significant findings were identified. Record review of the daily census report, dated 02/10/25, reflected a note that stated the BOM performed a head count of all 46 residents in the facility. All residents were accounted for. Record review of a signed statement, dated 02/10/25, reflected All doors and door alarms were checked and found to be in working order by myself [Administrator] and nurse's [RN D] and [RN A]. Record review of the psycho-social assessment, dated 02/10/25, reflected Resident #1 had a BIMS score of 3, which indicated severe cognitive impairment. The assessment reflected Resident #1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The assessment reflected Resident #1 was oriented to self and had poor memory in the present. The assessment reflected Resident #1 was anxious, agitated, and depressed at times. The assessment reflected Resident #1 wandered, was verbally abusive, physically abusive, and social inappropriate at times. Record review of the resident safe surveys, dated 02/10/25, reflected no significant findings. Record review of the in-service record dated 2/10/25 reflected education was provided on abuse policy and procedure. There were approximately 61 signatures. Record review of the in-service record dated 2/10/25 reflected education was provided on elopement to include procedure if elopement occurs. There were approximately 61 signatures. Record review of the in-service record dated 2/10/25 reflected education was provided on answering alarms and investigating source of alarms. There were approximately 61 signatures. Record review of the in-service record dated 2/10/25 reflected education was provided on exit doors to include not using them to enter and exit the building. Ensuring they are enabled and alarmed at all times. There were approximately 61 signatures. Record review of the in-service record dated 2/10/25 reflected education was provided on red box alarm keys to include location and sign out procedures. There were approximately 40 signatures. During an observation and interview on 02/20/25 beginning at 10:53 AM, Resident #1 was sitting up in the dining room. Resident #1 had bruising to his right eye. Resident #1 stated he had fallen across the street, but he was doing okay. Resident #1 was unable to give any further details of the incident on 02/10/25 as he was confused during the conversation. During an interview on 02/20/25 beginning at 10:55 AM, LVN E stated Resident #1 had eloped on the 2-10 shift on 02/10/25 and was found in the ditch, from what she told in report. LVN E stated Resident #1 was admitted to the facility because he had eloped at a previous facility. LVN E stated the door alarm had been turned off a couple of weeks prior to the incident because of the rain. LVN E stated Resident #1 was on the secured unit when the elopement happened. LVN E stated Resident #1 exit-seeks and tried to get out of the facility every day. LVN E stated she worked the 6-2 shift on the day Resident #1 eloped and he was exit-seeking. LVN E said when Resident #1 started exit-seeking the facility staff tried to redirect them, offer snacks, or increase activities. LVN E said Resident #1 was difficult to redirect at times because he was angry or belligerent. LVN E stated the staff used to use the exit-doors on the secured unit to enter and exit but they were not allowed to do that any longer since Resident #1 got out of the facility. During an observation on 02/20/25 beginning at 11:22 AM, CNA F assisted surveyor to the exit-doors on the secured unit. The right-side door was locked and unable to be opened without a code. Red box alarm noted on door in the on position. Door was opened and alarm sounded. The back door, off the hallway was locked. A keypad box was located beside the door and was functioning properly. Red box alarm noted on the door in the on position. Door was opened and alarm sounded. The patio door, off the dining room, was locked and the keypad was functioning properly. The outside patio was fenced in with no issues identified. The left-side hallway door was locked. A keypad box was located beside the door and was functioning properly. Red box alarm noted on the door in the on position. Door was opened and the alarm sounded. There was signage on all doors that stated Do not use. This is not an exit. During an interview on 02/20/25 beginning at 11:25 AM, CNA F stated the maintenance department was responsible for monitoring the doors to ensure they were functioning properly. CNA F stated the nurse's had access to turn the door alarms on and off with a key. CNA F stated the staff used to come in and out of the doors to the secured unit, but they do not use them any more after the incident with Resident #1. During an interview on 02/20/25 beginning at 11:46 AM, RN A stated on 02/10/25 she was the nurse assigned to the back secured unit, but she was also assigned residents in the front halls. RN A stated she was at the front getting blood sugars at approximately 4 PM - 4:30 PM. RN A stated when she returned to the secured unit, she was confronted by the BOM who asked her if she knew Resident #1 was missing. RN A stated she had no idea Resident #1 was missing and had not heard any alarms because she was at the front of the building. RN A stated the BOM stated she had received a call that Resident #1 was walking down the road. RN A stated she went to look for Resident #1 and found him down the road from the facility at a couple houses next door. RN A stated he was off the premises. RN A stated Resident #1 was standing up when she found him. RN A stated Resident #1 had apparently gotten hurt because he had an abrasion to his right eyebrow and right ear. RN A stated when Resident #1 returned to the facility, he was assessed and treated for his wounds. RN A stated Resident #1 was sent to the ER just to be sure because the fall was un-witnessed. RN A stated Resident #1 exhibited exit-seeking behaviors often. RN A stated staff used to use the exit-doors to the secured unit, but they were unable to use them since the incident with Resident #1. RN A stated after Resident #1 was sent to the ER, she checked the doors on the secured unit. RN A stated the back door, off the hallway had a keypad that was blinking green and red repetitively and the door was unlocked. RN A stated she reported the door to the Administrator and the maintenance staff were in that day to fix it. RN A stated she had noticed the keypad doing that before and had mentioned it to the management staff. RN A stated after the incident with Resident #1 the facility staff repaired the door, implemented 15-minute door checks, changed the door codes, and provided in-service education to staff on not using the side doors, ensuring red box alarms were turned on and functioning, abuse and neglect, and elopement policy and procedures. During an observation and interview on 02/20/25 beginning at 2:05 PM, the BOM stated she received a call from her friend who lives a few houses down, saying I think you have a resident out. The BOM stated her friend described the resident and she felt like it sounded like Resident #1, so she alerted the nurse and ran out the back door. The BOM stated as she was running out the back door, RN A was coming from the secured unit and they found Resident #1, escorted him back to the facility, and called EMS. The BOM assisted surveyor to the back parking lot and pointed out a mailbox and house approximately 150 feet from the back parking lot. The BOM stated that was where Resident #1 was found. The road ran in front of residential housing and the speed limit was 30 miles per hour. There were lightly wooded areas near the house. During an interview on 02/20/25 beginning at 2:17 PM, the Administrator stated she had just left the facility when she received a phone call from the BOM saying Resident #1 had gotten out. The Administrator stated she turned around and came back to the facility. The Administrator she had discovered Resident #1 received a small abrasion and was sent to the ER, he returned to the facility later that night before she had left. The Administrator stated the facility staff placed Resident #1 on frequent monitoring, changed the alarm codes, checked doors and alarms, performed a head count. The Administrator stated there was an issue with the keypad on the back door but it was fixed immediately. The Administrator stated they were unsure how Resident #1 got out of the facility and believed he could have slipped out after a family member left the facility. The Administrator stated all staff were provided in-service education on abuse and neglect, elopement policy and procedure, door codes, not using exit-doors as entrance to the facility, and red box alarms. The Administrator stated QAPI will be held at the end of the month. During an interview on 02/20/25 beginning at 2:24 PM, CNA B stated he was giving a shower on 02/10/25 when Resident #1 escaped, and he did not see anything. CNA B said he did not hear any alarms going off or he would have attempted to investigate. CNA B stated Resident #1 normally wandered and tried to get out of the facility. CNA B stated he last saw Resident #1 when he served them snacks and orange juice at approximately 4:30 PM. CNA B stated Resident #1 had been wandering up and down the hallways prior to the incident but he did not notice any issues or problems with the doors or door alarms. During interviews conducted on 02/20/25 between 1:29 PM and 3:45 PM, reflected ADON L, RN A, RN D, LVN E, LVN M, MA K, MA Q, CNA B, CNA F, CNA N, CNA O, CNA R, NA G, NA H, and NA P were provided in-service education on abuse and neglect, elopement policy and procedure, not using the exit-door on the secured unit for entrance and exit, door codes and red box alarms. The staff were able to give examples of the different types of abuse to include neglect, identify the abuse coordinator, and verbalize abuse or neglect should be reported immediately. The staff were able to verbalize policy and procedure for elopement and identified residents at risk. The staff were able to verbalize interventions that could be used to prevent elopement for residents at risk. The staff stated the were not able to use the exit-doors on the secured unit for entrance or exit to the facility. The staff stated the red box door alarms should be on the on position at all times. The staff stated the door codes were changed and they were instructed to not give the code out and if family members needed to leave the staff had to let them out. During an interview on 02/24/25 beginning at 11:33 AM, the Maintenance Director stated the exit-doors on the secured unit were checked weekly and for any complaints or as needed. The Maintenance Director stated the red box alarm batteries were changed every month. The Maintenance Director stated on 02/10/25 when he arrived at the facility, the red box alarm was on the off position, but the keypad and door were functioning properly. The Maintenance Director stated, you could have the best system in the world but if it isn't on then it won't work. Surveyor requested documentation of door checks. Record review of the maintenance door check logs reflected the exit doors were checked with no issues identified on 01/03/25, 01/06/25, 01/10/25, 01/13/25, 01/20/25, 01/24/25, 01/27/25, 01/31/25, 02/03/25, 02/07/25, 02/10/25, 02/14/25, 02/17/25, and 02/21/25. Record review of the Wandering, Unsafe Resident policy, revised December 2007, reflected the facility will strive to prevent unsafe wandering while maintaining the least restive environment for all residents who are at risk for elopement .nursing staff will document circumstances related to unsafe actions, including wandering, by a resident .staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement . The noncompliance was identified as PNC. The IJ began on 02/10/25 and ended on 02/10/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure an opened bag of potato chips was securely closed or stored in a secure container. 2. The facility failed to ensure the tin pan with stuffed green peppers in beef sauce was securely closed in the freezer. 3. The facility failed to ensure two measuring cups were stored with the top openings facing down. 4. The facility failed to ensure there was minimal carbon buildup on approximately 7 baking sheet pans. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations in the kitchen on 4/15/24 beginning at 8:57 AM and accompanied by DM, there was an opened bag of potato chips with top of bag folded over and not securely closed in the dry goods pantry. DM went and got a plastic zipper bag and put the opened bag of potato chips in it. In the freezer, there was a silver tin pan labeled green peppers in beef sauce with the top cover lifted revealing approximately a fourth of the food and it had small pieces of what appeared to be ice on the top of the stuffed bell peppers in beef sauce. The DM then securely closed the top of the stuffed bell peppers in beef sauce. There were approximately 7 baking sheet pans with thick black carbon buildup on the outside of the pans and rim. There were two measuring cups hanging from the ceiling potholder rack with the top openings facing up toward the ceiling. During an interview on 4/17/24 at 1:13 PM, Cook H said she had worked at the facility for about [AGE] years in the kitchen. Cook H said all kitchen staff were responsible for ensuring there was an open date on packages of food that had been opened and the opened packaged should be placed in a zip lock bag to keep anything from getting in the package of food. Cook H said all kitchen staff were responsible for ensuring food items were stored properly in the freezer. Cook H said the black stuff on the baking sheet pans were from years of use and they have scrubbed and scrubbed, and it would not come off. Cook H said they lined the baking sheet pans with foil before using them. Cook H said she was not sure what the risk of carbon buildup on the baking sheet pans was for the resident. Cook H said the if the chip bag was not securely closed or placed in a plastic zippered bag, the potato chips could become stale and would not be good and/or anything could get into the opened package of chips. Cook H said they used to have a problem with pests/roaches, but she had not seen any in a long time. Cook H said if the stuffed bell peppers were not securely closed in the freezer, they could get freezer burnt and it would not be good. Cook H said the ice particles on food normally meant it was freezer burnt, and it would not be good for the residents and should not be served. Cook H said the measuring cups hanging with the top openings facing up toward the ceiling could collect dust and should be stored with the top opening facing down. During an interview on 4/17/24 at 1:28 PM, the DM said she had worked at the facility since 1992. The DM said the opened bag of potato chips should have been stored in a plastic zippered bag with an open date on it to keep anything from getting into the bag and to preserve the quality of the bag of chips. The DM said the lid of bell peppers should have been tightly secured because it was unused. The DM said she checked the bell peppers and resecured the packaging to ensure the quality of the meal. The DM said they used a degreaser to try to remove the carbon buildup from the cookware, but it would not come off. The DM said she was working on replacing the pans but had not placed an order yet due to financial reasons. The DM said the carbon build up was not on the inside of the pans and they lined them with foil prior to using them, therefore there was not a risk to the residents. The DM said they washed the measuring cups prior to using them and did not see an issue with them hanging with the tops facing up on the hanging rack. The DM said she had not seen any pests/roaches in about a week when she saw one roach. The DM said they have a pest control company come spray weekly. The DM said she ended up tossing the opened bag of potato chips, because she did not know how long they had been open. The DM said the stuffed bell peppers had been delivered to the facility last Friday (4/12/24) and she inspected them and determined they were not freezer burnt and served them as an alternate on 4/16/24. During an interview on 4/17/24 at 2:55 PM, the ADM said she would expect food to be securely closed because anything could get in it and contaminate the food if not stored properly. The ADM said she would expect the baking pans to be free of carbon buildup due to it could contaminate the food. The ADM said they had been fighting a battle with pests/roaches in the facility, but it had gotten much better, and they had the pest control company come weekly. The ADM said if food was not stored properly or if the baking pans were not free of carbon buildup, it placed the residents at risk. Record review of the facility's policy titled Dietary Services dated 2007 indicated . the purpose . to prevent contamination of food products and therefore prevent foodborne illness . provide safe food services for residents . provide for the proper receipt and storage of all food supplies . utensils, cups, glasses and dishes must be handled in such a way as to avoid touching surfaces with which food or drink will come into contact .

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 16 residents reviewed for infection control. (Resident #35, Resident #6, Resident #7, Resident #103, Resident #18) 1.The facility failed to ensure CNA G changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #35. 2.The facility failed to ensure CNA G changed her gloves after providing incontinent care to Resident #35 prior to touching Resident #35's bare hip, bare leg, clean brief, clothing, bedding, pillow, 2 drinking cups, bedside table, and bed remote. 3. The facility failed to ensure CNA G and CNA J followed the Enhanced Barrier Precaution to don gown and gloves for incontinence care for Resident #6. 4. The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #7. 5. The facility failed to ensure CNA A changed her gloves after providing incontinent care to Resident #7 prior to touching Resident #7's POTUS boot (is designed to reduce heel ulcers (and skin sores) and turning her. 6. The facility failed to ensure CNA B changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #103. 7. The facility failed to ensure CNA B changed her gloves after providing incontinent care to Resident #103 prior to touching Resident #103's covers. 8. The facility failed to isolate Resident #18 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in his urine. These failures could place residents at risk for cross-contamination, increased risk of infection and the spread of infection. Findings included: 1. Record review of Resident #35's face sheet dated 4/15/24 indicated Resident #35 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), history of UTI (urinary tract infection), and atopic dermatitis-Eczema (itchy inflammation of the skin). Record review of Resident #35's quarterly MDS dated [DATE] indicated Resident #35 was understood and understood others. The MDS indicated Resident #35 had a BIMS score of 7 which indicated she had severe cognitive impairment. Resident #35 was always incontinent of bowel and bladder. Record review of Resident #35's undated care plan indicated she had the potential for a UTI related to a history of urinary infection, incontinent of bowel and bladder, and refuses care at times. Resident #35 had interventions including to ensure meticulous personal hygiene, especially after elimination, keep perineal area clean and dry, and use a front to back wiping technique; use principles of infection control and universal/standard precaution. Record review of Resident #35's orders revealed an order to apply nystatin powder (medication used to treat fungal and yeast infections of the skin) to affected area twice daily as needed with a start date of 4/13/21. During an observation on 04/15/24 at 10:30 AM, NA G said came to Resident #35's room to perform incontinent care. NA G told Resident #35 you are going to see me do things, I don't usually do but I want to do things the right way with her (surveyor) watching me. NA G removed everything including Resident #35's two drinking cups from her bedside table and placed them on side table. NA G washed hands and applied gloves, then she covered the bedside table with towel and placed two wash basins on table with soapy water in one and clean water in the other one. NA G said then handed Resident #35 a wet clean washcloth to wash her face with. NA G then used a clean wet soapy washcloth to wash under Resident #35's breasts and underarms and Resident #35 said she has tendency to get yeast and had some raw areas under arms and breast and inner thighs. Observed small, reddened areas under both of Resident #35's breasts and under arms. NA G then cleaned under both breasts and under arms with clean water and patted the areas dry. NA G then applied moisture barrier cream under underarms and breasts then applied powder to the areas. NA G then proceeded without changing her gloves to put a clean gown on Resident #35. NA G then without changing her gloves, cleaned Resident #35's front private area using front to back technique, then assisted Resident #35 to turn on left side by touching bare right hip and leg. NA G then without changing her gloves proceeded to clean Resident #35's buttocks that was soiled with feces. NA G then proceeded to apply moisture barrier cream to Resident #35's buttocks, without changing her gloves. NA G then assisted Resident #35 to turn back over onto her back by placing her same gloves on Resident #35's right hip and leg. NA G then proceeded using same gloves, assisted Resident #35 to roll to right side by placing same gloved hands on her left hip and leg. NA G then removed soiled brief and under pad and placed in a plastic bag. NA G then using same gloves, proceeded to place a clean under pad and brief under and on resident and then positioned resident back onto her back. NA G then without changing her gloves, NA G pulled Resident #35's gown down over brief, used the bed remote to lower the bed, pulled the resident's bedding over her, replaced the resident's 2 drinking cups from side table back onto the bedside table, and pulled the resident up in bed. NA G then removed her gloves and sanitized her hands. NA G performed all of the above using the same gloves throughout and did not change gloves or perform hand hygiene appropriately. During an interview on 4/17/24 at 10:13 AM, LVN E said staff should be changing their gloves when going from dirty to clean areas while performing incontinent care. LVN E said it would not be appropriate for a NA to provide incontinent care, then apply a cream to the resident's bottom, then apply cream to the resident's front private area, and then proceed to touch clean items with same gloves. LVN E said it would be cross contamination and increase the risk of infection for the resident. During an interview on 4/17/24 at 11:00 AM, NA G said she had worked at the facility for a year. NA G said she had completed the CNA program but was waiting to take her certification test. NA G said she told Resident #35 she was doing things different from how she normally cleaned her up because she wanted to make sure she did it right and she just wanted to let the resident know why it was different. NA G said she normally only used one wash basin and did not use two. NA G said she should have changed her gloves when going from front to back during incontinent care and she knew she messed up when she turned the resident back over after performing incontinent care. NA G said she had been told the redness areas under Resident #35's arms and breasts was yeast and the treatment nurse had a special cream she applied to the areas, but she was told to use moisture barrier cream in between when the treatment nurse applied the special cream. NA G said she messed up from top to bottom and cross-contaminated by not changing her gloves after applying cream under Resident's arms and breast, then cleaning resident's front peri area, then feces from buttocks, then applying cream to buttocks, then rolled resident over and applied cream to front peri area, then proceeded to touch bed remote, resident, covers, clothes, and drinking cups. NA G said it was cross-contamination and put the resident at risk for infection. NA G said she had received training on when to change gloves during incontinent care and infection control. NA G said she was so nervous to have the surveyor watching her and knew she had forgot to change her gloves and knew it was wrong. During an interview on 4/17/24 at 2:19 PM, the DON said staff should change gloves when going from a dirty to clean area during incontinent care and wash hands and/or use hand sanitizer with each glove change. The DON said CNA G should have changed her gloves and sanitized her hands after cleaning and applying moisture barrier under Resident #35's arms and breasts, then after cleaning feces from Resident #35's buttocks, then after applying moisture barrier cream to buttocks, then after applying moisture barrier to her front perineal area and inner thighs, and she should have removed her soiled gloves and sanitized her hands prior to handling the resident and items in her room. The DON said there was an increased risk of spreading infection without proper hand sanitation and changing gloves appropriately. During an interview on 4/17/24 at 2:55 PM, the ADM said staff should change their gloves anytime they are going from a dirty area to a clean area and when their gloves become soiled. The ADM said it was unacceptable for CNA G to not change her gloves and sanitize her hands prior to touching Resident #35's clean bare skin, clothing, clean brief, bedding, pillow, drinking cups, bedside table, and bed remote. The ADM said it was an infection control issue. Record review of the facility's Departmental Orientation titled Nursing-CNA, RNA revealed NA G began orientation on 2/09/24 and completed orientation on 2/09/24 and each item was to be checked off as completed . each item was to be fully explained, examples shown, and employee in-serviced on nursing responsibilities regarding . NA G was checked off on bathing (bed, tub, shower, partial, perineal care) . skin care (cleanliness, lotions/powders, massage, positioning) . cleaning procedures . Infection Control . cleaning/sanitizing of all work areas . hygiene (hand sanitizing, gloves) . isolation procedures/universal precautions . check off as completed, the employee must locate or demonstrate each of the following . NA G was checked off on . bathing . perineal care . personal patient hygiene, grooming, and care . proper hand sanitizing . and was signed by NA G on 2/09/24. 44933 2. Record review of face sheet printed 04/17/24 indicated Resident #6 was a [AGE] year-old, male and was admitted on [DATE] with diagnoses including colostomy status (is surgery to create an opening for the colon (large intestine) through the belly (abdomen)), Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), quadriplegia (is a symptom of paralysis that affects all a person's limbs and body from the neck down), and urinary incontinence (the loss of bladder control). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated Resident #6 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #6 required substantial/maximal assistance for oral hygiene, toileting hygiene, shower/bathe self, dressing, and personal hygiene. The MDS indicated Resident #6 was always incontinent of urine. The MDS indicated Resident #6 had an ostomy (is a surgery that creates an opening in the abdomen, changing the way that waste exits your body). Record review of a care plan dated 03/30/24 indicated Resident #6 was at increased risk for MDRO related to enhanced barrier precautions to be used (pressure ulcer). Interventions included before entering a resident's room with an EBP sign: gather all needed supplies and materials, clean hands correctly, put on a gown and gloves. After care, throw away gown and gloves, clean hands again. Finish all steps before moving on to another resident. Examples of high-contact resident care activities requiring gown and glove use for EBP included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. During an observation on 04/15/24 at 12:45 p.m., the WCN asked NA G to change Resident #6 so she could do his wound dressing change. NA G grabbed a bag of items to provide incontinent care, her and CNA J entered Resident #6's room. At Resident #6's door, was a plastic container with gowns and on the door was a Enhanced Barrier Precaution sign. During an observation on 04/15/24 at 12:50 p.m., NA G exited Resident #6's room and noticed the surveyor, WCN, and ADON were wearing gowns to enter another resident with EBP room. NA G stopped and said oops, I did not put that on for Resident #6. NA G went to the linen cart and got an item then reentered Resident #6's room without a gown. During an interview on 04/17/24 at 11:26 a.m., NA G said her, and CNA J did not wear gowns when they provided incontinent care for Resident #6 on 04/15/24. She said Resident #6 was on EBP for his colostomy and wound. She said there was a sign posted on Resident #6's door letting her know she needed to put in on before entering. She said she really did not understand why she had to wear a gown and gloves for EBP resident. She said she did not know the full reason why EBP was being used in the facility, but knew it was important. She said the EBP was done to protect the resident. She said she had been recently in-serviced on EBP. Record review of NA G's Departmental Orientation Nursing- CNA, RNA dated 02/09/24 indicated .check off each item as completed .each item is to be fully explained, examples shown, and employee in-services on nursing responsibilities regarding .check off completed for infection control .isolation procedures/universal precautions . Record review of CNA J's Nurse Aide Checklist dated 03/26/24 did not reveal a checkoff for isolation procedures. Record review of a facility's in-service training topic Enhanced Barrier Precautions by the DON, dated 04/01/24 indicated .enhanced barrier precautions .everyone must: clean their hands, including before entering and when leaving the room .providers and staff must also: wear gloves and gown for the following High-Contact Resident Care Activities .changing briefs or assisting with toileting . NA G and CNA J signatures noted on attendance roster. 3. Record review of a face sheet printed 04/17/24 indicated Resident #7 was an [AGE] year-old, female and was admitted on [DATE] and 12/23/22 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation (is an irregular and often very rapid heart rhythm), and nutritional deficiency (occurs when the body is not getting enough nutrients such as vitamins and minerals). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had a BIMS score of 06 which indicated severe cognitive impairment. The MDS indicated Resident #7 required substantial/maximal assistance for eating, oral hygiene, toileting hygiene, shower/bathe self, dressing, and personal hygiene. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of a care plan dated 05/17/18, revised 03/14/24 indicated Resident #7 required substantial/maximal assistance with ADL's related to impaired mobility, impairment in range of motion in all extremities, use of wheelchair for locomotion and transfer by Hoyer lift. Intervention included total assist x1 for bed mobility and toileting. During an observation on 04/15/24 at 1:38 p.m., NA G and CNA A provided Resident #7 incontinent care. NA G held Resident #7 on her side while CNA A wiped Resident #7's bottom with gloves. After CNA A finished cleaning Resident #7, without changing gloves, she assisted NA G with turning Resident #7 on back. CNA A, then lifted Resident #7's leg and straightened the POTUS boot on her left foot with the same gloves. During an observation on 04/17/24 at 11:18 a.m., CNA A said she did not remember not changing her gloves after cleaning Resident #7 then, touching Resident #7 and her POTUS boot. She said when gloves were removed, staff should wash their hands or use hand gel. She said she should have changed her gloves before touching the resident for infection control. Record review of CNA A's Departmental Orientation Nursing- CNA, RNA dated 02/09/24 indicated .check off each item as completed .each item is to be fully explained, examples shown, and employee in-services on nursing responsibilities regarding .check off completed for bathing ( .perineal care .) .check off completed for catheters ( .indwelling .) .check off completed for Infection control .hygiene ( .hand sanitizing, gloves .) . 