Every finding on record at San Antonio North Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to provide personal privacy for 1 of 2 residents (Resident #2) reviewed for privacy, in that: The facility failed to provide personal privacy to Resident #2 when the wound care nurse did not shut the door to the resident's room, or pull the privacy curtain around, before exposing the resident's wound that is located on the resident's left upper back to perform wound care on 08/06/2026. These failures could affect residents in need of privacy during wound care, or other procedures that can expose the residents, and place them at risk of being exposed and feeling embarrassed. The findings included: Record review of Resident #2's face sheet, dated 08/06/2026, revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with the diagnoses of: senile degeneration of brain (progressive loss of brain tissue and thinking skills); anxiety disorder (excessive ongoing fear, dread, and nervousness); depression (sadness and a loss of interest in things once liked); and neoplasm of bone, soft tissue, and skin (abnormal growth of cells that form in the body's connective and supporting structures). Record review of Resident #2's TAR, dated 08/06/2026, revealed treatments scheduled for August 2026, which stated: wound- lesion to left upper back. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/19/2026 and no end date. Record review of Resident #2's treatment orders, dated 08/06/2026, revealed an order for wound care, which stated, Wound lesion to left scapula. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/16/2026 and no end date. Record review of Resident # 2's Care Plan Report, dated 08/06/2026, revealed the resident's care plan addressed dignity and respect. The Focus stated, Will be treated with dignity and respect while at the facility-Date Initiated: 05/22/2026, with no end date. The Goal stated, Will be treated with dignity and respect through next review date-Date Initiated: 05/22/2026-Target Date: 09/07/2026; and Will have the right to privacy and confidentiality through next review date-Date Initiated: 05/22/2026-Target Date: 09/07/2026. The Intervention stated, Staff will treat him/her with dignity and respect-Date Initiated: 05/22/2026, with no end date. Upon observation on 08/06/2026 at 2:56 PM, of the wound care nurse performing wound care on Resident #2, for a non-pressure ulcer wound on Resident #2's left upper back. The wound care nurse knocked on the door and informed Resident # 2 that she would be performing wound care. The wound care nurse exposed resident back to start performing wound care. The wound care nurse did not shut the door to Resident #2's room, and she did not pull the privacy curtain around to provide privacy for Resident #2. The wound care nurse completed wound care for Resident # 2 and exposed Resident # 2's back throughout the entire procedure. During observation, there were facility staff and residents walking up and down the hall past the open doorway of Resident #2's room which visually exposed Resident #2 during her wound care procedure. During an interview with the wound care nurse, on 08/06/2026 at 3:05 PM, the wound care nurse stated that it was very important to shut Resident #2's door and pull her privacy curtain around to provide privacy to Resident #2. The wound care nurse stated that she did not know why she forgot to close Resident #2's door. The wound care nurse stated that the policy for providing wound care to residents was to ensure that the door is closed and the privacy curtain is pulled around to provide privacy. The wound care nurse stated that a possible outcome of failing to provide privacy to a resident was that the resident may become embarrassed. During an interview with the DON, on 08/06/2026 at 3:58 PM, the DON stated that her expectations of the wound care nurse were that the door should be closed and the curtain drawn to provide privacy when doing any procedure on a resident in accordance with the Promoting/Maintaining Dignity Policy. The DON stated that a consequence of not providing privacy to residents is that they can feel exposed. Record review of the facility's policy named, Promoting/Maintaining Resident Dignity, undated, revealed the statement, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Bullet #12 revealed the statement, Maintain resident privacy.

Based on observation, interview, and record review, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for quality of care, in that: The wound care nurse, during Resident #2's wound care procedure, did not gather all the supplies needed prior to the procedure, and she used contaminated gauze to clean the wound and apply treatment to the wound on 08/06/2026. These failures could affect residents by causing deterioration of the wound, a delay in wound healing, and an infection. The findings included: Record review of Resident #2's face sheet, dated 08/06/2026, revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with the diagnoses of: senile degeneration of brain (progressive loss of brain tissue and thinking skills); anxiety disorder (excessive ongoing fear, dread, and nervousness); depression (sadness and a loss of interest in things once liked); and neoplasm of bone, soft tissue, and skin (abnormal growth of cells that form in the body's connective and supporting structures). Record review of Resident #2's treatment orders, dated 08/06/2026, revealed an order for wound care, which stated, Wound lesion to left upper back. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/16/2026 and no end date. Record review of Resident #2's TAR, dated 08/06/2026, revealed treatments scheduled for August 2026, which stated: wound- lesion to left upper back. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/19/2026 and no end date. Record review of Resident #2's Care Plan Report, dated 08/06/2026, revealed the resident's care plan addressed the lesion on Resident #2's left scapula. The Focus stated, Altered skin integrity non pressure related to lesion to left scapula area-Date Initiated: 06/22/2026-Revision on: 06/22/2026. The Goal stated, Affected area will heal without complications through next review date-Date Initiated: 06/22/2026-Target Date: 09/07/2026. One of the interventions stated: Treatments as ordered-Date Initiated: 06/22/2026 with no end date. Record review of Resident #2's most recent quarterly MDS, dated [DATE], revealed Section M-Skin Conditions, subsection M1040-Other Ulcers, Wounds, and Skin Problems, bullet D indicated, Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion); Bullet G indicated, Application of non-surgical dressings (with or without topical medications) other than to feet; and bullet H indicated, Applications of ointments/medications other than to feet. In an observation on 08/06/2026 at 2:56 PM, observation revealed the wound care nurse provided wound care to Resident #2, for a non-pressure ulcer wound on Resident #2's left scapula. Observation revealed Wound Care nurse verified Resident #2's order for wound care prior to wound care. The wound care nurse prepped a bedside table with a cup of betadine with gauze sitting in it; another cup with a cleaning agent with gauze sitting in it; a packet of a skin adhesive pad; and an already dated and signed wound bandage. The wound care nurse proceeded to do hand hygiene, put on a pair of gloves, and retrieved the 2 pieces of gauze soaked in the cleansing agent. The wound care nurse started from the center of the wound, then cleansed around the outside of the wound. The wound care nurse folded the dirty gauze down in half, turned the 2 pieces of gauze over, and then went back into the center of the wound with the clean gauze but with the dirty gauze up against the back of it. The wound care nurse put the dirty gauze back into the cup of cleansing agent and removed her dirty gloves. The wound care nurse realized that she only had one glove, but there were no gloves located in Resident #2's room. The wound care nurse walked down the hall to grab a glove. The wound care nurse came back and did not perform hand hygiene before putting on the clean gloves after touching the door frame when entering back into the room with the glove. The wound care nurse retrieved the 2 pieces of gauze from the cup with the betadine and painted the betadine onto the center of the wound by holding the gauze against the wound so that the scab absorbed the betadine. The wound care nurse then did the same thing by folding down the dirty gauze and turning the 2 pieces over to paint the betadine around the wound with the clean gauze but with the dirty gauze up against the back of it. The wound care nurse put the dirty gauze back into the cup of betadine and removed her dirty gloves. The wound care nurse then realized she needed to get more gloves and walked back down the hall to get more gloves. The wound care nurse again touched the door frame when coming back into the room and failed to perform hand hygiene before attempting to put on clean gloves. She dropped one of the gloves on the floor which caused her to have to go back down the hallway to grab more gloves. The wound care nurse again touched the frame of the door when entering back into the room and did not perform hand hygiene before putting on the clean gloves. She proceeded to take a skin adhesive pad and applied it around the wound. The wound care nurse removed gloves and did not sanitize and donned new gloves. The wound care nurse took the clean bandage and placed it on the wound. During an interview with the wound care nurse, on 08/06/2026 at 3:05 PM, The wound care nurse stated that it is important to use clean supplies while doing wound care to prevent an infection. The wound care nurse stated that she is up to date on her infection control, hand hygiene, and wound care competencies. The wound care nurse stated that the possible outcomes for not performing hand hygiene and using gauze that is in contact with dirty gauze to do wound care is cross-contamination that can cause an infection. During an interview with the DON, on 08/06/2026 at 3:58 PM, the DON stated that her expectations of the wound care nurse are that she should wash her hands or sanitize her hands between changing gloves, use clean supplies, and use proper wound care techniques. The DON states that it is important to prevent cross-contamination by using clean supplies during wound care. The DON stated that the consequences of not washing or sanitizing the hands before putting on new gloves and not using clean supplies while performing wound care were cross-contamination and infection. The DON stated that an improper wound care technique can affect quality of care by causing infection, deterioration of the wound, and can stall wound healing. Record review of the wound care nurse's skills checklist, dated 03/11/2026, revealed under the category, Skills/Task Observed Completed, the skill topic on row 6 named, Infection Control/Prevention, with a bullet that stated, Hand Hygiene staff/residents, Was successfully completed on 03/11/2026. The skill topic on row 24 named, Treatment skills pass off, return demonstration on removing, assessing and cleaning and application of wound dressing, Special focus on glove use, hand hygiene, disposal of soiled dressing/barrier, one treatment order per wound, was successfully completed on 03/11/2026. Record review of the facility's policy named, Wound Treatment Management, undated, revealed the statement, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Record review of the facility's policy named, Infection Prevention and Control Program, undated, revealed the statement, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observation, interview, and record review the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for infection control, in that: The facility failed to maintain standard infection control precautions when the wound care nurse did not perform hand hygiene during wound care on Resident #2 on 08/06/0226. These failures could affect residents who require wound care and place them at risk for a wound infection. The findings included: Record review of Resident #2's face sheet, dated 08/06/2026, revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE], with the diagnoses of: senile degeneration of brain (progressive loss of brain tissue and thinking skills); anxiety disorder (excessive ongoing fear, dread, and nervousness); depression (sadness and a loss of interest in things once liked); and neoplasm of bone, soft tissue, and skin (abnormal growth of cells that form in the body's connective and supporting structures). Record review of Resident #2's treatment orders, dated 08/06/2026, revealed an order for wound care, which stated, Wound lesion to left upper back. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/16/2026 and no end date. Record review of Resident #2's TAR, dated 08/06/2026, revealed treatments scheduled for August 2026, which stated: wound- lesion to left upper back. Paint with betadine cover with dry dressing daily Q Day shift, with a start date of 06/19/2026 and no end date. Record review of Resident #2's Care Plan Report, dated 08/06/2026, revealed the resident's care plan addressed the lesion on Resident #2's left scapulae: The Focus stated, Altered skin integrity non-pressure related lesion to left scapula area-Date Initiated: 06/22/2026-Revision on: 06/22/2026. The Goal stated, Affected area will heal without complications through next review date-Date Initiated: 06/22/2026-Target Date: 09/07/2026. Two of the interventions stated: Monitor for signs and symptoms of infection such as swelling, redness, warm,discharge, odor notify physician of significant findings-Date Initiated: 06/22/2026, with no end date, and Treatments as ordered-Date Initiated: 06/22/2026 with no end date. Record review of Resident #2's most recent quarterly MDS, dated [DATE], revealed Section M-Skin Conditions, subsection M1040-Other Ulcers, Wounds, and Skin Problems, bullet D indicated, Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion); Bullet G indicated, Application of nonsurgical dressings (with or without topical medications) other than to feet; and bullet H indicated, Applications of ointments/medications other than to feet. In an observation on 08/06/2026 at 2:56 PM, of the wound care nurse providing wound care to Resident #2, for a non-pressure ulcer wound on Resident #2's left scapulae. Observation revealed the wound care nurse verified Resident #2's order for wound care prior to wound care The wound care nurse proceeded to do hand hygiene, put on a pair of gloves, and retrieved 2 pieces of gauze soaked in a cleansing agent. The wound care nurse started from the center of the wound, then cleansed around the outside of the wound. The wound care nurse folded the dirty gauze down in half, turned the 2 pieces of gauze over, and then went back into the center of the wound with the clean gauze but with the dirty gauze up against the back of it. The wound care nurse put the dirty gauze back into the cup of cleansing agent and removed her dirty gloves. The wound care nurse realized that she only had one glove, but there were no gloves located in Resident #2's room. The wound care nurse walked down the hall to grab a glove. The wound care nurse came back and did not perform hand hygiene before putting on the clean gloves after touching the door frame when entering back into the room with the glove. The wound care nurse retrieved 2 pieces of gauze from a cup of betadine and painted the betadine onto the center of the wound by holding the gauze against the wound so that the scab absorbed the betadine. The wound care nurse then did the same thing by folding down the dirty gauze and turning the 2 pieces over to paint the betadine around the wound with the clean gauze but with the dirty gauze up against the back of it. The wound care nurse put the dirty gauze back into the cup of betadine and removed her dirty gloves. The wound care nurse then realized she needed to get more gloves and walked back down the hall to get more gloves. The wound care nurse again touched the door frame when coming back into the room and failed to perform hand hygiene before attempting to put on clean gloves. She dropped one of the gloves on the floor which caused her to have to go back down the hallway to grab more gloves. The wound care nurse again touched the frame of the door when entering back into the room and did not perform hand hygiene before putting on the clean gloves. She proceeded to take a skin adhesive pad and applied it around the wound. Wound Care nurse removed gloves and did not sanitize and donned new gloves. The wound care nurse took the bandage and placed it on the wound. During an interview with the wound care nurse, on 08/06/2026 at 3:05 PM, the wound care nurse stated that hand hygiene is very important to perform in between changing of gloves. The wound care nurse stated that she squirted hand sanitizer that she kept in her pocket into her palm as she walked down the hall to get gloves because there were not any hand sanitizer dispensers inside or outside the rooms. The wound care nurse stated that it is important to use clean supplies while doing wound care to prevent an infection. The wound care nurse stated that she is up to date on her infection control, hand hygiene, and wound care competencies. The wound care nurse stated that the possible outcomes for not performing hand hygiene and using gauze that is in contact with dirty gauze to do wound care were cross-contamination and a wound infection. During an interview with the DON, on 08/06/2026 at 3:58 PM, the DON stated that her expectations of the wound care nurse are that she should wash her hands or sanitize her hands between changing gloves, use clean supplies, and use proper wound care techniques. The DON stated that it is important to prevent cross-contamination by using clean supplies during wound care. The DON stated that the consequences of not washing or sanitizing the hands before putting on new gloves and not using clean supplies while performing wound care were cross-contamination and infection. During an interview with the ADON/IP on 08/06/2026 at 4:34 PM, the ADON/IP stated that in accordance to the Infection Prevention and Control policy, and the Hand Hygiene policy, infections are prevented by hand washing or using hand sanitizer, ensuring only clean supplies are used, and by having all supplies available and ready. The ADON/IP stated that the hands should be washed or sanitized before putting on clean gloves or whenever indicated. The ADON/IP stated that the consequences of not washing or sanitizing the hands before putting on clean gloves and using contaminated gauze were cross contamination and wound infection. Record review of the wound care nurse's skills checklist, dated 03/11/2026, revealed under the category, Skills/Task Observed Completed, the skill topic on row 6 named, Infection Control/Prevention, with a bullet that stated, Hand Hygiene staff/residents, was successfully completed on 03/11/2026. The skill topic on row 24 named, Treatment skills pass off, return demonstration on removing, assessing and cleaning and application of wound dressing, Special focus on glove use, hand hygiene, disposal of soiled dressing/barrier, one treatment order per wound, was successfully completed on 03/11/2026. Record review of the facility's policy named, Hand Hygiene, undated, revealed the statement, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Bullet number 1 stated, Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Bullet number 6(a) stated, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility's policy named, Infection Prevention and Control Program, undated, revealed the statement, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents (Resident #1) reviewed for care plans, in that: The facility failed to ensure that the comprehensive care plan for Resident #1 was reviewed and revised by the interdisciplinary team after a physical assessment of Resident #1 revealed skin rashes that required treatment. This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings included: Record review of Resident #1's face sheet, dated 08/06/2026, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of: rash (inflammatory reaction on the skin); and xerosis cutis (dry skin). Record review of Resident #1's orders revealed: Nystatin External Powder 100000 UNITS/GM-Apply to affected areas topically two times a day for candidiasis (fungal infection), Initiated on 06/29/2026 with no end date. Record review of Resident #1's MAR, dated 08/06/2026, revealed that the resident was receiving the Nystatin twice a day Record review of Resident #1's Care plan, dated 08/06/2026, does not list the problem of the skin rashes. Record review of Resident #1's progress note, submitted on 7/22/2026, stated,Skin Issue: #002: Skin issue has been evaluated. Location: Left breast. Laterality / Orientation: Left. Issue type: Rash. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. Skin Issue: #003: Skin issue has been evaluated. Location: Right breast. Laterality / Orientation: Right. Issue type: Rash. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. Skin Issue: #004: Skin issue has been evaluated. Location: Lower back. Issue type: Rash. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. Skin Issue: #005: Skin issue has been evaluated. Location: Left antecubital space (inner elbow). Issue type: Rash. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. Skin Issue: #006: Skin issue has been evaluated. Location: Chest - generalized. Issue type: Rash. Progress: Improving: overall wound characteristics improved. Wound acquired in-house. During an interview with Resident #1, on 08/06/2026 at 2:33 PM, Resident #1 stated that she has a rash in her left underarm pit, left arm, under her bilateral breasts and her bottom. Resident #1 stated that they do not always put the Nystatin on her, and she would like them to leave the bottle at her bedside. Resident #1 stated that she had the rashes for 1&1/2 to 2 weeks. Upon observation, on 08/06/2026 at 2: 38 PM, CNA A turned Resident #1 over. Observation revealed red rashes, on otherwise intact skin, on her left axilla (under arm pit), left upper arm, underneath both breasts, and on the inner upper left thigh. There were no rashes on her back or buttocks. Observation revealed fresh powder on the rashes. During an interview with CNA A, on 08/06/2026 at 2:45 PM, CNA A stated that Resident #1 does not like the cream, so the nurses only put the Nystatin powder on her rash. CNA A stated that she has seen the nurses sometimes put the Nystatin powder on her during peri care. During an interview with the DON on 08/06/2026, at 3:58 PM, the DON stated that her expectations of the MDS coordination team are that new patient care problems should be discussed and added to the comprehensive care plan in a timely manner in accordance with the Comprehensive Care Plans policy. The DON stated that failing to update the care plan can have a negative impact on the quality of care for residents because staff within the resident's care team could be unaware of the problem. During an interview with MDS Coordinator A, on 08/06/2026 at 5:46 PM, MDS Coordinator A looked for the problem of the skin rash on the care plan for Resident #1. MDS Coordinator A stated that the new problem of the rashes was not on the problem list for Resident #1. MDS coordinator A stated that the care plans were discussed every day in a meeting and that the problem of the rashes had not been discussed and added to the problem list on Resident #1's care plan. MDS Coordinator A stated that care plans should be updated immediately once a new problem is identified in accordance with the facility's policy named, Comprehensive Care Plans, and that this problem was overlooked for this resident. Record review of the policy named, Comprehensive Care Plans, undated, revealed the statement, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 8 residents reviewed for medications. Facility nurses did not update Resident #1's physician order regarding Acetaminophen Capsule 500 mg - Give 2 capsules by mouth three times a day for chronic pain - Give with Tramadol when the resident's primary care physician changed the resident's Tramadol from schedule medication to PRN (as needed for pain) medication on 06/04/2026. This failure could place the residents at risk of not receiving therapeutic doses of their medication. Findings included:Record review of Resident #1's face sheet, dated 06/23/2026, revealed the resident was a 66-years-old female and admitted to the facility on [DATE] with diagnosis of chronic systolic heart failure (specific type of heart failure that occurs in the heart's left ventricle), peripheral vascular disease (slow and progressive disorder of the blood vessels), and non-pressure chronic ulcer of other part of right and left lower legs (persistent open sore that develops due to factors other than prolonged pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident cognitive was intact, and in Section M (Skin conditions), it was coded that Resident #1 had venous and arterial ulcers to the resident's right and left leg. Further record review of the MDS revealed the resident had frequently limited day-to-day activities because of pain in Section J (Health Conditions). Record review of Resident #1's comprehensive care plan, dated 09/15/2025, revealed as follows:[Resident #1] had altered skin integrity non-pressure related to vascular wound left and right lower leg. For intervention, treatment as order PRN (as needed) wound treatment is available for wound care. [Resident #1] has acute/chronic pain related to headache, history of left hip and knee fracture, and vascular wounds. For intervention, administer analgesia as per orders. Record review of Resident #1's physician order, dated 04/09/2026, revealed the resident had the order of Acetaminophen Capsule 500 MG (Acetaminophen) - Give 2 capsule by mouth three times a day for Chronic Pain DO NOT GIVE MORE THAN 3GM/24HR PERIOD - Give with Tramadol. Further record review of the physician order revealed the physician changed the resident's Tramadol from traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth three times a day for Chronic Pain to traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for chronic pain on 06/03/2026. Interview on 06/25/2026 at 2:28 p.m. with MA-A said she did not give Resident #1's Tramadol with Acetaminophen anymore because the order of Tramadol was changed from scheduled to PRN (as needed) on 06/03/2026, and she told to the nurses that the order of Acetaminophen 500 MG give 2 capsule three times a day with tramadol should have been changed or updated to Acetaminophen 500 MG give 2 capsule three times a day, and the nurse said they would contact the resident's physician. Interview on 06/25/2026 at 2:11 p.m. with LVN-B stated the resident's order of Acetaminophen 500 MG give 2 capsule three times a day with tramadol should have been changed or updated to Acetaminophen 500 MG give 2 capsule three times a day because the resident's doctor changed the resident's Tramadol from schedule to PRN (as needed), and the LVN-B said he did not know what reason the facility nurses, including himself, did not update the order, and physician order should have been updated accurately to prevent possible medication errors. Interview on 06/25/2026 at 2:32 p.m. with the DON said facility nurses should have updated Resident #1's Acetaminophen and Tramadol accurately to prevent possible medication errors, such as nurses might give Tramadol with Acetaminophen. Record review of the facility policy, titled Maintenance of Electronic Clinical Records, revised 5/16/2025, revealed This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. 1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #1 and #2) out of 8 residents reviewed for medical records in that: 1. Facility wound care nurse did not document in Resident #1's treatment administration record and nursing progress note on 06/02/2026 scheduled wound care date. 2. Facility staff did not document details of a facility reported incident that reportedly occurred on 6/8/2026 at 10:10am in Resident #2's electronic health record. Theses failures could place residents at risk for missed treatment and medications which could result in decline in healing and well-being. Findings included:1. Record review of Resident #1's face sheet, dated 06/23/2026, revealed the resident was a 66-years-old female and admitted to the facility on [DATE] with diagnosis of chronic systolic heart failure (specific type of heart failure that occurs in the heart's left ventricle), peripheral vascular disease (slow and progressive disorder of the blood vessels), and non-pressure chronic ulcer of other part of right and left lower legs (persistent open sore that develops due to factors other than prolonged pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident cognitive was intact, and in Section M (Skin conditions), it was coded that Resident #1 had venous and arterial ulcers to the resident's right and left leg. Further record review of the MDS revealed the resident had frequently limited day-to-day activities because of pain in Section J (Health Conditions). Record review of Resident #1's comprehensive care plan, dated 09/15/2025, revealed as follows:[Resident #1] had altered skin integrity non-pressure related to vascular wound left and right lower leg. For intervention, treatment as order PRN (as needed) wound treatment is available for wound care. [Resident #1] has acute/chronic pain related to headache, history of left hip and knee fracture, and vascular wounds. For intervention, administer analgesia as per orders. Record review of Resident #1's physician order, dated 03/27/2026, revealed the resident had the order of Clean with wound cleanser, pat dry, Apply triamcinolone cream to right and left low leg, topically every Tuesday and Friday for venous stasis ulcers, wrap with kerlix, wrap with ace bandage twice weekly until resolved every day shift every Tuesday and Friday. Record review of Resident #1's Treatment Administration Record from 06/01/2026 to 06/30/2026 revealed the resident received wound care as ordered, except 06/02/2026 (Tuesday) which was blank without any nurse's initial or document. Record review of Resident #1's nursing progress note on 06/02/2026 revealed there was no nursing note on the progress notes. Interview on 06/24/2026 at 12:30 p.m. with the nurse practitioner for wound care said she provided wound care to Resident #1 on 06/03/2026 (Wednesday) when she visited the facility for assessing the resident's wound, and providing wound care on 06/03/2026, instead of 06/02/2026, was fine. Interview on 06/25/2026 at 2:32 p.m. with the DON said the wound care nurse on 06/02/2026 did not document anything to the resident's treatment administration record and nursing progress note and left blank, and the wound care nurse did not work anymore since 06/03/2026 at the facility. The wound care nurse did not show up for work since 06/03/2026 with private reason, and the facility could not contact the wound care nurse anymore. The DON stated she did not know if the wound care nurse provided wound care to the resident on 06/02/2026 as ordered or not because of no documents in the resident's medical record, but the nurse practitioner for wound care visited and provided wound care on 06/03/2026. The DON said the wound care nurse should have documented something on the treatment administration record or nursing progress note such as the nurse's initial if the nurse provided wound care successfully or resident refused wound care, and documenting accurately was very important because inaccurate documenting might affect inappropriate cares, such as missing wound care or over doses of wound care. 2. Record review of Resident #2's face sheet dated 6/24/2026 revealed an [AGE] year old male admitted on [DATE] with diagnoses which included: senile degeneration of the brain (condition affecting memory, reasoning and ability to perform everyday activities), dementia (impaired ability to think, remember or make decisions due to brain cell damage), depression (mood disorder causing feelings of sadness and loss of interest), anxiety (condition in which a person has excessive worry and feelings of fear, dread or uneasiness) and violent behavior. Record review of Resident #2's care plan, printed 6/24/2026 indicates focus of at risk for behaviors r/t demonstrates physically abusive behaviors. Hx of him throwing chair at staff, grabbing med cart and trying to rip computer off, throwing items off cart, trying to hit staff with fork. Date initiated: 06/03/2026, Revision on: 06/08/2026. There is a corresponding goal of will not demonstrate physically abusive behaviors through next review date Date initiated: 06/03/2026, Target date: 06/21/2026. Interventions include documenting physically abusive behaviors in the clinical record which is dated 06/03/2026. Record review of Form 3613-A (Provider Investigation Report) faxed to complaint and incident intake department dated 6/15/2026 indicated that there was an incident involving Resident #2 and another resident on 6/8/2026 at 10:10am. The investigation documentation reviewed includes an assessment section that lists a description of the physical assessment performed, treatment provided, provider response and immediate interventions provided. Record review of Resident #2's electronic health record progress notes revealed documentation of an interdisciplinary team meeting held on 6/10/2026 at 9:47am to discuss the resident-to-resident altercation involving Resident #2 pushing his roommates wheelchair - roommate then made contact with (Resident #2). Root cause analysis and effectiveness of interventions were also documented within this note. Record review of progress notes for Resident #2 from 6/8/2026-6/24/2026 did not reveal documentation in the electronic health record about the details of facility reported incident that had occurred on 6/8/2026 at 10:10am. During an interview with the DON on 6/25/2026 at 2:38pm, the DON verified that the interdisciplinary team had met on 6/10/2026 to discuss the incident involving Resident #2 that had occurred on 6/8/2026 at 10:10am and verified that this was documented in the electronic health record. DON attempted to locate documentation of the 6/8/2026 incident in the electronic health record then stated that it was not present. She did not name who was responsible for the missed documentation and stated that the nurse must have forgotten to document the incident with so much going on with the resident and due to his discharge shortly thereafter. She stated that the incident should have been documented so that the resident's medical records would be complete and accurate. Record review of the facility policy, titled Maintenance of Electronic Clinical Records, revised 5/16/2025, revealed This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. 1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment including the right to be fully informed in language that he or she understood of his or her health status, including his or her medical condition for 1 of 1 resident (resident #3) reviewed for resident rights. The facility failed to have an effective method of communication with Resident #3 who was deaf and mute This failure could place residents at risk of poor communication and a demoralized sense of self-esteem and psychosocial wellbeing. The findings include: Record review of Resident #3's face sheet, dated 05/29/2026, revealed an admission date of 01/27/2025, and a readmission date of 03/27/2026, with diagnoses that included: Paraplegia (impairment in motor or sensory function of the lower extremities.), Type 2 diabetes mellitus ((high level of sugar in the blood), Focal traumatic brain injury (brain trauma in which damage is confined to a specific area of the brain, rather than affecting multiple regions), Chronic ulcer of right lower leg (nonhealing or slowly healing open sore that fails to progress through the normal wound healing sequence ), Dysphagia (Difficulty swallowing), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Deaf non speaking, Hypertension (High blood pressure). Record review of Resident #3's Quarterly MDS assessment, dated 05/14/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, needed limited to extensive assistance with his activities of daily living and was indicated to frequently be incontinent of bladder and bowel. Resident #3 was coded as having highly impaired hearing and no speech. Record review of Resident #3's care plan, dated 01/26/2025, reflected a problem of has impaired Communication due tobeing deaf and mute. Resident refuses to use a communication board, wishes only to have someone who can use signlanguage. Uses interpreter services with (removed name) via video. At times, resident will refuse video interpreter services provided by (removed names) Interpreters. Will communicate via IPAD. He will type and point to communicate his needs.There are staff members in the facility that basic needs for him to facility staff. VRI available for as needed communications. and an intervention of Communicate through identified communication method- sign language, writing or interrupter/communication device/pad, interrupter services. During an interview on 05/27/2025 at 11:13 a.m. the Ombudsman stated she learned from Resident #3 and the Administrator that the facility believed Resident #3 could read, write, spell, and read lips, when Resident #3 had poor reading, writing, spelling skills and could not read lips. The Ombudsman stated the facility had failed to assist Resident #3 with VRS and VRI services. During an interview on 05/28/2026 at 9:59 a.m., Anonymous stated when she visited the facility, she saw the staff giving Resident #3 medications and he did not know what they were giving him. Anonymous stated the staff did not seem to understand he was deaf and could not hear even if they talked loudly to him. She stated did not think they had a way to communicate with him since he understood very little English. During a wound care observation on 05/28/2026 at 12:27 a.m., ADON A scanned a QR code with her phone and an ASL translation service loaded with an ASL interpreter appearing on the screen. She told the interpreter what she wanted to say to the resident and the interpreter used sign language to talk to the resident, signed back. Communication during the provided care, from the nurse, was observed to be translated on the screen for the resident. During an interview on 05/28/2026 at 12:34 p.m. with Resident #3, he stated the majority of the staff did not use the ASL service and he stated they did not know how to use it. He stated he wanted them to use the ASL interpreter so he could understand them. During an interview on 05/28/2026 at 12:28 p.m., LVN B stated she provided care for Resident #3. She stated she usually wrote things on paper for him. She said she had not used the ASL application, yet because the only thing she did was to give him medications. She stated he knew what medications he took because he refused some of them. She stated she was not aware he could not understand English well. She stated they received an in-service about the [NAME] application, but it was not told to them to use it all the time with the resident or that he could not read English. During an interview on 05/29/2026 at 5:19 a.m. RN C stated Resident #3 could read lips, so she talked to him facing him and slow. She stated she was not aware of the ASL application and did not know about a QR code to scan to use the application and used an ASL translator to talk to the resident. She stated did not remember an in-service about it and did not know the resident only knew very little English. During an interview on 05/29/2026 at 5:42 a.m., LVN D stated Resident #3 used his tablet to write down what he wanted from them. She stated she did not remember an in-service about the ASL app and did not know about it. She stated she did not know Resident #3 didn't fully understand English and had been talking and writing to him. During an interview on 05/29/2026 at 5:56 a.m., CNA E stated he, sometimes, used Resident #3's pad to write back and forth to him and Resident #3 read lips. He stated he was not aware Resident #3 knew very little English. CNA E stated he was not aware they could use an application to access an ASL translator. During an interview on 05/29/2026 at 7:02 a.m., the DON stated she in- serviced the staff about the ASL application so she did not understand why they were not using it to communicate with him. She stated the policy of the facility was to use the best language for the residents to understand when communicating with them. Record review of Facility's policy, titled Effective Communication, dated 05/16/2025, revealed It is the policy of this facility to accommodate needs when communicating with residents who are deaf, hard of hearing, any other language than English to promote dignity, understanding, and safety. Further review revealed Effective communication describes a process of dialogue between individuals. The skills include speaking to others in a way they can understand and active listening and observation of verbal and non-verbal cues. Understanding what the resident is trying to communicate is essential to giving a response. Additionally, effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 resident (Resident #3) reviewed for infection control, in that: The facility failed to ensure ADON A wore a gown while providing wound care for Resident #3 who was on enhanced barrier precaution. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #3's face sheet, dated 05/29/2026, revealed an admission date of 01/27/2025, and a readmission date of 03/27/2026, with diagnoses that included: Paraplegia (impairment in motor or sensory function of the lower extremities.), Type 2 diabetes mellitus ((high level of sugar in the blood), Focal traumatic brain injury (brain trauma in which damage is confined to a specific area of the brain, rather than affecting multiple regions), Chronic ulcer of right lower leg (nonhealing or slowly healing open sore that fails to progress through the normal wound healing sequence ), Dysphagia (Difficulty swallowing), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Deaf non speaking, Hypertension (High blood pressure). Record review of Resident #3's Quarterly MDS assessment, dated 05/14/2026, revealed the resident had a BIMS score of 15, which indicated no cognitive impairment, needed limited to extensive assistance with his activities of daily living and was indicated to frequently be incontinent of bladder and bowel. Resident #3 was coded as having one venous ulcer. Record review of Resident #3's care plan, dated 12/19/2025, reflected a problem of Enhanced barrier precautions r/t chronic wound. Resident refuses to have sign and organizer on door- he will remove them and an intervention of [NAME] (put on) gown and gloves during high-contact personal care activities. Observation on 05/28/2026 at 11:27 a.m., revealed while providing wound care for Resident #3, ADON A did not put a gown on to enter the room and provide care. Resident #3 was on enhanced barrier precaution due to his wound. Interview on 05/28/2026 at 11:46 a.m., ADON A stated she forgot Resident #3 was on enhanced barrier precaution. She stated she had received training on enhanced barrier precautions. Interview on 05/28/2026 at 3:55 p.m., the DON stated staff needed to wear a gown and gloves for resident on enhanced barrier precaution, for the prevention of infection to the residents but also the staff. The DON stated infection control training was provided and skills were checked annually. Review of facility's policy, titled Enhanced Barrier Precautions , dated 04/11/2025, revealed Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Further review revealed High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes,hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing

Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse, to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) an allegation of Resident #1 being sexually abused by three unknown men in the facility on 4/1/16. This failure could place residents at risk for harm to include sexual abuse, a diminished quality of life, and psychosocial harm.The findings include:Record review of Resident #1's face sheet, dated 4/14/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: schizoaffective disorder (chronic mental health condition cauterized by hallucinations and delusions), bi-polar disorder (a serious mental illness characterized by shifts in mood), anxiety, quadriplegic (paralysis affecting all four limbs and the torso), and chronic pain. The RP was listed as: self.Record review of Resident#1's admissions MDS, dated [DATE], reflected a BIMS score of 15 indicative of no impairment in cognition. In section GG of the MDS, the ADLs for: bowel was a colostomy (a surgical opening to allow stool) and incontinent for urine. Transfer and Mobility was total assistance. ROM was upper and lower. Assistive devices: none.Record review of Resident #1's CP, undated, revealed the resident was at risk for behaviors associated with schizoaffective disorder, delusions and bi-polar disorder that could result in allegations of sexual abuse of self and others. Interventions included psych services and notifying the physician.Record review of Resident's #1 Nurse Note, dated 4/1/16 at 8:00 a.m., MHNP revealed Staff has reported numerous complaints of delusions including reports that somebody stuck a metal rod in between her vagina and her anus.Record review of Resident #1's Nurse Note dated 4/1/26 at 9:13 p.m., authored by the DON revealed Resident # 1 made an allegation of sexual abuse involving a mental rod inserted between her vagina and rectum. [The MD was not notified but the MHNP representing the MD was aware of the sexual allegation on 4/1/26] Record review of the facility's grievance log for the month of April 2026 revealed the alleged sexual abuse on 4/1/26 was not recorded as a grievance.Observation and interview on 4/15/26 at 10:00 a.m., Resident #1 was lying in bed with no visible injuries, skin tears, or bruises noted. The resident was noted to have contractures to both hands. Resident #1 stated three black men sexually abused her, and they shoved an object in her vagina and somehow it was removed. She stated [witnessed by SW] there was no need for a SANE exam because the men did not lay on top of her body and the object came out. Resident #1 stated the alleged sexual abuse occurred two weeks ago and she told the Administrator. She stated LVN A was present during the rape incident. During an interview on 4/15/26 at 10:04 a.m., the SW stated she heard the resident alleged during the surveyor's interview that three males did not rape her instead they put an object in her and the object came out. The SW stated that Resident #1 stated that a Nurse (LVN A) was present during the rape. The SW stated based on a prior interview with the resident, the resident felt safe in the facility. The SW stated she did not recall if the facility called law enforcement or HHS on 4/1/16. The SW stated preventative measures were put in place to have two female staff present when giving care to the resident after the sexual allegation on 4/1/16. During an interview on 4/15/26 at 10:57 a.m., LVN A stated she was not present during a rape scene on 4/1/26 and would not have let it happen. LVN A stated once she was alerted of the alleged sexual abuse by Resident #1 on 4/1/26, she informed the Administrator and the DON. LVN A stated at the time of the alleged sexual abuse on 4/1/26, she and another LVN (LVN B) did a head-to-toe on the-resident and there were no new skin issues. LVN A stated she did not remember whether an ER visit for a SANE examination was offered to the resident or if law enforcement or HHS were notified. LVN A stated based on her training on ANE, if a resident made an outcry of sexual abuse the procedure was to notify immediately the Administrator and law enforcement. LVN A stated the resident had a right to go to the hospital for an assessment of whether the allegation was real or a delusion. During an interview on 4/15/25 at 11:48 a.m., LVN B stated she had worked with Resident #1 since her admissions. LVN B stated the first time that the resident claimed a person put a metal rod though her vagina and it came out through her rectum was about two weeks ago. LVN B stated the resident was assessed on 4/1/26 and the Administrator and DON were informed of the alleged sexual abuse. LVN B stated the resident was offered an ER visit for a SANE examination but declined. LVN B stated by policy the Administrator/DON needed to be informed immediately about any allegations of sexual abuse whether it was true or not and follow any reporting polices. LVN B stated she received training on ANE, and the highlight of the training was to report ANE to the Abuse Coordinator, the Administrator. During an interview on 4/15/26 at 2:37 p.m., the ADON, LVN stated she did not have knowledge of Resident#1's first allegation of sexual abuse on 4/1/26. The ADON stated the facility's policy was when any resident made an outcry of sexual abuse the policy was to notify the Abuse Coordinator and send applicable reports to law enforcement and HHS. During an interview on 4/15/26 at 3:52 PM, the DON stated she had worked in the facility for over one and half years. The DON stated she was familiar with Resident #1's care and refusal of care and delusions. The DON stated that when any resident made an allegation of sexual abuse the facility's policy included: notify the abuse coordinator, any family member, law enforcement, and HHS and start an in-service on ANE and initiate a Provider investigation. The DON stated the first allegation of sexual abuse by Resident #1 occurred on 4/1/26 which was conveyed to her by the MHNP. The DON stated that law enforcement was not called because the resident had a history of making false sexual allegations and the assessment revealed there was no finding of sexual abuse. The DON stated the Administrator was aware of the allegation and as the Abuse Coordinator he would determine whether the facts merited filing a report with HHS. The DON stated she did not have an explanation why on the first allegation of sexual abuse, 4/1/26, was not reported to law enforcement or HHS but reported on the second incident of alleged sexual abuse on 4/14/26. During a telephone interview on 4/15/26 at 4:25 p.m., the MHNP stated that Resident #1 made an allegation of sexual abuse on 4/1/26. The MHNP stated she was familiar with the resident, and the resident had a history of false allegations and delusions. The MHNP stated the resident was delusional on an on-going basis and would make sexual abuse allegations. The MHNP stated she only did a psychological evaluation on 4/1/26 and the resident was not sent to the ER. The MHNP stated the facility (DON) was informed of the allegation and it was up to the facility to call law enforcement and HHS. Given the resident's delusional history and history of making delusional allegations the MHNP stated she did not write an order to send the resident to the ER unless facility nursing staff found evidence of an actual sexual assault. During an interview on 4/15/26 at 4:49 p.m., the Administrator stated he did not contact law enforcement or HHS on the first allegation of sexual abuse on 4/1/26 because: the MHNP felt the allegation made by Resident #1 was not in the realm of possibility and there were no named perpetrators except three unknown men. The Administrator stated the second allegation of sexual abuse on 4/14/26 was reported to HHS and law enforcement because there was a named alleged perpetrator [CNA E]. The Administrator stated that he was familiar with the facility's policy on reporting ANE. Record review of Facility's policy titled, Abuse, Neglect and Exploitation dated 7/2/2025, read . Abuse means the willful inflection of injury.resulting in physical harm, pain or mental anguish.it includes .sexual abuse.The facility will have written procedures that include:.Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time framed:. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.

Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration dates for 2 of the facility's 5 medication carts (1 cart for the 200-hall and 1 cart for the 400-hall) reviewed for medication storage. The Medication Aide 200-hall medication cart had 4 pill form medications stored in a small plastic cup and not in pharmacy labeled containers.The Nurse 400-hall medication cart had 3 pill form medications stored in a small plastic cup and not in pharmacy labeled containers. These failures could place residents at risk of not receiving the therapeutic effects of their medication. Findings included: During an observation and interview on 4/3/2026 at 3:40 PM MA I attended her medication cart on the 200-hall. MA I stated she was in the process of administering medications for residents on the 200-hall. MA I stated she had intended to administer medications for a resident but could not because the resident was receiving a shower. MA I stated she did not want to be wasteful, so she stored the pills in a small cup and then proceeded to administer medications to other residents. MA I revealed a small clear medication cup with 4 small pills in the cup which she had stored in the first drawer of the medication cart along with other medications. MA I stated she wrote the resident's name upon the cup as a reminder of whose medications they were. MA I identified the medications as risperidone, melatonin, quetiapine, and famotidine. MA I stated she understood the practice of pre-pouring medications was not acceptable as a professional standard but did not want to waste the medication and was aware of who the medication was intended. MA I stated the potential danger for residents was for a potential medication error. During an observation and interview on 4/3/2026 at 4:00 PM LVN J was at her nurse medication cart by the nurse station for the 400-hall. LVN J stated she had just returned from a 2-3-minute lunch break. LVN J opened her medication cart and demonstrated a small clear plastic cup with 3 pills within the cup. The cup had a handwritten resident's name on the side of the cup. LVN J identified the pills as Depakote 250mg and Depakote 500mg, and carbamazepine unknown milligrams. LVN J stated, I don't remember the dosage of the carbamazepine, I would need to look it up. LVN J stated she had pre-poured a resident's medication because when she prepared the medications the resident was not available for medication administration, so she stored the medications and took her lunch break. LVN J stated she understood the practice of pre-pouring was not per professional practice, but she intended to administer the medications as soon as she returned from her break. During an interview on 4/3/2026 at 4:20 PM ADON H stated the training, expectations and professional practice for medication administration was for nursing staff to identify the intended resident and then immediately dispense and administer the medications to the resident and the practice of pre-pouring medications was against policy and could lead to medication errors. During an interview on 4/3/2026 at 5:00 PM the Administrator stated he received a report of nursing staff pre-pouring medications and would have the DON review the incidents. A record review of the facility's policy Medication Administration dated 5/9/2025 revealed, Policy: medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: identify a resident; perform hand hygiene prior to administrating medication per facility protocol and product; knock or announce presence;; explain purpose of visit; provide privacy; . position resident to accommodate administration of medication; ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and write documentation. review medication administration record to identify medication to be administered. Compare medication source with medication administration record to verify resident name, medication name, form, dose, route, end time. remove medication from source, . administer medication . observe resident consumption of medication . sign medication administration record .

Based on observation, interview, and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 7 residents (Resident #2) reviewed for resolution of grievances. The facility failed to document, address, and attempted to resolve 11 grievances made by Resident #2 on:1/2/2026 at 11:49 AM.1/2/2026 at 12:06 PM.1/2/2026 at 1:33 PM.3/3/2026 at 11:56 AM.3/4/2026 at 9:39 AM.3/5/2026 at 12:31 PM.3/12/2026 at 2:29 PM.3/17/2026 at 5:08 PM.3/19/2026 at 12:01 PM.3/24/2026 at 5:12 PM.3/26/2026 at 8:33 AM. This failure could place residents at risk for psychosocial and physical decline by not having their grievances heard and resolved.Findings included: Record review of Resident #2's admission record, dated 4/3/2026, revealed an admission date of 11/11/2025 with diagnoses which included hypertensive heart with heart failure (high blood pressure and heart failure) and end stage chronic kidney disease (high blood pressure with heart damage and damaged kidneys.) Record review of Resident #2's quarterly MDS assessment, dated 2/8/2026, revealed a [AGE] year-old female admitted for long term care. Resident #2 was assessed as dependent on staff for support with ADL care and transfer assistance. Record review of the facility's grievance records, dated 01/01/2026 through 3/31/2026, revealed no documented grievances for Resident #2. Record review of the local Ombudsman grievance emails revealed the local Ombudsman sent the facility's Administrator 11 grievance emails as follows: From: (Ombudsman)Sent: Friday, January 2, 2026, 11:49 AMTo: (Administrators email address)Subject: SOS (a universally recognized distress signal for summoning help)(Administrator),(Resident #2) has been calling for help for 45 minutes. Can someone please assist her to get off the bedpan?Thank you,(Ombudsman) From: (Ombudsman)Sent: Friday, January 2, 2026, 12:06 PMTo: (Administrators email address)Subject: FW: SOSImportance: High(Administrator),No one has helped (Resident #2). In addition to that, no one is answering the main number when it is called and the voice mail box is full.(Ombudsman) From: (Ombudsman)Sent: Friday, January 2, 2026, 1:33 PMTo: (Administrators email address)Subject: (Resident #2) needs help again(Administrator),(Resident #2) has had her call light for 25-30 min this time. Light is being ignored. She needs help to get off the bedpan again. Please.Also, she needs (Nurse) to come and tend to the wraps for legs which are coming off her feet.Thank you,(Ombudsman) From: (Ombudsman)Sent: Tuesday, March 3, 2026, 11:56 AMTo: (Administrators email address)Subject: (Resident #2)(Resident #2) states they have left her on the bed pan for 50 minutes. Please send someone to help her.Thank you.(Ombudsman) From: (Ombudsman)Sent: Wednesday, March 4, 2026, 9:39 AMTo: (Administrators email address)Subject: Grievance(Administrator),It is my understanding that (Resident #2) has already issued a grievance previously that (CNA A) is not to go into her room. Yesterday, (CNA A) was on the 2-10 shift. She serviced (Resident #2). (CNA A) cleaned (Resident #2) by wiping her from her rectum to her vagina. Respectfully - I request that (CNA A) be in-serviced as that is improper hygiene.(Resident #2) AND her roommate have both requested that (CNA A) not attend to them going forward.Thank you,(Ombudsman) From: (Ombudsman)Sent: Thursday, March 5, 2026, 12:31 PMTo: (Administrators email address)Subject: (Resident #2)Hi (Administrator),Can someone please go give (Resident #2) the grilled cheese they have left on her dresser.Thank you,(Ombudsman) From: (Ombudsman)Sent: Thursday, March 12, 2026, 2:29 PMTo: (Administrators email address)Subject: Grievance reported(Administrator),(Resident #2) requested a grievance form yesterday, but no one provided it.(Resident #2) would like to report that she was on the bed pan Mon, Tues and Wed and (CNA B) never answered her call light or came in to help her get off. Others had to help her. (Resident #2) reports (CNA B) will not help her get off of the bed pan at all and leaves it for others. Often (CNA C) has to come from the other hall to help. (Resident #2) has even offered to work around (CNA B) on her break but she states she doesn't know when she is going on break and is just not very nice when responding to (Resident #2). (Resident #2) would appreciate a response to this grievance.(Ombudsman) From: (Ombudsman)Sent: Tuesday, March 17, 2026, 5:08 PMTo: (Administrators email address)Subject: Resident #2)Importance: High(Administrator),(Resident #2) has been left on the bed-pan again (45 min now). (CNA B) (is in her hall) and she is not coming in (there is a grievance) or getting her help. Please send (CNA C), ASAP!!!! .Thank you,(Ombudsman) From: (Ombudsman)Sent: Thursday, March 19, 2026, 12:01 PMTo: (Administrators email address)Subject: (Resident #2)(Administrator),So sorry to have missed you yesterday when I was at the facility! . Yesterday during my visit, (LVN D) promised to re-wrap (Resident #2's) leg after she reported that the wrap is too tight and is hurting. That was never done. Please address this oversight and get her leg tended to ASAP.Thank you,(Ombudsman) From: (Ombudsman)Sent: Tuesday, March 24, 2026, 5:12 PMTo: (Administrators email address)Subject: (Resident #2)(Administrator),. Also, please advise the CNA (CNA B) that she should not scold (Resident #2) regarding turning on the light.(Ombudsman) From: (Ombudsman)Sent: Thursday, March 26, 2026, 8:33 AMTo: (Administrators email address)Subject: Grievance from (Resident #2)(Administrator),(Resident #2) states that yesterday (LVN D) yelled at her. She states that her wraps were coming off and (LVN D) yelled at her accusing her of tearing off her leg wraps. She wishes to enter this grievance for the Resident Right of Dignity and Respect being violated.Also, (CNA B) continues to go into the room although a written grievance has been made that (CNA B) should not be providing care in that room.(Ombudsman). During an interview on 3/31/2026 at 9:40 a.m., the Administrator and the DON stated Resident #2 had a documented history of making unrealistic demands and uncooperating with staff in efforts to resolve her complaints and unreasonable demands. The Administrator and the DON stated Resident #2's behaviors were documented and the facility continued to support Resident #2 in all her needs. The Administrator and the DON stated Resident #2 requested the Administrator and the DON not enter her room and thus placed the local Ombudsman as her default Representative. The Administrator and the DON stated the Ombudsman would visit and communicate in person and via telephone calls and emails. During an interview on 3/31/2026 at 11:00 a.m., the Ombudsman stated the relationship between Resident #2 , the Administrator, and the DON, had deteriorated and Resident #2 had refused to allow the Administrator and the DON into her room and thus Resident #2 utilized the Ombudsman as a Representative to communicate her wants and needs to the Administrator. The Ombudsman stated she often verbally advocated for Resident #2 to the Administrator and the DON without resolutions and thus begun to document all communications and grievances to the Administrator via emails. The Ombudsman stated Resident #2's grievances still were not addressed. During an observation and interview on 4/3/2026 at 3:01 PM revealed Resident #2 in her room in bed. Resident #2 stated she was not being helped by the staff who ignored her call lights and was left alone on her bedpan for hours. Resident #2 stated she would use her cell phone to call the facility, but they would never answer and thus she would call the Ombudsman to complain. Resident #2 stated she had many complaints but recalled a few, for example, CNA B was rude and did not provide incontinent care properly and with kindness. Resident #2 stated she had requested that CNA no longer provide care for her and preferred CNA C. During an interview on 4/3/2026 at 4:00 p.m., the Administrator stated he had not documented a grievance for Resident #2 from the Ombudsman's emails and believed he and his staff had addressed Resident #2's concerns and needs by reviewing the emails and providing re-enforced training for the entire staff which included ANE prevention and reporting trainings, however Resident #2 continued to be unsatisfied and continued with her occasional care refusals. A record review of the facility's Resident and Family Grievances policy, dated 6/15/2025, revealed, Policy: It is the policy of this facility to support each resident and family members rights to voice grievances without discrimination reprisal or fear of discrimination or reprisal. Definitions: prompt effort to resolve, include facility acknowledgement of a complaint/grievance and actively working towards resolution of that complaint/grievance. Policy explanation and compliance guidelines: The administrator has been designated as the grievance official . The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations . a resident or family member may voice grievances with respect to care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding their long term care facility stay . The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form, take any immediate actions needed to prevent further potential violations of any resident right, report any allegations involving neglect, abuse, injuries of unknown source and or misappropriation of resident property, immediately to the administrator and follow procedures for those allegations . the grievance official will take steps to resolve the grievance and record information about the grievance and those actions on the grievance form.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 5 residents medication carts (200-hall medication cart) reviewed for food safety. The facility stored resident's pudding and jelly in the Resident's medication cart without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.Findings included: During an observation and interview on 4/3/2026 at 3:08 PM LVN D was at his medication cart preparing to administer medications for his assigned residents. The medication cart presented with a covered 1-gallon water pitcher filled with water. The water pitcher had no label to identify when the water was poured. LVN D demonstrated the first drawer where he stored a clear plastic cup with a lid which held approximately 2 ounces of pudding and another similar clear plastic cup with jelly. The containers had no labels and dates to indicate what the contents were or when they were served. LVN D stated he had filled the pitcher with water at the beginning of his shift today 4/3/2026 around 2:00 PM. LVN D stated he had received from the kitchen the pudding and jelly today 4/3/2026 around 2:00 PM. LVN D stated he had not labeled the water and the pudding and jelly and was aware per professional standards he was to label the water and pudding with a date they were prepared to indicate the water and pudding were safe to serve. During an interview on 4/3/2026 at 4:00 PM ADON H stated nursing staff used fresh water and puddings and jellies to assist residents consuming their medications. The ADON stated the training, professional practice, and policy was for nursing staff to place a label on the water pitcher indicating the date the water was poured and for the same practice for the pudding and jelly. The ADON stated the label indicated the date the water and the puddings were prepared and ensured the foods were safe to serve. The ADON stated the water and pudding without labels indicated an uncertainty when the foods were prepared and therefore uncertain if they were safe to serve. A record review of the facility's Medication administration policy dated 5/9/2025 revealed, Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by physician and in accordance with professional standards of practice, in any manner to prevent contamination or infection. Policy explanation and compliance guidelines: keep medication card clean, organized, and stocked with adequate supplies. Cover and date fluids and food.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 resident (Resident #1) reviewed for care plans. The facility failed to ensure the care plan included instructions necessary for implementing communication interventions with Resident #1 who was deaf and mute. This failure could place residents at risk of harm due to poor communication.The findings include: A record review of Resident #1's admission record revealed an admission date of 1/27/2025 with diagnoses which included deaf non-speaking, unspecified focal traumatic brain injury, schizoaffective disorder bipolar type (a chronic mental health condition combining psychotic symptoms (hallucinations, delusions) with manic and often depressive mood episodes). A record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for long term care with supports for ADL safety with his diagnosed paraplegia (the impairment of motor or sensory function in the lower half of the body, usually caused by spinal cord injury or disease). A record review of Resident #1's physicians orders dated 4/3/2026 revealed May use hand-talk for communication / interpretation with resident. A record review of Resident #1's care plan dated 4/3/2026 revealed there were no interventions instructions for how staff could call Resident #! On his ASL telephone, (Resident #1) Has impaired communication due to being deaf and mute. Resident refuses to use a communication board, which is only to have someone who can use sign language. Uses interpreter services with [language service] via video. Goals: Will be able to communicate basic needs with a communication / interpreter device through next review date . target date 3/18/2026 . Interventions: answer Questions as needed and repeat as necessary . communicate through communication method - sign language, writing or interpreter / communication device / pad, interpreter services. set up ASL (a complete, visual hand language used by the Deaf community in North America. During a joint interview on 3/31/2026 at 10:00 AM the Administrator and the DON stated Resident #1 was a deaf person who could communicate with hand gestures, could read and write, and could read lips. The Administrator and the DON stated the SW could communicate with Resident #1 with ASL and the facility had as needed interpreter services through an ASL interpreter contractor. The Administrator and the DON stated Resident #1 had a tablet computer an iPad which he used to call people and had a visual interpreter service. During an interview on 3/31/2026 at 3:00 PM the Facility's State Agency assigned Ombudsman stated she learned from Resident #1 and the Administrator that the facility believed Resident #1 could read, write, spell, and read lips, which Resident #1 had poor reading, writing, spelling skills, and could not lip read. The Ombudsman stated she learned from Resident #1's relative that Resident #1 had lost his hearing early in life before he could learn to speak, read, and write. The Ombudsman stated the facility had failed to assist Resident #1 with his iPad and VRS service. During an interview on 4/1/2026 at 11:00 AM with an independent Pro bono (a Latin phrase meaning for the public good) ASL interpreter and Resident #1, Resident #1 stated the facility has occasionally provided a meeting with an ASL interpreter who can actually sign but the Administrator had not helped him with his computer tablet calling program which has stopped working and when it did work the internet service was too slow and the visual signs could not be seen because of the choppy and blurry video. During a joint interview on 3/31/2026 at 3:35 PM CNA K and CNA L stated they were CNAs who cared for Resident #1 and demonstrated their CNA Kardex (a centralized, frequently updated, and easy-to-reference nursing electronic documentation system that acts as a summary of patient information and care plans) for Resident #1. CNA K and CNA L stated there were no instructions for communicating with Resident #1 with a phone call and were unaware of a VRS system. CNA K and CNA L stated they and Resident #1 would communicate with hand gestures and head nods for care with ADL. CNA K and CNA L stated they could not use or understand ASL. During an interview on 3/31/2026 at 3:44 PM LVN M stated she was the charge nurse for Resident #1 and reviewed Resident #1's care plan. LVN M stated the care plan had no interventions for a VRS telephone number. LVN M stated she was unaware of a VRS telephone system to communicate with Resident #1. LVN M stated she and Resident #1 would communicate with hand gestures and head nods for assessments and medication administration. LVN M stated she could not use or understand ASL. LVN M stated she was aware Resident #1 could somewhat read and write but the communication was poor. LVN M stated she was unaware how to set up an ASL translator to communicate with Resident #1 and if available she could call upon the SW because the SW could use ASL. During a joint interview on 4/2/2026 at 5:00 PM the Administrator, the DON, and the SW stated the SW had basic ASL communication skills and could interpret communication with Resident #1 but the SW had no formal ASL training and held no ASL certificates. The SW stated she worked 40-60 hours a week and served around 100 residents and did not work 7 days a week or 24 hours a day. The Administrator stated that during those times when SW was not available the FSM could also serve as an interpreter, however the FSM also did not have a formal education for ASL and did not hold any ASL certificates as an interpreter. The Administrator stated Resident #1 could read and write and could also read lips. The Administrator stated Resident #1 could also communicate with anyone with his iPad which he used to call out to anyone. The Administrator stated the service was provided by a language services company and identified Resident #1's phone number as (phone number) and stated the phone number was documented on Resident #1's admission record. The Administrator stated he had used the number to call Resident #1. The Administrator stated he believed Resident #1's care plan was accurate and adequate to provide instructions for care. A record review of the facility's Comprehensive Care Plans policy dated 5/5/2025 revealed, It is the policy of this facility to develop and implement A comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs and services that are identified in the residence comprehensive assessment and need professional standards of quality. The comprehensive care plan will describe, at a minimum, the following:the services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being. Resident specific interventions that reflect the residents' needs and preferences and align with the residents' cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate.