4. Record review of a face sheet printed 04/17/24 indicated Resident #103 was a [AGE] year-old, male and was admitted on [DATE] with diagnoses including malignant neoplasm of bronchus or lung (is a kind of cancer that starts as a growth of cells in the lungs), secondary malignant neoplasm (cancer) of brain and bone, Crohn's disease (is a chronic (long-lasting) disease that causes inflammation in your digestive tract), and personal history of urinary tract infections (infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract). Record review of a baseline care plan dated 04/11/24 indicated Resident #103 required assistance of bathing and dressing. Intervention included assist with ADLs and assess for restorative. A comprehensive care plan was not completed due to Resident #103 being admitted to the facility less than 21 days ago. Unable to complete a record review of the MDS due to Resident #103 being admitted to the facility less than 21 days ago. No MDS for Resident #103 was completed prior to exit. During an observation on 04/15/24 at 2:34 p.m., CNA B and NA J provided Resident #103 with Foley care. CNA B cleaned Resident #103's groin area and catheter. CNA B asked Resident #103 to turn towards her so NA G could do the back. Resident #103 turned on his right side, CNA B moved Resident #103 covers from around his feet without changing gloves. CNA B with the same gloves, touched the bag her incontinent supplies were in. On 04/17/24 at 11:37 a.m., called CNA B and left message to return phone call. CNA B did not return my phone call before or after exit. Record review of CNA B's Departmental Orientation Nursing- CNA, RNA dated 02/09/24 indicated .check off each item as completed .each item is to be fully explained, examples shown, and employee in-services on nursing responsibilities regarding .check off completed for bathing ( .perineal care .) .check off completed for catheters ( .indwelling .) .check off completed for Infection control .hygiene ( .hand sanitizing, gloves .) . 5. Record review of a face sheet printed 04/17/24 indicated Resident #18 was a [AGE] year-old, male and was admitted on [DATE] and 06/02/23 with diagnoses including chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), and Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #18 was understood and understood others. The MDS indicated Resident #18 had a BIMS score of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #18 required supervision for oral hygiene, toileting hygiene, shower/bathe self, dressing, and personal hygiene. The MDS indicated Resident #18 was always incontinent for urine and bowel. Record review of an acute plan of care for infection dated 01/09/24 indicated Resident #18 had diagnosis of UTI. Intervention included administer meds as per MD orders, monitor and report ill findings to MD as indicated. Record review of a care plan dated 04/01/24 indicated Resident #18 was at increased risk for MDRO related to enhanced barrier precaution to be used for ESBL. Intervention included gloves and gown prior to the high-contact care activity. Record review of a plan of care dated 04/05/24 indicated Resident #18 had UTI. Intervention included administer meds as per MD orders, monitor and report ill findings to MD as indicated. Record review of Resident #18's consolidated physician order dated 01/01/24-01/31/24 did not reveal contact isolation order. Record review of Resident #18's consolidated physician order dated 04/01/24-04/17/24 did not reveal contact isolation order. Record review of Resident #18's MAR dated 01/01/24-01/31/24 did not reveal contact isolation order. Record review of Resident #18's MAR dated 04/01/24-04/17/24 did not reveal contact isolation order. Record review of Resident #18's nurse's notes dated 01/10/24-01/16/24 did not reveal Resident #18 had been on contact isolation precaution due to ESBL in his urine. Record review of Resident #18's nurse's notes dated 04/04/24-04/12/24 did not reveal Resident #18 had been on contact isolation precaution due to ESBL in his urine. Record review of the facility's Infection Control Log dated 01/01/24-01/31/24 indicated .Resident #18 .infection related DX: UTI .Organism: Klebsiella Pneumonia .isolated: No . Record review of the facility's Infection Control Log dated 04/01/24 indicated .Resident #18 .Infection DX: UTI .isolated 04/04/24 . Record review of Resident #18's culture results dated 01/08/24 indicated .pathogens detected: High: Klebsiella Pneumonia .antibiotic notes: ESBL (Extended Spectrum Beta-lactamase) detected .antibiotic resistance genes .ESBL 1 . Record review of Resident #18's culture results dated 04/01/24 indicated .pathogens detected: Moderate: Klebsiella Pneumonia .antibiotic notes: ESBL (Extended Spectrum Beta-lactamase) detected .antibiotic resistance genes .ESBL 1 . Record review of Resident #18's 72-hour Antibiotic Time-Out dated 01/12/24 indicated .Resident #18 .UTI .strong odor .change antibiotic .DON . Transmission-based precautions was not selected. Record review of Resident #18's 72-hour Antibiotic Time-Out dated 04/04/24 indicated .Resident #18 .UTI .Transmission-based precautions: Contact .Enhanced Barrier Precaution .DON . During an interview on 04/17/24 at 8:50 a.m., the DON said they suspected Resident #18 was colonized (is the presence of bacteria on a body surface (like on the skin, mouth, intestines, or airway) without causing disease in the person) with ESBL in his urine. She said the doctor had order a urine culture after Resident #18 completed his antibiotics to see if he still tested for ESBL. She said normally if a resident tested positive for ESBL, the resident would be placed on contact isolation until antibiotic were completed then placed on enhanced barrier precautions. She said if a resident was placed on isolation, there should be an order in the resident's chart and the nurses should be documenting the resident being on isolation status in nurses note. During an interview on 04/17/24 at 9:00 a.m., Resident #18 said the only isolation he had been on was when he had COVID-19. He said he had not been on isolation for something growing in his urine. He said he mostly took care of his urine but sometimes staff emptied the urinal for him. During an interview on 04/17/24 at 10:51 a.m., LVN F said if a resident had a MDRO, she followed the physician order after the results were sent to the doctor. She said if the doctor ordered the resident to be on isolation, she would place the resident on isolation. She said isolation was important for resident with MDRO to prevent the transmission of the organism to the other residents. She said not isolating the resident risked spreading the MDRO in the facility. She said gloves should be changed after incontinent care was provided before staff touched the resident or the resident's stuff. She said it was important to change gloves, so germs were not spread. She said if staff touched items with contaminated gloves, then it risked some else touching the same area and spreading it. She said she tried to assist with incontinent care to monitor if the CNAs were providing correct incontinent care. She said gown and gloves were required for residents on EBP. She said residents with Foleys and wounds were placed on EBP. She said EBP was to prevent resident more susceptible to infection for getting an infection. She said no wearing gown and gloves during close care placed the resident at risked for an infection and exposure to germs. She said the resident could then need antibiotics or hospitalization . During an interview on 04/17/24 at 11:37 a.m., the DON said staff should wear gown and gloves for a resident on EBP and who had a MDRO. She said resident with devices such as catheters and wounds with dressing were placed on EBP. She said EBP was important to prevent the spread of infection. She said the DON and CNA coordinator should ensure staff were following the EBP guidelines. She said she tried to do in and out surveillance, but she could not be everywhere. She said the facility also educated the staff of EBP with in-service and video. She said she expected staff the remove their gloves after cleaning a resident then doing some form of hand hygiene. She said it was important to change gloves and perform hang hygiene to be aseptic. She said hand hygiene prevented infection and cross contamination. She said she sometimes observed CNAs perform incontinent care but mostly the CNA coordinator did the monitoring. During an interview on 04/17/24 at 11:56 a.m., CNA coordinator K said he had been in his position for 1-2 weeks. He said he was still working on observing the CNA's skills. He said he expected the CNAs to remove their gloves, perform hand hygiene then place new gloves on before touching the resident. He said it was important for infection control. He said just because something was not visible seen on the glove, did not mean something was not on them to spread. During an interview on 04/17/24 at 12:10 p.m., the ADM said not changing gloves after cleaning a resident then touching the residents and their items was not good infection control practice and had the potential to cause an outbreak in the facility. She said when staff provided direct care to resident on EBP, they were to wear a gown and gloves. She said EBP was important to protect the resident from infection and anything the staff may have on themselves. She said all staff knew to wear gown and gloves during direct contact for resident on EBP. She said the DON had done in-service of the topic. She said a resident with ESBL in their urine, should be placed on isolation. She isolation was important, so the infection did not spread. She said the Infection Control Preventionist was responsible for ensuring infection control was maintained in the facility. She said the DON was the Infection Control Preventionist. Record review of the facility's policy titled Handwashing/Hand Hygiene with a revised date of August 2015 revealed . the facility considered hand hygiene the primary means to prevent the spread of infection . all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections . wash hands with soap and water for following situations . when hands visibly soiled . use alcohol-based hand rub or soap and water for the following situations . before and after direct contact with residents . before donning sterile gloves . before moving from a contaminated body site to a clean body site during resident care . after contact with objects in the immediate vicinity of the resident . before and after entering isolation precaution settings . the use of gloves does not replace handwashing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . applying and removing gloves . perform hand hygiene before applying non-sterile gloves . Record review of the facility's policy titled Perineal Care with a revised date of October 2010 revealed . the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin . wash and dry hands thoroughly . put on gloves . for female resident . wash perineal area, wiping from front to back . wash rectal area thoroughly, wiping from the labia towards and extending over the buttocks . remove gloves and discard . wash and dry hands thoroughly . reposition the bed covers . make resident comfortable . Record review of a CMS Memorandum Enhanced Barrier Precautions in Nursing Homes dated 04/20/24 indicated .EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status .EBP refer to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities . Record review of a facility's Isolation- Categories of Transmission-Based Precautions policy revised 01/2012 indicated .TBP shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others .TBP will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions .for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .examples of infections requiring contact precautions included, but not limited to .infections with multi-drug resistant organisms .

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 12.5%, based on 4 errors out of 32 opportunities, which involved 4 of 6 residents (Resident #8, Resident #22, Resident #36, Resident #44) reviewed for medication administration. 1. MA L administered Acetaminophen-codeine 300-30mg (is a prescription pain medicine) at 10:30 a.m. instead of 8:00 a.m. as ordered on 04/15/24 for Resident #8. 2. MA L administered Aspirin 81mg (is an antiplatelet (make it harder for blood clots to form); effective at preventing heart attack or stroke) at 9:31 a.m. instead of 8:00 a.m. and without food as ordered on 04/15/24 for Resident #22. 3. MA L administered Esomeprazole Magnesium 20mg (is used to treat conditions where there is too much acid in the stomach) at 9:23 a.m. instead of 7:00 a.m. as ordered on 04/15/24 for Resident #36. 4. MA L administered Omeprazole 40mg (is used to treat certain conditions where there is too much acid in the stomach) at 9:56 a.m. instead of 7:00 a.m. and did not give it 30-60 minutes prior to eating food as ordered on 04/15/24 for Resident #44. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of a face sheet printed 04/17/24 indicated Resident #8 was a [AGE] year-old, female and was admitted on [DATE] with diagnoses including gout (is a type of inflammatory arthritis that causes pain and swelling in your joints), pain in left knee, chest pain, and pain. Record review of an admission MDS assessment dated [DATE] indicated Resident #8 was understood and understood others. The MDS indicated Resident #8 had a BIMS score of 09 which indicated moderate cognitive impairment. The MDS indicated Resident #8 required partial/moderate assistance for oral hygiene, toilet hygiene, shower/bathe self, dressing, and personal hygiene. The MDS indicated Resident #8 did not receive scheduled pain medication regimen, prn pain medication, or non-medication intervention for pain. Record review of a care plan dated 01/10/24 indicated Resident #8 had potential for complaints of chronic pain related to left knee and gout. Intervention included administer medications as directed. Record review of Resident #8's consolidated physician orders printed 04/17/24 indicated acetaminophen-codeine tablet 300-30mg, 1 tablet every 8 hours, 8:00 a.m., 4:00 p.m., 12:00 a.m. Start date 02/20/24, with no end date. Record review of Resident #8's MAR dated 04/01/24-04/30/24 indicated acetaminophen-codeine tablet 300-30mg, 1 tablet every 8 hours, DX: pain, 12:00 a.m., 8:00 a.m. Start date 02/20/24, with no end date. During an observation on 04/15/24 at 10:30 a.m., MA L prepared and administered Resident #8's acetaminophen-codeine tablet 300-30mg, 1 tablet with 12 other prescribed medications. 2. Record review of a face sheet printed 04/17/24 indicated Resident #22 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #22 was understood and understood others. The MDS indicated Resident #22 had a BIMS score of 07 which indicated moderate cognitive impairment. The MDS indicated Resident #22 required substantial/maximal assistance for oral hygiene, toileting hygiene, shower/bathe self, dressing, and personal hygiene. Record review of a care plan dated 09/14/23 indicated Resident #22 had Atrial Fibrillation with potential for abnormal bleeding and bruising related to antiplatelet therapy. Intervention included administer antiplatelet as ordered. Record review of Resident #22's consolidated physician orders printed 04/17/24 indicated Aspirin 81mg, 1 tablet, special instruction: **with food**, once a morning, 8:00 a.m. Start date 02/20/24, no end date. Record review of Resident #22's MAR dated 04/01/24-04/30/24 indicated Aspirin 81mg, 1 tablet, special instruction: **with food**, DX: cerebral infarction, once a morning, 8:00 a.m. Start date 02/20/24, no end date. During an observation on 04/15/24 at 09:31 a.m., MA L prepared and administered Resident #22's, Aspirin 81mg, 1 tablet with 3 other prescribed medications. Resident #22 was not eating at the time of the administration. 3. Record review of a face sheet printed 04/17/24 indicated Resident #36 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including gastro-esophageal reflux disease (means stomach acid is rising into your esophagus). Record review of an admission MDS assessment dated [DATE] indicated Resident #36 was understood and understood others. The MDS indicated Resident #36 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #36 required partial/moderate assistance for oral hygiene, toilet hygiene, shower/bathe self, dressing, and personal hygiene. Record review of a care plan dated 03/25/24 indicated Resident #36 ADL functions partial/moderate assistance. Intervention assist with ADLs as needed. The care plan did not address Resident #36's gastro-esophageal reflux. Record review of Resident #36's consolidated physician order printed 04/17/24 indicated Esomeprazole Magnesium 20mg, 1 capsule, oral, once a day, 7:00 a.m. Start date 03/19/24, no end date. Record review of Resident #36's MAR dated 04/01/24-04/30/24 indicated Esomeprazole Magnesium 20mg, 1 capsule, oral, once a day, DX: gastro-esophageal reflux disease 7:00 a.m. Start date 03/19/24, no end date. During an observation on 04/15/24 at 09:23 a.m., MA L prepared and administered Resident #36's, Magnesium 20mg, capsule with 1 other prescribed medication. 4. Record review of a face sheet printed 04/17/24 indicated Resident #44 was a [AGE] year-old, female and was admitted on [DATE] with diagnosis including gastro-esophageal reflux disease (means stomach acid is rising into your esophagus). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #44 was understood and understood others. The MDS indicated Resident #44 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #44 required substantial/maximal assistance for oral hygiene, toilet hygiene, shower/bathe self, dressing, and personal hygiene. Record review of a care plan dated 09/14/23 indicated Resident #44's ADL functions substantial/maximal assistance. Intervention included assist with ADLs as needed. The care plan did not address Resident #44's gastro-esophageal reflux. Record review of Resident #44's consolidated physician order printed 04/17/24 indicated Omeprazole 40mg, 1 capsule, oral, special instruction: *Give 30-60 mins prior to eating food*, twice a day, 7:00 a.m., 5:00 p.m. Start date 09/07/23, no end date. Record review of Resident #44's MAR dated 04/01/24-04/30/24 indicated Omeprazole 40mg, 1 capsule, oral, special instruction: *Give 30-60 mins prior to eating food*, DX: gastro-esophageal reflux disease, twice a day, 7:00 a.m., 5:00 p.m. Start date 09/07/23, no end date. During an observation on 04/15/24 at 09:56 a.m., MA L prepared and administered Resident #44's, Omeprazole 20mg, 2 capsule with 5 other prescribed medications. During an interview on 04/15/24 at 11:00 a.m., the Regional Nurse Consultant said medications with a specified administration time could be given 1 hour before and after the ordered time. She said the medications with a time range had to be given within that window of time. During an interview on 04/17/24 at 10:45 a.m., MA L said medication with specified time had to be given 1 hour before or after the ordered administration time. She said if a medication was scheduled for 7:00 a.m., she had to give it by 8:00 a.m. She said Resident #36 and Resident #44's medications were acid reducer so she should have given at 7:00 a.m. or before the resident ate. She said it was important to give the acid reducer before the resident ate to prevent acid erosion of the throat and stomach form the reflux. She said Resident 22's Aspirin should be given with food to prevent an upset stomach. She said after med pass with surveyor on 04/15/24, she realized she needed to revamp her med pass routine. She said she had to educate herself and the residents on the importance of giving certain medication at certain times. During an interview on 04/17/24 at 10:51 a.m., LVN F said the facility allowed scheduled medication with specified times to be given 1 hour before and after. She said acid reducers should be given at 7:00 a.m. and without food. She said acid reducers were more effective on an empty stomach and helped reduce the acid for food. She said Aspirin should be given with food reduced the chances of the rest getting an upset stomach. She said if medications were not given as ordered, resident could experience the symptoms the medication was trying to prevent. During an interview on 04/17/24 at 11:37 a.m., the DON said there was a 1 hour before and after window scheduled medications could be given. She said a scheduled medication given after the 1-hour window was considered late. She said acid reducer medication was supposed to be given before the reside ate to prevent acid reflux. She said if the medication was not given before the resident ate, the resident could experience ingestion. She said she did not know why Resident #22's Aspirin had to be given with food. She said she would have to do some digging to see why Resident #22 needed his Aspirin with food. She said some residents GI bleed could need their Aspirin with food. She said Resident #22's Aspirin should be given with food if that is what the order said. During an interview on 04/17/24 at 12:10 p.m., the ADM said she did not know about nursing to comment of medication administration times and the purpose of certain medications. Record review of a facility's Administering Medications policy revised 12/2012 indicated .medication shall be administered in a safe and timely manner, and as prescribe .medications must be administered in accordance with the orders, including any required time frame .medications must be administered within 1 hour of their prescribed time, unless otherwise specified .for example, before and after meals orders .

Based on interviews and record reviews, the facility failed to ensure the residents had the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 1 of 20 residents (Resident #102) reviewed for resident rights. The facility failed to obtain informed consent from Resident #102's RP prior to administering Prozac (antidepressant medication used to treat depression-persistent sadness) to Resident #102. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party and could place the residents at an increased risk for adverse reactions to the medications. Findings included: Record review of Resident #102's face sheet dated 4/15/24 indicated Resident #102 was an [AGE] year-old female and admitted to the facility 4/01/24 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, anxiety (intense, excessive, and persistent worry and fear about everyday situations), malignant neoplasm (cancer) of female breast, and depression (persistent sadness). Record review of Resident #102's quarterly MDS assessment dated [DATE] indicated Resident #102 was usually understood and understood others. The MDS indicated Resident #102's BIMS score was 7 which indicated she had severe cognitive impairment. The MDS indicated Resident #102 received an antidepressant medication. Record review of Resident #102's undated care plan indicated Resident #102 resisted care, refused bathing and changing soiled clothes, refused to staff to provide nail care with a problem start date of 4/15/24; Resident #102 wandered and was placed on the secure unit with a problem start date of 4/15/24; Resident #102 had behavioral symptoms not directed toward others, was sexually inappropriate would come into hallway take off her clothes and brief and start masturbating with a problem start date of 4/15/24; Resident #102 had a history of depression with a problem start date of 4/10/24; Resident #102 had cognitive impairment and poor decision making and placed on a special care unit for safety due to elopement attempts related dementia with a problem start date of 4/10/24. Record review of Resident #102's undated Orders revealed an order for Prozac (fluoxetine) 40 mg 1 capsule by mouth once a morning with a start date 4/14/24. Record review of Resident #102's Medication Flowsheet dated 4/01/24-4/30/24 revealed Prozac (fluoxetine) 40 mg every AM had been handwritten on the flowsheet as a new order and was initialed as being given on 4/16/24 and 4/17/24 by LVN F and sertraline 50 mg 1 tablet at bedtime was discontinued with last dose administered 4/15/24. Record review of Resident #102's nurse's notes dated 4/13/24 at 4:00 PM revealed LVN E documented Resident #102 was in the hallway, showing all of her peri area (private areas) and was masturbating (sexual self-stimulation), very difficult to redirect, would not go to her room, now covered, very argumentative with staff. LVN E then documented on 4/13/24 at 4:10 PM, Resident #102 attempted to go out of the side door and LVN E notified the DON and Resident #102 was moved to the back (secured) unit. LVN E documented on 4/13/24 at 5:45 PM, she notified the attending MD and received orders to discontinue Resident #102's sertraline and start Prozac 40 mg by mouth every AM. LVN E documented on 4/13/24 at 17:45 PM, she notified Resident #102's RP to inform him of Resident 102's behaviors and being moved to the secure unit and she talked to Resident #102's RP about giving verbal consent for the new order of Prozac. LVN E documented Resident #102's RP did not feel comfortable giving verbal consent and said he would come to the facility on [DATE] to sign the consent. During an interview on 4/16/24 at 9:55 AM, the RP for Resident #102 said Resident #102 lived with him in his guest house semi-independently for 4 1/2 years until about two weeks ago when he placed her in the facility. Resident #102's RP said Resident #102's dementia had progressed to the point that she could not walk about a month ago. Resident #102's RP said his only concern was the facility called and asked him to move Resident #102 to the dementia unit because she tried to leave the building and he did not see how she could have done that if she could not walk. Resident #102's RP said the facility also called him to change one of her psych meds to Prozac and they said she was hitting and refusing her medications. Resident #102's RP said he did not feel comfortable giving verbal consent over the phone and wanted to lay eyes on Resident #102 before he would consider giving consent. Resident #102's RP said if Resident #102 was refusing to take the medications she was already on, how would changing to a different medication help if she was refusing to take it. Resident #102's RP said he told them she took medications for him crushed and put in juice. Resident #102's RP said the facility told him they could not crush certain meds and he said he was just talking about her psych medications, so they could get the desired behaviors. Resident #102's RP said she would refuse to do things if they tried to do to many things at once and they needed to give her psych medications first thing in the morning to give the medications time to work before trying to get her dressed or feed her because she would refuse care. During an interview on 4/17/24 at 12:07 PM, Resident #102's RP said the facility notified him on 4/13/24 of wanting to change her antidepressant medication to Prozac and he told them he did not feel comfortable giving verbal consent over the phone without laying eyes on Resident #102. Resident #102's RP said he had planned to come see Resident #102 on 4/14/24 to review the need for Resident to change her antidepressant to Prozac, but he was not able to come on 4/14/24 and he was planning to come the weekend of 4/20/24. Resident #102's RP said he still had not given consent. During an interview on 4/17/24 at 8:30 AM, the ADON said the nurses should obtain written consent for psychotropic medications (antidepressants, antianxiety, antipsychotics, mood stabilizers, and stimulants) during the resident's admission or prior to starting a new psychotropic medication. The ADON said the nurses should obtain written signatures but if the family was not available, then they could obtain verbal phone consents with two nurses as witnesses. The ADON said then they would get the RP to physically sign the consents and when/if they came into the facility. The ADON said she reviewed consents to ensure they were done for required medications. The ADON said Resident #102 was to start on Prozac, but Resident #102's RP said he was not comfortable with giving verbal consent over the phone and he was supposed to come and sign the consent for the Prozac on Sunday (4/14/24). The ADON said Resident #102's RP had not come to the facility yet and Resident #102 had not started the Prozac. The ADON said psychotropic medications were not ever administered to a resident without consent. During an interview on 4/17/24 at 11:50 AM, LVN F said she had worked at the facility since August 2023 full time and had worked as needed for a couple years. LVN F said the nurses were responsible for obtaining consents for psychotropic medications upon admission and prior to starting a new psychotropic medication. LVN F said an antidepressant should not be administered without consent of the resident or the resident's RP. LVN F said Resident #102 had been receiving Prozac. LVN F said she did not know if consent had been received for Resident #102 to receive Prozac. During an interview on 4/17/24 at 11:55 AM, the ADON said they had not received consent for Resident #102 to receive Prozac because her RP did not feel comfortable giving verbal consent and was supposed to have come to the facility last Sunday (4/14/24) to sign the consent, but he did not come. The ADON said an antidepressant should not have been given without consent of RP. The ADON said she was not aware Resident #102 was administered Prozac without consent of her RP. During an interview on 4/17/24 at 2:19 PM, the DON said a consent should have been obtained from Resident #102's RP prior to administering the Prozac to Resident #102. The DON said the nurse should have notified the MD and the order for Prozac should have been placed on hold until consent was given by Resident #102's RP. The DON said obviously the physician felt the resident needed the medication due to exacerbation of behaviors. The DON said she did not know how being given Prozac without the Resident #102's RP's consent negatively affected Resident #102. During an interview on 4/17/24 at 2:35 PM, the Regional Nurse Consultant said she talked to LVN F and LVN F said she popped the Prozac out of the medication card, but Resident #102 refused to take the medication and LVN F said she had not been able to document Resident #102 had refused the Prozac because they had Resident #102's chart. The Regional Nurse Consultant said, however, the Prozac should not have been placed on Resident #102's MAR without obtaining consent. Surveyor informed the Regional Nurse Consultant that LVN F had stated to Surveyor, Resident #102 had been receiving Prozac. The Regional Nurse Consultant said she would go with what LVN F stated to Surveyor. During an interview on 4/17/24 at 2:55 PM, the ADM said she would expect staff to obtain consents for required medications prior to administering the medication. The ADM said by not obtaining consent, the resident could be given medications that the resident or their RP did not want them to have. Record review of the facility's policy titled Resident Rights with a revised date of December 2016 revealed . employees shall treat all residents with kindness, respect, and dignity . federal and state laws guarantee certain basic rights to all residents of the facility . rights include the resident's right to . be supported by the facility in exercising his or her rights . exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . be informed about his or her rights and responsibilities . appoint a legal representative of his or her choice . be notified of his or her medical condition and of any changes in his or her condition . be informed of, and participate in, his or her care planning and treatment . Record review of a facility provided document from Texas Health and Human Services titled Classes of Medications Frequently Used for Psychiatric Indications with a reviewed date of January 2023, revealed . consent was required for any medication that was used in the treatment of psychiatric diagnosis or symptom, whether or not the medication was included on this list or not . listed under Antidepressants . fluoxetine (Prozac) .