Based on interviews, and record reviews, the facility failed to evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress, and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective actions were taken for 1 of 6 residents (Resident #3) reviewed for abuse. On 2/22/2026 the facility failed to investigate and report the results of the investigation to the State Agency an allegation of sexual abuse when a hospice RN alleged Resident #3 was sexually abused. This failure could place residents at risk of harm by ANE and a diminished sense of self-worth.Findings included:A record review of Resident #3's admission record dated 4/3/2026 revealed an admission date of 2/24/2026 with diagnoses which included senile degeneration of brain (age-related, progressive decline in cognitive function caused by structural brain damage, commonly due to protein buildup), aphasia (impaired ability to understand or produce speech, as a result of brain disease or damage), second degree hemorrhoids (second-degree internal hemorrhoid bulges from the anus during bowel movements, then goes back inside by itself). A record review of Resident #3's change in status MDS assessment dated [DATE] revealed Resident #3 was an [AGE] year-old male admitted for hospice care. Resident #3 was assessed with a non-traumatic brain disorder and a serious mental illness, highly impaired sense of hearing, severely impaired sight, and could sometimes understand others and sometimes could make himself understood. Resident #3 was assessed as having memory problems and had severely impaired cognitive skills for daily decision making. Resident #3 was assessed as needing substantial maximal assistance with toileting hygiene. Resident #3 was assessed as always incontinent of bowel and bladder. A record review of Resident #3's care plan, dated 4/3/2026, revealed, .Potential for alteration in comfort related to hemorrhoids Date Initiated: 03/02/2026 . Assess for s/sa) small amount of blood in the stool or on toilet paper after wipingb) incomplete bowel movementsc) soft lump felt at the anal opening.d) rectal itching/burningDate Initiated: 03/02/2026 . A record review of Resident #3's physicians' orders revealed Resident #3 was admitted to hospice services on 6/22/2023, call (hospice services) 24/7 for anything (phone number provided). A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 2:57 PM that a CNA checked upon Resident #3 for incontinent care when she saw blood on Resident #3's bedding and adult brief; . nurse called (name of hospice service) hospice and they will send a nurse . A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 3:49 PM that a hospice nurse approved Resident #3's transfer to a hospital for a SANE evaluation (sexual assault nurse examiner); upon assessment and evaluation, (name of hospice contractor) hospice nurse approved of sending him to ER if there is suspicion of assault. A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 4:00 PM ADON and Administrator notified of Hospice order to send to ER (emergency room) for eval and treatment. A record review of Resident #3's nursing progress notes revealed LVN D documented on 2/24/2026 at 6:50 PM Resident #3 had returned from the hospital, Date and Time of Patient Arrival: 2/24/26 arrived at 6:20pm; Where admitted from: (name of hospital). A record review of Resident #3's nursing progress notes revealed NP G documented on 2/25/2026 that Resident #3 was assessed at the hospital by a sexual assault examiner with no evidence for sexual assault, . In the ER, thorough exam by SANE nurse showed no obvious external trauma, no abdominal or chest wall tenderness. likely source of bleeding from grade 2 hemorrhoids. During an interview on 4/3/2026 at 1:20 PM ADON H stated Resident #3's hospice nurse had alleged Resident #3 had been sexually assaulted and the facility sent Resident #3 to the hospital for rectal bleeding where he was assessed with hemorrhoids as the source of the bleeding. ADON H stated she was not aware if the facility had reported to the State Agency the alleged sexual assault for Resident #3. During an interview on 4/3/2026 at 5:00 PM the Administrator stated he was aware of the hospice nurses' allegation of sexual assault for Resident #3 and had not reported nor submitted an investigation report for the allegation of sexual abuse. A record review of the facility's undated Abuse, Neglect, and Exploitation policy revealed, Identification of abuse, neglect, and exploitation: the facility will have written procedures to assist staff in identifying the different types of abuse mental or verbal, sexual, physical, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: resident, staff or family report of abuse. Investigation of alleged abuse, neglect, and exploitation: an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. Reporting of all alleged violations to the Administrator, state agency, adult Protective Services, and to all other required agencies, (e.g., law enforcement when applicable) within specified time frames: immediately, But not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview, and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 6 residents (Resident #3) reviewed for reporting alleged violations. On 2/22/2026 the facility failed to report to the State Agency an allegation of sexual abuse when a hospice RN alleged Resident #3 was sexually abused. This failure could place residents at risk of ANE and a diminished sense of self-worth.Findings included: A record review of Resident #3's admission record, dated 4/3/2026, revealed an admission date of 2/24/2026 with diagnoses which included senile degeneration of brain (age-related, progressive decline in cognitive function caused by structural brain damage, commonly due to protein buildup), aphasia (impaired ability to understand or produce speech, as a result of brain disease or damage), second degree hemorrhoids (second-degree internal hemorrhoid bulges from the anus during bowel movements, then goes back inside by itself). A record review of Resident #3's change in status MDS assessment, dated 3/23/2026, revealed Resident #3 was an [AGE] year-old male admitted with hospice care. Resident #3 was assessed with a non-traumatic brain disorder and a serious mental illness, highly impaired sense of hearing, severely impaired sight, and could sometimes understand others and sometimes could make himself understood. Resident #3 was assessed as having memory problems and had severely impaired cognitive skills for daily decision making. Resident #3 was assessed as needing substantial maximal assistance with toileting hygiene. Resident #3 was assessed as always incontinent of bowel and bladder. A record review of Resident #3's care plan, dated 4/3/2026, revealed, .Potential for alteration in comfort related to hemorrhoids initiated 03/02/2026 . Assess for s/sa) small amount of blood in the stool or on toilet paper after wipingb) incomplete bowel movementsc) soft lump felt at the anal openingd) rectal itching/burning. A record review of Resident #3's physicians' orders, dated 4/3/2026, revealed Resident #3 was admitted to hospice services on 6/22/2023, call (hospice services) 24/7 for anything (phone number provided). A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 2:57 p.m. that a CNA checked on Resident #3 for incontinent care when she saw blood on Resident #3's bedding and adult brief; . nurse called (name of hospice service) hospice and they will send a nurse . A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 3:49 PM that a hospice nurse approved Resident #3's transfer to a hospital for a SANE evaluation (sexual assault nurse examiner); upon assessment and evaluation,(name of hospice contractor) hospice nurse approved of sending him to ER (emergency room) if there is suspicion of assault. A record review of Resident #3's nursing progress notes revealed LVN E documented on 2/22/2026 at 4:00 PM ADON and Administrator notified of Hospice order to send to ER for eval (evaluation) and treatment. A record review of Resident #3's nursing progress notes revealed LVN D documented on 2/24/2026 at 6:50 PM Resident #3 had returned from the hospital, Date and Time of Patient Arrival: 2/24/26 arrived at 6:20pm; Where admitted from: (name of hospital). A record review of Resident #3's nursing progress notes revealed NP G documented on 2/25/2026 that Resident #3 was assessed at the hospital by a sexual assault examiner with no evidence for sexual assault, . In the ER, thorough exam by SANE nurse showed no obvious external trauma, no abdominal or chest wall tenderness. likely source of bleeding from grade 2 hemorrhoids. During an interview on 4/3/2026 at 1:20 PM ADON H stated Resident #3's hospice nurse had alleged Resident #3 had been sexually assaulted and the facility sent Resident #3 to the hospital for rectal bleeding where he was assessed with hemorrhoids as the source of the bleeding. ADON H stated she was not aware if the facility had reported to the State Agency the alleged sexual assault for Resident #3. During an interview on 4/3/2026 at 5:00 PM the Administrator stated he was aware of the hospice nurses' allegation of sexual assault for Resident #3 and had not reported the allegation of sexual abuse. A record review of the facility's undated Abuse, Neglect, and Exploitation policy revealed, Identification of abuse, neglect, and exploitation: the facility will have written procedures to assist staff in identifying the different types of abuse mental or verbal, sexual, physical, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: resident, staff or family report of abuse. Investigation of alleged abuse, neglect, and exploitation: an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. Reporting of all alleged violations to the Administrator, state agency, adult Protective Services, and to all other required agencies, (e.g., law enforcement when applicable) within specified time frames: immediately, But not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment including the right to be fully informed in language that he or she understood of his or her health status, including his or her medical condition for 1 of 1 resident (Resident #1) reviewed for resident rights. 1. The facility failed to have an effective method of communicating with Resident #1 who was deaf and mute. This failure could place residents at risk of poor communication and a demoralized sense of self-esteem and psychosocial wellbeing.The findings include: A record review of Resident #1's admission record revealed an admission date of 1/27/2025 with diagnoses which included deaf non-speaking, unspecified focal traumatic brain injury, schizoaffective disorder bipolar type (a chronic mental health condition combining psychotic symptoms (hallucinations, delusions) with manic and often depressive mood episodes). A record review of Resident #1's admission MDS dated [DATE] revealed resident #1 was a [AGE] year-old male admitted for long term care with supports for ADL safety with his diagnosed paraplegia (the impairment of motor or sensory function in the lower half of the body, usually caused by spinal cord injury or disease). A record review of Resident #1's physicians orders dated 4/3/2026 revealed the physician ordered the facility for Resident #1, May use hand-talk for communication / interpretation with resident. A record review of Resident #1's care plan dated 4/3/2026 revealed (Resident #1) Has impaired communication due to being deaf and mute. Resident refuses to use a communication board, which is only to have someone who can use sign language. Uses interpreter services with (name of ASL contractor)[JE2] via video. Goals: Will be able to communicate basic needs with a communication / interpreter device through next review date . target date 3/18/2026 . Interventions: answer Questions as needed and repeat as necessary . communicate through communication method - sign language, writing or interpreter / communication device / pad, interpreter services. set up ASL (a complete, visual hand language used by the Deaf community in North America. During a joint interview on 3/31/2026 at 10:00 AM with the Administrator and the DON stated Resident #1 was a resident at the facility and described Resident #1 as a [AGE] year-old male deaf person who could communicate with hand gestures, could read and write, and could read lips. The Administrator and the DON stated the SW could communicate with Resident #1 with ASL and the facility had as needed interpreter services through an ASL interpreter contractor. The Administrator and the DON stated Resident #1 had a tablet computer an iPad which he used to call people and had a visual interpreter service. During an interview on 3/31/2026 at 3:00 PM the Facility's State Agency assigned Ombudsman stated The Ombudsman stated she learned from Resident #1 and the Administrator that the facility believed Resident #1 could read, write, spell, and read lips, which Resident #1 had poor reading, writing, spelling skills, and could not lip read. The Ombudsman stated she learned from Resident #1's (relative) that Resident #1 had lost his hearing early in life before he could learn to speak, read, and write. The Ombudsman stated the facility had failed to assist Resident #1 with his iPad and VRS service. During an interview on 4/1/2026 at 11:00 AM with an independent Pro bono (a Latin phrase meaning for the public good) ASL interpreter and Resident #1, Resident #1 stated The facility has occasionally provided a meeting with an ASL interpreter who can actually sign but (Name of the Administrator has not helped me with my computer tablet calling program which has stopped working and when it did work the internet service was too slow and the visual signs could not be seen because of the choppy and blurry video. During a joint interview on 3/31/2026 at 3:35 PM with CNA K and CNA L stated they were CNAs who cared for Resident #1 and demonstrated their CNA Kardex (a centralized, frequently updated, and easy-to-reference nursing electronic documentation system that acts as a summary of patient information and care plans) for Resident #1. CNA K and CNA L stated there was no instructions for communicating with Resident #1 with a phone call and were unaware of a VRS system. CNA K and CNA L stated they and Resident #1 would communicate with hand gestures and head nods for care with ADL. CNA K and CNA L stated they could not use or understand ASL. During an interview on 3/31/2026 at 3:44 PM LVN M stated she was the charge nurse for Resident #1 and reviewed Resident #1's care plan. LVN M stated the care plan had no interventions for a VRS telephone number. LVN M stated she was unaware of a VRS telephone system to communicate with Resident #1. LVN M stated she and Resident #1 would communicate with hand gestures and head nods for assessments and medication administration. LVN M stated she could not use or understand ASL. LVN M stated she was aware Resident #1 could somewhat read and write but the communication was poor. LVN M stated she was unaware how to set up an ASL translator to communicate with Resident #1 and if available she could call upon the SW because the SW could use ASL. During a joint interview on 4/2/2026 at 5:00 PM the Administrator, the DON, and the SW stated the SW had basic ASL communication skills and could interpret communication with Resident #1 but the SW had no formal ASL training and held no ASL certificates. The SW stated she worked 40-60 hours a week and served around 100 residents and did not work 7 days a week or 24 hours a day. The Administrator stated that during those times when SW was not available the FSM could also serve as an interpreter, however the FSM also did not have a formal education for ASL and did not hold any ASL certificates as an interpreter. The Administrator stated Resident #1 could read and write and could also read lips. The Administrator stated Resident #1 could also communicate with anyone with his iPad which he used to call out to anyone. The Administrator stated the service was provided by Sorenson's and identified Resident #1's phone number as (phone number) and stated the phone number was documented on Resident #1 admission record, The Administrator stated he had used the number to call Resident #1. The Administrator stated he believed Resident #1's care plan was accurate and adequate to provide instructions for care. A record review of The National Association Of The Deaf website www.nad.org accessed 4/9/2026 revealed, To Whom it May Concern:The National Association of the Deaf ( NAD) seeks to ensure that all healthcare providers, including long-term care facilities, rehabilitation facilities, skilled nursing facilities, and similar entities, understand their legal obligations with respect to serving deaf and hard of hearing patients and companions. The Americans with Disabilities Act ( ADA) has clear mandates requiring healthcare providers to provide effective communication to individuals who are deaf or hard of hearing. Healthcare providers that violate such provisions are subject to legal action . This letter contains all the information necessary for long-term care facilities and similar entities to understand the requirements for ADA compliance when serving deaf and hard of hearing patients and companions. Title III of the ADA applies to all private health care providers, including long-term care facilities and similar entities. Healthcare providers must furnish (that is, obtain and pay for) any auxiliary aid or service that is necessary to achieve effective communication with the deaf or hard of hearing patient or companion of a patient. To be effective, an auxiliary aid or service must ensure that the deaf or hard of hearing individual can both understand and participate in discussions or other interactions.c. The deaf population varies greatly in its ability to read lips and/or to communicate in written English. Therefore, a short or simple interaction may still require an interpreter if the deaf or hard of hearing individual communicates successfully only through sign language.d. Ultimately, the key inquiry is whether the communication was effective, that is, could the healthcare provider communicate with the patient (or other relevant party) as thoroughly and effectively as he or she could with a hearing person.3) Auxiliary aids and services include but are not limited to qualified sign language interpreters. See 28 C.F.R. S 36.303(b).a. Auxiliary aids and services can also include Video Remote Interpreters ( VRIs), oral interpreters, cued speech transliterators, tactile interpreters, Certified Deaf Interpreters ( CDIs), captioning of audio-visual materials, and text-based services such as Communication Access Realtime Transcription ( CART). See 28 C.F.R. S 36.303(b).b. Any interpreter provided must also be qualified.i. To be qualified, an interpreter must be able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. 28 C.F.R. S 36.104.ii. The following individuals are not qualified interpreters: (1) an employee or staff member who knows basic sign language; (2) family members, adult companions, and minor children of the patient or service recipient, except in certain cases of emergency; (3) any interpreter who does not communicate proficiently with the deaf or hard of hearing individual. It is important to ensure that the interpreter provided is properly licensed as many states require sign language interpreters to obtain state licenses.

Based on observation, interview and record review the facility failed to provide a safe, sanitary, comfortable, and homelike environment for 1 of 6 residents (Resident #1). The facility failed to ensure Resident #1's room was clean, sanitary and did not have a strong smell of urine. This failure could place residents at risk of living in unsafe, unsanitary, and uncomfortable conditions which could lead to a decline of mental and physical health and decreased social interactions. Findings included: Record review of Resident #1's admission Record, dated 02.13.2026, revealed Resident #1 was admitted to the facility on 10.03.2024 with diagnoses of Acute Kidney Failure, Chronic Kidney Disease, Muscle Weakness and the Need for assistance with personal care. Record review of Resident #1's MDS, dated 2.2.2026, revealed Resident #1 has a BIMS of 15. MDS also revealed that Resident #1 sometimes refuses care 1-3 days a week, and substantial assist to the toilet. Record review of Resident #1's Care Plan, last revision 2.2.2026, revealed Resident #1 suffers from incontinence related to impaired mobility and behaviors. Further review of the Care plan revealed Resident #1 should use briefs through the review period. During observation on 2.13.2026 at 11:23 am on the second floor of facility there was a strong odor of urine in the hallway noted when exiting the elevator. The odor could be smelled down the hallway and appeared to come from Resident #1's room. Resident #1 was observed opening his room door and the odor became stronger with an odor similar to the smell of ammonia. Observation of Resident #1's room revealed, a strong presence of an odor of urine, the bed was unmade and had a mattress protector in place. The mattress protector and sheet were a faded yellowish/brown color. Resident #1 stated that he could not smell the odor. Surveyor also noted two housekeepers on hallway. During an observation on 2.13.2026 at 2:28 pm Resident #1's door was closed. The hallway still smelled of urine, despite the room being closed. Upon opening Resident #1's door, the surveyor was overcome with the smell of urine. The bed had been made but the smell of urine was still so strong that the surveyor could only stay in room for a few minutes. During an interview on 2.13.2026 at 2:28 pm, the Housekeeper stated she normally worked 12:00 pm - 8:00 pm and cleaned Resident #1's room around three times a day. Housekeeper also stated the 6:00 am - 2:00 pm shift also cleaned the resident's room once a day. The Housekeeper stated they changed out the resident's mattress before trying to help with the odor of urine, but it had not helped. The Housekeeper stated other residents had not complained to her about the smell, but the staff complained all the time. During an interview on 2.13.2026 at 3:00 pm, the Maintenance Director stated Resident #1's room had smelled like that for a while now. The Maintenance Director stated they were aware and had been cleaning the room, but it had not helped. Surveyor asked the Maintenance Director if they had tried to strip the floor as maybe the urine has imbedded in the flooring. The Maintenance Director stated the floors in the rooms could not be stripped. He stated all they could do was try to keep cleaning the room. During an interview with facility Administrator on 2.13.2026 at 2:45 pm, the Administrator stated there had issues with Resident #1 not getting out of bed to utilize the toilet. The Administrator stated this had been an on-going issue. The Administrator further stated Resident #1 refused to use the briefs that were provided to him.

Based on interviews and record reviews, the facility failed to ensure the rights of the residents to be from from abuse for 3 of 3 residents reviewed for abuse.Resident # 6 was abused by LVN B.Resident #7 was abused by LVN B.Resident #8 was abused by LVN B.These failures could place residents at risk of more abuse and diminish their quality of life.Record review of Resident #8's face sheet dated 1.6.2026 revealed an [AGE] year-old female was admitted on 3.1.2019 with diagnoses: anxiety disorder, hypertensive heart disease without failure (high blood pressure that causes structural changes to the heart), and major depressive disorder.Record review of Resident #8's Care Plan dated 12.10.2025 revealed she was care planned for major depressive disorder, anxiety, and fall precautions due to dizziness and giddiness. Record review of Resident #8's AMDS dated 12.16.2025 revealed she had a BIMS score of 13, indicative of no cognitive impairment.Record review of Resident #6's face sheet dated 1.8.2026 revealed a 66 -year-old male was admitted on 7.24.2019 with diagnoses: end stage renal disease (kidneys failed), type 2 diabetes (body cannot produce enough insulin), and anxiety disorder.Record review of Resident #6's Care Plan dated 11.26.2025 revealed he was care planned for dialysis, and right leg below knee amputee.Record review of Resident #6's QMDS dated 12.21.2025 revealed he had a BIMS score of 15, indicative of cognitively intact.Record review of Resident #6's progress notes revealed Resident #6 was out to dialysis on 1.7.2026. Record review of Resident #7's face sheet dated 1.6.2026 revealed a [AGE] year-old male was admitted on 3.29.2024 with diagnoses: diabetes type 2, COPD, schizophrenia, and anxiety disorder.Record review of Resident #7's Care Plan dated 1.7.2026 revealed he was care planed for anxiety, schizophrenia, and behaviors with aggression.Record review of Resident #7's QMDS dated 12.3.2025 revealed he had a BIMS score of 5, indicative of severe cognitive impairment. However, the resident was able to interview and recalled incident with LVN B.Interview on 1.6.2026 at 3:00PM Resident #7 said he was pissed off about that nurse and what she did. He said LVN B was very disrespectful, and she always had a bad attitude. He said he was glad she was gone and things had been a lot better without her. He said he had signed himself out and wanted to listen to his radio but she would not put the code in for the door for him to go out the door to sit on the porch.Interview on 1.6.2026 at 3:10PM Resident #8 said she remembered that nurse and she was not very nice. She said that whole thing that happened went too far with her and she was glad that she was not there any longer. She said she was upset about it because it was none of her business what she did with her money, but she was glad she was gone and it's been much better without her because she acted like a bully.Interview on 1.8.2026 at 3:05PM Resident #6 said LVN B and he were going back and forth telling each other off. He said when she hit him, he hit her back, but he didn't say anything about it- it was nothing to me. I've had worse. Resident #6 said it all happened in front of other workers, and she pushed his chair and pushed him in the chest and he hit her back. He said he was very mad about it, and he wanted to find out what car she drove so he could flatten her tires. Resident #6 said when he found out she was fired, he was very happy, but he didn't say nothing to nobody, someone must have told about her and she got fired. He said he was mad for a little while and he felt better. He said when he found out she was fired, he felt much better. Interview on 01.09.2026 at 5:00PM The Administrator said LVN B called him and told him Resident #6 called her a black bitch nigger and Resident #6 was freaking out. He said she told him that the television was loud, and she asked him to turn it down but he refused, so she unplugged the television. He said she told him it was kind of late and she would turn it down and he would turn the volume back up again and he was fine at the time while he played chess with Resident #8. The Administrator said he received a call from MA C who told him that the call from LVN B was not true. He said she told him that Resident #6 was playing chest with Resident #8 and she asked him to turn the television down, but he did not hear because he was hard of hearing. He said CNA C told him since he did not turn it down, the LVN unplugged the television and Resident #6 became angry. He said the CNA told him that the LVN asked Resident #8 why she gave him $200 when he stole money from you? and Resident #6 became very angry and he asked CNA D to give him the telephone number to the Administrator so he could call him. MA C told him when Resident #6 tried to go to the nurses station to get the number because it was posted on the wall, LVN B grabbed his chair to keep him from going so he tried to hit LVN B and she grabbed Resident #6's wrist and held it against his chest. LVN B then used the medication cart to block Resident #6's entry. The Administrator said MA C told him that LVN B told them they were done playing chess and she dumped the pieces into the cubby under the table. MA C said Resident #6 and Resident #8 eventually returned to play chess. The Administrator said he sent a text message to LVN B who he thought was MA C (he had put the wrong number under the wrong name) and LVN B asked him if he had the right number. He said MA C told him when she was at work, LVN B confronted her and threatened to beat her up and she had threatened other staff. The Administrator said MA E recorded the incident with LVN B and Resident #7. The Administrator said he listened to the recording and LNV B told Resident #7 he could not go outside on the front porch to listen to music on his radio after he signed himself out. The Administrator said Resident #7 told LVN to shut up and she told Resident #7 to shut up. The Administrator said LVN B told Resident #7 he needed to go back upstairs, he didn't live down there and he was not going to disrespect her; there were 2 nurses upstairs and he needed to take his ass back upstairs to disrespect 2 nurses. The Administrator said LVN B had been suspended upon investigation and then terminated. He said he referred her nursing license as well. Interview on 1.13.2026 at 2:11PM during a returned call, MA C said Resident #6 and Resident #8 were playing chess and listening to music on the television. She said LVN B was on the phone with a provider, and she told Resident #6 to turn the television down, but he did not hear her. MA C said when LVN B got off the phone, she asked him to turn the television down and he turned it down but not to her satisfaction. MA C said Resident #6 asked LVN B what was her problem and she told him, we got rules down here. MA C said Resident #6 called out to CNA D to get the Administrator's telephone number and LVN B told him that until he respected her, he could not call the Administrator. MA C said she did not see when LVN B grabbed him, but Resident #6 became more angrier and called her names. MA C said LVN B asked Resident #8 why she gave Resident #6 $200 when he acted like that and she continued to antagonize her about the money and Resident #8 asked if she (MA C) told her about the money, but she (MA C) denied. MA C said she suggested to Resident #8 that maybe Resident #6 told someone because he was happy about the Christmas gift from her. MA C said LVN B tried to block Resident #6 from going to the nurses station to get the Administrator's telephone number by using a medication cart. Interview on 1.13.2026 at 4:20PM CNA D returned the call and said she was sitting at the nursing station and LVN B was on the phone. She said the television was on 15 for the sound and LVN B told them to turn it down; Resident #6 and Resident #8. CNA D said Resident #6 said it wasn't loud and LVN B told him to go back to his room. CNA D said LVN B then got up and unplugged the television because they did not turn it off. CNA D said Resident #6 asked LVN B why she did that and LVN B told him to go to his room. CNA D said while LVN B was at the nursing station, Resident #6 tried to swing on LVN B because she stopped him from going into the nurses station to get the Administrator's telephone number, and she grabbed his arm and put it on his chest. CNA D said Resident #6 told her it hurt and he sounded like he was about to cry and asking her if she was going to let it go. CNA D said LVN B finally let him go and she went to put the chess pieces away. CNA D said when LVN B called the Administrator, she lied about what happened.Record review of facility policy title, Abuse, Neglect, and Exploitation dated 2025 stated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under Policy Explanation and Compliance Guidelines stated in part: a. Prohibit and prevent abuse.

Based on observations and interviews, the facility failed to provide a safe and homelike for 3 of 3 residents' rooms observed for electricity and 3 of 3 residents affected (Resident #1, Resident #2, and Resident #3).Rooms #10 (Resident #3), #11 (Resident #1), and #12 (Resident #2) had no over the bed lights and electrical issues with other electronics.This failure could place residents at risk a lack of comfort, risk for falls, and a diminished quality of life in the facility. The findings included: Record review of Resident #1's face sheet dated 1/7/2026 revealed a [AGE] year-old-male was admitted to the facility on [DATE] with the diagnoses: major depressive disorder, schizoaffective disorder, bipolar type, traumatic brain injury, and PTSD.Record review of Resident #1's Care Plan dated 12/3/2025 revealed he was care planned for PTSD, traumatic brain injury, and risk for falls.Record review of Resident #1's QMDS dated [DATE] revealed he had a BIMS score of 14, indicative of cognitively intact.Record review of Resident #2's face sheet dated 1.7.2026 revealed a 64 - year- old male was admitted to the facility o 6.20.2024 with diagnoses: left side hemiplegia (left side paralysis), diabetes type 2 (body's inability to produce insulin), major depressive disorder (mood disorder that causes persistent sadness), and PTSD (Post Traumatic Stress Disorder- stems from witnessing or experiencing a traumatic event).Record review of Resident #2's Care Plan dated 12.17.2025 revealed he was care planned for PTSD, major depressive disorder, fall precautions due to hemiplegia, and mild cognitive impairment.Record review of Resident #2's QMDS dated 12.25.2025 revealed he had a BIMS score of 13, indicating no cognitive impairment.Record review of Resident #3's face sheet dated 1/7/2026 revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses: hypertension, anxiety disorder, and age related physical disability.Record review of Resident #3's Care Plan dated 12/29/2025 revealed she was care planned for falls, gait balance problem, falls related to seizures.Record review of Resident #3's QMDS dated [DATE] revealed she had a BIMS score of 14, indicative of cognitively intact.Interview on 1/6/2026 at 5:10PM MS said he replaced the outlets in rooms #10, #11, #12 and the main issue was room [ROOM NUMBER]. He said it was the wiring and he did not have the equipment to fix it. The MS said he had a list of electricians to contact including the one they use as contracted, but they all had prior appointments, and it would be over a month before they could come out. He said the circuit breaker was replaced but that was not the issue. He said the over-the bed lights were connected to the same circuit. The MS said the wires in the walls were old in an old building and in the past week, the circuit breaker would not stay on, so as a precaution he turned it off. He said they had a contracted electric company. The MS said it was important for the residents to be able to have things work in their rooms because it was their home. He said it was the residents' right to have a homelike environment.Interview on 1/6/2026 at 5:20PM the Administrator said they were working on finding a company to fix the electrical problems they had in the rooms. He said the residents had the right to live in an environment that was safe and homelike to maintain a livable quality of life. Observation and interview on 1/9/2026 at 4:42PM revealed room [ROOM NUMBER] was dark, only the light from the hallway gave some illumination to the room. Resident #1 was sitting in his wheelchair and his roommate was asleep with the cover over his head. Resident #1 said there had not been electricity in the room since a week before Halloween. He said the lights in the room didn't work, the television didn't work, nor the over the bed lights. He said he almost fell going to the bathroom because the room was dark. He said the bathroom light worked but he did not want to see his roommate use the bathroom or have the light on all the time. He said he was told they were working on it but nothing yet. He said he was told he could go to the common area to watch television, but he said he did not want to go there because there was too much noise. The investigator attempted to turn on the lights over the beds, but they did not work. The investigator attempted to turn on the main light in the room, but it did not work. Resident #1 attempted to turn on the television, but it did not work. Observation of room#12 and interview on 1/9/2026 at 4:50PM Resident #2 was in bed, watching television. His room was dark with the illumination from the hallway lighting the room partially. A digital clock was on the nightstand that displayed the correct time, and the air conditioner was on. Resident #2 said his television would short out while he would be watching it and wouldn't work. He said he was told they were working on it and they were going to find someone to fix the problem. Resident #2 said he felt like they did not care, especially for the money he paid monthly to live there. He said he did not want to go out to watch television, and he preferred to sit in his room because other people can be unruly, fighting one another, taking other people's things if you leave it too far from your reach. He said the breaker kept tripping and caused electrical issues for his room and others. The investigator attempted to turn on the over the bed light, but it did not work.Observation of room [ROOM NUMBER] and interview on 1/9/2026 at 4:56PM Resident #3 was sitting in her chair next to her bed, talking with other people in the room. The main light was turned on, but only provided enough light for the front of the room. The investigator attempted to turn on the over the bed lights, but they did not work. Resident #3 said sometimes the bathroom light did not work. She said it didn't bother her roommate in the first bed because she was blind, (the roommate agreed) but she fell when she tried to get back in bed after she had gone to the bathroom. She said she missed sitting on the bed and slid to the floor, but she was not injured. She said it occurred once in the bathroom when the light did not work, but again, she was not injured. Record review of facility policy titled, Safe and Homelike Environment dated 2025 stated: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 6. The facility will provide and maintain adequate and comfortable lighting levels in all areas.a. The Maintenance Director will perform periodic rounds to ensure functioning lights.

Based on interview and record review, the facility failed to utilize nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1of 1 facilities.The facility failed to ensure Staff Member A had an MA certificate from [DATE] to [DATE] for a total of 88 shifts and passed medications to residents.This failure could place residents at risk of medication errors, inaccurate assessment, and illness.The findings were: Record review of the staff roster provided by the facility on [DATE] revealed Staff Member A's title was LVN. Record review of Staff Member A's employee file revealed a hire date of [DATE] as a MA. Review of the Texas Board of Nursing license verification on [DATE] at 5:26 p.m. revealed Staff Member A had a graduation permit that was issued on [DATE] and expired on [DATE]. Record review of 4 resident's EMAR's for the facility revealed Staff Member A was signing as an MA. Record review of Staff Member A's shifts worked at the facility as a MA provided by the DON revealed Staff Member A worked the 6a-2p shift on [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], 10//27/25 through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE] 6a-5pm. This was a total of 88 shifts. Record review of a facility training for CMA's and nurses on documentation for [DATE] revealed Staff Member A signed the facility training on [DATE] at 1:45pm as a CMA.Record reviews of 4 resident records revealed no hospitalizations, harm, or negative outcomes due to Staff Member A's administration of medications to residents.Record review of TULIP application screenshot provided by the DON shows Staff Member A submitted her application for CNA examination on [DATE]. Under the NA certificate and MA permit status both say prospective.In an interview on [DATE] at 1:07 p.m., Staff Member A stated she was a GVN and had been working at the facility since March of 2025. Staff Member A stated she had been a GVN for 7 months. Staff Member A stated she was always supervised by the same nurse RN C and worked the same shift and schedule as RN C.Interview and observation with Staff A on [DATE] @ 4:30 p.m., Staff Member A pulled up her GVN number on her phone and the DON went to the Texas BON license verification portal and confirmed GVN name and number on Texas BON was expired [DATE]. Interview with DON on [DATE] @ 4:30 p.m. revealed the staff roster where Staff Member A was listed as an LVN was incorrect and she was unsure why she was listed as an LVN. The DON stated the facility was monitoring the BON status for Staff Member A. The DON then stated Staff Member A was not an MA and had not taken the MA test as she could not submit anything to the BON or TULIP and does not have her medication aide certificate. The DON confirmed Staff Member A was listed in the facility's computer system as an MA. The DON stated Staff Member A worked as an MA or CNA but not as a nurse since she was hired at this facility. The DON stated she was not aware of the expirations or that she had no MA certificate or that her CNA certificate had expired. The DON stated Staff Member A had always worked with a nurse's supervision and there had been no medication errors or incidents with Staff Member A administering medications. The DON stated Staff Member A only worked on the first-floor halls, which currently consisted of 40 residents. In an interview on [DATE] at 6:20 p.m., the HRD stated she had verified Staff Member A's GVN was expired upon hire, and she had no LVN license and she had no MA certificate. The HRD stated she informed the DON and the DON told her it was okay because she was going to work with Staff Member A in preparation for her licensure exam. In an interview on [DATE] at 6:45 p.m., the DON stated the possible consequences of staff not having certifications or permits could be complications in general but there had not been any. Interview with Administrator on [DATE], Administrator stated he was not aware that Staff A did not possess a current MA certificate. Review of the facility policy on license verification undated but at the bottom uses references dated 2025 with a copyright for 2025 revealed All personnel that require a license or certification shall be verified through the appropriate issuing agency. 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. 2. An individual will not be employed and or/will be terminated from employment (whichever case may apply) if: a. The individual has lost licensure/certification for any reason.