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to prevent development of pressure injuries was provided for 1 of 14 residents reviewed for pressure injuries. (Resident #15, #11) The facility did not prevent the development of two facility acquired unstageable pressure injury for Resident #15. The facility did not prevent the development of one facility acquired unstageable pressure injury for Resident #11. This failure could place residents at risk for new development or worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#15 was admitted [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#15's heels at all times while in bed. The care plan dated 4/6/19 indicated Resident #15 was at risk for pressure injury. The care plan indicated staff would turn and reposition every 2 hours. The most recent care plan update on 8/15/20 indicated Resident #15 had no skin issues. The most current MDS dated [DATE] indicated Resident #15 rarely/never understood others and was rarely/never understood. The MDS indicated Resident #15 required extensive assistance with bed mobility. The MDS indicated Resident #15 was at risk for developing a pressure injury but did not have a pressure injury at the time. The skin treatment flowsheet dated October 2020 indicated Resident #15's heels were not floated on 10/3/20-10/4/2, 10/10/20-10/11/20, 10/17/20-10/18/20, 10/21/20, 10/24/20-10/25/20, and 10/29/20-10/31/20 during the day shift. The flowsheet indicated Resident #15's heels were never floated on the evening or night shift. The flowsheet indicated Resident #15's heels were never floated on the evening or night shift up to 11/5/20. The skin treatment flowsheet dated November 2020 indicated Resident #15's heels were not floated 11/1/20 and 11/3/20-11/5/20 during the day shift. The twenty-four hour nursing report from 11/2/20 to 11/5/20 did not indicate Resident #15 had a newly acquired pressure injury. Weekly skin assessments for Resident #15 indicated: *10/26/20 - No skin issues noted. *11/2/20 - Black colored area to right heel and small discoloration to left heel. A wound report dated 11/3/20 by the wound doctor indicated Resident #15 had a 2 x 1.5 x 0.1-centimeter unstageable pressure injury to the right heel with light serous exudate. The treatment plan was a foam silicone border dressing three times weekly. Recommendations were to off load the wound, prevalon boots, and repositioning resident every two hours. The wound report indicated Resident #15 had a 1 x 1-centimeter unstageable pressure injury to the left heel. The treatment plan was [MEDICATION NAME] applied daily. Recommendations were to off load the wound and prevalon boots. During an observation on 11/2/20 at 11:04 a.m., there was a sign on Resident #15's wall indicating to float Resident #15's heels while in bed. During observations of Resident #15's positioning, the following was noted: *11/02/20 11:04 a.m.-Approximately 1.5 inch round dark purple wound to right heel, approximately 0.5 inch red unblanchable area to left heel. Heels were not floated and were in direct contact with the mattress. Heel protectors were lying on the bed. *11/02/20 1:20 p.m. -Heels were not floated and were in direct contact with the mattress. Heel protectors were lying on the bed. *11/2/20 3:00 p.m. -Heels were not floated and were in direct contact with the mattress. Heel protectors were lying on the bed. *11/3/20 8:55 a.m. - Heels were not floated and were in direct contact with the mattress. Heel protectors were lying on the bed. *11/3/20 10:41 a.m. -Heels were not floated and were in direct contact with the mattress. Heel protectors were lying on the bed. *11/3/20 2:01 p.m. -Heels were not floated and the right heel was in direct contact with the mattress. Heel protector was on the left foot. The other heel protector was lying on the bed. *11/4/20 9:00 a.m. - Heels were not floated and were in direct contact with the mattress. Heel protectors were in the chair. *11/5/20 9:21 a.m. -Heels were not floated and were in direct contact with the mattress. Heel protectors were in the chair. During an interview on 11/2/20 at 11:06 a.m., CNA N said she had just found the discoloration on Resident #15's heels this morning (11/2/20). She said she had reported it to treatment nurse. She said Resident #15's heels were not discolored like that last week. CNA C said she did not float Resident #15's heels. She said she tried to remember to place the heel protectors on, but sometimes she forgot. During an interview on 11/5/20 at 9:23 a.m., LVN E said she was not aware Resident #15 developed a pressure injury to each heel. She said the new skin issues should have been included on the twenty-four hour report. LVN E said Resident #15 was supposed to have her heels floated at all times while in bed. She said she monitored the residents positioning every two hours. LVN E said she was just overwhelmed and had not realized Resident #15's heels were not being floated. During an interview on 11/5/20 at 9:48 a.m., the treatment nurse said she had been working as the treatment nurse for almost a year. She said she did not have any specialized training in wound care. She said she had not worked as a treatment nurse prior to this. The treatment nurse said the CNA notified her of the new skin issues on Resident #15's heels on 11/2/20. The treatment nurse said Resident #15 had heel protectors to wear and she should have her heels floated at all times while in bed. The treatment nurse said the CNAs should make sure Resident #15's heels are positioned correctly. The treatment nurse said the charge nurse should be aware of Resident #15's new pressure injuries. The treatment nurse said Resident #15's new pressure injuries should be recorded on the twenty-four hour report. She said it was her responsibility to add the new skin issues to the report. She said she forgot to add Resident #15's new pressure injuries to the twenty-four hour report. The treatment nurse said the wound physician saw Resident #15 on 11/3/20 and she now has new treatment orders. During an interview on 11/5/20 at 10:10 a.m., the administrator said she was not aware of Resident #15's new pressure injuries. She said she would expect staff to follow all physician orders [REDACTED].#15's heels. 2. Physician orders [REDACTED].#11 was admitted [DATE] with [DIAGNOSES REDACTED]. Current treatment orders are: Physician orders [REDACTED]. The order indicated Resident #11 was to be turned every 2 hours, both heels were to be elevated, and she was to wear heel protectors. The care plan dated 9/12/2018 indicated Resident #11 was at risk for pressure Ulcer. The care plan indicated staff would turn and reposition every 2 hours, keep clean and dry, provide incontinent care The most recent care plan update on 10/26/2020 indicated Resident #11 had a pressure injury, interventions are to turn resident every 2 hours and elevate both heels. The twenty-four-hour nursing report from 11/2/20 to 11/5/20 did not indicate Resident #11's heels were to be elevated and heel protectors were to be worn. During observations of Resident #11 the following was noted: *11/02/20 11:00 a.m.-. heels were not floated and were in direct contact with the Geri chair. No heel protectors were on, both feet noted [MEDICAL CONDITION] *11/02/20 1:30 p.m. -heels were not floated and were in direct contact with the mattress. No Heel protectors. *11/3/20 8:30 a.m. - heels were not floated and were in direct contact with the mattress. no heel protectors, resident had socks on could not see heel condition *11/3/20 11:00 a.m. - resident up in Geri chair, both feet dangling no heel protectors *11/4/20 9:00 a.m. - heels were not floated and were in direct contact with the mattress. No heel protectors *11/4/2020 at 11:45 a.m. Resident #11 was in a Geri chair. The resident's heels were not elevated , were hanging off the side of the Geri chair *11/5/20 1:30 pm. -heels were not floated and were in direct contact with the mattress. treatment nurse and hospice nurse at bedside. During an interview on 11/5/20 at 10:00 a.m., LVN H said she was not aware Resident #11 had orders to elevate heels and wear heel protectors. She said the new skin issues should have been included on the twenty-four-hour report. LVN H said Resident #11 should be transferred to a medical unit, due to non-mobile and her was more medical care. She said she monitored the residents positioning every two hours. During an interview on 11/5/20 at 9:48 a.m., the treatment nurse said she had been working as the treatment nurse for about 12 months . She said she did not have any specialized training in wound care. She said she had not worked as a treatment nurse prior to this. The treatment nurse said Resident #11 has heel protectors to wear and she should have her heels floated at all times while in bed. The treatment nurse said the CNAs should make sure Resident #11's heels were positioned correctly. She said she tried to remind the CNAs to keep the heel protectors on, and elevate heels, but even she forgot at times. During an interview on 11/3/20 at 12:15pm, CNAs C,D and G who were working together on unit, said they were not aware Resident #11 was supposed to have heel protectors and they did not put heel protectors in place, noted did they not know that they were to keep feet elevated An undated Pressure Ulcer and skin Tear policy indicated .goal is prevention of pressure ulcers .protect high risk area such as elbows, heels, sacrum from friction injury .raise heels of bed bound residents off the bed .turn and reposition bed bound clients every two hours .raise heels of bed bound residents off the bed using either pillows or heel protection devices . The National Pressure Injury Advisory Panel website was accessed 11/17/20 and indicated .A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer and can be painful .stage one pressure injury is non blanchable [DIAGNOSES REDACTED] of intact skin .Unstageable pressure injury is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 6 residents reviewed for accidents. (Resident #s 11 and 34) Resident #11 was totally dependent upon staff for bed mobility and transferred with a Hoyer lift. Resident #11 fell to the floor when his bed deflated. The fall was unwitnessed. Resident #11 sustained a laceration to his right forehead. Resident #34 had a history of [REDACTED].#34 fell , was sent to the emergency room for treatment and sustained a nasal fracture. The facility did not implement revised interventions to prevent falls. This failure could place the residents at risk of injuries and neglect. Findings included: 1. An undated face sheet indicated Resident #34 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #34 had adequate hearing, clear speech, sometimes made herself understood and sometimes understood. Resident #34 had impaired vision and functioned with severely impaired cognitive skills. This MDS indicated Resident #34 required extensive one person physical assistance with toilet use, transfers, walk in room, locomotion both on and off the unit. This MDS indicated Resident #34 was only able to stabilize with staff assistance and had impairment on both sides of lower extremity. A care plan dated 02/04/20 addressed Resident #34's history of falling related to dementia and weakness with multiple falls prior to admission. Impulsive with attempts to ambulate without assistance. Very weak and unsteady. Holds on to furniture to transfer self. Requires extensive assistance of one for transfers and ambulation. Uses wheelchair for locomotion around unit with staff assistance. Has walker in room but refuses to use it. 02/04/20 - fall, complaint of pain to left hip, skin tear to left elbow portable x-ray negative. 02/20/20 still complaining of pain to left hip, refuses to bear weight on left leg, sent to hospital for x-rays - negative. Approaches, with start date of 02/10/20 included to: encourage resident to use environmental devices such as hand grips, hand rails, etc., fall mat beside bed, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, place resident on a fall prevention program, provide toileting assistance every two hours and scoop mattress to bed. Handwritten on this care plan was the following: 03/01/20 - fall to fall mat with no injury; 03/26/20 - fall with no injury - every 30 minute observations; 04/03/20 - fall with no injury - every 15 minute observations; 04/12/20 - fall with no injury - call light sign reminder sign placed in room in view; 04/18/20 - fall - sent to ER (emergency room ) - nasal fracture - one on one observations for 72 hours. A care plan dated 02/10/20 addressed Resident #34's complaints of acute pain to left hip related to previous fall with partial hop replacement and recent fall. A care plan dated 02/10/20 addressed Resident #34's disordered thinking/awareness related to Alzheimer's dementia. The listed goal was for Resident #34 to communicate needs effectively during the next assessment period (10/20/20). Approaches included to: If resident becomes frustrated or agitated, give some free time and re-approach later. Kindly assure resident that you understand his/her frustration. Monitor for safety awareness until resident exhibits safe habits . During an interview and observation on 11/05/20 at 9:10 a.m., Resident #34 was in bed. The bed was mid-level, not in the lowest position without a fall mat at bedside. Resident #34 did not respond to questions. During an interview on 11/05/20 at 12:08 p.m., LVN Q said Resident #34 fell [DATE] and was sent out to the ER due to complaints of pain and hitting her head. LVN C said, beside one on one observation monitoring for 72 hours, there were no changes or new permanent interventions put into place by the facility to address Resident #34's falls. LVN Q said Resident #34 continues to get up without assistance and attempt to transfer herself. An Incident Report dated 04/18/20 indicated Resident #34 fell at 4:10 a.m. in her room. The fall was witnessed by a facility staff assigned to provide increased level of supervision due to falls. The report indicated Resident #34 fell forward onto her face when she attempted to stand unassisted. The report indicated there was active bleeding from Resident #34's nose and a cloth was held under her nose for five minutes to control the bleeding prior to being sent to the emergency room . A handwritten statement dated 04/18/20 at 4:04 a.m. by CNA P indicated she kept telling Resident #34 to sit down and about the time I (CNA P) was able to get to the door to get help, she (Resident #34) fell forward after she took a step. A Fall Investigation/Post Fall assessment dated [DATE] indicated the fall was probably due to an improper transfer. A hospital Radiology Report dated 04/18/20 indicated Resident #34 fell and sustained a left nasal bone fracture. A Provider Investigation Report (PIR) dated 04/23/20 at 4:10 a.m. indicated Resident #34 suffered a nasal fracture and remained one on one due to dementia, repeated falls, Alzheimer's and weakness. This report noted CNA P repeatedly tried to inform Resident #34 to sit down, CNA P went to the door to get help, Resident #34 fell on her face. During an interview on 11/02/20 at 2:52 p.m., the administrator said CNA P was the facility sitter assigned to supervise and assist Resident #34 on 04/18/20 due to repeated falls. The administrator said Resident #34 was coded as no supervision because her family provided private sitters 8a-8p. She said the facility tried to provide a night sitter depending upon staffing but it was not always possible. The administrator said this incident occurred overnight. She said Resident #34 required extensive assistance. She said CNA P repeatedly tried to get Resident #34 to sit down but Resident #34 would not and kept attempting to get up. At some point, CNA P went to the door to get help and when she walked away that's when Resident #34 fell on her face. She said the hospital x-rays confirmed Resident #34 suffered a nasal fracture. The administrator said it was an unwitnessed fall because CNA P did not actually see Resident #34 fall but based on the repeated behavior of getting out of bed unassisted it was most probable she tried to stand and fell forward. The administrator said she would expect staff not to let any resident out of sight, especially if they are fidgety and engaging in unsafe behavior. During an interview on 11/02/20 at 3:20 p.m., the DON said technically CNA P broke Resident #34's line of sight supervision on 04/18/20, resulting in Resident #34 falling and breaking her nose. An undated Care Planning Process policy indicated the purpose was to develop an individualized interdisciplinary plan designed to meet the resident's needs and to review, update as residents condition, or needs change and according to State/Federal regulations. 2. Physician order [REDACTED].#11 was a [AGE] year-old male, readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 was severely cognitively impaired. This MDS indicated Resident #11 was totally dependent upon staff for physical assistance of one person for bed mobility and transfers. A care plan with the start date of 09/12/18 indicated Resident #11 was unable to transfer without staff assistance. An care plan revised 10/26/20 addressed Resident #11's ADL self-care deficit. The care plan indicated, I am totally dependent on staff for all ADL's. I am non-ambulatory. Interventions included: bathing, bed mobility, dressing, personal hygiene, toilet use, and transfer - required total dependence of 1 or 2 staff. A nursing note dated 10/26/20 at 12:20 a.m. indicated Resident #11 was found on the floor beside his bed laying on his right side with visible bleeding from the right side of his forehead. Resident #11 was sent to the emergency room to be evaluated an treated. A nursing note dated 10/26/20 at 4:00 a.m. indicated Resident #11 required 5 sutures and sustained a subdural hematoma. A nurses communication log dated 10/26/20 in the acute charting section indicted Resident #11 was sent out due to a fall with a laceration to his right forehead but returned with 5 sutures covered with steri-strips, diagnosed with [REDACTED]. A Clinical Services Nurse Practitioner Medication Review dated 10/28/20 at 8:45 a.m. indicated Resident #11 recently fell with sutures to right forehead. The note indicated Resident #11's mattress deflated causing Resident #11 to fall out of bed and hit his head. During an observation on 11/3/2020 at 11:00 a.m. Resident #11 was up in his gerichair, hanging over the side of chair. During an observation on 11/04/20 at 9:35 a.m., Resident #11 was seated in a gerichair, draped in a blanket in his room. Resident #11 was being fed his meal. During an interview on 11/04/2020 at 10:00 a.m., MR CNA G said Resident #11 required total assistance with all ADLs and could do nothing for himself. She said for the six months she had been working on the secured unit Resident #11 had always been a total assist and could not get out of bed at all. During an interview on 11/04/20 at 10:05 a.m., CNA C and CNA D said Resident #11 required total care with all ADL's. They said Resident #11 could not walk or bear weight and was gotten out of bed daily with a gerichair. CNA C and CNA D said Resident #11 required 2 staff for transfers with the Hoyer lift. A care plan/elopement risk assessment dated [DATE] indicated Resident #11 ambulated independenlty, understood and verbalized acceptance of his need ffor nursing home care, functioned with modified independence in cognitive skills for daily decision making, no attempts to leave the facility, demonstrated restless behavior. Resident #11 scored 13 on this assessment, indicating he was a high risk for elopment. This assessment indicated Resident #11 scored exactly the same on 08/20/20, 05/26/20, 03/09/20, 12/09/19, 09/10/19, 06/11/19 and 03/11/19. During an interview on 11/04/2020 at 1:15 PM, the DON said Resident #11 was a total assist, was in a Geri chair, and was no longer an elopement risk and they had start looking into moving Resident #11 out the Secure Unit. She said the reason why Resident #11 was still on the memory care unit was because they just haven't got around to it yet, that was a slip on their part. During an interview on 11/05/2020 at 10:10 a.m., LVN H said she had been working on the secured unit for about 3 years. LVN H said Resident #11 was totally dependent upon staff for all ADL care and could could not move or reposition himself in bed. She said the staff turned Resident #11 every 2 hours and used a Hoyer lift to transfer him. LVN H said Resident #11 was thrown out of bed and suffered a laceration to his forehead on 10/26/20 because his mattress deflated. She said she did not know who was responsible for checking or maintaining air mattresses but it was not in a low position at the time of the fall because Resident #11 does not move himself at all. During an interview on 11/05/20 at 11:50 a.m., LVN Z said Resident #11 could not walk or use a wheelchair and required two staff for all transfers. She said the staff resideded on the memory care unit but was no longer ambulatory and was bedbound. She said Resident #11 required the use the Hoyer Lift for all transfers. During an observation on 11/05/20 at 12:41 p.m., a new bed was being delivered for Resident #1 along with a mattress with bolsters, following surveyor intervention. A gerichair with a hoyer lift pad in it was at the bedside of Resident #11. During an interview on 11/05/20 at 3:45 p. m., the administrator said Resident #11 rolled out of bed and possibly hit his head. The administrator said the nurse said they had just repositioned him about 15 minutes prior to the fall from his bed. She said ReEsident #11 was found on the floor with active bleeding from his head. She said Resident #11 required maximum assistance with all ADLs and received hospice services. Due to advanced dementia, she said Resident #11 was unable to state what happened. The administrator said Resident #11 was sent out to the hospital for treatment and returned wtih a a subdural hematoma and required 4 or 5 sutures to his forehead after hitting it on the floor. She said she did not know if Resident #11 had a fall mat in place at the time of the fall with injury but received a mattress with bolsters. During an interview on 11/05/20 at 4:00 p.m., LVN Y said he was the nurse on duty at the time of Resident #11's fall. LVN Y said Resident #11 rolled out of bed because his mattress deflated causing it to be flatter on one side. LVN Y said he was in Resident #11's room at approximately 11:45 p.m providing care and repositioned Resident #11 onto his right side. LVN Y said at approximately midnight on 10/26/20, Resident #11 was found on the floor on his right side, the same side we turned him (Resident #11) on. LVY Y said, The deflated was replaced by an egg crate and the egg crate was replaced today with the mattress with wings. A care plan dated 10/26/20 indicated Resident #11 was to have wings added to his mattress for increased safety. An undated Falls/Prevention policy indicated it was the policy of the facility to evaluate residents for their fall risk and develop interventions for prevention. It noted residents should be evaluated following any change of status that may affect balance, mobility or safety and following a fall with suggested interventions including to evaluate and implement a toileting program and place bed in lowest position. This policy indicated the care plan would be reviewed and interventions updated.

Based on observations, interviews and record reviews, the facility failed to ensure their written policy and procedures to prevent abuse was implemented for 1 of 5 resident reviewed for abuse. (Resident #1) The facility did not implement their abuse and neglect policy to prevent CNA A from abusing Resident #1. CNA A forced Resident #1, who was diagnosed with [REDACTED]. Resident #1 became combative and CNA A continued to physically force Resident #1 to change clothes by holding her arms and requesting assistance to hold down the resident's legs. Resident #1 sustained a skin tear and bleeding, bruising and swelling to her nose resulting in an emergency room visit. This failure could place residents at risk for abuse, loss of dignity and physical injury. Findings included: An Abuse/Neglect and Prohibition policy revised 01/15/20 which included Texas State Bill of Rights of the Facility indicated, .An elderly individual has the right to be treated with dignity and respect .a. has the right to make individual's own choices regarding person affairs, care, benefits and services; b. has the right to be free from abuse, neglect, and exploitation . The resident, responsible party and/or legal guardian will receive on admission the Statement of Resident Rights, which outlines their rights to be free from any type of abuse, neglect or exploitation. A Notice to employees, Freedom from Abuse .Abuse includes, but is not limited to .b. Physical abuse: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, corporal punishment of to the similar treatment . Physician orders [REDACTED].#1admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was alert to person and had severely impaired cognition. The MDS indicated Resident #1 had delusions 1-3 days a week, wandering behaviors and resided in the secured unit. The MDS indicated the resident required limited assistance with ADLs including personal hygiene, toilet use and dressing. The care plan dated 07/13/20 indicated Resident #1 had delusions related to Alzheimer's dementia and was known to have verbal and physical outbursts. The care plan indicated Resident #1 was combative with care and rejected care. The care plan indicated Resident #1 had difficulty making self-understood related to Alzheimer's dementia, and had clear speech with disorganized thinking when conversing. Needs known through sporadic words here and there. A hand written, undated addition to the care plan indicated staff would allow Resident #1 time to calm before continuing care when combative. During an interview on 09/29/20 at 10:15 AM, the administrator said she was the abuse coordinator and was in the process of investigating the incident. The administrator said CNA A had been suspended pending the result of the investigation. During an observation on 09/29/20 at 3:30 PM, Resident # 1 was sitting in her room on her bed wrapping a baby doll with a blanket. There was visible purple discoloration to the left side of her nose up near the bridge. There was light discoloration under the right eye on the upper cheek. The was a small bandage about the size a of dime on the lower part of her right forearm. Resident #1 said she did not remember being at the hospital recently and did not recall the incident. During an interview on 09/29/20 at 10:15 a.m., the DON said on the evening of 09/24/20, Resident #1 became combative with CNA A when she was attempting to change the resident's clothes. She said Resident #1 did not like to change clothes and often became combative, hitting and kicking at staff. The DON said CNA A continued to attempt to change Resident #1's clothes even though Resident #1 was fighting with CNA A and saying she did not want her clothing changed. She said Resident #1 sustained a skin tear to the arm and bruising to her nose. The DON said she did not know the extent of the injuries to Resident #1's nose but there was some discoloration DON described as bruising. She said the injury could have been caused by Resident #1's glasses. She said she saw Resident #1 the next day 09/25/20, and the resident had swelling to her nose and was sent to the ER for evaluation. The DON said there was swelling on the left side of Resident #1's nose and bruising on the left side of Resident #1's nose that spread under her left eye. The DON said Resident was sent to the hospital for evaluation. The DON said when a resident was combative or agitated, staff should stop what they are doing and give the resident time to calm down. The DON said the behavior should be reported to the nurse. During an interview on 09/29/20 at 10:50 a.m. FHS A said she was working 09/24/20 during the evening shift at the time of the incident. FHS A said she was in the hallway outside of Resident #1's room when she heard a commotion. She said she could hear CNA A telling Resident #1 to stop hitting and kicking me. She said she entered the room and saw Resident #1 lying on the bed and CNA A was holding Resident #1's arms trying to keep Resident #1 from hitting her. FHS A said she saw Resident #1 swinging and kicking in a combative manner while CNA A was attempting to change Resident #1 clothes. She said CNA A asked her to hold Resident #1's legs down so CNA A would not get kicked. FHS A said she did not hold Resident #1's legs as requested by CNA A. She said she saw Resident #1's nose bleeding from the nostril on one side. She said she did not see CNA A hit Resident #1 and did not feel CNA A meant to cause any harm but was just trying to get Resident #1 dressed for bed. FHS A said Resident #1 never wanted to change clothes. She said when Resident #1 became combative, staff were to stop what they were doing and give Resident #1 time to calm down before continuing care. During an interview on 09/29/20 at 2:08 p.m. FHS B said she was working 09/24/20 on the evening shift at the time of the incident. She said she was a sitter for Resident #1 almost every day but did not provide ADL care. FHS B said around 7:30 pm, CNA A was attempting to change Resident #1's clothes to get ready for bed. She said Resident #1 became combative and CNA A asked for help to calm Resident #1 down. FHS B said she did not touch Resident #1. She said Resident #1 continued to be combative. FHS B said she did not know what caused the injury to Resident #1, but there was a skin tear to her arm, bleeding on the right side of her nose where her glasses rest and from her nostril. FHS B said Resident #1 repeated My nose is broke. FHS B said there was a few drops of blood on the bed sheets. She said CNA B walked in the room and went to report what was happening to LVN A. During an interview on 09/29/20 at 3:10 PM. CNA B said she was working on the evening shift on 09/24/20 at the time of the incident. CNA B said she was not certain of the time, but it was after the evening meal when staff were assisting residents for bed. CNA B said she walked into Resident #1's room and saw CNA A attempting to change Resident #1's clothes. She said Resident #1 was very combative with CNA A, swinging and kicking. CNA B said she went to get the charge nurse, LVN A. CNA B said she observed a few drops of blood from Resident #1's nostril and a small amount of blood on the bridge of her nose. CNA B said Resident #1 was resistant to care most of the time, would become combative and would not allow staff to change her clothes. CNA B said she had been trained if a resident refused care, became combative or agitated, she should stop and give the resident time to calm down and try again later. She said if the resident continued the behavior she should report it to the nurse. During an interview on 09/29/20 at 1:45 PM, LVN A said he was the charge nurse on 09/24/20 on the evening shift at the time of the incident. LVN A said he was called to Resident #1's room by CNA B. LVN A said CNA B reported Resident #1 was being very combative. LVN A said when he arrived in the room CNA A was already in the room. LVN A said he assessed Resident #1's condition and found a small skin tear to her right forearm and some bruising along the bridge of the nose and a pin-point scratch where her glasses rest on the nose. LVN A said there was no active bleeding, but CNA A had already cleaned the area before he arrived. LVN A said he did not see any blood coming from Resident #1's nostril. LVN A said he did not see any rags that would indicate there was more bleeding than observed. LVN A said when a resident became combative, staff should stop what they were doing and report the behavior to the nurse. LVN A said Resident #1 had a history of [REDACTED]. LVN said an incident report was made concerning the incident. A written statement dated 09/24/20 at 6:45 PM by CNA A indicated I was doing patient care changing resident into her nightgown. She started fighting and she kick my back an scratched my face and I talk to her to calm her down. She reached at me trying to hit me and I blocked her arm from hitting me in my face and it was reported to the nurse. The surveyor attempted to contact CNA A on 09/29/20 at 2:00 PM, 09/30/20 at 12:42 PM and 09/30/20 at 12:44 PM using 2 different phone numbers provided by the facility to contact. CNA A did not answer and since it could not be determined if the voice mail system belonged to CNA A, no message was left. Contact information was provided to the facility for CNA A to call the surveyor with information concerning the incident. During an interview on 09/30/20 at 12:13 PM, CNA D said she was working the morning shift on 09/25/20. She said she noticed Resident #1's nose looked funny and appeared to be broken. The CNA said there was swelling and a bruise on the left side that started at the bridge of the nose and went under the left eye. CNA D said she reported it to RN A and LVN B. CNA D said on 09/24/20 Resident #1 had some bruising to her face from a previous fall, but these injuries had occurred more recent and she knew the injuries were not there the day before. CNA D said LVN B came to the room to assess Resident #1. CNA D said she was trained if a resident became combative to stop and report the behavior to the nurse. CNA D said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. During an interview on 09/30/20 at 12:05 PM. CNA C said she was working in the secured unit during the morning shift of 09/25/20. She said the day before, 09/24/20, Resident #1 had a small area on her nose where her glasses had rubbed. CNA C said on the morning of 09/25/20 Resident #1 had a new injury with swelling and bruising that went from the bridge of the nose and spread under her eye. CNA C said Resident #1's nose looked funny like it may be broken. CNA C said the change in condition was reported to the charge nurse and the treatment nurse. CNA C said she had received training on dealing with combative and aggressive residents and if a resident became aggressive or combative during care, she was to stop and give the resident space and time to settle down. She said once the resident was given time, she would attempt to provide service once again. CNA C said if the resident continued to refuse care, she would report the refusal or behavior to the charge nurse. During an interview on 09/30/20 at 1:20 PM, LVN B said she was working on 09/25/20 when a CNA reported Resident #1's nose looked funny and thought it may be broken. LVN B said she assessed Resident #1 and found there was swelling and bruising to the left side of the nose. The bruising went from the left bridge of her nose to under the left eye. LVN B said Resident #1 had a recent fall that caused bruising to the face, but this appeared to be a new bruise. The LVN said the DON also assessed Resident #1 and it was determined Resident #1 should be sent to the hospital for evaluation and x-ray. LVN B said Resident #1's nose appeared to be crooked and it may have been broken. LVN B said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. An EMS report dated 09/25/20 at 1:33 PM indicated EMS was dispatched to the facility due to a person with facial swelling. The report indicated EMS arrived at 1:33 p.m. and noted the resident had bruising on the left side of nose and right eye and complained of back pain. The report indicated staff said the patient was being combative last night and the CNA got rough with her while trying to change her. The report indicated staff said the CNA was banging the patient's head against the wall and that the CNA had to write a statement afterwards about what happened. Hospital admission records dated 09/25/20 at 2:29 PM indicated Resident #1, was examined at the hospital. The record stated: This is an unfortunate [AGE] year-old female patient presents to the ER today for an assault. Patient was assaulted by an employee . at Rose Haven Retreat. Reports from EMS staff . it was done last night . and she had her head banged against the wall a few times. Patient has dementia and cannot remember any of the events but says she does hurt all down her spin her head her neck. The report indicated Resident #1 had bruising to the right and left side of the bridge of her nose. A radiology report dated 09/25/20 at 1:50 p.m. for Resident #1 indicated the bones are osteoporotic and there are no fractures as seen and the soft tissue was normal, spine was in good alignment. CT of facial bones: No definite facial fracture demonstrated. Mild irregularity of nasal bone, acuity uncertain. Sinuses and mastoid air cells are unremarkable. Impression: No definite acute facial fracture. Irregularity of the nasal bone of uncertain acuity. Correlated clinically to exclude acute fracture.

Based on observations, interviews and record reviews the facility failed to ensure the right to be free from abuse was provided for 1 or 5 residents reviewed for abuse. (Resident #1) The facility did not prevent CNA A from abusing Resident #1. CNA A forced Resident #1, who was diagnosed with [REDACTED]. Resident #1 became combative and CNA A continued to physically force Resident #1 to change clothes by holding her arms and requesting assistance to hold down the resident's legs. Resident #1 sustained a skin tear and bleeding, bruising and swelling to her nose resulting in an emergency room visit. This failure could place residents at risk for abuse, loss of dignity and physical injury. Findings included: Physician orders [REDACTED].#1admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was alert to person and had severely impaired cognition. The MDS indicated Resident #1 had delusions 1-3 days a week, wandering behaviors and resided in the secured unit. The MDS indicated the resident required limited assistance with ADLs including personal hygiene, toilet use and dressing. The care plan dated 07/13/20 indicated Resident #1 had delusions related to Alzheimer's dementia and was known to have verbal and physical outbursts. The care plan indicated Resident #1 was combative with care and rejected care. The care plan indicated Resident #1 had difficulty making self-understood related to Alzheimer's dementia, and had clear speech with disorganized thinking when conversing. Needs known through sporadic words here and there. A hand written, undated addition to the care plan indicated staff would allow Resident #1 time to calm before continuing care when combative. During an interview on 09/29/20 at 10:15 AM, the administrator said she was the abuse coordinator and was in the process of investigating the incident. The administrator said CNA A had been suspended pending the result of the investigation. During an observation on 09/29/20 at 3:30 PM, Resident # 1 was sitting in her room on her bed wrapping a baby doll with a blanket. There was visible purple discoloration to the left side of her nose up near the bridge. There was light discoloration under the right eye on the upper cheek. The was a small bandage about the size a of dime on the lower part of her right forearm. Resident #1 said she did not remember being at the hospital recently and did not recall the incident. During an interview on 09/29/20 at 10:15 a.m., the DON said on the evening of 09/24/20, Resident #1 became combative with CNA A when she was attempting to change the resident's clothes. She said Resident #1 did not like to change clothes and often became combative, hitting and kicking at staff. The DON said CNA A continued to attempt to change Resident #1's clothes even though Resident #1 was fighting with CNA A and saying she did not want her clothing changed. She said Resident #1 sustained a skin tear to the arm and bruising to her nose. The DON said she did not know the extent of the injuries to Resident #1's nose but there was some discoloration DON described as bruising. She said the injury could have been caused by Resident #1's glasses. She said she saw Resident #1 the next day 09/25/20, and the resident had swelling to her nose and was sent to the ER for evaluation. The DON said there was swelling on the left side of Resident #1's nose and bruising on the left side of Resident #1's nose that spread under her left eye. The DON said Resident was sent to the hospital for evaluation. The DON said when a resident was combative or agitated, staff should stop what they are doing and give the resident time to calm down. The DON said the behavior should be reported to the nurse. During an interview on 09/29/20 at 10:50 a.m. FHS A said she was working 09/24/20 during the evening shift at the time of the incident. FHS A said she was in the hallway outside of Resident #1's room when she heard a commotion. She said she could hear CNA A telling Resident #1 to stop hitting and kicking me. She said she entered the room and saw Resident #1 lying on the bed and CNA A was holding Resident #1's arms trying to keep Resident #1 from hitting her. FHS A said she saw Resident #1 swinging and kicking in a combative manner while CNA A was attempting to change Resident #1 clothes. She said CNA A asked her to hold Resident #1's legs down so CNA A would not get kicked. FHS A said she did not hold Resident #1's legs as requested by CNA A. She said she saw Resident #1's nose bleeding from the nostril on one side. She said she did not see CNA A hit Resident #1 and did not feel CNA A meant to cause any harm but was just trying to get Resident #1 dressed for bed. FHS A said Resident #1 never wanted to change clothes. She said when Resident #1 became combative, staff were to stop what they were doing and give Resident #1 time to calm down before continuing care. During an interview on 09/29/20 at 2:08 p.m. FHS B said she was working 09/24/20 on the evening shift at the time of the incident. She said she was a sitter for Resident #1 almost every day but did not provide ADL care. FHS B said around 7:30 pm, CNA A was attempting to change Resident #1's clothes to get ready for bed. She said Resident #1 became combative and CNA A asked for help to calm Resident #1 down. FHS B said she did not touch Resident #1. She said Resident #1 continued to be combative. FHS B said she did not know what caused the injury to Resident #1, but there was a skin tear to her arm, bleeding on the right side of her nose where her glasses rest and from her nostril. FHS B said Resident #1 repeated My nose is broke. FHS B said there was a few drops of blood on the bed sheets. She said CNA B walked in the room and went to report what was happening to LVN A. During an interview on 09/29/20 at 3:10 PM. CNA B said she was working on the evening shift on 09/24/20 at the time of the incident. CNA B said she was not certain of the time, but it was after the evening meal when staff were assisting residents for bed. CNA B said she walked into Resident #1's room and saw CNA A attempting to change Resident #1's clothes. She said Resident #1 was very combative with CNA A, swinging and kicking. CNA B said she went to get the charge nurse, LVN A. CNA B said she observed a few drops of blood from Resident #1's nostril and a small amount of blood on the bridge of her nose. CNA B said Resident #1 was resistant to care most of the time, would become combative and would not allow staff to change her clothes. CNA B said she had been trained if a resident refused care, became combative or agitated, she should stop and give the resident time to calm down and try again later. She said if the resident continued the behavior she should report it to the nurse. During an interview on 09/29/20 at 1:45 PM, LVN A said he was the charge nurse on 09/24/20 on the evening shift at the time of the incident. LVN A said he was called to Resident #1's room by CNA B. LVN A said CNA B reported Resident #1 was being very combative. LVN A said when he arrived in the room CNA A was already in the room. LVN A said he assessed Resident #1's condition and found a small skin tear to her right forearm and some bruising along the bridge of the nose and a pin-point scratch where her glasses rest on the nose. LVN A said there was no active bleeding, but CNA A had already cleaned the area before he arrived. LVN A said he did not see any blood coming from Resident #1's nostril. LVN A said he did not see any rags that would indicate there was more bleeding than observed. LVN A said when a resident became combative, staff should stop what they were doing and report the behavior to the nurse. LVN A said Resident #1 had a history of [REDACTED]. LVN said an incident report was made concerning the incident. A written statement dated 09/24/20 at 6:45 PM by CNA A indicated I was doing patient care changing resident into her nightgown. She started fighting and she kick my back an scratched my face and I talk to her to calm her down. She reached at me trying to hit me and I blocked her arm from hitting me in my face and it was reported to the nurse. The surveyor attempted to contact CNA A on 09/29/20 at 2:00 PM, 09/30/20 at 12:42 PM and 09/30/20 at 12:44 PM using 2 different phone numbers provided by the facility to contact. CNA A did not answer and since it could not be determined if the voice mail system belonged to CNA A, no message was left. Contact information was provided to the facility for CNA A to call the surveyor with information concerning the incident. During an interview on 09/30/20 at 12:13 PM, CNA D said she was working the morning shift on 09/25/20. She said she noticed Resident #1's nose looked funny and appeared to be broken. The CNA said there was swelling and a bruise on the left side that started at the bridge of the nose and went under the left eye. CNA D said she reported it to RN A and LVN B. CNA D said on 09/24/20 Resident #1 had some bruising to her face from a previous fall, but these injuries had occurred more recent and she knew the injuries were not there the day before. CNA D said LVN B came to the room to assess Resident #1. CNA D said she was trained if a resident became combative to stop and report the behavior to the nurse. CNA D said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. During an interview on 09/30/20 at 12:05 PM. CNA C said she was working in the secured unit during the morning shift of 09/25/20. She said the day before, 09/24/20, Resident #1 had a small area on her nose where her glasses had rubbed. CNA C said on the morning of 09/25/20 Resident #1 had a new injury with swelling and bruising that went from the bridge of the nose and spread under her eye. CNA C said Resident #1's nose looked funny like it may be broken. CNA C said the change in condition was reported to the charge nurse and the treatment nurse. CNA C said she had received training on dealing with combative and aggressive residents and if a resident became aggressive or combative during care, she was to stop and give the resident space and time to settle down. She said once the resident was given time, she would attempt to provide service once again. CNA C said if the resident continued to refuse care, she would report the refusal or behavior to the charge nurse. During an interview on 09/30/20 at 1:20 PM, LVN B said she was working on 09/25/20 when a CNA reported Resident #1's nose looked funny and thought it may be broken. LVN B said she assessed Resident #1 and found there was swelling and bruising to the left side of the nose. The bruising went from the left bridge of her nose to under the left eye. LVN B said Resident #1 had a recent fall that caused bruising to the face, but this appeared to be a new bruise. The LVN said the DON also assessed Resident #1 and it was determined Resident #1 should be sent to the hospital for evaluation and x-ray. LVN B said Resident #1's nose appeared to be crooked and it may have been broken. LVN B said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. An EMS report dated 09/25/20 at 1:33 PM indicated EMS was dispatched to the facility due to a person with facial swelling. The report indicated EMS arrived at 1:33 p.m. and noted the resident had bruising on the left side of nose and right eye and complained of back pain. The report indicated staff said the patient was being combative last night and the CNA got rough with her while trying to change her. The report indicated staff said the CNA was banging the patient's head against the wall and that the CNA had to write a statement afterwards about what happened. Hospital admission records dated 09/25/20 at 2:29 PM indicated Resident #1, was examined at the hospital. The record stated: This is an unfortunate [AGE] year-old female patient presents to the ER today for an assault. Patient was assaulted by an employee . at Rose Haven Retreat. Reports from EMS staff . it was done last night . and she had her head banged against the wall a few times. Patient has dementia and cannot remember any of the events but says she does hurt all down her spin her head her neck. The report indicated Resident #1 had bruising to the right and left side of the bridge of her nose. A radiology report dated 09/25/20 at 1:50 p.m. for Resident #1 indicated the bones are osteoporotic and there are no fractures as seen and the soft tissue was normal, spine was in good alignment. CT of facial bones: No definite facial fracture demonstrated. Mild irregularity of nasal bone, acuity uncertain. Sinuses and mastoid air cells are unremarkable. Impression: No definite acute facial fracture. Irregularity of the nasal bone of uncertain acuity. Correlated clinically to exclude acute fracture. An Abuse/Neglect and Prohibition policy revised 01/15/20 which included Texas State Bill of Rights of the Facility indicated, .An elderly individual has the right to be treated with dignity and respect .a. has the right to make individual's own choices regarding person affairs, care, benefits and services; b. has the right to be free from abuse, neglect, and exploitation . The resident, responsible party and/or legal guardian will receive on admission the Statement of Resident Rights, which outlines their rights to be free from any type of abuse, neglect or exploitation. A Notice to employees, Freedom from Abuse .Abuse includes, but is not limited to .b. Physical abuse: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, corporal punishment of to the similar treatment .

Based on observations, interviews and record reviews the facility failed to ensure the right to be treated with dignity and respect and the right to make individual choices regarding person care was provided for 1 or 5 residents reviewed for resident rights. (Resident #1) CNA A did not treat Resident #1 with dignity and respect while assisting in changing her clothing. CNA A physically forced Resident #1 to change clothes when Resident #1 said she did not want to change. This action resulted in Resident #1 sustaining an injury to the nose and forearm. This failure placed Resident #1 at risk for not being treated with dignity and respect and caused physical injury to her forearm and nose resulting in being sent to the hospital for treatment. Findings included: Physician orders [REDACTED].#1admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was alert to person and had severely impaired cognition. The MDS indicated Resident #1 had delusions 1-3 days a week, wandering behaviors and resided in the secured unit. The MDS indicated the resident required limited assistance with ADLs including personal hygiene, toilet use and dressing. The care plan dated 07/13/20 indicated Resident #1 had delusions related to Alzheimer's dementia and was known to have verbal and physical outbursts. The care plan indicated Resident #1 was combative with care and rejected care. The care plan indicated Resident #1 had difficulty making self-understood related to Alzheimer's dementia, and had clear speech with disorganized thinking when conversing. Needs known through sporadic words here and there. A hand written, undated addition to the care plan indicated staff would allow Resident #1 time to calm before continuing care when combative. During an interview on 09/29/20 at 10:15 AM, the administrator said she was the abuse coordinator and was in the process of investigating the incident. The administrator said CNA A had been suspended pending the result of the investigation. During an observation on 09/29/20 at 3:30 PM, Resident # 1 was sitting in her room on her bed wrapping a baby doll with a blanket. There was visible purple discoloration to the left side of her nose up near the bridge. There was light discoloration under the right eye on the upper cheek. The was a small bandage about the size of a dime on the lower part of her right forearm. Resident #1 said she did not remember being at the hospital recently and did not recall the incident. During an interview on 09/29/20 at 10:15 a.m., the DON said on the evening of 09/24/20, Resident #1 became combative with CNA A when she was attempting to change the resident's clothes. She said Resident #1 did not like to change clothes and often became combative, hitting and kicking at staff. The DON said CNA A continued to attempt to change Resident #1's clothes even though Resident #1 was fighting with CNA A and saying she did not want her clothing changed. She said Resident #1 sustained a skin tear to the arm and bruising to her nose. The DON said she did not know the extent of the injuries to Resident #1's nose but there was some discoloration DON described as bruising. She said the injury could have been caused by Resident #1's glasses. She said she saw Resident #1 the next day 09/25/20, and the resident had swelling to her nose and was sent to the ER for evaluation. The DON said there was swelling on the left side of Resident #1's nose and bruising on the left side of Resident #1's nose that spread under her left eye. The DON said Resident was sent to the hospital for evaluation. The DON said when a resident was combative or agitated, staff should stop what they are doing and give the resident time to calm down. The DON said the behavior should be reported to the nurse. During an interview on 09/29/20 at 10:50 a.m. FHS A said she was working 09/24/20 during the evening shift at the time of the incident. FHS A said she was in the hallway outside of Resident #1's room when she heard a commotion. She said she could hear CNA A telling Resident #1 to stop hitting and kicking me. She said she entered the room and saw Resident #1 lying on the bed and CNA A was holding Resident #1's arms trying to keep Resident #1 from hitting her. FHS A said she saw Resident #1 swinging and kicking in a combative manner while CNA A was attempting to change Resident #1 clothes. She said CNA A asked her to hold Resident #1's legs down so CNA A would not get kicked. FHS A said she did not hold Resident #1's legs as requested by CNA A. She said she saw Resident #1's nose bleeding from the nostril on one side. She said she did not see CNA A hit Resident #1 and did not feel CNA A meant to cause any harm but was just trying to get Resident #1 dressed for bed. FHS A said Resident #1 never wanted to change clothes. She said when Resident #1 became combative, staff were to stop what they were doing and give Resident #1 time to calm down before continuing care. During an interview on 09/29/20 at 2:08 p.m. FHS B said she was working 09/24/20 on the evening shift at the time of the incident. She said she was a sitter for Resident #1 almost every day but did not provide ADL care. FHS B said around 7:30 pm, CNA A was attempting to change Resident #1's clothes to get ready for bed. She said Resident #1 became combative and CNA A asked for help to calm Resident #1 down. FHS B said she did not touch Resident #1. She said Resident #1 continued to be combative. FHS B said she did not know what caused the injury to Resident #1, but there was a skin tear to her arm, bleeding on the right side of her nose where her glasses rest and from her nostril. FHS B said Resident #1 repeated My nose is broke. FHS B said there was a few drops of blood on the bed sheets. She said CNA B walked in the room and went to report what was happening to LVN A. During an interview on 09/29/20 at 3:10 PM. CNA B said she was working on the evening shift on 09/24/20 at the time of the incident. CNA B said she was not certain of the time, but it was after the evening meal when staff were assisting residents for bed. CNA B said she walked into Resident #1's room and saw CNA A attempting to change Resident #1's clothes. She said Resident #1 was very combative with CNA A, swinging and kicking. CNA B said she went to get the charge nurse, LVN A. CNA B said she observed a few drops of blood from Resident #1's nostril and a small amount of blood on the bridge of her nose. CNA B said Resident #1 was resistant to care most of the time, would become combative and would not allow staff to change her clothes. CNA B said she had been trained if a resident refused care, became combative or agitated, she should stop and give the resident time to calm down and try again later. She said if the resident continued the behavior she should report it to the nurse. During an interview on 09/29/20 at 1:45 PM, LVN A said he was the charge nurse on 09/24/20 on the evening shift at the time of the incident. LVN A said he was called to Resident #1's room by CNA B. LVN A said CNA B reported Resident #1 was being very combative. LVN A said when he arrived in the room CNA A was already in the room. LVN A said he assessed Resident #1's condition and found a small skin tear to her right forearm and some bruising along the bridge of the nose and a pin-point scratch where her glasses rest on the nose. LVN A said there was no active bleeding, but CNA A had already cleaned the area before he arrived. LVN A said he did not see any blood coming from Resident #1's nostril. LVN A said he did not see any rags that would indicate there was more bleeding than observed. LVN A said when a resident became combative, staff should stop what they were doing and report the behavior to the nurse. LVN A said Resident #1 had a history of [REDACTED]. LVN said an incident report was made concerning the incident. A written statement dated 09/24/20 at 6:45 PM by CNA A indicated I was doing patient care changing resident into her nightgown. She started fighting and she kick my back an scratched my face and I talk to her to calm her down. She reached at me trying to hit me and I blocked her arm from hitting me in my face and it was reported to the nurse. The surveyor attempted to contact CNA A on 09/29/20 at 2:00 PM, 09/30/20 at 12:42 PM and 09/30/20 at 12:44 PM using 2 different phone numbers provided by the facility to contact. CNA A did not answer and since it could not be determined if the voice mail system belonged to CNA A, no message was left. Contact information was provided to the facility for CNA A to call the surveyor with information concerning the incident. During an interview on 09/30/20 at 12:13 PM, CNA D said she was working the morning shift on 09/25/20. She said she noticed Resident #1's nose looked funny and appeared to be broken. The CNA said there was swelling and a bruise on the left side that started at the bridge of the nose and went under the left eye. CNA D said she reported it to RN A and LVN B. CNA D said on 09/24/20 Resident #1 had some bruising to her face from a previous fall, but these injuries had occurred more recent and she knew the injuries were not there the day before. CNA D said LVN B came to the room to assess Resident #1. CNA D said she was trained if a resident became combative to stop and report the behavior to the nurse. CNA D said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. During an interview on 09/30/20 at 12:05 PM. CNA C said she was working in the secured unit during the morning shift of 09/25/20. She said the day before, 09/24/20, Resident #1 had a small area on her nose where her glasses had rubbed. CNA C said on the morning of 09/25/20 Resident #1 had a new injury with swelling and bruising that went from the bridge of the nose and spread under her eye. CNA C said Resident #1's nose looked funny like it may be broken. CNA C said the change in condition was reported to the charge nurse and the treatment nurse. CNA C said she had received training on dealing with combative and aggressive residents and if a resident became aggressive or combative during care, she was to stop and give the resident space and time to settle down. She said once the resident was given time, she would attempt to provide service once again. CNA C said if the resident continued to refuse care, she would report the refusal or behavior to the charge nurse. During an interview on 09/30/20 at 1:20 PM, LVN B said she was working on 09/25/20 when a CNA reported Resident #1's nose looked funny and thought it may be broken. LVN B said she assessed Resident #1 and found there was swelling and bruising to the left side of the nose. The bruising went from the left bridge of her nose to under the left eye. LVN B said Resident #1 had a recent fall that caused bruising to the face, but this appeared to be a new bruise. The LVN said the DON also assessed Resident #1 and it was determined Resident #1 should be sent to the hospital for evaluation and x-ray. LVN B said Resident #1's nose appeared to be crooked and it may have been broken. LVN B said she did not hear anyone tell EMS staff that someone had banged Resident #1's head against the wall. An EMS report dated 09/25/20 at 1:33 PM indicated EMS was dispatched to the facility due to a person with facial swelling. The report indicated EMS arrived at 1:33 p.m. and noted the resident had bruising on the left side of nose and right eye and complained of back pain. The report indicated staff said the patient was being combative last night and the CNA got rough with her while trying to change her. The report indicated staff said the CNA was banging the patient's head against the wall and that the CNA had to write a statement afterwards about what happened. Hospital admission records dated 09/25/20 at 2:29 PM indicated Resident #1, was examined at the hospital. The record stated: This is an unfortunate [AGE] year-old female patient presents to the ER today for an assault. Patient was assaulted by an employee . at Rose Haven Retreat. Reports from EMS staff . it was done last night . and she had her head banged against the wall a few times. Patient has dementia and cannot remember any of the events but says she does hurt all down her spin her head her neck. The report indicated Resident #1 had bruising to the right and left side of the bridge of her nose. A radiology report dated 09/25/20 at 1:50 p.m. for Resident #1 indicated the bones are osteoporotic and there are no fractures as seen and the soft tissue was normal, spine was in good alignment. CT of facial bones: No definite facial fracture demonstrated. Mild irregularity of nasal bone, acuity uncertain. Sinuses and mastoid air cells are unremarkable. Impression: No definite acute facial fracture. Irregularity of the nasal bone of uncertain acuity. Correlated clinically to exclude acute fracture. An Abuse/Neglect and Prohibition policy revised 01/15/20 which included Texas State Bill of Rights of the Facility indicated, .An elderly individual has the right to be treated with dignity and respect .a. has the right to make individual's own choices regarding person affairs, care, benefits and services; b. has the right to be free from abuse, neglect, and exploitation . The resident, responsible party and/or legal guardian will receive on admission the Statement of Resident Rights, which outlines their rights to be free from any type of abuse, neglect or exploitation. A Notice to employees, Freedom from Abuse .Abuse includes, but is not limited to .b. Physical abuse: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, corporal punishment of to the similar treatment .

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents were provided for 1 of 3 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1, who was totally dependent on 2 staff for all care, from sustaining a closed head injury, hematoma above her right eye, bruising below her right eye, and a nose fracture. The resident received incontinent care with the assistance of one staff while her MDS and care plan indicated she would receive assistance from 2 staff. This failure placed residents requiring assistance with transfers, positioning, and incontinent care at risk of injury. Findings included: A physician order report dated 12/16/19-01/16/20 indicated Resident #1 was an [AGE] year-old female, admitted on [DATE] with diagnoses of diaper [CONDITION(S)], [CONDITION(S)], bladder disorder, Type 2 diabetes mellitus, [CONDITION(S)], Alzheimer's disease, and dementia with behavioral disturbance. A care plan revised on 09/18/19 indicated Resident #1 was always incontinent of bladder and bowel related to cognition, unsteady balance, impaired mobility, non-ambulatory, dependent on staff for toileting/incontinent care and impairment in ROM (range of motion), both lower extremities and both upper extremities. Resident #1 was at risk for falls related to diagnosis of [CONDITION(S)], impaired cognition, impaired vision, and required extensive assistance to being dependent on staff for all ADLs (activities of daily living). Resident #1 required 2-person assistance for bed mobility and a Hoyer lift for all transfers. An MDS dated [DATE] indicated Resident #1 was total dependent and required at least two people for bed mobility and transfers. An ADL tracking form dated 01/04/20 indicated Resident #1 was incontinent of bowel and bladder on the 10 p.m. to 6 a.m. shift. An incident report dated 01/04/20 indicated Resident #1 had a hematoma above her right eye and bruising below her right eye. The incident report indicated the origin of the injury was unknown. A hospital report dated 1/06/20 indicated Resident #1 sustained a closed head injury/traumatic hematoma of the forehead and a nasal fracture. During an interview on 01/15/20 at 12:26 p.m., LVN A said she checked on Resident#1 at 8:10 p.m. on 01/04/20 and she could see her face. She said she took a temporal temperature and there was no bruising. LVN A indicated the origin of the injury was unknown and Resident #1 required total care. During an interview on 01/15/20 at 2:18 p.m., CNA B said Resident #1 had never tried to get out of bed and was bed-bound. During an interview on 01/15/20 at 2:40 p.m., CNA B said Resident #1 required a Hoyer to get up and 2 people were needed to perform care. During an interview on 01/15/20 at 3:49 p.m., LVN D said on the morning of 01/04/20, CNA E called her to Resident #1's room where she did a focused assessment and observed a large hematoma above Resident #1's right eye. LVN D said she did not know what happened to Resident #1. LVN D said CNA E was the only CNA working with her on the 6 p.m. to 6 a.m. shift that performed incontinent care. LVN D said she did not assist the CNA with incontinent care or positioning of Resident #1. said she did a focused assessment only. LVN D said she did not know what happened to Resident #1. A witness statement dated 01/05/20 completed by CNA E indicated CNA E observed a little red mark above Resident #1's eye on 01/04/20 at 10:00 p.m. during rounds, and on 01/05/20 at 5:45 a.m. the red mark was huge. CNA E indicated she changed Resident #1's pad at 2:00 a.m.

Based on observation, interview and record review, the facility failed to thoroughly investigate and prevent further potential abuse for 2 of 4 residents reviewed for abuse. (Resident #s 29 and 20) The facility did not thoroughly investigate an allegation of sexual and prevent further potential abuse when Resident #44 sexually abused Resident #s 29 and 20. Resident #44 touched Resident #29's vaginal area. The administrator who was the abuse coordinator did not protect residents on the secured unit from further potential abuse because he did not feel Resident #44 touched Resident #29's vaginal area on purpose on 3/18/19. Resident #44 was observed touching Resident #29's breast on a date after 3/18/19; however the facility did not document the incident. Resident #44 continued to exhibit inappropriate sexual behaviors with staff. An Immediate Jeopardy (IJ) situation was identified 5/15/19. While the IJ was removed on 5/16/19 at 1:09 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents residing on the secured unit at risk for abuse. Findings included: 1. Physician orders [REDACTED].#44, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Klonopin 0.5 milligram (mg) two times a day for anxiety was initiated on 1/4/19, [MEDICATION NAME] 125mg two times a day was initiated on 3/15/19, [MEDICATION NAME] 500mg two times a day was initiated 3/22/19, and [MEDICATION NAME] 10mg sublingual was initiated 4/9/19 for [MEDICAL CONDITION] disorder. There were no orders to admit to the secured unit. A nursing note dated 3/10/19 at 1:30 p.m., indicated Resident #44 was moved to the secured unit for safety. An MDS dated [DATE] indicated Resident #44 had unclear speech, was sometimes understood, sometimes understood others, and had severe cognitive impairment. His behavioral symptoms directed towards others were identified such as, hitting, kicking, pushing, scratching, grabbing, and abusing others sexually occurred 4 to 6 days. Resident #44's verbal behaviors directed towards others included threatening, screaming and cursing others occurred 4 to 6 days out of 7. Resident #44 required extensive assistance of 1 staff for transfers and limited assistance of 1 person for locomotion while in wheelchair. A care plan initiated on 2/1/19 indicated Resident #44 had behavioral symptoms of exit seeking, rejection of care, hitting, cursing at staff, intruding on the privacy of others, and puts himself and others at risk of injury. The goal was .will not harm self or others secondary to socially inappropriate/disruptive behaviors . Interventions included .monitor and record medication effectiveness, assess whether the behavior endangered the resident and/or others, remove resident from other residents' rooms and unsafe situations, move resident to a quiet, calm environment when socially inappropriate/disruptive . The care plan did not identify inappropriate sexual contact with staff or residents and there were no specific approaches to protect residents from unwanted sexual contact. During an observation on 5/15/19 at 4:45 p.m., Resident #44 was in his wheelchair at the nursing station. The nurse redirected Resident #44 to the dining room. When redirected to the dining room, Resident #44 said, do you want me to shove them out of the way? Indicating with a head nod he was referring to other residents in the dining room. A nursing note dated 3/12/19 at 5:25 p.m., completed by RN D indicated Resident #44 was making inappropriate sexual comments towards staff while in the dining room. A nursing note dated 3/12/19 at 6:10 p.m., completed by RN D indicated Resident #44 became inappropriate with a CNA, grabbing her inappropriately and required another staff to intervene. During an interview on 5/15/19 at 2:20 p.m. RN D could not recall any specific incident where Resident #44 was sexually inappropriate toward staff. An incident report dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 touched a female resident (Resident #29) inappropriately. Resident #44 was heard saying I'm sorry I'm sorry and moved away from the female resident at the dining table when staff approached. The female resident (Resident #29) reported she was touched by Resident #44, down there, way down there while indicating with her hand where she was touched. Resident #44 said he had not touched 'no damn body' and when staff attempted to provide one-on-one monitoring, Resident #44 became aggressive and hit and kicked staff several times. LVN A indicated she was unable to redirect Resident #44. The report indicated the DON and administrator were notified on 3/18/19 at 8:36 a.m. There was no follow up or new interventions noted on the incident report. The medical record for Resident #44 dated (MONTH) 18, 2019 through (MONTH) 31, 2019 did not have documention of 1:1 observation. Physician orders [REDACTED].#29 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. An order with a start date of 10/9/18 indicated Resident #29 was admitted to the secure unit due to cognitive impairment and wandering. An MDS dated [DATE] indicated Resident #29 had severe impairment of cognition, clear speech, was sometimes understood, and sometimes understood others. Resident #29 required limited assist of one staff for bed mobility and locomotion, and extensive assist of 1 staff for transfers. A care plan dated 9/17/18 and revised on 3/19/19, indicated Resident #29 was touched inappropriately in the vaginal area through her clothes by another resident. There were no interventions to address the sexual abuse. During an observation on 5/13/19 at 10:25 a.m., Resident #29 was walking in the dining room. Resident #29 was unable to answer direct questions appropriately. A nursing note for Resident #29 dated 3/18/19 at 8:30 a.m., competed by LVN A indicated Resident #29 was sitting in the dining room in a chair when a CNA heard a male resident saying, I'm sorry, I'm sorry. The note indicated the CNA found the male resident wheeling his chair backward away from Resident #29. The note indicated Resident #29 was anxious. Resident #29 told the CNA the male resident touched her down there and pointed with her hand. The administrator and DON were notified A nursing note for Resident #44 dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 was heard saying he was sorry and was observed self-propelling his wheelchair away from the female resident at the next table. The female resident reported Resident #44 touched her down there, way down there. Resident #44 denied touching the female resident and became combative hitting LVN A in the back and right side with his fist and kicked her in the back of her right leg with his foot. LVN A indicated she was unable to redirect Resident #44 and the administrator sat with the resident. A Monthly Behavior Monitoring Flowsheet dated (MONTH) 1-31, 2019 did not indicate Resident #44's sexual inappropriate behaviors were monitored. The Behaviors monitored were continuous yelling, striking out/hitting, fighting, and noisy. A social service Psychosocial Evaluation dated 3/18/19 indicated Resident #44 was oriented to self, he was anxious and agitated, had behaviors of wandering, verbal and physical abuse, and socially inappropriate behaviors. He was interviewed in his room and said he was being good and said he was sorry when asked about touching Resident #29 in the vaginal area on 3/18/19. Resident #44 could not explain what happened. During an interview on 5/16/19 at 1:05 p.m., the social services director said she interviewed Resident #44 on 3/18/19 after the reported inappropriate touching of Resident #29 in the genital area. She said Resident #44 did not deny he touched Resident #29 in the genital area and apologized when questioned about the behavior. She said Resident #44 was aware of what he was doing and felt he placed other residents at risk. A NP medication review dated 3/19/19 at 8:15 a.m., indicated staff reported Resident #44 exhibited inappropriate sexual touching of a female resident in her groin area on 3/18/19 and when confronted by staff Resident #44 became aggressive and hit at staff. Th NP recommended to increase Resident #44's [MEDICATION NAME] (used to treat mental/mood behaviors) from 250 milligram (mg) two times a day to 500 mg two times a day. The note indicated the primary care physician signed the recommendation on 3/20/19. A mental health progress note dated 3/19/19 indicated Resident #44 was referred for .sexually inappropriate behavior . and further noted Resident #44 .is very difficult to redirect. He can be quite cantankerous and defiant . New orders to start [MEDICATION NAME] (an atypical antipsychotic psychiatric medication used to treat certain mental/mood disorders) 5mg every day was given and signed by Resident #44's primary care physician on 3/20/19. A care plan initiated on 2/1/19 indicated [MEDICATION NAME] 5mg was initiated on 3/22/19 and increased to 10mg on 4/9/19 but did not indicate the reason or other interventions. Care plan interventions included assess if resident behavioral symptoms present a danger to the resident or others and intervene as needed and quantitatively and objectively document the resident's behavior. An activity progress note dated 5/1/19 indicated Resident #44 was often combative and sexually inappropriate with staff. During an interview on 5/14/19 at 3:49 p.m., the DON said she was somewhat aware of the allegation of a male resident touching Resident #29 in the vaginal area through her clothes. The DON said she could not readily recall the details. During an interview on 5/14/19 at 3:55 p.m., the administrator said he was the abuse coordinator. He said he was notified by LVN A that Resident #29 was alleging she was touched down there by Resident #44. The administrator said, he was unable to verify if Resident #44 had inappropriately touched Resident #29 in the vaginal area. He said he believed Resident #44 may have accidentally reached out and touched Resident #29 or bumped her with his wheelchair. He said he did not question the CNA or any other staff about the incident. The administrator said Resident #29's reference to down there could have meant her feet. He said he believed Resident #44 did not intend to touch Resident #29 because he was saying I'm sorry. The administrator said he thought the nursing staff wanted it to look like Resident #44 touched Resident #29 in the vaginal area because they did not like him (Resident #44). The administrator said Resident #44 was aggressive and verbally abusive and would strike out at staff. He was unable to answer and said he would have to think about if Resident #44 exhibited inappropriate sexual advances toward other residents or staff. The administrator said he asked for a psychological assessment following the incident with Resident #29 and Resident #44's medication was adjusted. The administrator said he did not report the incident with Resident #29 to the state agency because he did not believe Resident #44 touched Resident #29. He said had he believed it, he would have interviewed staff and taken statements, and reported to the state agency. During an interview on 5/15/19 at 8:35 a.m., RN G said she heard Resident #44 had touched Resident #29 in the vaginal area and LVN A said Resident #29 was very upset. RN G said Resident #44 had a history of [REDACTED]. RN G indicated she would report inappropriate sexual behavior and remove resident from the situation. She said Resident #44 at times would attempt to run over residents with his wheelchair and always says he was sorry when staff intervenes. During an interview on 05/15/19 at 8:43 a.m., the DON said previously Resident #44 had touched a CNA inappropriately by either grabbing her butt or touching on her leg, but she could not recall the details. The DON said after she received the report from LVN A about Resident #44 inappropriately touching Resident #29, she took the incident report to the administrator and she did not investigate any further. The DON did not indicate any other interventions were put in place. During an interview on 5/15/19 at 9:06 a.m., CNA B said she worked on the secured unit. She said on 3/18/19 at approximately 8:30 a.m. she was standing at the nursing station when she heard Resident #29 saying no, no. CNA B said when she looked in the dining room, Resident #44 was wheeling away from Resident #29. She said Resident #29 said Resident #44 touched her and pointed at her groin area (between her legs). She said Resident #29 was upset, frightened, and shaking. CNA B said it took LVN A awhile to calm Resident #29 down. CNA B said LVN A assessed Resident #29 and notified the administrator and the DON. She said LVN A told her she was very concerned about Resident #44's sexual behavior and thought he should be transferred for treatment because his behaviors were getting worse and worse. CNA B said she tried to keep an eye on Resident #44 and keep him away from other residents when his behaviors escalated but could not watch him all the time. CNA B said she did not know what the administrator told LVN A to do about Resident #44 touching Resident #29 in the vaginal area. During an interview on 5/15/19 at 9:31 a.m., the MDS coordinator said he was responsible for updating resident's care plans. He said he was told Resident #44 had touched Resident #29 in the vaginal area through her clothes and he needed to care plan it. He said he did not add any interventions to address inappropriate touching specific to Resident #29 or other female residents. During an interview on 5/15/19 at 9:40 a.m., the DON said the allegation of Resident #44 touching Resident #29 in the genital area was not believed by the administrator but should have been investigated and reported to the state agency. 2. During an interview on 5/15/19 at 9:06 a.m., CNA B worked on the secured unit. She said about a month and a half ago she came to work one morning and was instructed by LVN A to keep an eye on Resident #44 because he was caught fondling Resident #20's breast., She said she believed the incident with Resident #20 occurred on the 2:00 p.m.-10:00 p.m. shift. CNA B did not know any other specific intervention, other than monitor Resident #44 and report inappropriate behavior. During an interview on 5/15/19 at 9:25 a.m., CNA J said she worked on the secured unit. She said she was told by LVN A to keep Resident #44 away from other residents because he was found touching Resident #20 inappropriately in the dining room. CNA J said the incident with Resident #20 occurred about a month to 2 months ago. CNA J said Resident #44 was not on 1:1 observation but had been in the past because of his sexual behaviors towards other residents. Physician orders [REDACTED].#20, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The orders initiated 3/13/17 indicated Resident #20 was admitted to the secure unit due to wandering. An MDS dated [DATE] indicated Resident #20 had unclear speech, was rarely understood, rarely understood others, and had severe cognitive impairment. She was dependent on one staff for transfers, dressing, toileting, and hygiene. A care plan dated 4/2/18 indicated Resident #20 was admitted to hospice services on 9/24/18 and used a Broda chair (specialty seating that accommodates repositioning needs) while out of bed for proper positioning. During an observation and interview on 5/16/19 at 11:55 a.m., Resident #20 was seated in a Broda chair (reclining chair) in the dining room. She was alert and pleasantly confused. She offered no complaints and could not recall any inappropriate touching or behaviors toward her by other residents. During an interview on 5/15/19 at 12:03 p.m., AD C said she was walking in front of the dining room on the secure unit about a month or month and a half ago when she saw Resident #44 massaging Resident #20's boobs. She said she immediately told Resident #44 to stop and he began saying he was sorry and backed away. AD C said she reported the incident to RN D who said she would handle it. AD C said she knew it was reported to the administrator because he came the next day and asked her questions about the incident. She said she told the administrator Resident #44 was massaging Resident #20's boobs. She said the administrator said he would attend to the matter. During an interview on 5/15/19 at 10:41 a.m., the administrator said he was not made aware of the inappropriate touching of Resident #20 by Resident #44. He said if he would have been aware he would have investigated the incident and notified the state agency. During an interview on 5/15/19 at 2:20 p.m., RN D said she could not recall a specific resident that Resident #44 may have touched. She said it was hard to keep up with all the residents on the secure unit because there were only three staff and they could not keep one resident under constant observation. RN D said they tried to monitor Resident #44's behavior and keep him away from other residents but could not successfully do it all the time. She said she has so much reported to her in a day she just could not recall if it was reported to her that Resident #20 was touched on the breast by Resident #44. The nursing notes dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 for Resident #20 had no documentation to indicate Resident #44 was massaging her boobs. The incident log dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 did not contain an incident regarding Resident #44 touching Resident #20's breast area. During an interview on 5/15/19 at 9:40 a.m., the DON said she did not receive a report concerning a new allegation of Resident #44 rubbing on Resident #20's breast. She said she reviewed the incident log and could not find a report. During an interview on 5/15/19 at 8:28 a.m., Housekeeper [NAME] said about 2 weeks ago, Resident #44 approached her telling her how pretty she was and reached for her vaginal area. She said she pushed his hand away and he started saying he was sorry. She said she reported the behavior to LVN H and was asked if she wanted the police notified. During an interview on 5/15/19 at 8:15 a.m., LVN H said staff tried to keep an eye on Resident #44 because of his multiple aggressive and inappropriate behaviors. She said Resident #44 screamed and hollered at residents and staff. She said he constantly requested coffee and cigarettes and watched the clock when given a smoke time. LVN H said she was not aware of Resident #44 touching female residents inappropriately but believed he was capable and knows what he was doing. LVN H said anytime Resident #44 was told his behavior was inappropriate he would say he was sorry. LVN H said she redirects Resident #44 when he becomes aggressive, removes him from other residents, but cannot watch him all the time. LVN H said she might remember a staff member reporting he was sexually inappropriate but is not sure. During an interview on 5/15/19 at 4:12 p.m., transport F said Resident #44 made multiple sexual advances towards her. She said about two weeks ago Resident #44 approached her and rubbed her breast and down her waist. She said when she told Resident #44 to stop, he said he was sorry. Transport F said he attempted to touch her several times before that time. Transport F said she reported Resident #44's behavior to RN D. Transport F said she had not been interviewed by administrative staff about Resident 44's sexual advances towards her and she just tried to stay away from him. During an interview on 5/15/19 at 9:31 a.m. the MDS coordinator said he was not told about any inappropriate touching by Resident #44 towards Resident #20. He said touching down there generally indicated the female genitalia. He said touching the genitalia area and rubbing on female breasts by a male resident would be considered abuse and should be reported to the abuse coordinator. An Abuse Policy dated 5/2017 indicated: .PURPOSE: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect .PR[NAME]EDURE: The administrator and/or Designee is responsible for maintaining ALL facility policies that prohibit abuse, neglect, .to include the following: .Prevention of occurrences, Identification of possible incidents or allegations that need to be investigated, Investigation of allegations, Resident protection during investigation, Reporting of Incidents, investigations and facility response to results of investigations to all appropriate regulatory entities . Resident inappropriate sexual behavior: The facility's first concern will always be to protect the residents involved in this type of situation .If the resident is confused or unable to make decisions then the facility will be the advocate and protect the resident from harm even if the resident appears to be a willing participant . The use of specific monitoring sheets to document behavior will be done and staff will be in-serviced to discuss the behavior and actions to take when it is observed. The monitoring sheets will be left in the acute rack for 14 days to determine if the behavior reoccurs. The charge nurses will closely monitor and document in the nurse notes and care plan the behavior of both residents involved in the incident and document this on each shift. The facility will investigate the incident and get statement from any witnesses. All interventions by nursing, social workers, and any outside referral sources will be maintained in either the clinical record or the investigative packet. State guidelines will be followed for reporting these types of incidents. Repeat behavior by the resident may result in an appropriate transfer from the facility to protect not only resident involved but other residents in the facility. The proper approach in handling this type of situation will always be interdisciplinary with all interventions being documented . Facility Investigation Policy/Procedure . To gather all the accurate and pertinent information possible when an allegation of abuse, neglect or exploitation has been lodged . Procedure: 1. When an allegation has been lodged notify the administrator and the director of nurses, they in turn will begin an investigation using the Facility Internal Investigation packet .2. Following the Facility Internal Investigation packet-answer all questions completely and accurately .3. Make sure to interview all staff members and residents involved using the appropriate form in the package. 4. Make sure to interview alert and oriented residents on the same hall where the alleged incident occurred if needed. 5. Have all staff members write a statement, make sure to include the date and time .Protection: It is the most importance that the resident or resident suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm .In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged . During the time that the perpetrator is being discharged , the facility will monitor this resident one-on-one to protect all other residents. The director of nursing will coordinate this and setup the monitoring. If a threat does not exist, then an appropriate assessment will be done, and the behavior will be care planned to meet this resident's needs and protect others. The assistant administrator, corporate nurse, DON, and ADON was informed on 5/15/19 at 3:44 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/19 at 5:48 p.m. and included: .1. Administrator who failed to report and investigate resident to resident abuse, and who failed to put measures in place to protect other residents has been terminated by Vice President of Operations. Completed at 4:00 p.m. 5/15/19. 2. Alleged perpetrator, male resident on a secured unit has been transferred to Behavioral Hospital to undergo treatment for [REDACTED]. Completed by Regional RN at 5:35 p.m. 5/15/19. 3. Regional Director of Operations, LFNA, has been made abuse prevention coordinator for the facility and his number has been posted in prominent locations throughout the building. 4. All Staff have been in-serviced on What Constitutes Abuse, Including Resident to Resident Abuse; and, Reporting Abuse. Completed by RN, DON, 6:00 p.m. 5/15/19 (will be continued at the beginning of each shift until all employees are in-serviced - no employee will be allowed to work until they have completed this training). This training includes who to contact if the Abuse Prevention Coordinator fails to respond. 5. All residents on the secured unit have been assessed for signs or symptoms of abuse, including verbal reports, and non-verbal signs and symptom to include, but not limited to: tearfulness / crying, acting withdrawn, poor appetite, or any other unusual behaviors. 6. All residents on the secured unit have been assessed head to toe for any physician signs or symptoms of abuse such as bruising, red marks, abrasions, or trauma of any kind. 7. Safe surveys have been conducted with all residents in the facility to ensure that no other abuse has occurred . On 5/16/19 at 1:09 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: The facility training included in-services on reporting sexual abuse, exploitation, misappropriation of resident property, mistreatment and neglect as who to report, when to report, and what to report. The staff in-serviced included: 28 Nurses and CNAs, 11 sitters and hospitality aides, and 25 staff from maintenance, housekeeping, laundry, dietary, transport, activities, medical records, social services, therapy and administration. 14 nurses, CNAs, and hospitality aids, 1 activity employee, 1 housekeeping employee,1 dietary employee, and 2 administrative employees were interviewed, from different shifts, on the different types of abuse, who to report to, when to report and where to document incidents. All staff were able to verbalize the correct answers. On 5/16/19 at 1:09 p.m., corporate nurse, assistant administrator, and DON was informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 of 4 residents reviewed for abuse. (Resident #s 29 and 20) The facility did not implement and develop effective care plan interventions to prevent Resident #44 from sexually abusing Resident #s 29 and 20. Resident #44 touched Resident #29's vaginal area. The administrator who was the abuse coordinator did not protect residents on the secured unit from further potential abuse because he did not feel Resident #44 touched Resident #29's vaginal area on purpose on 3/18/19. Resident #44 was observed touching Resident #29's breast on a date after 3/18/19; however the facility did not document the incident. Resident #44 continued to exhibit inappropriate sexual behaviors with staff. An Immediate Jeopardy (IJ) situation was identified 5/15/19. While the IJ was removed on 5/16/19 at 1:09 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents residing on the secured unit at risk for abuse. Findings included: 1. Physician orders [REDACTED].#44, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Klonopin 0.5 milligrams (mg) two times a day for anxiety was initiated on 1/4/19, [MEDICATION NAME] 125mg two times a day was initiated on 3/15/19, [MEDICATION NAME] 500mg two times a day was initiated 3/22/19, and [MEDICATION NAME] 10mg sublingual was initiated 4/9/19 for [MEDICAL CONDITION] disorder. There were no orders to admit to the secured unit. A nursing note dated 3/10/19 at 1:30 p.m., indicated Resident #44 was moved to the secured unit for safety. An MDS dated [DATE] indicated Resident #44 had unclear speech, was sometimes understood, sometimes understood others, and had severe cognitive impairment. His behavioral symptoms directed towards others were identified such as, hitting, kicking, pushing, scratching, grabbing, and abusing others sexually occurred 4 to 6 days. Resident #44's verbal behaviors directed towards others included threatening, screaming and cursing others occurred 4 to 6 days out of 7. Resident #44 required extensive assistance of 1 staff for transfers and limited assistance of 1 person for locomotion while in wheelchair. A care plan initiated on 2/1/19 indicated Resident #44 had behavioral symptoms of exit seeking, rejection of care, hitting, cursing at staff, intruding on the privacy of others, and puts himself and others at risk of injury. The goal was .will not harm self or others secondary to socially inappropriate/disruptive behaviors . Interventions included .monitor and record medication effectiveness, assess whether the behavior endangered the resident and/or others, remove resident from other residents' rooms and unsafe situations, move resident to a quiet, calm environment when socially inappropriate/disruptive . The care plan did not identify inappropriate sexual contact with staff or residents and there were no specific approaches to protect residents from unwanted sexual contact. During an observation on 5/15/19 at 4:45 p.m., Resident #44 was in his wheelchair at the nursing station. The nurse redirected Resident #44 to the dining room and Resident #44 said, do you want me to shove them out of the way? Indicating with a head nod he was referring to other residents in the dining room. A nursing note dated 3/12/19 at 5:25 p.m., completed by RN D indicated Resident #44 was making inappropriate sexual comments towards staff while in the dining room. A nursing note dated 3/12/19 at 6:10 p.m., completed by RN D indicated Resident #44 became inappropriate with a CNA, grabbing her inappropriately and required another staff to intervene. During an interview on 5/15/19 at 2:20 p.m., RN D could not recall any specific incident where Resident #44 was sexually inappropriate toward staff. An incident report dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 touched a female resident (Resident #29) inappropriately. Resident #44 was heard saying I'm sorry I'm sorry and moved away from the female resident at the dining table when staff approached. The female resident (Resident #29) reported she was touched by Resident #44, down there, way down there while indicating with her hand where she was touched. Resident #44 said he had not touched 'no damn body' and when staff attempted to provide one-on-one monitoring, Resident #44 became aggressive and hit and kicked staff several times. LVN A indicated she was unable to redirect Resident #44. The report indicated the DON and administrator were notified on 3/18/19 at 8:36 a.m. There was no documentation of followup or implementation of interventions noted on the incident report. The medical record for Resident #44 dated (MONTH) 18, 2019 through (MONTH) 31, 2019 did not have documention of 1:1 observation. Physician orders [REDACTED].#29 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. An order with a start date of 10/9/18 indicated Resident #29 was admitted to the secured unit due to cognitive impairment and wandering. An MDS dated [DATE] indicated Resident #29 had severe impairment of cognition, clear speech, was sometimes understood, and sometimes understood others. Resident #29 required limited assist of one staff for bed mobility and locomotion, and extensive assist of 1 staff for transfers. A care plan dated 9/17/18 and revised on 3/19/19, indicated Resident #29 was touched inappropriately in the vaginal area through her clothes by another resident. There were no interventions to address the sexual abuse. During an observation and interview on 5/13/19 at 10:25 a.m., Resident #29 was ambulatory. Resident #29 was unable to answer direct questions appropriately. A nursing note for Resident #29 dated 3/18/19 at 8:30 a.m., competed by LVN A indicated Resident #29 was sitting in the dining room in a chair when a CNA heard a male resident saying, I'm sorry, I'm sorry. The note indicated the CNA found the male resident wheeling his chair backward away from Resident #29. The note indicated Resident #29 was anxious. Resident #29 told the CNA the male resident touched her down there and pointed with her hand. The administrator and DON were notified. A nursing note for Resident #44 dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 was heard saying he was sorry and was observed self-propelling his wheelchair away from the female resident at the next table. The female resident reported Resident #44 touched her down there, way down there. Resident #44 denied touching the female resident and became combative hitting LVN A in the back and right side with his fist and kicked her in the back of her right leg with his foot. LVN A indicated she was unable to redirect Resident #44 and the administrator sat with the resident. A Monthly Behavior Monitoring Flowsheet dated (MONTH) 1-31, 2019 did not indicate Resident #44's sexual inappropriate behaviors were monitored. The behaviors monitored were continuous yelling, striking out/hitting, fighting, and noisy. A social service Psychosocial Evaluation dated 3/18/19 indicated Resident #44 was oriented to self, he was anxious and agitated, had behaviors of wandering, verbal and physical abuse, and socially inappropriate behaviors. He was interviewed in his room and said he was being good and said he was sorry when asked about touching Resident #29 in the vaginal area on 3/18/19. Resident #44 could not explain what happened. During an interview on 5/16/19 at 1:05 p.m., the social services director said she interviewed Resident #44 on 3/18/19 after the reported inappropriate touching of Resident #29 in the genital area. She said Resident #44 did not deny he touched Resident #29 in the genital area and apologized when questioned about the behavior. She said Resident #44 was aware of what he was doing and felt he placed other residents at risk. A NP medication review dated 3/19/19 at 8:15 a.m., indicated staff reported Resident #44 exhibited inappropriate sexual touching of a female resident in her groin area on 3/18/19 and when confronted by staff Resident #44 became aggressive and hit at staff. Th NP recommended to increase Resident #44's [MEDICATION NAME] (used to treat mental/mood behaviors) from 250 milligram (mg) two times a day to 500 mg two times a day. The note indicated the primary care physician signed the recommendation on 3/20/19. A mental health progress note dated 3/19/19 indicated Resident #44 was referred for .sexually inappropriate behavior . and further noted Resident #44 .is very difficult to redirect. He can be quite cantankerous and defiant . New orders to start [MEDICATION NAME] (an atypical antipsychotic psychiatric medication used to treat certain mental/mood disorders) 5mg every day was given and signed by Resident #44's primary care physician on 3/20/19. A care plan initiated on 2/1/19 indicated [MEDICATION NAME] 5mg was initiated on 3/22/19 and increased to 10mg on 4/9/19 but did not indicate the reason or other interventions. Care plan interventions included assess if resident behavioral symptoms present a danger to the resident or others and intervene as needed and quantitatively and objectively document the resident's behavior. An activity progress note dated 5/1/19 indicated Resident #44 was often combative and sexually inappropriate with staff. During an interview on 5/14/19 at 3:49 p.m., the DON said she was somewhat aware of the allegation of a male resident touching Resident #29 in the vaginal area through her clothes. The DON said she could not readily recall the details. During an interview on 5/14/19 at 3:55 p.m., the administrator said he was the abuse coordinator. He said he was notified by LVN A that Resident #29 was alleging she was touched down there by Resident #44. The administrator said, he was unable to verify if Resident #44 had inappropriately touched Resident #29 in the vaginal area. He said he believed Resident #44 may have accidentally reached out and touched Resident #29 or bumped her with his wheelchair. He said he did not question the CNA or any other staff about the incident. The administrator said Resident #29's reference to down there could have meant her feet. He said he believed Resident #44 did not intend to touch Resident #29 because he was saying I'm sorry. The administrator said he thought the nursing staff wanted it to look like Resident #44 touched Resident #29 in the vaginal area because they did not like him (Resident #44). The administrator said Resident #44 was aggressive and verbally abusive and would strike out at staff. He was unable to answer and said he would have to think about if Resident #44 exhibited inappropriate sexual advances toward other residents or staff. The administrator said he asked for a psychological assessment following the incident with Resident #29 and Resident #44's medication was adjusted. During an interview on 5/15/19 at 8:35 a.m., RN G said she heard Resident #44 had touched Resident #29 in the vaginal area and LVN A said Resident #29 was very upset. RN G said Resident #44 had a history of [REDACTED]. RN G indicated she would report inappropriate sexual behavior and remove resident from the situation. She said Resident #44 at times would attempt to run over residents with his wheelchair and always says he was sorry when staff intervenes. During an interview on 05/15/19 at 8:43 a.m., the DON said previously Resident #44 had touched a CNA inappropriately by either grabbing her butt or touching on her leg, but she could not recall the details. The DON said after she received the report from LVN A about Resident #44 inappropriately touching Resident #29, she took the incident report to the administrator and she did not investigate any further. The DON did not indicate any other interventions were put in place. During an interview on 5/15/19 at 9:06 a.m., CNA B said she worked on the secured unit. She said on 3/18/19 at approximately 8:30 a.m. she was standing at the nursing station when she heard Resident #29 saying no, no. CNA B said when she looked in the dining room, Resident #44 was wheeling away from Resident #29. She said Resident #29 said Resident #44 touched her and pointed at her groin area (between her legs). She said Resident #29 was upset, frightened, and shaking. CNA B said it took LVN A awhile to calm Resident #29 down. CNA B said LVN A assessed Resident #29 and notified the administrator and the DON. She said LVN A told her she was very concerned about Resident #44's behavior and thought he should be transferred for treatment because his sexual behaviors were getting worse and worse. CNA B said she tried to keep an eye on Resident #44 and keep him away from other residents when his sexual behaviors escalated but could not watch him all the time. CNA B said she did not know what the administrator told LVN A to do about Resident #44 touching Resident #29 in the vaginal area. During an interview on 5/15/19 at 9:31 a.m., the MDS coordinator said he was responsible for updating resident's care plans. He said he was told Resident #44 had touched Resident #29 in the vaginal area through her clothes and he needed to care plan it. He said he did not add any interventions to address inappropriate touching specific to Resident #29 or other female residents. During an interview on 5/15/19 at 9:40 a.m., the DON said the allegation of Resident #44 touching Resident #29 in the genital area was not believed by the administrator. 2. During an interview on 5/15/19 at 9:06 a.m., CNA B worked on the secured unit. She said about a month and a half ago she came to work one morning and was instructed by LVN A to keep an eye on Resident #44 because he was caught fondling Resident #20's breast., She said she believed the incident with Resident #20 occurred on the 2:00 p.m.-10:00 p.m. shift. CNA B did not know any other specific intervention, other than monitor Resident #44 and report inappropriate behavior. During an interview on 5/15/19 at 9:25 a.m., CNA J said she worked on the secured unit. She said she was told by LVN A to keep Resident #44 away from other residents because he was found touching Resident #20 inappropriately in the dining room. CNA J said the incident with Resident #20 occurred about a month to 2 months ago. CNA J said Resident #44 was not on 1:1 observation but had been in the past because of his sexual behaviors towards other residents. Physician orders [REDACTED].#20, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The orders initiated 3/13/17 indicated Resident #20 was admitted to the secured unit due to wandering. An MDS dated [DATE] indicated Resident #20 had unclear speech, was rarely understood, rarely understood others, and had severe cognitive impairment. She was dependent on one staff for transfers, dressing, toileting, and hygiene. A care plan dated 4/2/18 indicated Resident #20 was admitted to hospice services on 9/24/18 and used a Broda chair (specialty seating that accommodates repositioning needs) while out of bed for proper positioning. During an observation and interview on 5/16/19 at 11:55 a.m., Resident #20 was seated in a Broda chair (reclining chair) in the dining room. She was alert and pleasantly confused. She offered no complaints and could not recall any inappropriate touching or behaviors toward her by other residents. During an interview on 5/15/19 at 12:03 p.m., AD C said she was walking in front of the dining room on the secured unit about a month or month and a half ago when she saw Resident #44 massaging Resident #20's boobs. She said she immediately told Resident #44 to stop and he began saying he was sorry and backed away. AD C said she reported the incident to RN D who said she would handle it. AD C said she knew it was reported to the administrator because he came the next day and asked her questions about the incident. She said she told the administrator Resident #44 was massaging Resident #20's boobs. She said the administrator said he would attend to the matter. During an interview on 5/15/19 at 10:41 a.m., the administrator said he was not made aware of the inappropriate touching of Resident #20 by Resident #44. During an interview on 5/15/19 at 2:20 p.m., RN D said she could not recall a specific resident that Resident #44 may have touched. She said it was hard to keep up with all the residents on the secure unit because there were only three staff and they could not keep one resident under constant observation. RN D said they tried to monitor Resident #44's behavior and keep him away from other residents but could not successfully do it all the time. She said she has so much reported to her in a day she just could not recall if it was reported to her that Resident #20 was touched on the breast by Resident #44. The nursing notes dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 for Resident #20 had no documentation to indicate Resident #44 was massaging her boobs. The incident log dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 did not contain an incident regarding Resident #44 touching Resident #20's breast area. During an interview on 5/15/19 at 9:40 a.m., the DON said she did not receive a report concerning a new allegation of Resident #44 rubbing on Resident #20's breast. She said she reviewed the incident log and could not find a report. During an interview on 5/15/19 at 8:28 a.m., housekeeper [NAME] said about 2 weeks ago, Resident #44 approached her telling her how pretty she was and reached for her vaginal area. She said she pushed his hand away and he started saying he was sorry. She said she reported the behavior to LVN H and was asked if she wanted the police notified. During an interview on 5/15/19 at 8:15 a.m., LVN H said staff tried to keep an eye on Resident #44 because of his multiple aggressive and inappropriate behaviors. She said Resident #44 screamed and hollered at residents and staff. She said he constantly requested coffee and cigarettes and watched the clock when given a smoke time. LVN H said she was not aware of Resident #44 touching female residents inappropriately but believed he was capable and knows what he was doing. LVN H said anytime Resident #44 was told his behavior was inappropriate he would say he was sorry. LVN H said she redirects Resident #44 when he becomes aggressive, removes him from other residents, but cannot watch him all the time. LVN H said she might remember a staff member reporting he was sexually inappropriate but was not sure. During an interview on 5/15/19 at 4:12 p.m., transport F said Resident #44 made multiple sexual advances towards her. She said about two weeks ago Resident #44 approached her and rubbed her breast and down her waist. She said when she told Resident #44 to stop, he said he was sorry. Transport F said he attempted to touch her several times before that time. Transport F said she reported Resident #44's behavior to RN D. Transport F said she had not been interviewed by administrative staff about Resident 44's sexual advances towards her and she just tried to stay away from him. During an interview on 5/15/19 at 9:31 a.m., the MDS coordinator said he was not told about any inappropriate touching by Resident #44 towards Resident #20. He said touching down there generally indicated the female genitalia. He said touching the genitalia area and rubbing on female breasts by a male resident would be considered abuse and should be reported to the abuse coordinator. An Abuse Policy dated 5/2017 indicated: .PURPOSE: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect .PR[NAME]EDURE: The administrator and/or Designee is responsible for maintaining ALL facility policies that prohibit abuse, neglect, .to include the following: .Prevention of occurrences, Identification of possible incidents or allegations that need to be investigated, Investigation of allegations, Resident protection during investigation, Reporting of Incidents, investigations and facility response to results of investigations to all appropriate regulatory entities . Resident inappropriate sexual behavior: The facility's first concern will always be to protect the residents involved in this type of situation .If the resident is confused or unable to make decisions then the facility will be the advocate and protect the resident from harm even if the resident appears to be a willing participant . The use of specific monitoring sheets to document behavior will be done and staff will be in-serviced to discuss the behavior and actions to take when it is observed. The monitoring sheets will be left in the acute rack for 14 days to determine if the behavior reoccurs. The charge nurses will closely monitor and document in the nurse notes and care plan the behavior of both residents involved in the incident and document this on each shift. The facility will investigate the incident and get statement from any witnesses. All interventions by nursing, social workers, and any outside referral sources will be maintained in either the clinical record or the investigative packet. State guidelines will be followed for reporting these types of incidents. Repeat behavior by the resident may result in an appropriate transfer from the facility to protect not only resident involved but other residents in the facility. The proper approach in handling this type of situation will always be interdisciplinary with all interventions being documented . Facility Investigation Policy/Procedure . To gather all the accurate and pertinent information possible when an allegation of abuse, neglect or exploitation has been lodged . Procedure: 1. When an allegation has been lodged notify the administrator and the director of nurses, they in turn will begin an investigation using the Facility Internal Investigation packet .2. Following the Facility Internal Investigation packet-answer all questions completely and accurately .3. Make sure to interview all staff members and residents involved using the appropriate form in the package. 4. Make sure to interview alert and oriented residents on the same hall where the alleged incident occurred if needed. 5. Have all staff members write a statement, make sure to include the date and time .Protection: It is the most importance that the resident or resident suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm .In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged . During the time that the perpetrator is being discharged , the facility will monitor this resident one-on-one to protect all other residents. The director of nursing will coordinate this and setup the monitoring. If a threat does not exist, then an appropriate assessment will be done, and the behavior will be care planned to meet this resident's needs and protect others . The assistant administrator, corporate nurse, DON, and ADON was informed on 5/15/19 at 3:44 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/19 at 5:48 p.m. and included: .1. Administrator who failed to report and investigate resident to resident abuse, and who failed to put measures in place to protect other residents has been terminated by Vice President of Operations. Completed at 4:00 p.m. 5/15/19. 2. Alleged perpetrator, male resident on a secured unit has been transferred to Behavioral Hospital to undergo treatment for [REDACTED]. Completed by Regional RN at 5:35 p.m. 5/15/19. 3. Regional Director of Operations, LFNA, has been made abuse prevention coordinator for the facility and his number has been posted in prominent locations throughout the building. 4. All Staff have been in-serviced on What Constitutes Abuse, Including Resident to Resident Abuse; and, Reporting Abuse. Completed by RN, DON, 6:00 p.m. 5/15/19 (will be continued at the beginning of each shift until all employees are in-serviced - no employee will be allowed to work until they have completed this training). This training includes who to contact if the Abuse Prevention Coordinator fails to respond. 5. All residents on the secured unit have been assessed for signs or symptoms of abuse, including verbal reports, and non-verbal signs and symptom to include, but not limited to: tearfulness / crying, acting withdrawn, poor appetite, or any other unusual behaviors. 6. All residents on the secured unit have been assessed head to toe for any physician signs or symptoms of abuse such as bruising, red marks, abrasions, or trauma of any kind. 7. Safe surveys have been conducted with all residents in the facility to ensure that no other abuse has occurred . On 5/16/19 at 1:09 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: The facility training included in-services on reporting sexual abuse, exploitation, misappropriation of resident property, mistreatment and neglect as who to report, when to report, and what to report. The staff in-serviced included: 28 Nurses and CNAs, 11 sitters and hospitality aides, and 25 staff from maintenance, housekeeping, laundry, dietary, transport, activities, medical records, social services, therapy and administration. 14 nurses, CNAs, and hospitality aids, 1 activity employee, 1 housekeeping employee,1 dietary employee, and 2 administrative employees were interviewed, from different shifts, on the different types of abuse, who to report to, when to report and where to document incidents. All staff were able to verbalize the correct answers. On 5/16/19 at 1:09 p.m., corporate nurse, assistant administrator, and DON was informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse for 2 of 4 residents reviewed for abuse. (Resident #s 29 and 20) The facility did not investigate or report an allegation of sexual abuse immediately to the administrator and the state agency when Resident #44 sexually abused Resident #s 29 and 20. Resident #44 touched Resident #29's vaginal area. The administrator who was the abuse coordinator did not protect residents on the secured unit from further potential abuse because he did not feel Resident #44 touched Resident #29's vaginal area on purpose on 3/18/19. Resident #44 was observed touching Resident #29's breast on a date after 3/18/19; however the facility did not document the incident. Resident #44 continued to exhibit inappropriate sexual behaviors with staff. An Immediate Jeopardy (IJ) situation was identified 5/1519. While the IJ was removed on 5/16/19 at 1:09 p.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents residing on the secured unit at risk for abuse. Findings included: An Abuse Policy dated 5/2017 indicated: .PURPOSE: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect .PR[NAME]EDURE: The administrator and/or Designee is responsible for maintaining ALL facility policies that prohibit abuse, neglect, .to include the following: .Prevention of occurrences, Identification of possible incidents or allegations that need to be investigated, Investigation of allegations, Resident protection during investigation, Reporting of Incidents, investigations and facility response to results of investigations to all appropriate regulatory entities . Resident inappropriate sexual behavior: The facility's first concern will always be to protect the residents involved in this type of situation .If the resident is confused or unable to make decisions then the facility will be the advocate and protect the resident from harm even if the resident appears to be a willing participant . The use of specific monitoring sheets to document behavior will be done and staff will be in-serviced to discuss the behavior and actions to take when it is observed. The monitoring sheets will be left in the acute rack for 14 days to determine if the behavior reoccurs. The charge nurses will closely monitor and document in the nurse notes and care plan the behavior of both residents involved in the incident and document this on each shift. The facility will investigate the incident and get statement from any witnesses. All interventions by nursing, social workers, and any outside referral sources will be maintained in either the clinical record or the investigative packet. State guidelines will be followed for reporting these types of incidents. Repeat behavior by the resident may result in an appropriate transfer from the facility to protect not only resident involved but other residents in the facility. The proper approach in handling this type of situation will always be interdisciplinary with all interventions being documented . Facility Investigation Policy/Procedure . To gather all the accurate and pertinent information possible when an allegation of abuse, neglect or exploitation has been lodged . Procedure: 1. When an allegation has been lodged notify the administrator and the director of nurses, they in turn will begin an investigation using the Facility Internal Investigation packet .2. Following the Facility Internal Investigation packet-answer all questions completely and accurately .3. Make sure to interview all staff members and residents involved using the appropriate form in the package. 4. Make sure to interview alert and oriented residents on the same hall where the alleged incident occurred if needed. 5. Have all staff members write a statement, make sure to include the date and time .Protection: It is the most importance that the resident or resident suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm .In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged . During the time that the perpetrator is being discharged , the facility will monitor this resident one-on-one to protect all other residents. The director of nursing will coordinate this and setup the monitoring. If a threat does not exist, then an appropriate assessment will be done, and the behavior will be care planned to meet this resident's needs and protect others . 1. Physician orders [REDACTED].#44, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Klonopin 0.5 milligram (mg) two times a day for anxiety was initiated on 1/4/19, [MEDICATION NAME] 125mg two times a day was initiated on 3/15/19, [MEDICATION NAME] 500mg two times a day was initiated 3/22/19, and [MEDICATION NAME] 10mg sublingual was initiated 4/9/19 for [MEDICAL CONDITION] disorder. There were no orders to admit to the secured unit. A nursing note dated 3/10/19 at 1:30 p.m., indicated Resident #44 was moved to the secured unit for safety. An MDS dated [DATE] indicated Resident #44 had unclear speech, was sometimes understood, sometimes understood others, and had severe cognitive impairment. His behavioral symptoms directed towards others were identified such as, hitting, kicking, pushing, scratching, grabbing, and abusing others sexually occurred 4 to 6 days. Resident #44's verbal behaviors directed towards others included threatening, screaming and cursing others occurred 4 to 6 days out of 7. Resident #44 required extensive assistance of 1 staff for transfers and limited assistance of 1 person for locomotion while in wheelchair. A care plan initiated on 2/1/19 indicated Resident #44 had behavioral symptoms of exit seeking, rejection of care, hitting, cursing at staff, intruding on the privacy of others, and puts himself and others at risk of injury. The goal was .will not harm self or others secondary to socially inappropriate/disruptive behaviors . Interventions included .monitor and record medication effectiveness, assess whether the behavior endangered the resident and/or others, remove resident from other residents' rooms and unsafe situations, move resident to a quiet, calm environment when socially inappropriate/disruptive . The care plan did not identify inappropriate sexual contact with staff or residents and there were no specific approaches to protect residents from unwanted sexual contact. During an observation on 5/15/10 at 4:45 p.m., Resident #44 was sitting in his wheelchair at the nursing station. When redirected to the dining room, Resident #44 said, do you want me to shove them out of the way? Indicating with a head nod he was referring to other residents in the dining room. A nursing note dated 3/12/19 at 5:25 p.m., completed by RN D indicated Resident #44 was making inappropriate sexual comments towards staff while in the dining room. A nursing note dated 3/12/19 at 6:10 p.m., completed by RN D indicated Resident #44 became inappropriate with a CNA, grabbing her inappropriately and required another staff to intervene. During an interview on 5/15/19 at 2:20 p.m., RN D could not recall any specific incident where Resident #44 was sexually inappropriate toward staff. An incident report dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 touched a female resident (Resident #29) inappropriately. Resident #44 was heard saying I'm sorry I'm sorry and moved away from the female resident at the dining table when staff approached. The female resident (Resident #29) reported she was touched by Resident #44, down there, way down there while indicating with her hand where she was touched. Resident #44 said he had not touched 'no damn body' and when staff attempted to provide one-on-one monitoring, Resident #44 became aggressive and hit and kicked staff several times. LVN A indicated she was unable to redirect Resident #44. The report indicated the DON and administrator were notified on 3/18/19 at 8:36 a.m. There was no follow up or intervententions noted on the incident report. The medical record for Resident #44 dated Resident #44 did not have documention of 1:1 observation. Physician orders [REDACTED].#29, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. An order with a start date of 10/9/18 indicated Resident #29 was admitted to the secure unit due to cognitive impairment and wandering. An MDS dated [DATE] indicated Resident #29 had severe impairment of cognition, clear speech, was sometimes understood, and sometimes understood others. Resident #29 required limited assist of one staff for bed mobility and locomotion, and extensive assist of 1 staff for transfers. A care plan dated 9/17/18 and revised on 3/19/19, indicated Resident #29 was touched inappropriately in the vaginal area through her clothes by another resident. There were no interventions to address the sexual abuse. During observation and interview on 5/13/19 at 10:25 a.m., Resident #29 was ambulatory and seated in the dining room visiting with another female resident. Resident #29 was unable to answer direct questions appropriately. A nursing note for Resident #29 dated 3/18/19 at 8:30 a.m., competed by LVN A indicated Resident #29 was sitting in the dining room in a chair when a CNA heard a male resident saying, I'm sorry, I'm sorry. The note indicated the CNA found the male resident wheeling his chair backward away from Resident #29. The note indicated Resident #29 was anxious. Resident #29 told the CNA the male resident touched her down there and pointed with her hand. The administrator and DON were notified A nursing note for Resident #44 dated 3/18/19 at 8:30 a.m., completed by LVN A indicated Resident #44 was heard saying he was sorry and was observed self-propelling his wheelchair away from the female resident at the next table. The female resident reported Resident #44 touched her down there, way down there. Resident #44 denied touching the female resident and became combative hitting LVN A in the back and right side with his fist and kicked her in the back of her right leg with his foot. LVN A indicated she was unable to redirect Resident #44 and the administrator sat with the resident. A Monthly Behavior Monitoring Flowsheet dated (MONTH) 1-31, 2019 did not indicate Resident #44's sexual inappropriate behaviors were monitored. The Behaviors monitored were continuous yelling, striking out/hitting, fighting, and noisy. A social service Psychosocial Evaluation dated 3/18/19 indicated Resident #44 was oriented to self, he was anxious and agitated, had behaviors of wandering, verbal and physical abuse, and socially inappropriate behaviors. He was interviewed in his room and said he was being good and said he was sorry when asked about touching Resident #29 in the vaginal area on 3/18/19. Resident #44 could not explain what happened. During an interview on 5/16/19 at 1:05 p.m., the social services director said she interviewed Resident #44 on 3/18/19 after the reported inappropriate touching of Resident #29 in the genital area. She said Resident #44 did not deny he touched Resident #29 in the genital area and apologized when questioned about the behavior. She said Resident #44 was aware of what he was doing and felt he placed other residents at risk. A NP medication review dated 3/19/19 at 8:15 a.m., indicated staff reported Resident #44 exhibited inappropriate sexual touching of a female resident in her groin area on 3/18/19 and when confronted by staff Resident #44 became aggressive and hit at staff. Th NP recommended to increase Resident #44's [MEDICATION NAME] (used to treat mental/mood behaviors) from 250 milligram (mg) two times a day to 500 mg two times a day. The note indicated the primary care physician signed the recommendation on 3/20/19. A mental health progress note dated 3/19/19 indicated Resident #44 was referred for .sexually inappropriate behavior . and further noted Resident #44 .is very difficult to redirect. He can be quite cantankerous and defiant . New orders to start [MEDICATION NAME] (an atypical antipsychotic psychiatric medication used to treat certain mental/mood disorders) 5mg every day was given and signed by Resident #44's primary care physician on 3/20/19. A care plan initiated on 2/1/19 indicated [MEDICATION NAME] 5mg was initiated on 3/22/19 and increased to 10mg on 4/9/19 but did not indicate the reason or other interventions. Care plan interventions included assess if resident behavioral symptoms present a danger to the resident or others and intervene as needed and quantitatively and objectively document the resident's behavior. An activity progress note dated 5/1/19 indicated Resident #44 was often combative and sexually inappropriate with staff. During an interview on 5/14/19 at 3:49 p.m., the DON said she was somewhat aware of the allegation of a male resident touching Resident #29 in the vaginal area through her clothes. The DON said she could not readily recall the details. During an interview on 5/14/19 at 3:55 p.m., the administrator said he was said he was the abuse coordinator. He said he was notified by LVN A that Resident #29 was alleging she was touched down there by Resident #44. The administrator said, he was unable to verify if Resident #44 had inappropriately touched Resident #29 in the vaginal area. He said he believed Resident #44 may have accidentally reached out and touched Resident #29 or bumped her with his wheelchair. He said he did not question the CNA or any other staff about the incident. The administrator said Resident #29's reference to down there could have meant her feet. He said he believed Resident #44 did not intend to touch Resident #29 because he was saying I'm sorry. The administrator said he thought the nursing staff wanted it to look like Resident #44 touched Resident #29 in the vaginal area because they did not like him (Resident #44). The administrator said Resident #44 was aggressive and verbally abusive and would strike out at staff. He was unable to answer and said he would have to think about if Resident #44 exhibited inappropriate sexual advances toward other residents or staff. The administrator said he asked for a psychological assessment following the incident with Resident #29 and Resident #44's medication was adjusted. The administrator said he did not report the incident with Resident #29 to the state agency because he did not believe Resident #44 touched Resident #29. He said had he believed it, he would have interviewed staff and taken statements, and reported to the state agency. During an interview on 5/15/19 at 8:35 a.m., RN G said she heard Resident #44 had touched Resident #29 in the vaginal area and LVN A said Resident #29 was very upset. RN G said Resident #44 had a history of [REDACTED]. RN G indicated she would report inappropriate sexual behavior and remove resident from the situation. She said Resident #44 at times would attempt to run over residents with his wheelchair and always says he was sorry when staff intervenes. During an interview on 05/15/19 at 8:43 a.m., the DON said previously Resident #44 had touched a CNA inappropriately by either grabbing her butt or touching on her leg, but she could not recall the details. The DON said after she received the report from LVN A about Resident #44 inappropriately touching Resident #29, she took the incident report to the administrator and she did not investigate any further. The DON did not indicate any other interventions were put in place. During an interview on 5/15/19 at 9:06 a.m., CNA B said she worked on the secured unit. She said on 3/18/19 at approximately 8:30 a.m. she was standing at the nursing station when she heard Resident #29 saying no, no. CNA B said when she looked in the dining room, Resident #44 was wheeling away from Resident #29. She said Resident #29 said Resident #44 touched her and pointed at her groin area (between her legs). She said Resident #29 was upset, frightened, and shaking. CNA B said it took LVN A awhile to calm Resident #29 down. CNA B said LVN A assessed Resident #29 and notified the administrator and the DON. She said LVN A told her she was very concerned about Resident #44's inappropriate sexual behaviors and thought he should be transferred for treatment because his behaviors were getting worse and worse. CNA B said she tried to keep an eye on Resident #44 and keep him away from other residents when his behaviors escalated but could not watch him all the time. CNA B said she did not know what the administrator told LVN A to do about Resident #44 touching Resident #29 in the vaginal area. During an interview on 5/15/19 at 9:31 a.m., the MDS coordinator said he was responsible for updating resident's care plans. He said he was told Resident #44 had touched Resident #29 in the vaginal area through her clothes and he needed to care plan it. He said he did not add any interventions to address inappropriate touching specific to Resident #29 or other female residents. During an interview on 5/15/19 at 9:40 a.m., the DON said the allegation of Resident #44 touching Resident #29 in the genital area was not believed by the administrator but should have been investigated and reported to the state agency. 2. During an interview on 5/15/19 at 9:06 a.m., CNA B worked on the secured unit. She said about a month and a half ago she came to work one morning and was instructed by LVN A to keep an eye on Resident #44 because he was caught fondling Resident #20's breast., She said she believed the incident with Resident #20 occurred on the 2:00 p.m.-10:00 p.m. shift. CNA B did know any other specific intervention, other than monitor Resident #44 and report inappropriate behavior. During an interview on 5/15/19 at 9:25 a.m., CNA J said she worked on the secured unit. She said she was told by LVN A to keep Resident #44 away from other residents because he was found touching Resident #20 inappropriately in the dining room. CNA J said the incident with Resident #20 occurred about a month to 2 months ago. CNA J said Resident #44 was not on 1:1 observation but had been in the past because of his sexual behaviors towards other residents. Physician orders [REDACTED].#20, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The orders initiated 3/13/17 indicated Resident #20 was admitted to the secured unit due to wandering. An MDS dated [DATE] indicated Resident #20 had unclear speech, was rarely understood, rarely understood others, and had severe cognitive impairment. She was dependent on one staff for transfers, dressing, toileting, and hygiene. A care plan dated 4/2/18 indicated Resident #20 was admitted to hospice services on 9/24/18 and used a Broda chair (specialty seating that accommodates repositioning needs) while out of bed for proper positioning. During an observation and interview on 5/16/19 at 11:55 a.m., Resident #20 was seated in a Broda chair (reclining chair) in the dining room. She was alert and pleasantly confused. She offered no complaints and could not recall any inappropriate touching or behaviors toward her by other residents. During an interview on 5/15/19 at 12:03 p.m., AD C said she was walking in front of the dining room on the secure unit about a month or month and a half ago when she saw Resident #44 massaging Resident #20's boobs. She said she immediately told Resident #44 to stop and he began saying he was sorry and backed away. AD C said she reported the incident to RN D who said she would handle it. AD C said she knew it was reported to the administrator because he came the next day and asked her questions about the incident. She said she told the administrator Resident #44 was massaging Resident #20's boobs. She said the administrator said he would attend to the matter. During an interview on 5/15/19 at 10:41 a.m., the administrator said he was not made aware of the inappropriate touching of Resident #20 by Resident #44. He said if he would have been aware he would have investigated the incident and notified the state agency. During an interview on 5/15/19 at 2:20 p.m., RN D said she could not recall a specific resident that Resident #44 may have touched. She said it was hard to keep up with all the residents on the secure unit because there were only three staff and they could not keep one resident under constant observation. RN D said they tried to monitor Resident #44's behavior and keep him away from other residents but could not successfully do it all the time. She said she has so much reported to her in a day she just could not recall if it was reported to her that Resident #20 was touched on the breast by Resident #44. The nursing notes dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 for Resident #20 had no documentation to indicate Resident #44 was massaging her boobs. The incident log dated (MONTH) 1-28/2019 through (MONTH) 15, 2019 did not contain an incident regarding Resident #44 touching Resident #20's breast area. During an interview on 5/15/19 at 9:40 a.m., the DON said she did not receive a report concerning a new allegation of Resident #44 rubbing on Resident #20's breast. She said she reviewed the incident log and could not find a report. During an interview on 5/15/19 at 8:28 a.m., Housekeeper [NAME] said about 2 weeks ago, Resident #44 approached her telling her how pretty she was and reached for her vaginal area. She said she pushed his hand away and he started saying he was sorry. She said she reported the behavior to LVN H and was asked if she wanted the police notified. During an interview on 5/15/19 at 8:15 a.m., LVN H said staff tried to keep an eye on Resident #44 because of his multiple aggressive and inappropriate behaviors. She said Resident #44 screamed and hollered at residents and staff. She said he constantly requested coffee and cigarettes and watched the clock when given a smoke time. LVN H said she was not aware of Resident #44 touching female residents inappropriately but believed he was capable and knows what he was doing. LVN H said anytime Resident #44 was told his behavior was inappropriate he would say he was sorry. LVN H said she redirects Resident #44 when he becomes aggressive, removes him from other residents, but cannot watch him all the time. LVN H said she might remember a staff member reporting he was sexually inappropriate but was not sure. During an interview on 5/15/19 at 4:12 p.m., transport F said Resident #44 made multiple sexual advances towards her. She said about two weeks ago Resident #44 approached her and rubbed her breast and down her waist. She said when she told Resident #44 to stop, he said he was sorry. Transport F said he attempted to touch her several times before that time. Transport F said she reported Resident #44's behavior to RN D. Transport F said she had not been interviewed by administrative staff about Resident 44's sexual advances towards her and she just tried to stay away from him. During an interview on 5/15/19 at 9:31 a.m. the MDS coordinator said he was not told about any inappropriate touching by Resident #44 towards Resident #20. He said touching down there generally indicated the female genitalia. He said touching the genitalia area and rubbing on female breasts by a male resident would be considered abuse and should be reported to the abuse coordinator. The assistant administrator, corporate nurse, DON, and ADON was informed on 5/15/19 at 3:44 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/19 at 5:48 p.m. and included: .1. Administrator who failed to report and investigate resident to resident abuse, and who failed to put measures in place to protect other residents has been terminated by Vice President of Operations. Completed at 4:00 p.m. 5/15/19. 2. Alleged perpetrator, male resident on a secured unit has been transferred to Behavioral Hospital to undergo treatment for [REDACTED]. Completed by Regional RN at 5:35 p.m. 5/15/19. 3. Regional Director of Operations, LFNA, has been made abuse prevention coordinator for the facility and his number has been posted in prominent locations throughout the building. 4. All Staff have been in-serviced on What Constitutes Abuse, Including Resident to Resident Abuse; and, Reporting Abuse. Completed by RN, DON, 6:00 p.m. 5/15/19 (will be continued at the beginning of each shift until all employees are in-serviced - no employee will be allowed to work until they have completed this training). This training includes who to contact if the Abuse Prevention Coordinator fails to respond. 5. All residents on the secured unit have been assessed for signs or symptoms of abuse, including verbal reports, and non-verbal signs and symptom to include, but not limited to: tearfulness / crying, acting withdrawn, poor appetite, or any other unusual behaviors. 6. All residents on the secured unit have been assessed head to toe for any physician signs or symptoms of abuse such as bruising, red marks, abrasions, or trauma of any kind. 7. Safe surveys have been conducted with all residents in the facility to ensure that no other abuse has occurred . On 5/16/19 at 1:09 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: The facility training included in-services on reporting sexual abuse, exploitation, misappropriation of resident property, mistreatment and neglect as who to report, when to report, and what to report. The staff in-serviced included: 28 Nurses and CNAs, 11 sitters and hospitality aides, and 25 staff from maintenance, housekeeping, laundry, dietary, transport, activities, medical records, social services, therapy and administration. 14 nurses, CNAs, and hospitality aids, 1 activity employee, 1 housekeeping employee,1 dietary employee, and 2 administrative employees were interviewed, from different shifts, on the different types of abuse, who to report to, when to report and where to document incidents. All staff were able to verbalize the correct answers. On 5/16/19 at 1:09 p.m., corporate nurse, assistant administrator, and DON was informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect was provided and written policies and procedures that prohibited neglect were implemented for 1 of 9 residents reviewed for neglect. (Resident #6) The facility did not secure Resident #6 in her wheelchair during transportation. No shoulder strap was used and when the van suddenly stopped Resident #6 sustained a fall from her wheelchair with resultant fractured leg. An Immediate Jeopardy situation was identified on 07/25/17. The Immediate Jeopardy was removed on 07/26/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor the effectiveness of the plan of removal. This failure could place 19 residents who required transportation in wheelchairs in the facility's van at risk for injury or death. Findings included: The undated Abuse and Neglect Prohibition Policy indicated, .'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . A Face Sheet dated 07/25/17 indicated Resident #6 was a [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #6 was totally dependent with transfers, used a wheel for ambulation, and was totally dependent with bathing and hygiene. Resident #6 had moderately impaired cognition, disorganized thoughts, and often rejected care. A care plan dated 01/25/17 related to functional and rehabilitation potential indicated Resident #6 was dependent with transfers and required two staff members to transfer using the Hoyer lift. The care plan indicated she had impaired range of motion present in all extremities. Resident #6 did not bear weight and used the wheelchair for mobility. She had a history of [REDACTED]. An incident report completed 07/24/17 by LVN A indicated Resident #6 experienced a witnessed fall in the van. The report indicated the resident returned back to the facility at 5:10 p.m. and did not verbalize pain. There was documentation of an abrasion to her left knee, but two hours later indicated the resident began to complain of pain and had bruising to her left knee. An x-ray was obtained and revealed a tibia fracture. The resident was transferred to the emergency room for treatment. During a telephone interview on 07/25/17 at 4:00 p.m., LVN A said she was informed of Resident #6's fall during report. She said the resident returned to the facility after the resident's physician's appointment around 5 p.m. She said the resident was assessed by the ADON upon her return. She said the resident did not complain of pain until two hours after her return. She said at that point she obtained an order for [REDACTED]. During an observation and interview on 07/25/17 at 9:30 a.m., Resident #6 was in bed with her left leg elevated and in a splint. LVN B said Resident #6 was diagnosed with [REDACTED]. During an interview on 07/25/17 at 10:45 a.m., Resident #6 said she was in her wheelchair in the van and fell out of the wheelchair onto the floor when the van driver hit her brakes on 07/24/17. She said she went to her nephrologist appointment and returned to the facility before her fracture was diagnosed . She said she was now confined to the bed because of the broken leg. She said prior to the accident she got up in the morning and was up and around the facility in her wheelchair. She said she was sad that she could not get up because of her pain and broken leg. During an interview on 07/25/17 at 10:48 a.m. CNA D (van driver) said Resident #6 was still sitting in her wheelchair when she pulled into the parking lot at the physician's office on 07/24/17. She said when she walked around the van and opened the door to remove the resident from the van she saw the resident on the floor of the van. CNA D said the resident removed her seatbelt and fell to the floor. She said she called the DON, reported what happened, and was instructed to go inside the physician's office and ask for help to get Resident #6 out of the van. CNA D said the resident attended her physician's office visit or returned to the facility. She said Resident #6 did not complain of pain during her office visit and the return trip to the facility. CNA D said she secured the wheels of the wheelchair and the lap belt, but did not secure the shoulder strap around Resident #6 during her transport. During an interview on 07/25/17 at 10:50 a.m., the administrator said he was informed of the event regarding Resident #6 this morning and was starting his investigation into the matter. He said the driver was trained by the housekeeping supervisor and CNA C. During an interview on 07/25/17 at 10:55 a.m., the DON said she was informed of the incident on 07/24/17 regarding Resident #6 as soon as the event happened around 1:00 p.m. on 07/24/17. She said CNA D was the driver and she went into the physician's office to request help to get Resident #6 off of the floor of the van and she was informed the resident took her seatbelt off and fell to the floor of the van after they arrived at the physician's office. The DON said CNA D informed her the resident did not complain of pain. The resident attended her nephrologist appointment and then came back to the facility before she said she was in pain initially. The DON said x-rays were obtained at that time and Resident #6 was sent to the emergency room of the local hospital for evaluation and treatment of [REDACTED]. She said she was told the wheelchair straps were secured to the wheels, but not across the resident's shoulder because that would be considered a restraint. During an interview on 07/25/17 at 11:10 a.m., the administrator said CNA C and the housekeeping supervisor trained the driver (CNA D). During observation and interview on 07/25/17 at 11:20 a.m., CNA C and the housekeeping supervisor were unable to return demonstrate securing the seat belts across a resident's legs or the accurate placement of the shoulder straps. They said they did not know how to secure the shoulder straps. They said the shoulder strap observed tied in a knot on the right rear side was broken and not used. CNA C released the knot and attempted to determine its use. Neither she nor the housekeeping supervisor were able to secure the wheelchair with the seatbelts. The DON came to the vehicle and was not able to return demonstrate the procedure. The DON said the maintenance supervisor was responsible for assuring the van was in working order and assuring the van drivers were properly trained. During interview and observation on 07/25/17 at 12:30 p.m., the maintenance supervisor said he did not know how to secure a wheelchair in the van. He said he did not have anything to do with training the van drivers. He said that was a nursing responsibility. During observation and interview on 07/25/17 at 12:35 p.m., the administrator said he did not know how to secure a resident in the van. He came into the vehicle and was unable to complete the procedure as well. He said the maintenance supervisor was responsible for assuring the van was in working order and assuring the van drivers were properly trained. During observation and interview on 07/25/17 at 12:40 p.m., CNA D (van driver) came to the van and was unable to secure the wheelchair in the van using the leg and shoulder belts. She said she did not know what the knotted shoulder strap was used for. She said if she had been trained to use the shoulder belts she would have used it. During interview on 07/25/17 at 12:45 p.m., the DON said it was not her responsibility to assure the residents were safe when they were in the van. She said that was maintenance's responsibility. She said she did not have any documentation or assurance that the drivers were adequately trained to secure and transport the residents on the van. During interview on 07/25/17 at 1:00 p.m., the administrator provided a procedure manual that illustrated the proper use of the lift, but did not have a copy of the procedure to properly secure a resident in a wheelchair during transport. During an interview on 07/25/17 at 5:45 p.m., the ADON said she did not assess the resident on her return to the facility. The administrator and DON were notified on 07/25/17 at 4:59 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 07/25/17 at 6:43 p.m. and included: 1. Van has been taken out of commission. Keys locked in a safe accessible only to the Administrator. Transportation will be provided by private transport companies or the ambulance. No resident appointment will be delayed for any reason 2. Training on the van starts today and will be completed by the end of 7/26/17. All staff that will use the van will be trained. Regional Nurse Consultant will be responsible for training. 3. Effective immediately, staff member will sit with resident during transport/appointments after they have been trained. 4. All residents that has been transported in the van for the past 7 days will be assessed (head to toe/ROM to ensure there was no injury) On 07/26/17 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: During an observation and interview on 07/25/17 at 6:28p.m., the van keys were locked in the administrator's office. The administrator said the keys would be secured until the drivers were trained to properly secure a resident in the van during transport. During an interview on 07/25/17 at 6:41 p.m., the DON said there were no appointments scheduled for the residents until 07/31/17. She said if there was a need for transportation they would use a nonemergency transportation company. She said there were no residents in the facility who needed [MEDICAL TREATMENT] or any other regularly scheduled appointment During an observation and interview on 7/26/17 at 10:28a.m., CNA D said she had received training this morning from the corporate nurse. CNA D said she was shown how to appropriately secure the resident in the van. CNA D demonstrated how to successfully strap the resident in the van. During an interview on 07/26/17 at 11:30 a.m., the housekeeping supervisor was able to verbalize the steps to properly secure a resident who was wheelchair dependent in the van. She was able to verbalize the need to have a CNA on the van for every transport. During an interview on 07/26/17 at 11:35 a.m., housekeeper G was able to verbalize the steps to properly secure a resident who was wheelchair dependent in the van. He was able to verbalize the need to have a CNA on the van for every transport. On 07/26/17 at 11:53 a.m. the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor effectiveness of the plan of removal. A list provided by the administrator on 07/25/17 indicated 19 wheelchair dependent residents utilized the van for transportation.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents were provided for 2 of 9 residents reviewed for accidents. (Residents #6 and #7) The facility did not properly secure Resident #6 in her wheelchair during transportation. No shoulder strap was used and when the van suddenly stopped, Resident #6 sustained a fall from her wheelchair with a resultant fractured leg. An Immediate Jeopardy situation was identified on 07/25/17. The Immediate Jeopardy was removed on 07/26/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor the effectiveness of the plan of removal. The facility did not implement interventions to prevent Resident #7 from elopement after the resident attempted to elope in July 2017. This failure could place 19 residents who required transportation in wheelchairs in the facility's van at risk for injury or death and 18 residents who exhibited elopement behaviors at risk of inadequate supervision. Findings included: A Face Sheet dated 07/25/17 indicated Resident #6 was a [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #6 was totally dependent with transfers, used a wheel for ambulation, and was totally dependent with bathing and hygiene. Resident #6 had moderately impaired cognition, disorganized thoughts, and often rejected care. A care plan dated 01/25/17 related to functional and rehabilitation potential indicated Resident #6 was dependent with transfers and required two staff members to transfer using the Hoyer lift. The care plan indicated she had impaired range of motion present in all extremities. Resident #6 did not bear weight and used the wheelchair for mobility. She had a history of [REDACTED]. An incident report completed 07/24/17 by LVN A indicated Resident #6 experienced a witnessed fall in the van. The report indicated the resident returned back to the facility at 5:10 p.m. and did not verbalize pain. There was documentation of an abrasion to her left knee, but two hours later indicated the resident began to complain of pain and had bruising to her left knee. An x-ray was obtained and revealed a tibia fracture. The resident was transferred to the emergency room for treatment. During a telephone interview on 07/25/17 at 4:00 p.m., LVN A said she was informed of Resident #6's fall during report. She said the resident returned to the facility after the resident's physician's appointment around 5 p.m. She said the resident was assessed by the ADON upon her return. She said the resident did not complain of pain until two hours after her return. She said, at that point, she obtained an order for [REDACTED]. During an observation and interview on 07/25/17 at 9:30 a.m., Resident #6 was in bed with her left leg elevated and in a splint. LVN B said Resident #6 was diagnosed with [REDACTED]. During an interview on 07/25/17 at 10:45 a.m., Resident #6 said she was in her wheelchair in the van and fell out of the wheelchair onto the floor when the van driver hit her brakes on 07/24/17. She said she went to her nephrologist appointment and returned to the facility before her fracture was diagnosed . She said now she was confined to the bed because of the broken leg. She said prior to the incident, she got up in the morning and was up and around the facility in her wheelchair. She said she was sad that she could not get up because of her broken leg. During an interview on 07/25/17 at 10:48 a.m. CNA D (van driver) said Resident #6 was still sitting in her wheelchair when she pulled into the parking lot at the physician's office on 07/24/17. She said when she walked around the van and opened the door to remove the resident from the van she saw the resident on the floor of the van. CNA D said the resident removed her seatbelt and fell to the floor after the van stopped. She said she called the DON, reported what happened, and was instructed to go inside the physician's office and ask for help to get Resident #6 out of the van. CNA D said the resident attended her physician's office visit and returned to the facility. She said Resident #6 did not complain of pain during her office visit or the return trip to the facility. CNA D said she secured the wheels of the wheelchair and the lap belt, but did not secure the shoulder strap around Resident #6 during her transport. During an interview on 07/25/17 at 10:50 a.m., the administrator said he was informed of the incident regarding Resident #6 this morning and was starting his investigation into the matter. He said the driver was trained by the housekeeping supervisor and CNA C. During an interview on 07/25/17 at 10:55 a.m., the DON said she was informed of the incident on 07/24/17 regarding Resident #6 as soon as the event happened around 1:00 p.m. on 07/24/17. She said CNA D was the driver and she went into the physician's office to request help to get Resident #6 off of the floor of the van and she was informed the resident took her seatbelt off and fell to the floor of the van after they arrived at the physician's office. The DON said CNA D informed her the resident did not complain of pain. The resident attended her nephrologist appointment and then came back to the facility before she said she was in pain initially. The DON said x-rays were obtained at that time and Resident #6 was sent to the emergency room of the local hospital for evaluation and treatment of [REDACTED]. She said she was told the wheelchair straps were secured to the wheels, but not across the resident's shoulder because that would be considered a restraint. During an interview on 07/25/17 at 11:10 a.m., the administrator said CNA C and the housekeeping supervisor trained the driver (CNA D). During observation and interview on 07/25/17 at 11:20 a.m., CNA C and the housekeeping supervisor were unable to return demonstrate securing the seat belts across a resident's legs or the accurate placement of the shoulder straps. They said they did not know how to secure the shoulder straps. They said the shoulder strap, observed tied in a knot on the right rear side, was broken and not used. CNA C released the knot and attempted to determine its use. Neither she nor the housekeeping supervisor were able to secure the wheelchair with the seatbelts. The DON came to the vehicle and was not able to return demonstrate the procedure. The DON said the maintenance supervisor was responsible for assuring the van was in working order and assuring the van drivers were properly trained. During interview and observation on 07/25/17 at 12:30 p.m., the maintenance supervisor said he did not know how to secure a wheelchair in the van. He said he did not have anything to do with training the van drivers. He said that was a nursing responsibility. During observation and interview on 07/25/17 at 12:35 p.m., the administrator said he did not know how to secure a resident in the van. He came into the vehicle and was unable to complete the procedure as well. He said the maintenance supervisor was responsible for assuring the van was in working order and assuring the van drivers were properly trained. During observation and interview on 07/25/17 at 12:40 p.m., CNA D (van driver) came to the van and was unable to secure the wheelchair in the van using the leg and shoulder belts. She said she did not know what the knotted shoulder strap was used for. She said if she had been trained to use the shoulder belts, she would have used it. During interview on 07/25/17 at 12:45 p.m., the DON said it was not her responsibility to assure the residents were safe when they were in the van. She said that was maintenance's responsibility. She said she did not have any documentation or assurance that the drivers were adequately trained to secure and transport the residents on the van. During interview on 07/25/17 at 1:00 p.m., the administrator provided a procedure manual that illustrated the proper use of the lift, but did not have a copy of the procedure to properly secure a resident in a wheelchair during transport. The administrator and DON were notified on 07/25/17 at 4:59 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 07/25/17 at 6:43 p.m. and included: 1. Van has been taken out of commission. Keys locked in a safe accessible only to the Administrator. Transportation will be provided by private transport companies or the ambulance. No resident appointment will be delayed for any reason 2. Training on the van starts today and will be completed by the end of 7/26/17. All staff that will use the van will be trained. Regional Nurse Consultant will be responsible for training. 3. Effective immediately, staff member will sit with resident during transport/appointments after they have been trained. 4. All residents that has been transported in the van for the past 7 days will be assessed (head to toe/ROM to ensure there was no injury) On 07/26/17 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: During an observation and interview on 07/25/17 at 6:28p.m., the van keys were locked in the administrator's office. The administrator said the keys would be secured until the drivers were trained to properly secure a resident in the van during transport. During an interview on 07/25/17 at 6:41 p.m., the DON said there were no appointments scheduled for the residents until 07/31/17. She said if there was a need for transportation they would use a nonemergency transportation company. She said there were no residents in the facility who needed dialysis or any other regularly scheduled appointment. During an observation and interview on 7/26/17 at 10:28a.m., CNA D said she had received training this morning from the corporate nurse. CNA D said she was shown how to appropriately secure the resident in the van. CNA D demonstrated how to properly strap the resident in the van. During an interview on 07/26/17 at 11:30 a.m., the housekeeping supervisor was able to verbalize the steps to properly secure a resident who was wheelchair dependent in the van. She was able to verbalize the need to have a CNA on the van for every transport. During an interview on 07/26/17 at 11:35 a.m., housekeeper G was able to verbalize the steps to properly secure a resident who was wheelchair dependent in the van. He was able to verbalize the need to have a CNA on the van for every transport. On 07/26/17 at 11:53 a.m. the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor effectiveness of the plan of removal. 2. Consolidated physician orders [REDACTED].#7 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #7 had clear speech, was sometimes understood and could sometimes understand. The resident's cognition was severely impaired with inattention and disorganized thinking behaviors being present continuously without fluctuation. The MDS also noted Resident #7 exhibited wandering behavior 4 to 6 days, but less than daily, the wandering placed the resident at significant risk of getting to a potentially dangerous place and the wandering significantly intruded on the privacy or activities of others. The most recent care plan dated 05/29/17 indicated Behavioral Symptoms included Resident #7 wandered and was on the secured unit. During an observation on 07/26/17 at 9:35 p.m., Resident #7's room faced the back parking lot where the smoking area, maintenance office, and storage buildings were located. The back parking lot was not fenced in and Resident #7's window was approximately 20 plus feet away from the road of the neighborhood next to the facility. During an interview on 07/26/17 at 10:00 a.m., LVN E indicated Resident #7 attempted to elope by using a television to break the window in his room. The LVN indicated the resident's window faced the smoking area and was not on the side of the secured unit facing the gated area. During an observation and interview on 07/26/17 at 11:07 a.m., the administrator said Resident #7 exit seeks and in July 2017 had an episode in which he threw his television through the window in his room. The administrator said Resident #7 did not attempt to exit the window. He said Resident #7 was moved into a room next door to his room until the window was repaired, the facility placed a 4 drawer chest in front of the window, and the resident was placed on 15 minute checks at that time. The administrator said the windows on the secure unit did not fully raise. Upon checking Resident #7's room with the administrator, there was a small chest in front of the window and the window raised the full height. The window did not face into the secured unit fenced area. The administrator said he did not feel Resident #7 was in an unsafe situation because the window being difficult to raise. During an observation and interview on 07/26/17 at 11:45, the DON said she felt Resident #7 was safe where his room was because the windows on the unit did not raise all the way. Upon checking Resident #7's room, the DONwas able to raise the window to its full height and when pushed the window screen the right bottom corner of the screen was not secure. Upon checking the room next door, there were screws in the metal frame that prevented the window from raising more than a foot. During an interview on 07/27/17 at 1:42 p.m., the administrator said Resident #7 was placed on 1 to 1 close observation until a room change could be done. He said the resident was to be placed in a room facing the fenced yard of the secured unit. A list provided by the administrator on 07/25/17 indicated 19 wheelchair dependent residents utilized the van for transportation. The resident roster dated 07/25/17 indicated 18 residents exhibited elopement behaviors.

Based on interview, and record review, the facility failed to ensure timely radiology services to meet the need of 1 of 5 residents reviewed for assessment. (Resident #1) Resident #1 fell on [DATE] and sustained injuries that resulted in pain. The facility did not obtain an x-ray for 16 hours. An x-ray report dated 04/05/16 indicated Resident #1 sustained a left [MEDICAL CONDITION]. This failure could place 19 residents who resided on the secure unit at risk for not receiving care and treatment to meet their needs. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually had difficulty communicating words and was sometimes able to understand others. The resident was severely impaired cognitively and was able to walk with limited assistance of one person. A care plan dated 03/09/16 indicated Resident #1 had problems communicating and behavioral symptoms. The plan documented Resident #1 resided on the secure and used a rolling walker to walk. The plan indicated the resident had a problem of pain and an intervention included obtain diagnostic tests as ordered. An incident and accident report dated 04/04/16 at 4:30 p.m. indicated Resident #1 was unsteady on his rolling walker and his legs gave way. The resident fell in the hallway and hit his head on the doorway. A Physician's telephone order dated 04/04/16 indicated Resident #1 had an order for [REDACTED]. A Radiology Report dated 04/05/16 and electronically signed at 10:08 a.m. indicated Resident #1 had a left [MEDICAL CONDITION]. A nursing note dated 4/5/16 at 10:45 a.m. Resident #1 was transported to the hospital for evaluation and treatment. A nursing note dated 4/4/16 at 5:00 p.m. indicated a new order for a front and side x-ray of Resident #1 ' s left hip. The note indicated the x-ray technician said the machine down tonight. The note documented LVN G told the x-ray technician the x-ray could wait until the next day. During an interview on 4/18/16 at 11:15 a.m. LVN G said Resident #1 fell on [DATE]. She said she did not witness the fall but was told what happened by the ADON. She said she did a neurology assessment and full body assessment and found a small knot at the back of his head that was tender to touch. She said it took two people to assist Resident #1 into the wheelchair because he could not bear weight on his legs. She said when the CNAs were making their last rounds for the night Resident #1 complained of pain again and she ordered an x-ray on 4/4/16. She said she was told the mobile x-ray machine was out of service. She said she told them it was okay to wait until the next day. LVN G said she dropped the ball and should have sent Resident #1 sent to the emergency room for an x-ray. She said she was suspended on 04/05/16 and terminated on 04/07/16. During an interview on 04/18/16 at 12:39 p.m. the DON said LVN G should have contacted her regarding Resident #1 ' s fall and the mobile machine not being available to obtain an x-ray. She said if the mobile x-ray could not be performed the resident should be sent to the emergency room . She said if a resident falls and no pain was voiced mobile x-ray had 24 hours to perform the x-ray. The DON said LVN G did not follow protocol when Resident #1 fell and she was terminated. During an interview on 04/18/16 at 11:05 a.m. LVN F said Resident #1 fell on the 2 p to 10 p shift on 4/4/16. She said LVN G told her during report a portable x-ray was ordered on [DATE] but it was not completed due to the machine not working. She said if the portable x-ray machine was not working they were to contact the DON or ADON and send the resident to the emergency room for an x-ray. An undated Radiology Policy indicated . the facility is responsible for the quality and timeliness of the services. If mobile radiology and other diagnostic services are unable to perform the diagnostic testing the facility will make arrangements for the resident to be transferred to nearest emergency room for radiology and other diagnostic testing . An Abuse Prevention policy dated 03/22/16 indicated .should see to the immediate need of the resident. The charge nurse should get whatever immediate attention is necessary and assess the physical status of the resident. The DON should confirm that the physician and family have been notified . A Resident Rights Policy dated 02/28/03 indicated . residents have the right to all care necessary for the highest possible level of health, and to have a safe, decent, and clean condition . During an interview on 04/20/16 the DON said 19 residents resided on the secure unit.

Based on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for assessment. (Resident #1) Resident #1 fell on [DATE] and sustained injuries that resulted in pain. The facility did not obtain an x-ray immediately, and did not notify the physician and family about resident's increased pain until 04/05/16. An x-ray report dated 04/05/16 indicated Resident #1 sustained a left [MEDICAL CONDITION]. This failure may have contributed to Resident #1 ' s pain after sustaining a [MEDICAL CONDITION]. This failure could place 19 residents who resided on the secure unit at risk for not receiving care and treatment to meet their needs. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually had difficulty communicating words and was sometimes able to understand others. The resident was severely impaired cognitively and was able to walk with limited assistance of one person. A care plan dated 03/09/16 indicated Resident #1 had problems communicating and behavioral symptoms. The plan documented Resident #1 resided on the secure and used a rolling walker to walk. The plan indicated the resident had a problem of pain and an intervention included obtain diagnostic tests as ordered. A nursing note dated 04/04/16 at 4:30 p.m. indicated Resident #1 fell and the DON and the physician were notified. An incident and accident report dated 04/04/16 at 4:30 p.m. indicated Resident #1 was unsteady on his rolling walker and his legs gave way. The resident fell in the hallway and hit his head on the doorway. The report indicated neurology checks were initiated and the DON and physician were notified of the fall. The report indicated Resident #1 ' s wife was notified at 5:00 p.m. During a phone interview on 04/15/16 at 1:50 p.m. Resident #1 ' s daughter said Resident #1 ' s wife was not immediately notified of the resident ' s fall on 4/4/16. She said the family was notified on 04/05/16 at 11:07 a.m. A Physician's telephone order dated 04/04/16 indicated Resident #1 had an order for [REDACTED]. A pain management flow sheet indicated Resident #1 was administered the following: *Tylenol on 4/4/16 at 5:00 p.m. for generalized pain at 6:00 p.m. the resident was resting quietly, *[MEDICATION NAME] on 4/5/16 at 7:00 a.m. for left side pain at 8:00 a.m. the resident indicated he guessed it was better, and * [MEDICATION NAME] on 4/5/16 at 10:00 a.m. for pain all over at 11:00 a.m. resident indicated the pain was some better. A Patient Report dated 04/05/16 and electronically signed at 10:08 a.m. indicated Resident #1 had a left [MEDICAL CONDITION]. A nursing note dated 4/5/16 at 10:45 a.m. Resident #1 was transported to the hospital for evaluation and treatment. During an interview on 4/18/16 at 11:15 a.m. LVN G said Resident #1 fell on [DATE]. She said she did not witness the fall but was told what happened by the ADON. She said she did a neurology assessment and full body assessment and found a small knot at the back of his head that was tender to touch. She said it took two people to assist Resident #1 into the wheelchair because he could not bear weight on his legs. She said when the CNAs were making their last rounds for the night Resident #1 complained of pain again and she ordered an x-ray on 4/4/16. She said she was told the mobile x-ray machine was out of service. She said she told them it was okay to wait until the next day. She said she left a message on Resident #1 ' s wife cell phone about the incident on 4/4/16. She said she never spoke with any of the family. She said she did not notify the physician she ordered an x-ray and that the resident was experiencing pain. LVN G said she dropped the ball and should have continued to try to contact the family and have Resident #1 sent to the emergency room for an x-ray. She said Resident #1 ' s wife came to the facility on [DATE] and was very upset about no one contacting her concerning the fall. She said Resident #1 ' s wife said the cell phone was not working. She said she was suspended on 04/05/16 and terminated on 04/07/16. A nursing note dated 4/4/16 at 5:00 p.m. indicated a new order for a front and side x-ray of Resident #1 ' s left hip. The note indicated the x-ray technician said the machine down tonight. The note documented LVN G told the x-ray technician the x-ray could wait until the next day. During an interview on 04/18/16 at 12:39 p.m. the DON said LVN G should have contacted her regarding Resident #1 ' s fall and the mobile machine not being available to obtain an x-ray. She said if the mobile x-ray could not be performed the resident should be sent to the emergency room . She said if a resident falls and no pain was voiced mobile x-ray had 24 hours to perform the x-ray. She said the physician and family are to be notified of any falls or change of condition. She said when there are several numbers for a family on the face sheet the staff should utilize all numbers to contact family members. She said LVN G did not follow protocol when Resident #1 fell and she was terminated. During an interview on 04/18/16 at 11:05 a.m. LVN F said Resident #1 fell on the 2 p to 10 p shift on 4/4/16. She said LVN G told her during report a portable x-ray was ordered on [DATE] but it was not completed due to the machine not working. She said she immediately assessed the resident on 4/5/16 when she started her shift. LVN F said the resident complained of pain all over his body and she gave his [MEDICATION NAME]. LVN F said she contacted the resident ' s physician regarding transporting Resident #1 to the emergency room . She said if the portable x-ray machine was not working they were to contact the DON or ADON and send the resident to the emergency room for an x-ray. During an interview on 04/18/16 at 10:19 a.m. the ADON said Resident #1 lost his balance and fell while walking with his rolling walker. She said Resident #1 said he was not hurt and could move his legs. She said Resident #1 could not bear weight on his legs. During an interview on 04/18/16 at 10:36 a.m. CNAs C and A said Resident #1 was able to walk with his walker prior to the fall on 4/5/16. During an interview on 04/18/16 CNA L said she worked on 4/5/16 when Resident #1 fell . She said the resident did not complain of pain immediately. She said during her shift the resident complained of pain and she notified LVN G during the end of the shift. She said LVN G said she ordered an x-ray but the machine was down and the x-ray would have to wait until the morning. During an interview on 04/18/16 at 2:30 p.m. CNA H said she worked the day Resident #1 fell . She said it took two people to get him into a wheelchair because he could not use both of his legs to get up. An undated Radiology Policy indicated . the facility is responsible for the quality and timeliness of the services. If mobile radiology and other diagnostic services are unable to perform the diagnostic testing the facility will make arrangements for the resident to be transferred to nearest emergency room for radiology and other diagnostic testing . An Abuse Prevention policy dated 03/22/16 indicated .should see to the immediate need of the resident. The charge nurse should get whatever immediate attention is necessary and assess the physical status of the resident. The DON should confirm that the physician and family have been notified . A Resident Rights Policy dated 02/28/03 indicated . residents have the right to all care necessary for the highest possible level of health, and to have a safe, decent, and clean condition . During an interview on 04/20/16 the DON said 19 residents resided on the secure unit.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent injury for 1 of 6 residents reviewed for hazards and supervision. (Resident #1) Resident #1 had a physical altercation with two residents in April. He was involved in another physical altercation with Resident #2 on 7/11/15. On 7/18/15, he physically assaulted Resident #2 again, resulting in Resident #2 being hospitalized with a facial fracture requiring the use of a ventilator. The facility did not implement additional interventions to prevent residents from injury, and had not trained staff on working with residents with traumatic brain injury. An Immediate Jeopardy situation was identified on 7/28/15. The Immediate Jeopardy was removed on 7/29/15. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 54 residents at risk for injury or death. Findings included: 1. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and usually understood others. His cognition was moderately impaired and he exhibited disorganized thinking. No behavioral issues were noted. A history and physical dated 2/17/15 indicated Resident #1 isolated himself and was very combative. An incident report dated 4/19/15 indicated Resident #1 became combative and hit a resident with a chair and kicked the resident. Resident #1 then went down the hall and hit another resident with a walker and kicked that resident as well. Resident #1 was sent to the emergency room for evaluation and was sent back to the facility the same day. He was on 15 minute checks for three days. The checks were discontinued on 4/22/15 due to the resident showing no further signs of physical behaviors. Resident #1 requested to eat his meals in his room following the incident due to the noise. A care plan initiated 4/21/15 indicated Resident #1 did not like loud noises or cursing. The care plan indicated Resident #1 had verbal and physical behaviors towards other residents and employees. Resident #1 requested to eat meals in his room to avoid over stimulation from others. The care plan was revised on 7/11/15 and indicated Resident #1 was involved in a resident to resident altercation on 7/11/15 with Resident #2 over sharing an adjoining bathroom. The interventions indicated Resident #1 was placed on 15 minute checks for three days which were discontinued on 7/14/15 due to no physical behaviors, a bed side commode was offered to Resident #1 and declined, and a new room was offered and declined. The care plan was revised on 7/18/15 and indicated Resident #1 was involved in another resident to resident incident with Resident #2 over sharing an adjoining bathroom on 7/18/15. Resident #1 was placed on 1:1 supervision and the other resident in the adjoining room was moved to another room to allow Resident #1 bathroom privacy. 2. Consolidated physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was sometimes understood and rarely or never understood others. His cognition was severely impaired and he exhibited signs and symptoms of delirium. His mood assessment indicated Resident #2 had become short tempered or easily annoyed several days in a two week period. He had delusions, but no other behaviors were indicated. A care plan initiated 12/3/14 indicated Resident #2 had a history of [REDACTED]. The care plan was revised on 3/2/15 and indicated Resident #2 was frequently in the restroom for extended periods of time and became easily annoyed upon checking on him by staff. The care plan was revised on 6/30/15 and indicated Resident #2 slapped his hands together and made disruptive noises. The staff was required to determine if Resident #2's decisions endangered himself or other residents and to intervene if necessary. The care plan was revised on 7/11/15 and 7/18/15 and indicated Resident #2 was involved in two resident to resident incidents with Resident #1 due to Resident #2's cursing loudly at the other resident in the adjoining bathroom. An incident report dated 7/11/15 indicated Resident #2 was sitting on the commode in the bathroom when Resident #1 entered unaware it was occupied. Resident #2 began to curse at Resident #1 who became agitated and attempted to push Resident #2 off the toilet. Resident #2 pushed Resident #1 back. The residents were separated. Resident #1 was placed on 15 minute checks. Resident #1 and Resident #2 were both offered bed side commodes and offered to move rooms. Resident #1 and Resident #2 declined those offers. During an interview on 7/22/15 at 8:51 a.m. the DON said Resident #1 became agitated during the incident on 4/19/15 because he did not like cursing. She said Resident #1 was evaluated by the hospital and was not appropriate for a behavioral unit. She said Resident #1 returned to the facility and requested to not eat in the dining room because he did not want to be around loud noises and cursing. She said Resident #2 was short-tempered, easily annoyed, and had a history of [REDACTED]. She said Resident #1 and Resident #2 had an altercation in the residents adjoining bathroom on 7/11/15. She said the residents were arguing over whose bathroom it was and they pushed each other. The DON said after the incident both residents were offered bedside commodes and were offered to move rooms. She said both residents declined the offer. She said Resident #1 said the he would not hit Resident #2 again. A resident observation record dated 7/11/15 to 7/14/15 indicated Resident #1 was on 15 minute checks from 7/11/15 at 2:30 p.m. to 7/14/15 at 5:45 p.m. During an interview on 7/22/15 at 10:36 a.m. LVN A said after the incident on 7/11/15, she or the CNA would check on Resident #1 every 15 minutes. She said Resident #1 stayed in his room and was usually in his chair or in the bathroom. She said he did not like loud noises or cursing. She said Resident #2 had a history of [REDACTED]. During an interview on 7/22/15 at 10:08 a.m. the DON said the 15 minute checks were discontinued due to Resident #1 not exhibiting any further behaviors. She said aside from the 15 minute checks, and offering the bedside commodes and offering to move residents rooms, no other interventions were utilized following the incident on 7/11/15. An incident report dated 7/18/15 indicated Resident #2 was found in bathroom floor with blood on his lip. Resident #1 was standing in the bathroom doorway and said he hit Resident #2. The nurse assessed Resident #2, and Emergency Medical Services (EMS) was called to transport Resident #2 to the hospital. During an interview on 7/22/15 at 8:51 a.m. the DON said on 7/18/15 Resident #2 was found on the floor. She said Resident #1 hit Resident #2 because he cursed at him. She said Resident #1 was placed on 15 minute checks for 15 minutes, then was placed on 1:1 supervision. She said Resident #1 would remain on 1:1 supervision until placement at a behavioral unit could be found. During an interview on 7/22/15 at 11:45 a.m. LVN B said on 7/18/15 she heard a loud noise and heard Resident #2 saying no. She said when she got to Resident #2's room, Resident #2 was lying on the floor in the bathroom with blood on his nose and mouth. She said Resident #1 was standing in the doorway and made the statement I hit him, then turned and went back to his room. She said Resident #2 was immediately sent by ambulance to the hospital. Hospital records dated 7/21/15 indicated Resident #2 was admitted to the hospital following an assault. He had swelling and bruising to his face and left eye and sustained a six part fracture to his facial bones. The records indicated Resident #2 was sedated on a ventilator. During an interview on 7/28/15 at 4:20 p.m. the administrator said the facility staff had not been in-serviced on Traumatic Brain Injury, or specifically how to manage Resident #1's behaviors. During an interview on 7/28/15 at 4:45 p.m. the DON said Resident #1 did not receive a psychiatric consult until after the incident on 7/18/15 and that his psychiatric medications had not been adjusted since admission. The facility's policy on unmanageable residents dated April 2010 required staff to provide for the safety of all concerned residents if a residents behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others. An undated policy on behavior management required staff to manage any situation that such as physical assault or violence so the safety of all residents in the environment are protected, and to prevent another occurrence. The administrator and DON were notified on 7/28/15 at 4:50 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/28/15 at 6:55 p.m. and included: 1) Following the incident on 7/18/15 staff separated Resident #1 and Resident #2. Resident #1 was easily redirected back to his room. Resident #2 was sent to the emergency room for evaluation. Assessed Resident #1 who was noted to have a 0.4cm circular skin tear to the R) hand with skin care provided no other injuries noted; Resident #2 was noted to have a hematoma to the nasal bridge, and a laceration to the lower lip, Resident #2 was sent to the emergency room for further evaluation. Resident #1 was in stable condition and placed on Q15min checks x 1 for 15 minutes then 1:1 supervision. Resident #2 was sent to the emergency room for evaluation and treatment as necessary on 7/18/15. 2) Other resident who resides in adjoining room was moved 7/18/15 to allow Resident #1 bathroom privacy and to avoid any resident to resident conflicts. 3) Psych evaluation requested by outside agency counseling agency on 7/18/15 - they will follow Resident #1. The counselling agency performed psych evaluation on Monday 7/20/15. Any residents will be redirected away from Resident #1's room on 7/18/15 and on-going. 4) Weekend RN in-serviced all staff on resident to resident to resident incident, and abuse/neglect on 7/18/15. 5) DON performed interviews and statements of residents, and staff members on 7/18/15. 6) Notified DON, Administrator, MD, Family, Police Dept, and the regulatory agency on 7/18/15. 7) Resident #1 will remain 1:1 supervision until placement in behavior hospital occurs on 7/18/15 and on-going. 8) Resident #1 was evaluated by attending physician no changes to current orders, received new orders for x-ray of right hand which showed no fractures or injuries and ABT (antibiotic therapy) for skin tear to right hand on 7/18/15. 9) Facility will continue to seek placement for Resident #1: contacted thus far- . 10) DON/ADON will in-service all staff on Traumatic Brain Injuries and how to manage related behaviors on 7/28/15. 11) Resident #1 remains on one-on-one and has been at all times since implemented by addition of an extra staff member for his individual needs on 7/18/15 and on-going. Training Specific to Resident #1 · Resident #1 reacts negatively to loud noises and cursing. Keep Resident #1's immediate environment free of loud noises and keep any residents or others who are talking loudly or cursing away from him at all times. · Resident #1 has severely reduced impulse control due to his condition. He, unlike you or I, cannot be expected to rationally stop himself from reacting negatively (sometimes violently) to loud music, cursing, or residents who (even accidentally) enter what he considers his space. · Resident is to eat all of his meals in his room (since 4/19/15). This reduces the amount of possible stimulation from other residents and Resident #1 actually enjoys eating alone. · Always redirect any residents who approach Resident #1. Resident #1 should only interact with staff as much as possible. Interactions with other residents should be kept to a minimum and should only be with supervision. · Resident #1 should remain in a private room with his own private bath. 12) Staff training regarding Resident #1 in addition to general training on traumatic brain injury, and explosive anger outbursts on 7/28/15 by DON/ADON. (sic) The surveyor confirmed the Plan of Removal had been implemented to sufficiently remove the Immediate Jeopardy by: During an interview on 07/28/15 at 4:45 p.m., the DON said they were in-servicing all staff about traumatic brain injury and how to manage Resident #1's behaviors before each employee started duty. She said psychiatric services visited Resident #1 today and would continue to be involved with Resident #1's care. A dietary aid, one housekeeper, one CNA, two charge nurses, and the treatment nurse were interviewed and said they had received an in-service regarding traumatic brain injury and how to manage Resident #1's behaviors. They were told to redirect Resident #1 from loud noises or cursing if he chose to come out of his room and were told he required 1:1 supervision at all times. Resident #1 was observed to be monitored 1:1 in his room on 07/29/18 at 3:45 p.m. During an interview on 7/29/15 at 3:49 p.m., Housekeeper C said he was monitoring Resident #1 1:1 and was told to redirect Resident #1 away from loud noises or other residents if Resident #1 left his room. He said he was in-serviced on Resident #1's behaviors and Traumatic Brain Injury prior to providing 1:1 supervision. A traumatic brain injury fact sheet from the National Institute of Neurological Disorders and Stroke (NINDS), last updated 07/17/15, lists common disabilities associated with head-injuries; including problems with cognition. communication. behavior or mental health. including personality changes, aggression, acting out, and social inappropriateness. During an interview on 7/28/15 at 4:20 p.m., the administrator said they were continuing to seek placement for Resident #1. On 7/29/15 at 4:01 p.m. the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance out at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS form 672 dated 7/22/15 indicated the facility had a census of 54 residents.