Based on interviews and record review the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for psychosocial concerns. LVN A failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of fear on 05/01/2024. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal. This failure to ensure interventions were implemented or psychiatric services were promptly arranged can result in the individual not receiving the necessary care to prevent a decline in health. Findings included: Record review of Resident #1's Admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on [DATE] to an acute care hospital. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills. Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated he had moderately severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. Record review of Resident #1's care plan revealed: - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan. Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation, and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion, and pulling hard on the shirt to make it tighten enough to cut off his airflow. Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.). In an interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff were really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. In an interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring. In an interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of the care plan that she needed information on. In an interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. In an interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including (3) which professional services are responsible for each element of care . This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows: Summary of details which lead to outcomes. On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: 0742: The facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for Resident #1. Immediate Corrective Actions for Removal of Immediate Jeopardy: On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern: - Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. - All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. - All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned. - All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. - Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness, and reporting psychosocial changes to provider with a completion date of 5/26/2024. - Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 5/26/2024. Identification of other affected: All residents who are diagnosed with a mental disorder or psychosocial adjustment have the potential to be affected. Systemic Changes and/or Measures: - Education provided to all nursing staff on May 26, 2024, on behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted with a completion date of 5/27/2024. - Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives, and timetables to assure residents highest functional, and psychosocial well-being are attained with a completion date of 5/27/2024. - Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 pm Tracking and Monitoring: - Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately and physician will be notified via phone with any observations noted. - Assistant Director of Nursing, or designee, will review 24 hours report in EHR, daily Monday through Friday, to identify any new, acute, mental, or psychosocial concerns from previous day, and validate they were addressed to include follow up with provider/physician was completed as indicated. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately and physician will be notified via phone with any observations noted. The facility's POR Verification was as follows: Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed: 1. A copy of the two Ad hoc QAPI Meetings: - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring orders. Interviews with 17 of 19 licensed nursing staff from different shifts were completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). In an interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial medications, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered, and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records, and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward with their monitoring and interventions to reflect the facility's resident's needs and behaviors more accurately. In an interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. In an interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended the Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal. In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report dated start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. 1. Record review of Resident #2's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview. Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA. Record review of Resident #2's care plan revealed: - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision-making, long-term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility, and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: antidepressant medication- observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: antianxiety medication- observe for behavior AGITATION. Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well-being. 2. Record review of Resident #3's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills. Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #3's care plan revealed: - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift enter progress note describing behaviors observed if applicable. The second order was: Observation: antidepressant medication- observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. 3. Record review of Resident #4's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #4's care plan revealed: - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety. - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood problems related to dementia with behaviors and history or suicidal behaviors with interventions, date initiated 02/29/2024, Monitor/record/report to MD prn acute episode feelings or sadness ., Monitor/record/report to MD prn mood patters s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, Monitor/record/r [TRUNCATED]

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 13 residents reviewed for comprehensive care plan, in that: LVN A failed to follow the plan of care on 05/01/2024 which required Resident #1 to be monitored and a PCP to be notified if Resident demonstrated a fear of being alone. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal. This failure could result in residents not receiving the necessary care to prevent a decline in health due to failure to follow a resident's care plan. Findings included: Record review of Resident #1's Admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on [DATE] to an acute care hospital. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills. Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated the resident had moderate severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. Record review of Resident #1's care plan revealed: - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan. Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. The note revealed Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion and pulling hard on the shirt to make it tighten enough to cut off his airflow. Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.). Interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff was really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. Interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring. Interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of care plan that she needed information on. Interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. Interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including .(3) which professional services are responsible for each element of care; . This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows: Summary of details which leads to outcomes. On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F656: The facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for Resident #1. Immediate Corrective Actions for Removal of Immediate Jeopardy: On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern: - Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. - All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. - All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned. - All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. - Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness and reporting psychosocial changes to provider with a completion date of 05/26/2024. - Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 05/26/2024 Identification of Other Affected: All residents who are diagnosed with a mental disorder or psychosocial adjustment have the potential to be affected. Systemic Changes and/or Measures: - Education provided to all nursing staff on May 26, 2024, on Behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted, with a completion date of 05/27/2024. - Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives and timetables to assure residents highest functional, and psychosocial well-being are attained, with a completion date of 05/24/2024. - Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of Removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 p.m. Tracking and Monitoring: - Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately, and physician will be notified via phone with any observations noted. - Assistant Director of Nursing, or designee, will review 24 hours report in EHR, to identify any new, acute, mental, or psychosocial concerns from previous day, to validate they were addressed and follow up with provider/physician was completed as indicated. Physician will be notified via phone with any observations noted. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately. The facility's POR verification was as follows: Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed: 1. A copy of the two Ad hoc QAPI Meetings: - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring order. Interviews with 17 of 19 licensed nursing staff from different shifts was completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). Interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial mediations, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward word their monitor and interventions to reflect the facility's resident's needs and behaviors more accurately. Interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. Interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal. Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders ordered on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. 1. Record review of Resident #2's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview. Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA. Record review of Resident #2's care plan revealed: - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, long term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: AntiDepressant Medication- Observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: Antianxiety Medication- Observe for behavior AGITATION. Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well being. 2. Record review of Resident #3's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills. Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #3's care plan revealed: - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease Process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift Enter progress note describing behaviors observed if applicable. The second order was: Observation: AntiDepressant Medication- Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. 3. Record review of Resident #4's Admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #4's care plan revealed: - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety. - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood problems related to dementia with behaviors and history or suicidal behaviors with interventions, date initiated 02/29/2024, Monitor/record/report to MD prn acute episode feelings or sadness ., Monitor/record/report to MD prn mood patters s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols, Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide ., and Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation . Record review of facility

Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 was safely discharged to a homeless shelter on 8/15/23. Resident #1's whereabouts remained unknown until 8/18/23, when he was found at a local park. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 8/18/23 at 6:32 p.m. While the IJ was removed on 8/19/23, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm with a scope identified as a isolated until interventions were put in place to ensure residents were discharged safely. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were: Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this document revealed Resident #1 did not have a responsible party or a guardian. Further record review of this face sheet revealed Resident #1 was discharged on [DATE] and his length of stay was 20 days. Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of this same document, revealed the following items: - Section G, Item G0110. Activities of Daily Living (ADL) Assistance. Review of this item revealed Resident #1 required one-person physical assist with the following activities of daily living: bed mobility, transfer, walking in room, walking in corridor, dressing, eating, toilet use, and personal hygiene. - Item Q0300A. Resident's Overall Expectation: Select one for resident's overall goal established during assessment process. The answer to this item was: Unknown or uncertain. The other options which were not selected for item Q0300 were: Expects to be discharged to the community, expects to remain in this facility, and expects to be discharged to another facility/institution. - Item Q0300B. Indicate information source for Q0300A. The answer to this item was: Resident. - Item Q0400A. Discharge Plan: Is active discharge planning already occurring for the resident to return to the community? The answer to this item was: No. - Items Q0500B. Return to the community: Ask the resident . 'Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?' The answer to this item was Unknown or uncertain. Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed. Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary form. There was no documentation regarding a discharge location or coordination of care to the local homeless shelter. Record review of Care Conference Summary, dated 8/16/23 at 11:01 a.m., revealed the DOR documented the following in the section titled: Summary of Therapy and/or Restorative: Resident was on therapy and was D/C on 8/11/23; Resident was on OT ST and PT; Resident is not a safe DC secondary to the Montreal Cognitive Assessment (MOCA) which the resident scored 6/30 which is severe cognitive deficits. Per IDT; it was determined that the resident was not a safe DC. There was no documentation on this Care Conference regarding a future discharge location or coordination of care for a safe discharge. Record review of Resident #1's orders, obtained on 8/17/23, revealed no physician order for Resident #1's discharge. Further record review of this document revealed Resident #1 had the following medications: - AmLODIPine Besylate Tablet 5 M [G [a medication used to lower blood pressure] Give 1 tablet by mouth one time a day for hypertention hold if bp below. Ordered on 7/27/23. - Bisacodyl Suppository [a medication used to relieve constipation] 10 MG Insert 1 suppository rectally every 24 hours as needed for constipation Bowel Protocol #3: Give if constipation unrelieved by oral laxative; If ineffective after 4 hours then do assessment. Ordered on 7/26/23. - cloNIDine [a medication used to treat hypertension] Transdermal Patch Weekly 0.1 MG/24HR (Clonidine) Apply 1 patch transdermally one time a day every Mon for hypertension notify provider if BP less than 110/60, pulse less thab 60 and remove per schedule. Ordered on 8/4/23. - Fleet Oil Enema (Mineral Oil) [a medication used to treat constipation] Insert 1 application rectally every 24 hours as needed for constipation Bowel Protocol #4: Give if constipation unrelieved by suppository: If ineffective, call provider. Ordered on 7/26/23. - Lactulose Oral Solution 10 GM/15ML (Lactulose) [a medication used to treat constipation] Give 30 ml by mouth one time a day for elevated ammonia. Ordered on 7/27/23. - Milk of Magnesia Concentrate Suspension (Magnesium Hydroxide) [a medication used to treat constipation] Give 30 ml by mouth every 12 hours as needed for constipation Bowel Protocol #2: Give if no BM in last 3 days. Ordered on 7/26/23. - Multi-Vitamin/Iron Tablet (Multiple Vitamins-Iron) Give 1 tablet by mouth one time a day for supplement. Ordered on 7/27/23. - Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) [a type of vitamin] Give 1 tablet by mouth two times a day for Supplement. Ordered on 7/27/23. Record review of ST Progress Report, dated 8/8/23 and written by ST K, revealed the following: Remaining Impairments: Patient Demonstrates with severe cognitive deficits . Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: decreased ability to return to prior level of supervision/assistance, decrease leisure task participation and decreased participation with functional tasks. Record review of Speech Therapy Discharge Summary, dated 8/11/23 and written by ST K, revealed the following: How often does patient demonstrate adequate cog/com skills to complete age-appropriate complex living tasks?=26-49% of the time; How often does patient function safely without additional assistance/supervision due to cognitive deficits?=26-49% of the time. Memory= Impaired. Record review of OT Therapy Progress Note, dated 8/8/23 and signed by OT H, revealed: Patient characteristics that may Impact Treatment=Lacks capacity for chronic disease management, lacks insight into condition and risk factors. Record review of Resident #1's Occupational Therapy Treatment Encounter Note, dated 8/10/23 and written by COTA I, revealed: Pnt confused, disoriented to time and place, easily distracted, needs constant redirection, verbal and visual cues to follow one-step instructins [sic], sequencing of task. Record review of Resident #1's OT Discharge Summary, dated 8/11/23 and signed by OT H, revealed the following documentation in regards to Resident #1's ability to perform ADLs: - Lower body dressing: supervision or touching assistance. - Shower/bathe self: supervision or touching assistance. - Discharge Recommendations: 24 hour care. Record review of Physical Therapy Treatment Encounter Note(s), dated 8/11/23 and written by PTA J, revealed the following: Precautions: Confusion and Fall Risk. Record review of Resident #1's PT Discharge Summary, dated 8/17/23 and signed by PT A, revealed the following: -12 steps [referring to the patient's ability to safely go up and down twelve steps]: Partial/moderate assistance [which the resident does 50% of the work the rehabilitation therapist is doing 50% of the exercise or activity.] - Patient will exhibit improved dynamic activity/ambulation tolerance as evidenced by increase in distance on the Six Minute Walk Test to 1590 feet . Pt unable to follow test instructions on DC. - Assessment and summary of Skilled Services .Pt requires S/U - SUP for functional mobility due to cognitive deficits. - Discharge Recommendation and Status . Discharge Recommendations: Assistance with IADLs and 24 hour care. Record review of Resident #1's progress notes from 7/26/23 to 8/17/23, revealed the following progress notes: - Nursing Progress Note dated 8/15/23 at 4:17 p.m. and written by LVN G: This nurse was informed that pt was d/c to [local homeless shelter.] - Nursing Progress Note dated 8/15/23 at 11:29 a.m. and written by the DON: This nurse with the IDT agreed that this was an unsafe DC. - Discharge Plan Update Note dated 8/14/23 at 3:29 p.m. and written by the SW: In anticipation of upcoming discharge of resident, the following agencies were contacted for possible housing for resident: [8 local agencies were listed here, including the local homeless shelter Resident #1 was ultimately discharged to.] SW was informed by agencies ID is required or other forms of identification and would have to register, and resident had no form of ID. Administrator was informed of requirements for housing and that resident had none. SW told Adm. this is an unsafe discharge Adm. responded [Resident #1] had no payor source and would have to be discharged today. Adm. stated he should have been out yesterday because we are not getting paid. SW will continue to follow closely. Further record review of these progress notes ranging from 7/26/23 to 8/17/23 revealed no documentation that written records were provided to Resident #1's discharge location: the local homeless shelter. During an interview on 8/17/23 at 2:51 p.m., PT A stated Resident #1 had problems with sequencing . If you handed him a list of instructions, I don't think he would sequence things like that. Like pick this up, bring it over here, bring it back to me. PT A stated Resident #1 required queuing. PT A stated Resident #1 was on physical therapy for generalized weakness . just seeing if he had deficits and balance deficits. PT A stated Resident #1 had physical therapy from 7/27/23 until 8/11/23. PT A stated Resident #1 was discharged from physical therapy because per physician or case manager. They just discharged from the facility. I don't have a whole lot to do on that end. During an interview on 8/17/23 at 2:59 p.m., COTA B stated Resident #1 had occupational therapy from 7/27/23 to 8/11/23 and he had several goals such as increasing his ability to maintain balance, increase ability to perform lower body dressing, and bathe himself with the use of a bath bench. COTA B stated Resident #1 was discharged from the facility because he achieved his highest practicable level. During an interview on 8/17/23 at 3:15 p.m., the DOR stated, in the morning it's usually [the Administrator] . myself, the BOM, the SW, who attended that meeting because we talk about discharges, where they're [the residents are] at, and what's the plan. Well, that day [8/15/23] . we talked about [Resident #1] and that it's an unsafe discharge and [Resident #1] needs help with feeding in terms of verbal queues and he's at risk for failure to thrive. And I said that his last day for us would be at 8/11/23, and he'd need to be a long-term . We talked about him being long-term and the money. No one knew nothing about it [Resident #1's discharge.] [Resident #1] was gone before we ever walked out of the room. During an interview on 8/17/23 at 3:36 p.m., the Driver stated he transported Resident #1 to the local homeless shelter on 8/15/23 between 2:00 - 3:00 p.m. The Driver stated that his direct supervisor, the Maintenance Director, said he [the Driver] needed to transport Resident #1 to [the local homeless shelter]. The Driver stated he transported Resident #1's to the local homeless shelter's intake area, but did not see if Resident #1 entered the premises before leaving the area. The Driver stated he did not know why Resident #1 was discharged and stated Resident #1 only had the clothes he [Resident #1] was wearing when Resident #1 left the facility. The Driver sated he did not see Resident #1's nurse provide him with medications. During an interview on 8/17/23 at 4:01 p.m., CNA C stated she helped Resident #1 with changing his clothes, but did not assist him with eating. CNA C stated on 8/15/23 she was asked to pack Resident #1's belongings. CNA C stated, we were in the room and I was like, 'this man don't have any belongings. He don't have no clothes.' .So he didn't leave with any belongings.So we were like, 'where's he going?' And they said he was going to the homeless shelter. And then I went back to working. CNA C stated she did not see if Resident #1's nurse provided him with medications when he left. During a confidential interview on 8/17/23 on 4:38 p.m., the confidential interviewee stated they worked on 8/15/23. The interviewee stated, if we know the patient is discharged , then we have to do the necessary documentation, like the discharge papers and anything, prepare all of those that needs to be done, like the medications and everything, if they will go with their medications . [The DON or ADON] will inform us beforehand so we can prepare the necessary materials and the documentations that go with that and we can give report to the facility where they're going, but in that case [of Resident #1] nobody said nothing. Usually we have this discharge paper form that we need to fill out-all the departments, the nursing, everything-so we have to consolidate that discharge paper form. But at that point, I was surprised and I wasn't able to prepare anything for [Resident #1.] The interviewee stated Resident #1 was alert and oriented by 1 . He can answer his name and simple questions, he can answer that. But he has a Wanderguard [a monitoring bracelet worn by a resident that alerts staff when a resident attempts to leave a safe area] on. And most of the time he wants in my hallway and back and forth. And we can just redirect him and he will follow. But he always forget easily . He doesn't take that much medications . but I know he's taking blood pressure pills . He could still manage to put on his clothes, but there should be somebody because he might put it on upside down or something like that.He can do it, but someone has to supervise him. Just for him to know what he needs to do . He could eat by himself . maybe he could [bathe] himself, but there has to be somebody to queue him. During he his stay he is polite. He is a happy person. Every time he always smiles. I feel so sorry that he's gone because he's easy to be with. He didn't give you any problems at all. The interviewee stated on 8/15/23, she was assisting someone with their lunch meal and thought Resident #1 went to therapy. The interviewee stated, I didn't know he was discharged until someone told me. And I said 'discharged ? Where?' And it was the med aide who told me he was discharged . So I said, 'to where?' And she goes, 'I don't know but he was discharged . So when I looked back and checked the orders, there was no order from the doctor to discharge. The interviewee stated she did not prepare Resident #1 for discharge. The interviewee stated she did not know who prepared Resident #1 for discharge. During an interview on 8/17/23 at 5:05 p.m., the SW stated the discharge planning process started at time of admission. The SW stated, I ask what their [the resident's] plans are once they meet their goals. Well, I follow up with the family and see what the family says and sometimes we have to wait until they [the resident] finish their therapy and see how they're doing if they're going to stay for long term. When asked when a resident is able to discharge, the SW stated, If they [the residents] come in for therapy, once they've met their goals on therapy, and this population, the psychiatric ones, they're long-term. Meaning they'll stay here unless the family wants them to go to another facility. When asked what was the facility's policy on facility-initiated discharges, the SW stated, Well, like in 30 days, behaviors, non-payment, once they met their needs, and if we're not able to meet their needs. I issue [the 30 day discharge.] I present it to the resident. And then I tell him this is the 30-day discharge and I tell him the reason and I tell him I will assist them in finding alternative placement. When asked if a resident was able to appeal a discharge notice, the SW stated, Yes. When asked how a resident would appeal a discharge, the SW stated I don't know, but if they [the residents] tell me they want to appeal, I'm going to find out real fast. Continuing the interview with the SW on 8/17/23 at 5:05 p.m., when asked if Resident #1 required 24-hour care, the SW stated, I'm going to say no, because he is a street person. He can survive by himself. When asked if Resident #1 met criteria for long-term care, the SW stated, Well, this is my conundrum: he could do everything, but his-he was confused. Yet, he could function. When asked if Resident #1 had medically necessity to stay, the SW stated, I personally don't think so. Just because you're confused and a street person, why does that give you medical necessity? Now I may be wrong. When asked what were Resident #1's discharged goals, the SW stated, He wanted to leave . Back to the community. When asked why Resident #1 was discharged , the SW stated, Because he had already used up his Medicare days and he had no funding and there was no family member to help him get his financial Medicaid. I would have said that he has the right to leave. You may want him on Medicaid or think that he's better her, but the man has a right to leave. We can't tell him what's best for him and the way to live. That's my opinion. The SW stated, Medicare pays for 100% for the first day until the 20th day and 80% from the 21st day to the 100th day. When asked who initiated Resident #1's discharge, the SW stated, I guess I did. I was told [by the Administrator] that 'it's time for him to go and do what you need to do.' When asked how the Administrator made the determination to discharge Resident #1, the SW stated, when he [Resident #1] ran out of his Medicare. When asked how Resident #1 was involved in his discharge, the SW stated, He couldn't say he just-he just wanted to go And he made that clear throughout his stay . he said that he's a drifter and lives out in the streets. Continuing the interview with the SW on 8/17/23 at 5:05 p.m., when asked how she ensured Resident #1 had a safe discharge, the SW stated, I told the Administrator it was not a safe discharge. Over and over, multiple times. Not only me, but the Director of Nurses, the ADON, the IDT kept saying it's not a safe discharge. [The Administrator] just said he had to go. He had to be discharged because of the money. The SW stated Resident #1 went to the local homeless shelter. The SW stated she started reaching out to multiple agencies on 8/14/23, the day before Resident #1 was discharged . The SW stated, I called multiple places but they required an ID, or some sort of ID which he didn't have, or some type of money, so he ended up having to go [the local homeless shelter.] When asked about what she knew about the day Resident #1 was discharged , the SW stated, All I know is that our van was going to take him to [the local homeless shelter.] When asked how the local homeless shelter could address Resident #1's needs, the SW stated, he would at least get a place to sleep. It was the best place that I was able to locate for him, period. All these agencies require ID. They have all these requirements that he didn't have it. That was the very best that I could do for him. When asked if Resident #1 had medications or medical records when he was discharged , the SW stated, No. During an interview on 8/18/23 at 8:50 a.m., the Maintenance Director stated he worked on 8/15/23. The Maintenance Director stated, when I got to the meeting on Tuesday morning [8/15/23] . I guess [the SW] raised questions of what we're going to do with [Resident #1.] And I think [the Administrator] stated [the local homeless shelter.] Then they went on and went on . So at the end of the meeting . I said, 'what do you want me to do for [Resident #1?] Do you want me to take him to [the local homeless shelter?] And [the Administrator] basically said 'yes.' .He looked at me and nodded, like yes. And so then I proceeded by leaving the meeting. I went to the second floor, I found [the Driver], I said, 'you need to go [Resident #1's room] and find [Resident #1] to take him to [the local homeless shelter]' and [the Driver] brought [Resident #1] down in the hallway. [Resident #1] was at the elevator, I cut the bracelet [the Wanderguard] off his arm and that was the end of it.And [Resident #1] was a flight risk, and that stuff on his arm [the Wanderguard], he didn't like it. He said, 'I need to leave, I want to leave,' even the day before that. Because he left previously before that. And I thought, 'well, it's an agreement they made with [Resident #1] to take him to [the local homeless shelter.] During an interview on 8/18/23 at 9:43 a.m., a representative from the local homeless shelter, Representative E, stated Resident #1 was not at the local homeless shelter. Representative E stated, we have a discharge process for our intake center since we're not a medical facility. We want to make sure that people who are discharged from a medical facility, we have a form that is submitted. We didn't have any records that the form was submitted [for Resident #1.] And we did search for [Resident #1] . we searched by the date of birth and SSN provided and we didn't have anyone there . And then usually the facility, they will transport by non-emergency vehicle or ambulance and they'll usually pull up in front of our intake center and then walk the individual inside, like a 'warm hand-off.' We don't have a record of anyone bringing him into our intake center and that paperwork . I believe [the facility] should know our process, because [Resident #1] wouldn't have been accepted here, it would have been an inappropriate placement. We do have our [clinic] that will come and look at him, but our ADLs are just different than the standard ADLs. It mainly comes down to how far they can walk on their own and things like that. During an interview on 8/18/23 at 10:56 a.m., the Administrator stated he was currently on suspension due to Resident #1's discharge on 8/15/23. The Administrator stated typically discharge planning started even before the resident was admitted to the facility. The Administrator stated, There's a process to it. Sometimes they come in long-term but then they become short-term because of the resident's wishes. We have meetings. We talk about discharging if they're going to be short-term or long-term . The social worker helps with the discharge planning. When asked when a resident was able to be discharged , the Administrator stated, If the resident is expressing they want to leave and they don't want to be there anymore, obviously we can't hold them hostage in the building or keep them there. We have to find a plan and get them to a place they want to be . or if their skilled stay is up. And if it comes down to financial or behavioral, where we can't meet their needs, we've had to issue a 30-day notice. When asked what were the state guidelines for facility-initiated discharges, the Administrator stated, I know there's 30-day notices. If it's an immediate discharge there's a letter you can send out or write up. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., when asked if Resident #1 had medical necessity, the Administrator stated, I do believe he met medical necessity. I want to say he was on skilled services. I don't know if he was all three therapies or just one. When asked what were Resident #1's discharge goals, the Administrator stated, I do recall that he wanted to leave. I know we had an elopement at one point with him. He wanted to leave and I know the [resident's] hospital paperwork said Resident #1 worked for [the local homeless shelter] and resided there. That was one of the things he wanted. Personally, I wasn't the one who sat down with him and asked him what were his goals. When asked why Resident #1 was discharged , the Administrated stated, He was a short-term resident. When he first got here we saw that he was going to be potentially a long-term but due to him not having co-insurance and things, we looked at that. But he also verbalized to our social worker and the business office manager that he wanted to leave and I was aware the resident was homeless. And during our PDPM meeting it was discussed that the resident had to be discharged after 20 days. And according to the SW and BOM that he had expressed a desire to leave. The DON and SW, we made that decision to find placement for him. That's when I looked at my SW . for discharge planning and she looked at multiple different facilities and [the local homeless shelter] came up and it seemed like she [the SW] had it under control and taken care of it and I trusted that and that's when we made the decision. When asked if Resident #1 was discharged because he (Resident #1) could not pay for his stay, the Administrator stated, It was part of that yeah . But I took the fact that he wanted to leave into consideration into it, too. When asked when was the decision made to discharge Resident #1, the Administrator stated, Maybe the week before because we had those daily meetings. The Administrator was not sure exactly when the SW began looking for alternative placement for Resident #1. The Administrator stated he was aware Resident #1 was going to the local homeless shelter before Resident #1 was discharged but did not check if arrangements were made for Resident #1 to discharge. The Administrator stated, When my social worker said that [Resident #1] was ready to go to [the local homeless shelter] and we just needed someone to transport him there. Right then and there I was thinking plans had been arranged and we can proceed with this. I didn't question it. When asked how Resident #1 was involved in his discharge, the Administrator stated, I heard that he was ready to go and happy to leave over there. But I'm not sure involved he personally was. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., the Administrator stated at 9:00 a.m. during the usual morning meeting, the SW stated Resident #1 was ready to go to [the local homeless shelter] and they just needed someone to pick up Resident #1 and take him to [the local homeless shelter.] The Administrator stated, And that's when the [Maintenance Director] stood up and got someone and they went upstairs to discharge him. The Administrator stated Resident #1 was discharged around the afternoon, but did not recall exactly when Resident #1 discharged . When asked what sort of items went with Resident #1, the Administrator stated, he didn't have anything. He didn't have much to begin with. When asked if Resident #1 went with any medications or medical records, the Administrator stated, I wasn't present at the time of his actual discharge. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., when asked how he ensured Resident #1's discharged was safe, the Administrator stated, I look at his past. That he was homeless before and this was his home base . And to me it was like he's been to [the local homeless shelter] before. He's been homeless before. He wants to leave. When asked how the local homeless shelter Resident #1 was discharged to would have been able to address his needs, the Administrator stated, I don't know, I honestly don't know. When [the SW] said he was ready to go to [the local homeless shelter], I trusted it. When asked if he felt Resident #1's discharge location was safe for Resident #1, the Administrator stated, Because I heard that he was a homeless resident before, and that was his baseline, I did, but I knew that-ok, being homeless, regardless, is not safe . I don't know much about [the local homeless shelter], I don't know anything about it. I assumed he was going there and that he'd be taken care of. Instead of just discharging him to a street . The fact that I saw it as a place he could go to, I took that as okay. When asked if anyone protested Resident #1's discharge, the Administrator stated, I know that there was talk of it being an unsafe discharge. But it was just-as an IDT team we have to discuss the pros and cons of things and there were some [the DON and the SW] that discussed and said it was unsafe. But when I spoke to [the SW] to find placement she said she'd be happy to look and see what she can find . That's when she said he's ready to go for [the local homeless shelter.'] That's when I dropped it. I'm sure they all thought regardless this was an unsafe discharge just because he-in our minds he was homeless before . And it seemed after the fact that this was an unsafe discharge. When asked if there was anything he could have changed about Resident #1's discharge, the Administrator stated, Definitely trusting and verifying . micromanaging, diving into every detail. When asked if he would have considered another place to discharge Resident #1 the Administrator stated, I think, sure, yeah, if our sister facilities would have taken him. If he wanted to go . at that point, we were looking for anywhere he wanted to go. During an interview on 8/18/23 at 12:08 p.m., the DON stated the discharge planning process started at the point of admission. When asked when a resident was able to be discharged , the DON stated, they [the residents] can be discharged at their request, but there's safety criteria that we have to meet. When asked what were the state guidelines for facility-initiated discharges, the DON stated, they have to be planned, it has to be a safe discharge, it cannot be not because of funds . It has to be safe. That's why we do PDPM to make sure we're following the plans . You have to give a 30 day [notice] and you have to assist in finding placement. When asked what typically happened when a resident is discharged , the DON stated, we have to have an order in place. We have to call the physician and let him [the physician] know . We have to get a [medication] refill call-in for the week. We try to set up a follow-up within 7-10- days. But the nurses initiate that. But what happened here is that the nurses didn't even know that he was being taken off the floor. Because we had no discharge order. Continuing the interview with the DON on 8/18/23 at 12:08 p.m., when asked if Resident #1 required 24-hr care, the DON stated, yes, at first. Because of his cognition. When asked if Resident #1 had medical necessity, the DON stated, he had medications that we were giving. Basic ADLs and his food . I kn [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for wandering, in that: Resident #1 eloped from the facility, traveled approximately 1.5 miles away from the facility and required medical treatment in emergency room for hypokalemia [low potassium] and hypotension [low blood pressure]. An Immediate Jeopardy (IJ) was identified on 08/03/2023 at 4:41 p.m. While the IJ was removed on 08/05/2023 at 6:34 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. This deficient practice could place residents at risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 08/04/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: [Metabolic Encephalopathy] occurs when problems with your metabolism cause brain dysfunction, [Thrombocytopenia] a condition that occurs when the platelet count in your blood is too low; [ Metabolic acidosis] a condition in which acids build up in your body. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS of 8, indicating moderately impaired cognition. Further review of the MDS revealed the resident's balance during transfers and walking was not steady, but he was able to stabilize without staff assistance, and he required assistance from others to complete activities such as planning regular tasks (shopping or remembering to take medication). Record review of LN-Elopement/Wandering Evaluation-V2, in Resident #1's clinical record, revealed an admitted [DATE]; The elopement wandering assessment on 7/26/2023 revealed Resident #1 was assessed at a score of 4, at risk for elopement. Record review of orders dated 8/1/2023 did not reveal orders for the wandering guard. Record review of the care plan dated 7/26/23 did not reveal a care plan to address elopement. Record Review of the resident sign-out log for dates 7/26/23 to 8/1/23 found at Receptionist desk', did not reveal any sign-out signatures for Resident #1. Record review of the initial facility report to the State Agency, dated 08/2/2022, revealed, The reporter [Administrator] first learned of the incident on 08/1/2023 at 11:30 a.m. [Resident #1] was last seen on the morning of 08/01/2023. The resident was noted to be missing on 08/01/2023 at 11:30 a.m. It is unknown what time he left the facility since he did not notify anyone .There were no witnesses to the incident. During an interview with the Facility Administrator and DON on 08/02/2023 at 9:45 a.m., the Administrator stated he was notified by facility staff that they were unable to locate Resident #1 on 08/01/2023 at approximately 11:30 am. The Administrator stated he did not know how Resident #1 exited the building. The DON stated the facility knew Resident #1's had been indigent prior to his admission. The DON stated Resident #1 had not voiced his desire to return to the community. The DON stated that Resident #1 had frequently wandered within the facility since his admission but that there had not been any reports of exit-seeking behavior. The DON stated that resident #1 did not have a care plan or wander guard system as he was not considered an elopement risk at admission on 7/26/23. Surveyor requested hospital discharge records from elopement on 8/1/2023, and DON stated that since he was not admitted , no discharge paperwork was provided at discharge. During an interview with Local police officer on 8/2/23 at 12:10 pm stated he arrived at Name of Facility on 8/1/2023 at 10:35 am to file a missing person's report. He stated it was unclear on how resident #1 eloped from the facility. The Police Officer stated he had one helicopter and three patrol officers searching the area for Resident #1, when on 8/1/2023, at approximately 11:30 am, an elderly man was found by name of the street, meeting the resident's description was found by emergency department and taken to name of the hospital. Police officer stated that when he arrived at the name of the hospital to confirm the identity of Resident #1, he was welcomed by the name of nursing facility nursing scheduler, who had just located the resident moments prior. During an interview with the Nursing scheduler on 8/2/2023 at 10:05 am revealed she had left the facility to search for Resident #1 at nearby hospitals she stated this was helpful last time an incident like this occurred, and she found Resident #1 at local hospital on 8/1/2023 at approximately 11:35 a.m. and notified the Administrator and DON via text message. During an interview with CNA C on 08/02/2023 at 1:45 p.m., CNA C stated she was assigned to work on the resident hall where Resident #1 resided on 8/1/23. CNA C reported that Resident #1 was not known to exit seek within the facility. CNA C stated she notified the Charge nurse when Resident #1 could not be located at lunchtime. CNA C further reported that the Charge nurse immediately instructed staff members to search the facility and the grounds. During an interview with LVN A on 08/02/2023 at 11:45 a.m., LVN A stated she was the assigned nurse for Resident #1 on 8/1/23. LVN A did not know how Resident #1 eloped as he was in the facility at one minute and not there the next minute other. LVN A stated that Resident #1 did not have a history of attempting to leave the facility. During an interview with Receptionist B on 08/02/2023 at 11:08 a.m., Receptionist B reported she worked from 8 a.m. to 5 p.m. Monday through Friday. Receptionist B stated she was at her workstation by the entrance door, monitoring staff, visitors, and patients that went outside. Receptionist B stated she did not see Resident #1 leave the facility as residents signed themselves out on the Resident's sign-out book. During an interview with the Maintenance Director on 08/02/2023 at 1:50 p.m., the Maintenance Director stated that all doors in the facility opened after 15 seconds of applying pressure on the breaker bar following the elopement incident; Maintenance Director demonstrated to the Surveyor that both door alarms were in working order. Observation on 08/02/2023 at 5:30 p.m. revealed that the alarm on the front door and back door leading to the outside emitted a loud sound when engaged, and two staff members immediately responded to the alarm. Record review of Hospital discharge paperwork dated 08/01/2023 revealed Resident #1 arrived in emergency room triage at approximately 11:35 a.m. via ambulance, and he was discharged on [DATE] at 11:00 p.m. Resident #1 was found on the street by an emergency response team at a time unknown, approximately 1.5 miles from the facility. Resident #1 was found oriented to person only and was treated with epinephrin x 2 via intramuscular route, 1500 ML of intravenous fluids, and taken to the hospital emergency room . Record review of Hospital Medication administration records dated 8/1/23 revealed resident # 1 was administered potassium bicarbonate 40 MEQ orally for hypokalemia and Sodium Chloride 1,000 ML via the intravenous route for hypotension . Record review of the facility policy titled Elopement/Unsafe Wandering, dated 2001; revised March 2019, revealed, If Identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an Immediate Jeopardy (IJ) on 08/03/2023 at 4:41 p.m. and the Administrator was notified at 4:58 p.m. and was provided with the IJ template on 08/03/2023. The following Plan of Removal (POR) was accepted on 08/04/2023 at 2:23 p.m. and indicated the following: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On August 1, 2023, at approximately 9:00pm Resident #1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was readmitted to second floor on August 1, 2023. The director of nursing reassessed Resident #1 for Elopement risk and wander guard was placed on Left ankle on 8/2/2023 to monitor for resident exiting facility. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On August 3, 2023, at approximately 5:30pm the following actions were taken; Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Education will be completed prior to staff working next scheduled shift, and ongoing with general orientation for all new hires. Start Date: 8/3/2023 Completion Date: 8/4/2023 Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning with wander guard system and alarms placed on exit emergency release doors and placed audio alarm for notification of opening doors. Start Date: 8/3/2023 Completion Date: 8/4/2023 Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Completed Elopement Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment. Start Date: 8/3/2023 Completion Date: 8/3/2023 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff and residents regarding the process for safe discharge as well as risks associated with heat exhaustion including signs and symptoms to watch for. Start Date: 8/3/2023 Completion Date: Ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation. Start Date: 8/3/2023 Completion Date: 8/4/2023 and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 8/3/2023 Start Date: 8/3/2023 Completion Date: 8/3/2023 Responsible: Administrator/Designee Tracking and Monitoring * Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 8/4/2023. * Director of Nursing/Designee will complete audits for those residents who wear a wander guard to ensure electronic monitoring device is functioning every shift for 7 days beginning 8/4/23 then will monitor electronic monitoring devices daily 5 times per week. * Administrator/designee will complete random audit every shift for 7 days, beginning 8/4/2023, for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week. * Administrator/designee will complete audit of exits for proper functioning of doors, alarms and wander guard system for proper functioning every shift for 7 days, beginning 8/4/2023 then will monitor random shifts, 5 times a week. * Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review On 08/04/2023 through 08/05/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. Verification: Record review of the face sheet with Resident #1's room change to 35B. Reviewed Resident #1's updated care plan and Elopement risk assessment dated [DATE]. Observation and interview on 08/04/2023 at 11:30 a.m. of Resident #1 in his room on the second floor with wander guard in place. Resident #1 stated he liked being at the facility but that he liked to be outside also. An interview with the Corporate Registered Nurse (CRN) on 08/05/2023 at 5:22 p.m. revealed the activity department was available to take a walk around the building or sit in the courtyard with residents who enjoy spending time outdoors. Residents that received therapy services could request to do some of their therapy outside, weather permitting. Smoking times were also an opportunity for any resident to go outdoors regardless of if they chose to smoke. Record review of in-services titled Wandering and Elopements and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed 64 of 93 staff signatures. Of the employees in-serviced in person currently; 31 are nursing/direct care staff, 11 are therapy/activities staff, 6 are administrative staff, and 16 are ancillary staff. In an interview with the Corporate Registered Nurse (CRN) on 08/04/2023 at 3:45 pm revealed all staff training began on 08/03/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 are nursing/direct care staff, 2 are therapy/activities staff, 1 is administrative/office staff, and 4 are ancillary staff. There are 9 employees, 2 CNAs, 2 housekeepers, the Marketer, 2 physical therapists, and 2 nurses) that the DON/designee has been unable to reach via telephone at this time. Interviews with 18 employees were conducted on 08/04/2023 by surveyor, all were able to verbalize an understanding of elopement risk and stated they were provided handouts to reference as needed. Of the employees interviewed all shifts were covered, including: (4) 6am - 2pm, (2) 2pm - 10pm, (2) 10pm - 6pm, (1) 6am - 6pm (12-hour shift), (1) 6am - 10pm (doubles), (7) 8am - 5pm/8pm (office staff). An interview with the Administrator on 08/04/2023 at 4:45 pm revealed wander guard system and alarms had been tested and were operational. An interview with the CRN on 08/04/2023 at revealed additional alarms had been purchased to increase the volume and ensure alarm could be heard in all areas of the building. Observations on 08/04/2023 through 08/05/2023 revealed the alarms were being tested frequently. In an interview with the DON on 08/04/2023 at 5:40 pm, the DON revealed all wander guard systems had been tested with the additional alarms installed and there was a noticeable difference in the volume. Observation by surveyor on 08/04/23 at 12:30 pm of the DON testing the wander guard system with a resident near the front entrance revealed the wander guard system was operational. An interview with CRN on 08/04/2023 at 3:45 pm revealed nursing had completed new Elopement Risk Assessments on all residents in the facility on 08/03/2023. Record review of the Resident Listing Report revealed an updated list of each resident's elopement risk status. Record review for all residents identified as high risk revealed care plans had been updated. Record review of in-services titled Transfer or Discharge, Resident-Initiated and Heat Exhaustion, revealed 64 of 93 staff signatures. In an interview with the Corporate Registered Nurse on 08/04/2023 at 4:20 pm, the CRN stated employees were trained on this policy to ensure the employee's ability to educate residents prior to them leaving AMA or signing out on leave/pass since sometimes residents choose to not return. The CRN revealed this staff training began on 08/03/2023 and employees who have not worked since the incident will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Record review of in-services titled Wandering and Elopements and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed 64 of 93 staff signatures. An interview with the Corporate Registered Nurse revealed all staff training began on 08/03/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person by the DON/designee on a one-to-one basis before they are allowed to work their next shift. Record review of additional in-services initiated on 08/04/2023 titled Use of the door alarm and Responding to all door alarms, targeted for completion by 08/07/2023. In an interview with the CRN on 08/04/2023 at 03:45 pm revealed an Ad hoc QAPI meeting had been held on 08/03/2023 to review the IJ and POR. At that time, the Administrator in-serviced all managers on the wandering and elopement and abuse and neglect policies. Medical Director, attended via phone. Record review completed of the sign-in sheets provided by the Administrator of the Ad hoc QAPI meeting on 08/03/2023. In an interview with CRN on 08/04/2023 at 3:45 pm the CRN stated all residents in the facility had been reviewed to determine At Risk for wandering or elopement on 08/04/2023 to assure appropriate interventions were in place. The CRN provided Resident Listing Report for review. The DON/Designee will continue reviewing residents At Risk 5 times per week. In an interview with the DON on 08/05/2023 at 12:05 pm she stated audits were being completed each shift for residents who wear a wander guard to ensure devices are functioning. She stated most can be tested with a tester that was brought to the resident however one resident becomes agitated if they attempt to interfere with her personal space and layers of clothing she wears so they take her near the door to test her device. Observation on 08/04/23 at 12:30 pm of the DON testing the wander guard system with a resident near the front entrance revealed the wander guard system was operational. Record review on 08/05/2023 of monitoring logs revealed four (2) audits completed by the DON and (2) completed by the treatment nurse, who the Administrator stated has been assigned several administrative duties in recent months, one for each shift beginning with 08/04/2023. In an interview with the Administrator on 08/04/2023 at 5:25 pm he stated he was completing audits of staff response each shift. Record review on 08/05/2023 of a monitoring log revealed four (4) audits completed by the Administrator, one for each shift beginning with 08/04/2023. In an interview with the Administrator on 08/04/2023 at 5:25 pm he stated he had gone through the facility on 08/03/2023 to ensure all wander guard system doors were working properly. The Administrator stated the doors were working however he wanted to improve the overall system and added extra alarms on 08/04/2023. Observation on 08/04/2023 by surveyors revealed the alarms had been purchased, were being tested and operational. Record review on 08/05/2023 of a monitoring log revealed four (4) audits completed by the Administrator, one for each shift beginning with 08/04/2023. The Administrator was informed the Immediate Jeopardy was removed on 08/05/2023 at 6:34 p.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 14 residents (Resident #1) whose records were reviewed for Full code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:07 p.m. While the IJ was removed on [DATE] at 9:23 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical, and psychological health and result in serious injury and or death. Findings include: Record review of Resident #1's face sheet in her electronic medical record, dated [DATE] revealed a 57-year female who was initially admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain (a term used to describe the mental deterioration that is associated with old age.), impulse behavior(an improvised or unpredicted course of action that's not based on logic.), dysphagia(inability to speak), unspecified dementia(general name for a decline in cognitive abilities that impacts a person's ability to do every day activities.), and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was 0 reflective of severe cognitive impairment and was rarely or never understood. She required extensive assistance by 2 persons for ADL's. The MDS did not reflect code status. Record review of Resident #1's Care Plan, date initiated [DATE], with a revision date of [DATE], revealed Focus: Advanced Directives: Full Code Status, Goal: Resident will maintain their optimal level of comfort, advanced directive will be honored, and resident/family will be advised of Advanced Directive Forms upon admission, annual review, or significant change in status through next review. Interventions: MD and staff to be made aware of code status/treatment decisions. Staff will start CPR should cardiac arrest occurs and/or breathing independently cease, call EMS and transport to hospital as ordered. Staff will maintain all advanced directives in a prominent location in the medical record. Record review of Resident #1's active physician orders for [DATE] revealed she had an order for Full code with original date [DATE]. Record review of Resident #1's Resident Admission Agreement, signed by Resident #1 on [DATE],revealed on page ,d+[DATE] of 41; section titled: Care Planning, Refusal of Treatment and Issuance of Advance Directive; The Resident may issue an Advance Directive in accordance with state law that describes the Resident's wishes with respect to treatments that may be administered or withheld in the event the Resident becomes unable to make health care decisions for him or herself. Further review of Resident #1's medical record revealed there was no Advance Directive. Record review of Resident #1's progress notes, dated [DATE], at 9:00 a.m. authored by Agency LVN A, read as follows: -Resident #1 was found unresponsive by Nurse Aide F and Nurse Aide G. They both informed charge nurse Agency LVN A immediately of Resident #1 not breathing and cold to touch. Agency LVN A went to Resident #1's room immediately, checked Resident #1 finding Resident #1 in semi-fowler's, with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous to rigor mortis setting in, did not initiate CPR. Agency LVN A alerted ADON LVN B and was advised to place call to hospice. Hospice was notified at 10:00 a.m. on [DATE]. During an interview on [DATE] at 1:00 p.m. CNA F revealed he was working during the 6:00 a.m. to 2:00 p.m. shift. He was asked by Agency LVN A to give a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. He stated he provided Resident #1 a bed bath at that time with assistance from CNA G. He further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. He stated when he returned to check Resident #1 at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. He stated he immediately told Agency LVN A and she immediately went to Resident #1's room. He stated he did not know the code status of the resident , Agency LVN A left Resident #1's room after checking for pulse respirations. CNA F stated , Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR. When asked if CNA F was CPR certified, he stated yes. When asked if he started CPR on Resident #1, he stated no because he did not know the code status on Resident #1 at the time and he was not directed by Agency LVN A to do any first aide. During an interview on [DATE] at 1:07 p.m. CNA G revealed she was working during the 6:00 a.m. to 2:00 p.m. shift. She was asked by Agency LVN A to assist CNA F in giving a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. She stated she provided Resident #1 a bed bath at that time with assistance from CNA F. She further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. She stated when she returned to check Resident #1, with CNA F at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. She stated CNA F immediately told Agency LVN A and she immediately went to Resident #1's room. She stated she did not know the code status of the resident, Agency LVN A left Resident #1's room after checking for pulse respirations. CNA G stated, Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR CNA G stated she was not CPR certified and did not perform first aide on Resident #1 because she was not directed by Agency LVN A to do anything. During an interview on [DATE] at 1:12 p.m. Hospice RN revealed she was informed via telephone call from Agency LVN A that Resident #1 had expired and would need an RN from hospice to pronounce her. Hospice RN stated she arrived at facility and pronounced Resident #1 at 10:16 a.m. on [DATE]. Hospice RN stated Resident #1 was full code. During an interview on [DATE] at 1:21 p.m. Agency LVN A revealed she found Resident #1 in semi-fowler's position in bed with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous movement. No respiratory sounds on auscultation, no pulses palpable in carotid or femoral arteries. Agency LVN A stated, due to rigor mortis setting in, she did not initiate CPR even though she was aware that Resident #1 was a Full Code from her medical record. She further revealed she had last seen Resident #1 at 8:30 a.m. and she was in no distress. She stated rigor mortis had set in. When asked if she knew how to determine if rigor mortis is present or how long it would take for rigor mortis to be present, she stated, I just know stiffening occurs with the body, I am not sure how long it actually takes. Agency LVN A stated she then went downstairs to speak with ADON LVN B to ask her for recommendations on what she should do about Resident #1, as she felt that she had expired. She stated ADON LVN B told her to contact hospice, as Resident #1 was under the services of hospice care. During an interview on [DATE] at 3:00 p.m. with ADON-LVN B revealed Agency LVN A did not perform CPR after assessment of Resident #1, when she was found unresponsive by CNA F and CNA G. ADON-LVN B stated she was in the management role of ADON and there was no current DON working at the facility. ADON-LVN B further revealed there was no RN in the building at the time of the incident with Resident #1. During an interview on [DATE] at 3:00 p.m. the facility ADON LVN B revealed, if a resident is found to be unresponsive and is a Full Code, the primary nurse should begin CPR and contact 911. She further revealed staff should follow the protocol of a Full code and receive interventions such as CPR. During an interview on [DATE] at 3:02 p.m. the facility Administrator stated staff should follow the protocol of a Full code and receive interventions such as CPR. Record review of CPR certification status for Agency LVN A revealed she had a current active CPR certification with an issue date of [DATE] and renew by ,d+[DATE] provided by the American Heart Association. Record review of facility policy titled, Emergency Procedure- Cardiopulmonary Resuscitation. Section General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is CPR certified in CPR/BLS shall initiate CPR unless: a: It is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual: or b. There are obvious signs of irreversible death (e.g., rigor mortis). Review of website: https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, revealed the definition of Rigor Mortis to be in stages: Pallor mortis: The main change that occurs is increased paleness because of the suspension of blood circulation. This is the first sign and occurs quickly, within ,d+[DATE] minutes of death.Algor mortis: Humans are warm-blooded creatures, which means that we keep a consistent body temperature, regardless of the external environment. The brain is our temperature regulator, and the circulatory framework is the principal heat dissipator. After death, the brain cells stop signaling, and the heart stops pumping blood, which means the body begins to match the external temperature. Our normal body temperature level is 98.6 F (37 C). Assuming the surrounding temperature around the dead body is not exactly the same, it normally takes somewhere in the range of ,d+[DATE] hours for the body's temperature to match the external temperature. Rigor mortis: Following death, the body will turn stiff. The muscles become loose and limp, yet the entire body will stiffen after a couple of hours. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:07 p.m. and the Administrator was notified at 2:07 p.m. and was provided with the IJ template on [DATE]. The following Plan of Removal(POR) was accepted on [DATE] at 9:23 p.m. and indicated the following: Immediate corrective actions for removal of immediate jeopardy: On [DATE], at approximately 3:00 p.m. the following actions were taken: Director of Nursing/designee completed immediate education with LVN A, and CNA B who were in attendance on proper response to emergency situation, when to initiate CPR on a resident and including the following steps for emergency response. a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. e. LVN role in determining when to initiate CPR. o Director of Nursing/designee validated all resident current Code status were up to date and in EHR, including care planned and on direct care Kardex on [DATE]. o The Corporate Clinical Resource completed education with Assistant Director of nursing regarding requirements on Emergency response, including, following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on [DATE]. o Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on [DATE]. IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. o The Director of nursing/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff Kardex care record on [DATE]. SYSTEMIC CHANGES AND/OR MEASURES: o The Corporate Registered Nurse/Designee will complete education with all staff to include agency staff on proper procedures to follow in case of Emergency, including initiation of emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aid in support areas, such as initiating 911, validating code status, etc. Education will be initiated on [DATE] to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status. This education will be ongoing with all staff to include agency prior to working their next scheduled shift. o The Corporate Registered Nurse/Designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. Education will be initiated on [DATE] and be ongoing will all staff prior to working next scheduled shift. o Administrator/Designee will upload policy on Emergency Procedure-Cardiopulmonary resuscitation policy to agency website for new agency staff to review and acknowledge prior to working shift. o Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure-Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on [DATE] @ 4:00 pm o The Corporate Registered Nurse/Designee will initiate a process to conduct quarterly Mock Code training with clinical staff beginning the week of [DATE]-[DATE]. o The Corporate Registered Nurse/Designee will conduct post code blue debriefing with staff following a code blue events to ensure proper procedures were followed. TRACKING AND MONITORING: o The Corporate Registered Nurse/Designee will, through record review, monitor resident code status in PCC to validate codes are in place and on plan of care, daily x 7 days, then 5 x per week beginning [DATE]. o The Corporate Registered Nurse/Designee will conduct observational rounds and interviews, daily x 7 days, then 5 x per week beginning [DATE], to validate that staff can verbalize understanding of how and where to find resident code status and proper steps for initiating emergency response if needed. Are they keeping a list of staff they have conducted observational rounds and interviews with this is supposed to be post in-service training? o The Administrator/designee will monitor that licensed staff are certified and certifications are up to date, to perform CPR, for all current staff, then weekly for all new hires. o The Administrator/designee will conduct a monthly audit to ensure staff that have CPR certifications that are going to be expiring soon will be set up to take CPR recertification. o Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. The Administrator will be responsible for ensuring the adequate process regarding Emergency Response, including initiation of CPR are followed per policy. The education on process/system was initiated on [DATE]. Verification: Verified; Record review of in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with ADON and the Corporate Registered Nurse on [DATE] revealed LVN A and CNA B were trained step by step in the emergency response procedure via phone initially on [DATE] to cover immediacy, by the ADON, the Corporate Registered Nurse and Administrator. Upon returning for their next shift, LVN A on [DATE] and CNA B on [DATE], they were brought into the office, provided a copy of the procedure and were able to verbalize understanding of procedure. See in-service sheets attached. Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited. Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with the Corporate Registered Nurse and ADON on [DATE] revealed the ADON and Treatment Nurse were immediately trained on [DATE] in the emergency response procedures to ensure they were able to train other staff. Verified; Record review of the staff schedule dated [DATE] - [DATE] revealed at least one CPR certified staff was scheduled on each shift. CPR cards for each of these staff members were attached to the schedule as well. Interview with the Corporate Registered Nurse on [DATE] verified that all staff not fully certified at this time are scheduled to attend CPR on [DATE] at 10:30 with [name of company]. Record review of a confirmation text from [name of company] verified CPR is scheduled for [DATE] at 10:30 am at the facility. Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited. Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, revealed 44 of 87 staff signatures. Interviews with the Corporate Registered Nurse and ADON on [DATE] revealed all staff training began immediately on [DATE]. The ADON reported she and the Treatment Nurse went to each employee together to instruct in the emergency procedures and make sure they understood the importance of the situation. The ADON added that each staff member had to be able to verbalize understanding of the procedure. Copies of the procedure were provided to each staff member. Staff members who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis before they are allowed to work their next shift. On [DATE], 17 direct care staff members, including RNs, LVNs, CNAs and an Activity Director, to include all shifts at the facility were interviewed and verified they had received inservice training on the facility's Emergency Procedures for CPR. Verified; record review of a printout from the [name of agency] website revealed link that agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. Interview with Corporate Registered Nurse on [DATE] revealed all staff that had previously read and accepted the previous version must now read and accept the updated policy prior to working. Verified; record review of the [name of agency] site (agency website) and interview with Corporate Registered Nurse [DATE] revealed agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. Verified; Record review of sign-in sheets provided by the Administrator of Ad hoc QAPI meeting on [DATE]. The Administrator in-serviced all managers on emergency procedures for CPR policy and POR for IJ. Medical Director, Physician J attended via phone. Verified; Record review Ad hoc QAPI meeting and interview with Corporate Registered Nurse on [DATE] revealed Mock code scheduled for [DATE] (1st shift), [DATE] (2nd shift) and [DATE] (3rd shift). Verified; Each mock code packet contains a debriefing sheet that staff will complete following code to discuss what occurred and any improvements that could be made. This will be presented at QA. These sheets are also to be used in the event of an actual code. Verified; Interview with Corporate Registered Nurse on [DATE] acknowledged the invalid OOH-DNR and initiated correction of document immediately. Verified; record review of Observational Rounds/Interviews CPR logs for [DATE] (13 staff) and [DATE] (14 staff) revealed ADON (the designee) rounded to ensure staff continued to verbalize understanding of content from previous in-service training on [DATE]. Verified; record review of CPR audit completed on [DATE] and interview with the Corporate Registered Nurse on [DATE] revealed a CPR course is scheduled for [DATE] at 10:30 with [name of company]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at . While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal .