Every finding on record at Shady Acres Health & Rehabilitation

Based on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure an RN worked for 8 consecutive hours for 20 of 116 days reviewed in January, February, March and April 2026. The facility failed to designate an RN as a DON on a full-time basis for 30 of 87 days reviewed in February, March and April 2026. This failure could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight. Findings included: During an record review and interview on 04/29/26 at 09:30 a.m. with the facility HR Director and record review of the facility's RN staff payroll hours for the period of 01/01/26 - 04/29/26 indicated no RN Services on the following dates: 01/03/26, 01/04/26, 01/17/26, 01/18/26, 01/22/26, 01/31/26, 02/01/26, 02/21/26, 02/22/26, 02/23/26, 03/01/26, 03/05/26, 03/10/26, 03/15/26, 03/19/26, 03/28/26, 03/29/26, 04/24/26, 04/25/26 and 04/26/26. The HR Director said the facility had not hired a full-time DON when DON R resigned 02/18/26 with notice until DON S hired 02/24/26 totaling of 6 days without a DON in February 2026. The HR Director said DON S resigned 03/04/26 and the facility was without a DON until DON H hired on 3/20/26 totaling 16 days in March 2026 without a DON. The HR Director said DON H resigned last week 4/20/26 with no notice and the Facility has been without a DON for 8 days for April 2026 so far. The HR Director said the facility Administrator was responsible for making sure the facility had RN coverage daily and hiring a DON. The HR Director said the Administrator had conducted interviews with DON candidates but had not hired anyone. The HR Director said the risk of not have a DON is getting cited for no DON or RN coverage, she said the residents have had no negative outcomes. Record review of Incidents & Accidents for 01/2026, 02/2026, 03/2026, and 04/2026 did not reveal any negative outcomes to residents related to not having RN services. During an interview on 04/29/26 at 11:00 a.m., ADON (who is a LVN) said she had worked for the facility for over 20 years and the DON quit last week through a text message to the Administrator. The ADON said she felt the lack of RN and DON coverage was a concern as an LVN because on certain occasions it could pose a challenges like needing the DON or RN to physically look at a patient to do a more in depth assessment. She said, the facility had no corporate oversight, and although the facility occasionally employed RNs and DONs, there were periods when neither was present. The ADON said in such instances, she would seek supervisory guidance by consulting the DON from another facility, physicians, or Nurse Practitioner. The ADON stated that when appropriate, she would seek advice from the pharmacy or dietitian as well. The ADON said she and the Administrator had been reviewing the staffing schedule and the Administrator was responsible for hiring a DON. The ADON said the DON had a critical role in a nursing facility because the DON was responsible for overseeing nursing staff, providing guidance as needed, and ensuring compliance with regulations, policies, and procedures to maintain quality of care. She stated it was important to have RNs, as they provided guidance, support, and performed nursing tasks beyond the scope of CNAs and LVNs. The ADON said there was no negative outcome because of no DON because you could still call someone. During an interview on 04/29/26 at 11:45 a.m., the Administrator said he was aware the facility did not have RN coverage or an acting DON. He said he expected the facility to have an RN working eight consecutive hours a day every day of the week. He said he expected there to be an acting DON or full-time DON in the facility. The Administrator said the previous DON quit last week via text on 04/20/26 with no notice and the facility had been actively advertising for the DON position. He said the facility had been attempting to hire and a DON, advertising the position on different platforms in the past, and just recently added incentives to make the position more desirable. He said they had one or two applicants to interview for DON next week. He said his desire to hire someone more experienced in management of resident care and staff, and the fact that the area is rural led to the failure of the DON position not to be filled. He said he was the one who was responsible for making sure there was a DON and the facility had RN coverage. The Administrator said he was not aware there was no RN coverage on those dates, but what could he do if there were no RNs available to work. Administrator said there was no corporate RN or Regional RNs to assist in the DON roll until one is hired. The Administrator said he was aware of the importance of having an RN at the facility for clinical management. The Administrator said the Director of Nurses was responsible for ensuring RN coverage as required and notifying Administrator of non-coverage. He stated there was improvement to be made, and the management was aware of the issue prior to today. The Administrator said that there were no reported quality concerns attributable to the lack of RNs or DONs coverage. He said no residents missed services or treatment because an RN was not onsite. The Administrator said it was important to have RN coverage because they were more skilled than an LVN and were able to assess patients differently. He said he had some quality LVNs better than the last DONs hired. The Administrator said they were interviewing one or two candidates for an RN DON at the end of the week. Record review of the facility's policy titled Director of Nursing Services, dated August 2006, read in part: Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse.1. The Nursing Services Department is managed by the director of nursing services. The director is a registered nurse licensed by this state and has experience in nursing service administration rehabilitation and geriatric nursing. 2. The directors employed full-time 40 hours per week.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety requirements. The facility failed to ensure there was no fly tape with bugs on it approximately 12 inches away from refrigerator B.The facility failed to ensure floors did not have a sticky substance.The facility failed to ensure there were no fuzzy green spots on refrigerator A's wire rack.The facility failed to ensure the ice machine was free of lime build up.The Dietary Supervisor and Dietary Aide/ [NAME] C did not have bread restraints on their beards. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During initial tour on 04/27/2026 at 8:51 a.m., the following were identified: The Dietary Supervisor and Dietary Aide/ [NAME] C did not have bread restraints on their beards. There was a long brown tape hanging from the ceiling approximately 12 inches from refrigerator B filled with bugs. The floors had debris on them and were sticky throughout the kitchen. Inside refrigerator A, there were small fussy green spots on the refrigerator wire rack. There was lime build up on the outside and inside of the ice machine. During a follow-up tour on 04/27/2026 at 10:52 a.m., the following were identified: The Dietary Supervisor did not have a beard restraint on his beard. there was a long brown tape hanging from the ceiling approximately 12 inches from refrigerator B filled with bugs. The floors had debris on them and were sticky throughout the kitchen. Inside refrigerator A, there were small fussy green spots on the refrigerator wire rack. There was lime build up on the outside and inside of the ice machine. During an interview on 04/27/2026 at 12:40 a.m., the Dietary Supervisor said he knew he and Dietary Aide/Cook C should have had a beard restraint on to prevent hairs getting into the residents food. He said the kitchen staff clean the floors by mopping daily multiple times a day but were unable to get the sticky substance up unless boiling hot water was used. The dietary Supervisor said the potential risk was residents being risk of foodborne illness and cross contamination due to beard hairs not restrained, kitchen floors unsanitary, and fly tape with bugs approximately 12 inches from refrigerator B. He said he did not know when the last time was the ice machine was drained and cleaned. He said the ice machine should be cleaned weekly by kitchen staff to ensure there was no lime built up. He said he did not have a person designated to clean the ice machine.The Dietary Supervisor said the kitchen staff are scheduled for cleaning but could not provide documentation. During an interview on 04/27/2026 at 1:00 p.m., Dietary Aide/ [NAME] C said the bug tape should not have been in the kitchen nor within approximately 12 inches of refrigerator B. He said he was responsible for cleaning the kitchen (refrigerator and ice machine included) daily after-meal services to prevent cross contamination and foodborne illnesses. He said he did not know when the last time ice machine was drained and cleaned. He said it had been a while. Dietary Aide/ [NAME] C said he forgot to put his beard restraint on. He said he should have had a beard restraint on to prevent any hair falling into residents' food. During an interview on 04/28/2026 at 12:45 p.m., the Administrator said the bug tape should not have been in the kitchen nor within approximately 12 inches of refrigerator B. He said the Dietary Supervisor was responsible for overseeing the kitchen (refrigerator and ice machine included) was cleaned daily and after each meal service to prevent cross contamination. The Administrator said all staff with beards of any length should wear beard restraints to prevent hairs getting into residents food. Record review of facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revision date: October 2017, indicated: Policy Statement- Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of facility's policy titled Sanitization revision date: October 2008, indicated: Policy Statement- The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. Plasticware, China and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded.16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of https://www.fda.gov/media/164194/download?attachment accessed on 3/31/2026 indicated: Chapter 4. Equipment, Utensils, and Linens Multiuse 4-101.11Characteristics. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment.

Based on interviews and record reviews, the facility failed to ensure residents were free of significant medication errors, for 1 of 14 residents reviewed for significant medication errors. (Residents #3)The facility failed to ensure staff held Resident #3's two blood pressure medications when the blood pressure was outside the prescribed parameters.This failure could place residents receiving medication to lower the blood pressure at risk for adverse consequences and decline in health.Findings included:Record review of Resident #3's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of hypertension (high blood pressure).Record review of Resident #3's quarterly MDS assessment, dated 03/11/26, indicated a BIMS score of 03 indicating Resident #3 was cognitively severely impacted. Hypertension was included as one of Resident #3's diagnoses.Record review of Resident #3's care plan dated 01/03/2026 indicated a diagnosis of hypertension. Interventions included Give anti-hypertensive medications as ordered.Record review of Resident #3's April 2026's physician orders indicated the following:1.Lisinopril 10 mg. daily. Give 1 tablet by mouth daily for hypertension. Hold if SBP less than 110 or DBP less than 60. SBP (systolic blood pressure) is the pressure in the arteries when the heart contracts and is the top number in BP recordings). DBP (diastolic blood pressure) is the bottom/lower number in BP readings and it measures the pressure your blood is pushing against your artery walls while the heart is at rest.2. Metoprolol tartrate 25 mg. Give 1 tablet by mouth twice daily for hypertension. Hold if SBP less than 100 or DBP less than 60 or heart rate less than 60. Record review of Resident #3's April 2026 MAR indicated the following:1. On the following dates and times, LVN A administered Lisinopril 10 mg. to Resident #3 when the vital signs were outside the prescribed parameters:On 04/05/2026 at 8:00 a.m., the BP was 100/56;On 04/08/2026 at 8:00 a.m., the BP was 115/57; On 04/09/2026 at 8:00 a.m., the BP was 103/53;On 04/14/2026 at 8:00 a.m., the BP was 108/52; [NAME] 04/23/2026 at 8:00 a.m., the BP was 107/52.2. Metoprolol tartrate 25 mg. Give 1 tablet by mouth twice daily for hypertension. Hold if SBP less than 100 or DBP less than 60 or heart rate less than 60. On the following dates and times, LVN A administered Metoprolol tartrate 25 mg. to Resident #3 when the vital signs were outside the prescribed parameters:On 04/05/2026 at 8:00 a.m., the BP was 100/56;On 04/08/2026 at 8:00 a.m., the BP was 115/57; On 04/09/2026 at 8:00 a.m., the BP was 103/53;On 04/14/2026 at 8:00 a.m., the BP was 108/52; [NAME] 04/23/2026 at 8:00 a.m., the BP was 107/52. During an interview on 04/28/2026 at 1:15 p.m., LVN A said it was a careless mistake administering the B/P medications to Resident #3. She said she should have held the medications as prescribed by the physician. LVN A said she had been educated and re-educated on administering medications with parameters. LVN A said she should have paid more attention to the directions prescribed for the blood pressure medications. LVN A said Resident #3 had not experienced any adverse signs or symptoms such as decreasing blood pressure or increased heart rate. During an interview on 04/28/2026 at 1:40 p.m., the ADON said her expectations were for all medications to be administered by physician orders including according to parameters. She stated this failure could result in resident's blood pressure becoming lower, cause fainting and injury, or resulting in fall with major injuries.During an interview on 04/29/2026 at 12:00 p.m., the Administrator said his expectations were for all medications to be administered by physician orders.A facility policy titled Administering Medications dated revised April 2019 indicated the following:. Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frames.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 3 medication carts observed (Hall D and Hall C medication carts).The facility failed to ensure Hall D and Hall C medication cart drawers did not have loose pills in the bottom of the carts. These failures could place residents at risk of misappropriation of drugs, not receiving prescribed drugs or contaminated medication.Findings included:During an observation and interview on 04/28/2026 at 2:25 p.m., during review of the Hall D medication cart with the QA nurse, she said she was giving patient medication off this cart today. The cart review revealed the 2nd drawer contained 18 whole and 5 broken loose unidentified pills. The QA nurse said the medication cart should be cleaned and no loose pills should be in the drawers.During an observation and interview on 04/28/2026 at 2:39 p.m., during review of the Hall C medication cart with the QA nurse, she said she was giving patient medication off this cart today. The cart review revealed the 2nd drawer contained 5 whole and 1 broken loose unidentified pill she said the medication cart should be cleaned and no loose pills should be in the drawers. The QA nurse said the nurses giving medication off the medication cart were responsible for ensuring no loose pills were left on the medication cart and the back up to double check was herself as the QA nurse or DON. She said she had been working the floor a lot recently and had not been able to do QA duties more than a day or two a week. The QA nurse said all the nurses had been educated to keep the medication carts clean with no loose pills on the medication cart. She said the loose pills were overlooked. The QA nurse said the risk of loose pills on the medication cart was that a resident could run out of their prescription too soon.During an interview on 04/28/2026 at 2:47 p.m., the ADON said the nurses giving medication off the nurse's medication cart were responsible for ensuring no pills were loose on the medication cart at the end of the shift and the DON and QA nurse were the back up to double check the medication carts. She said there was no current DON. She said the nurses were all educated to keep the medication carts clean and remove loose pills. She said the pills were overlooked. The ADON said the residents risk if loose pills on the medication cart was a resident could run out of prescribed medication and they would have to be refilled too soon. During an interview on 04/29/2026 at 12:25 p.m., the Administrator said the nurses providing medication off the medication cart were responsible for ensuring the medication cart was clean with no loose medication. He said the QA nurse and DON were the backup and they were responsible to ensure the medication carts were clean with no loose medication. He said the DON quit last Wednesday (04/22/2026) without notice.The Administrator said the loose medication was overlooked. He said the residents risk of loose medication on the medication cart was that a resident could run out of prescribed medication too soon. Record review of a facility policy revised April 2019, titled, Storage of Medications indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) reviewed for infection control. The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #5 who was on enhanced barrier precaution. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.Findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of dysphagia (difficulty swallowing).Record review of Resident #5's quarterly MDS assessment, dated 03/12/26, indicated a BIMS score of 03 indicating Resident #3 was cognitively severely impacted. Feeding tube was included as one of Resident #5's nutritional approaches.Record review of Resident #5's care plan dated 02/23/2026 indicated requires a tube feeding. Interventions included the resident is dependent with tube feeding and water flushes.Record review of Resident #5's April 2026's physician orders indicated tube feeding only diet.During an observation on 04/27/26 at approximately 9:35 AM, Resident #5 had EBP signage in place and PPE (Personal protective equipment) was noted at the entrance to the resident room. During an observation on 04/27/26 at approximately 9:40 AM, CNA E entered Resident #5's room to perform ADL care and failed to don (put on) a gown to perform ADL care. Resident #5 was on enhanced barrier precaution due to his gastrostomy tube (a tube directly in abdomen to the stomach to deliver liquids for food, medication and hydration) CNA E cleaned Resident #5's peri-area, changed his brief and CNA F entered the room and helped CNA E pull Resident #5 up in bed. During the procedure both CNAs bare uniform clothes touched Resident #5's gown and his bed linens. During an interview on 04/27/26 at approximately 10:00 AM with CNA's E and F both stated they both failed to put on a gown to do ADLs with Resident #5 and his room had sign indicating EBP, they said they knew the resident was on Enhanced Barrier Precaution, but they forgot to put a gown on. They stated they did not know why they had forgotten. CNA E and F confirmed it was a risk of cross-contamination for the resident and both CNAs said they received infection control training on EBP and PPE. During an interview with the ADON the infection control preventionist, on 04/28/26 at 10:30 a.m., the ADON stated that a resident with a gastrostomy tube was on Enhanced Barrier Precaution and the staff should wear a gown and gloves while providing care. She stated the staff were provided with infection control and Enhanced Barrier Precaution training and the risk of not following the EBP increases the risk of cross-contamination. In an interview on 04/29/26 at 11:45 AM the Administrator stated staff in the building had all been trained and retrained on EBP (Enhanced Barrier Precautions). He said those failures could place residents at risk for cross contamination, spread of infection and violated the infection prevention and control requirements. The Administrator said staff needed to wear a gown and gloves for residents on enhanced barrier precaution to prevent the spread of infection to the residents but also the staff. The Administrator stated infection control training was provided and skills were checked annually. Record Review on 04/27/26 of EBP Enhanced Barrier Precautions Policy dated 03/2024 indicated, EBP employs targeted gown, and gloves use in addition to standard precaution during high contact residents care activities when contact precaution do not otherwise apply . Record Review of the EBP signage states: When providing care for Dressing, bathing/Showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from sexual abuse for two of six residents (Residents #2 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from sexual abuse when Resident #1 came into Resident #2's room on 11/02/2025 and inappropriately touched her breast and genital area. 2. The facility failed to ensure Resident #3 was free from sexual abuse when Resident #3 reported to facility staff on 11/04/2025 on an unidentified date Resident #1 touched her breast without consent. The noncompliance was identified as a past non-compliance (PNC) Immediate Jeopardy. The Immediate Jeopardy (IJ) began on 11/02/2025 and ended on 11/05/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included:Resident #1 Record review of Resident #1's admission record, dated 12/10/2025, indicated an [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE]. His diagnoses included mood disorder (mental disorders that primarily affect a person's emotional state), dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities) and high risk of heterosexual behaviors added 11/04/2025. Record review of Resident #1's quarterly MDS dated [DATE] indicated he was intact cognitively with a BIMS score of 15 out of 15 and had no behaviors. He was able to make himself understood and understood others. Record review of Resident #1's care plan reviewed on 12/10/2025 indicated he had potential for inappropriate sexual behaviors on initiated on 11/03/2025. The goal was he will have no evidence of behavior problems such as inappropriate sexual behavior. Interventions included anticipate and meet resident's needs, if reasonable, discuss the resident's behaviors, explain/reinforce why behavior is inappropriate and/or unacceptable, intervene as necessary to protect the rights and safety of other residents and provide Every 15 minute tracking with documentation if resident is alone in his room due to no behavior symptoms since return from psych hospital and one-on-one monitoring while in general population such as hallways dining room or activities. Record review of Resident #1's incident report dated 11/03/2025 authored by BOM B indicated alleged abuse, incident location was in Resident #2's room. Resident #2 reported to BOM B she was touched on her right breast and her cat (peri area) by a male resident (Resident#1). Resident #1 stated that he didn't do anything wrong before he was told what we wanted to question him about. He also stated, that he thought they were asking him about the female resident across the hall because she tried to get his attention and she wasn't covered. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #1's Progress Notes indicated the following:-On 11/03/2025 at 11:45 a.m., LVN A wrote 1:1 monitoring with q15 minute documentation check started at 11:45 am due to incident with another resident. Resident #1 has been in his room he only left to go to the dining room to eat lunch and dinner then he went back to his room.-On 11/03/2025 at 12:00 p.m., LVN A wrote Late Entry I was made aware by the facility DON that there was an incident between Resident #1 and Resident #2 resident and Resident #2 stated to the front office business manager that Resident #1 touched her right breast and grabbed her cat (vagina). I was also informed that the abuse coordinator, ADON, and RPs had already been notified. The resident was placed on 1:1 monitoring with 15-minute documentation until further notice.-On 11/04/2025 at 5:23 a.m., LVN C wrote Late Entry 1:1 monitoring, 15-minute documentation resident location tracking done for this shift. Resident #1 stayed in room the entire shift, currently in his room watching TV, waiting to be taken to the shower room for shower day. 1:1 monitoring continues with q15 minute documentation.-On 11/04/2025 at 9:49 a.m., LVN A wrote 1:1 monitoring with every 15 minutes documentation started at 11:45 am on 11/03/2025.-On 11/04/2025 at 9:52 a.m., LVN A wrote Late Entry Resident #1 is on 1:1 with every 15 minutes documentation per administration until further notice, The resident was in his room until 7am until C hall came took him to the shower room for his shower he returned from the shower at approx.7:22 am, remained in his room until 8:26 am when he was taken to the dining room for breakfast and was assessed back to his room at approx.8:50 am where he has remained.- On 11/04/2025 at 12:00 p.m., LVN A wrote Late Entry I was made aware by a staff member during investigation process that there was an incident between Resident #1 and another female resident (Resident #3) and she alleged that Resident #1 made her uncomfortable and touched her breast without consent, and that the abuse coordinator was notified along with the DON, ADON facility physician and both residents emergency contacts/RPs were notified.- On 11/04/2025 at 6:00 p.m., LVN A wrote Late Entry Resident #1 remained in his room for the majority of the 12-hour shift after breakfast the resident only left out his room for lunch and to the nurses' station at approximately 2:15 p.m. to ask about upcoming eye appointment and went directly back to his room. Resident #1 is still on 1:1 monitoring with 15-minute documentation.-On 11/05/2025 at 5:31 a.m., LVN C wrote Late Entry 1:1 monitoring, 15-minute documentation resident location tracking continued for resident. Resident #1 came and sat in the hallway at 6:30pm and stayed there for about 10 minutes then went back into his room where he watched TV and rested in bed for the rest of this shift. Resident is currently in his room lying in bed, resting with eyes closed. 1:1 monitoring continues with q15 minute documentation.- On 11/05/2025 at 9:41 a.m., LVN D wrote Late Entry Resident #1 continues 1:1 monitoring with Q15 minute documentation. The resident is currently sitting on rollator walker in his room. Resident #1 had his breakfast meal in the dining room; resident also did some exercise on the bike in the Physical Therapy room. The resident has no complaints or pain or discomfort at this time.- On 11/05/2025 at 12:33 p.m., LVN D wrote Resident #1 continues on 1:1 monitoring with Q15 minute documentation. Resident #1 is currently ambulating with use of the rollator walker. Resident #1 ambulated outside with CNA for just a little while. Resident #1 had no complaints or pain or discomfort at this time.- On 11/05/2025 at 6:07 p.m., LVN D wrote Resident #1 continues on 1:1 monitoring with Q15 minute documentation. Resident #1 stayed in his room watching television most of the evening. No complaints voiced per resident. No acute distress noted.- On 11/05/2025 at 6:09 p.m., LVN D wrote Initial dose Zoloft 25mg and Estrace 0.5mg administered per MD orders. Resident #1 shows no sign or symptom of any adverse reactions noted.- On 11/05/2025 at 8:29 p.m., ADON wrote Resident #1 continues on 1:1 tracking every 15 minutes. He has been in his room thus far this shift.- On 11/05/2025 at 8:38 p.m., ADON wrote Received a call from behavioral hospital stating that first thing in the morning they will run his insurance, and the intake team will look at his clinicals and she will get back to us.- On 11/06/2025 at 1:29 p.m., LVN D wrote Resident #1 continues on 1:1 monitoring with Q15 minute documentation. Resident #1 stayed in his room watching television most of the evening. Resident #1 had his lunch meal in the dining room with CNA supervision. No complaints voiced at this time.- On 11/06/2025 at 2:45 p.m., LVN D wrote Received phone call from the behavioral hospital. Report given to CN for Resident #1's transport to facility. Behavioral hospital RN notified this nurse that resident is to bring only 3 outfits (without strings or they would have to be cut out) 1 pair shoes/ slippers and the transportation will be arriving around 3:15 p.m. Explained to Resident #1 regarding the amount of clothing & shoes to pack. Resident verbalized understanding. The resident continues 1:1 monitoring with Q15 minute documentation. The resident remains in his room gathering his items. CNA is currently in the room assisting the resident.- On 11/06/2025 at 3:30 p.m., LVN D wrote Behavioral hospital transportation arrived at facility to transport Resident #1 with 2 attendants present. Resident #1 in his room and continuing gathering of his personal items to Backpack. CN instructed the resident that he will now be transported to another facility. Resident verbalized understanding. CN & CNA walked with Resident #1 along with attendants to the transportation van. Resident #1 was ambulating with use of rollator walker as 1:1 monitoring continued until the resident was assisted into the van and in the care of behavioral hospital transportation staff.- On 11/21/2025 at 1:00 p.m., LVN D wrote Resident #1 returned to facility around 1300 after a stay at behavioral hospital; transported by them as well. Resident #1 ambulating with rollator assistive device accompanied by two behavioral hospital staff. Resident#1 assigned to room with all belongings. Covid test negative. VS WNL. Resident AAOx3. VS assessed and WNL. Resident #1 breathing on room air. No new medications. Freedoms staff declined any behavioral concerns as well as sexual moves or tendencies. Upon return, Resident #1 will be 1-on-1 watch and documented every 15 minutes. Resident continent to bowel and bladder. Lung sounds clear to auscultation all lobes. Skin assessment completed by SN; no wounds/skin concerns noted.Record review of Resident #1's 1:1 monitoring with q 15minute documentation tracking log indicated Resident #1 was monitored from 11/03/2025 at 11:45 a.m. until 11/06/2025 at 3:30 p.m. with no new behaviors indicated on tracking log. Record review of Resident #1's behavioral hospital records dated 11/14/2025 indicated Resident #1 did admit to the behavioral hospital staff he had bonded with, his inappropriate behaviors at the nursing facility.Record review of Resident #1's 1:1 monitoring with q 15minute documentation tracking log indicated Resident #1 was monitored from 11/21/2025 at 1:00 p.m. until 12/10/2025 at 8:00 a.m. with no new behaviors indicated on tracking log.Resident #2 Record review of Resident #2's admission record, dated 12/10/2025, indicated a [AGE] year-old female originally admitted on [DATE]. Her diagnoses included spina bifida (a condition that occurs when the spine and spinal cord don't form properly), anxiety disorder (persistent and excessive worry that interferes with daily activities), depressive episodes, and diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar). Resident #2 discharged on 11/16/2025. Record review Resident #2's admission MDS dated [DATE] indicated she was moderately impaired cognitively with a BIMS score of 09 out of 15 and had inattention and disorganized thinking. She was usually able to make herself understood and usually understood others. Record review of Resident #2's care plan reviewed on 12/10/2025 indicated she had the right to be safe in general initiated on 11/03/2025. The goal was she would remain safe. Interventions included perform safety risk evaluations, and safety measures including strategies to reduce the risk of injuries or incidents. 1. Record review of a Provider Investigation Report dated 11/03/2025 indicated an incident categorized as Abuse occurred on 11/03/2025. The incident involved Resident #1 and Resident #2. Resident #1 inappropriately touched Resident #2 on her breast and genitals. Resident #1 placed on 1:1 tracking/monitoring, call to behavioral hospital for transfer/discharge. Resident #1 denied the allegation. An assessment was conducted by nursing staff on Resident #2 indicated she had no identifiable marks noted.Record review of Resident #2's incident report dated 11/03/2025 authored by LVN A indicated alleged abuse, incident location was in Resident #2's room. Resident #2 reported to a staff member she was touched by a male resident (Resident#1). She stated while he was in her room he touched her right breast and grabbed her cat. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #2's Weekly Skin Assessment, dated 10/05/2025, indicated she had redness to her peri area related to incontinence and barrier cream applied. No bruising or discoloration indicated. Record review of Resident #2's Progress Notes indicated the following: -On 10/30/2025 at 7:09 p.m., LVN A wrote while standing outside in the hallway of Resident #2's room overheard her say that the sex scene in the movie on TV was making her horny. -On 11/03/2025 at 12:02 p.m., LVN A wrote Late Entry It was brought to my attention that a male resident (Resident #1) made unwanted advancements towards Resident #2 by grabbing her right breast and rubbing her genitals. It was immediately reported to the abuse coordinator, ADON, DON, NP and RP. -On 11/03/2025 at 12:05 p.m., LVN A wrote Late Entry I was made aware by the facility DON that there was an incident between the Resident #2 and another male resident (Resident #1), and she stated to the front office business manager that the male resident touched her right breast and grabbed her cat (vagina). I was also informed that the abuse coordinator, ADON, RP and facility physician had already been notified. -On 11/05/2025 at 8:42 p.m., ADON wrote Resident #2 has been in her room thus far this shift. She has had no complaints and does not exhibit any signs of discomfort.- On 11/07/2025 at 10:07 a.m., LVN G wrote Resident #2 moved to new assigned room with all belongings.Observation and interview on 12/10/2025 at 10:21 a.m. with Resident #1 indicated a well-groomed male sitting at a table alone in the facility dining room with 1:1 monitoring by facility activity staff. He denied any sexual abuse allegations or inappropriate touching of female residents. He said he was sent to a behavioral hospital for an evaluation due to the allegations but continues to deny the allegation during interviews. During an interview on 12/10/2025 at 9:30 a.m., LVN A said she was the CN working when Resident #2 reported to BOM B Resident #1 had touched her inappropriately. LVN A said she was notified of the incident by management staff (Administrator, DON and ADON). LVN A said she assessed Resident #2 and did not identify any injuries. LVN A said Resident #2 did not notify her of any sexual abuse incident and the only sexual in nature incident with Resident #2 was she overheard her say a sex scene in a movie was making her horny. LVN A said Resident #2 seemed impaired cognitively and would seek attention and flirt with male residents and staff. LVN A said Resident #1 was placed on immediate 1:1 monitoring and did not exhibit any s/s of sexual behaviors during her shift. LVN A said she was not aware of Resident #1 having a history of sexual behaviors. LVN A said Resident #1 stayed on 1:1 monitoring until sent out to behavioral hospital for evaluation and upon his return to the facility. LVN A said Resident #1 has recently been placed on 1:1 monitoring while outside of his room and every 15-minute tracking while is his room. LVN A said Resident #1 was waiting for an open bed at an all-male nursing facility. LVN A said she had received training regarding sexual abuse and if it occurred to keep residents safe, the perpetrator should be placed on 1:1 monitoring immediately and administrator, DON, ADON, MD/NP, RP and authorities are notified. During an interview on 12/10/2025 at 10:30 a.m., CNA F said she was one of the CNAs provided 1:1 monitoring with Resident #1 prior and after his behavioral hospital stay. CNA F said during her 1:1 monitoring Resident #1 did not exhibit any sexual behaviors. CNA F said she was not aware of Resident #1 having a history of sexual behaviors. During an interview on 12/10/2025 at 1:50 p.m., BOM B said Resident #2 was in her office visiting with her and towards the end of the conversation she said Resident #1 had touched her inappropriately on the breast and cat (peri area). She said she immediately reported it to the abuse coordinator and DON. During an interview on 12/10/2025 at 3:15 p.m., LVN E said Resident #1 was placed on 1:1 monitoring after the sexual abuse allegation and did not exhibit any s/s of sexual behaviors during her shifts. LVN E said Resident #1 did not have a history of sexual behaviors. LVN E said Resident #1 stayed on 1:1 monitoring until sent out to behavioral hospital for evaluation and upon his return to the facility. LVN E said Resident #1 has recently been placed on 1:1 monitoring while outside of his room and every 15-minute tracking while is his room. LVN E said Resident #1 was waiting for an open bed at an all-male nursing facility. LVN E said she had received training regarding sexual abuse and if it occurred to keep residents safe, the perpetrator should be placed on 1:1 monitoring immediately and administrator, DON, ADON, MD/NP, RP and authorities are notified.During a phone interview on 12/11/2025 at 8:15 a.m., Resident #2 with noted increased emotional tone said Resident #1 came into her room and touched her breast, twisted her nipples and then grabbed her cat (genital area) with her clothing in place. She said she did not want him to touch her and told him to stop several times, she said he did stop and left the room. She said she told the lady in the front office regarding the incident the next day. She said the incident was not witnessed and only recalls it occurred in the evening when her roommate (Resident #3) was out of the room for a smoke break. She expressed I did not want him touching me like that. Resident #2 denied any sexual penetration into a body orifice. Resident #3Record review of Resident #3's admission record, dated 12/10/2025, indicated a [AGE] year-old female originally admitted on [DATE]. Her diagnoses included stroke affecting her right dominant side, aphasia following her stroke (communication disorder that affects her ability to speak, understand, read and write), anxiety disorder (persistent and excessive worry that interferes with daily activities), depressive episodes, and diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar).Record review of Resident #3's annual MDS dated [DATE] indicated she was rarely or never understood and moderately impaired (decisions poor; curs/supervision required) cognitively for daily decision making. She rarely makes herself understood and usually understands others. Record review of Resident #3's care plan reviewed on 12/10/2025 indicated she had the right to be safe in general initiated on 11/03/2025. The goal was she would remain safe. Interventions included perform safety risk evaluations, and safety measures including strategies to reduce the risk of injuries or incidents.2. Record review of a Provider Investigation Report dated 11/04/2025 indicated an incident categorized as Abuse occurred on 11/04/2025. The incident involved Resident #1 and Resident #3. Resident #1 made Resident #3 feel uncomfortable and touched her breast without consent on an unidentified date. Resident #1 was already on 1:1 tracking/monitoring and waiting for transfer/discharge to behavioral hospital. Resident #1 denied the allegation. An assessment was conducted by nursing staff on Resident #3 indicated she was not hurt and no identifiable marks noted. Record review of Resident #1's incident report dated 11/04/2025 authored by LVN A indicated alleged abuse, incident location was in Resident #3's room. Resident #3 reported to facility staff member Resident #1 makes her uncomfortable and he had touched her breast without consent. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #1's physicians ordered dated 11/04/2025 indicated Resident #1 was started on Estrace 0.5mg daily for sexual behaviors. Record review of Resident #3's incident report dated 11/04/2025 authored by LVN A indicated alleged abuse, incident location was unknown. Resident #3 reported to facility staff member Resident #1 makes her feel uncomfortable and he had touched her breast without consent. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #3's Progress Notes indicated the following:- On 11/04/2025 at 12:00 p.m., LVN A wrote Late Entry I was made aware by a staff member that there was an incident between Resident #3 and a male resident (Resident #1) and she alleged that Resident #1 made her uncomfortable and touched her breast without consent, and that the abuse coordinator was notified along with the DON, ADON facility physician and both residents emergency contacts/RPs were notified. - On 11/05/2025 at 8:44 p.m., ADON wrote Resident #3 has been in her room this shift with exception to go smoke at 7:00 p.m. She does not exhibit any signs of discomfort with staff or her roommate.- On 11/06/2025 at 11:30 a.m., LVN E wrote Resident #3 has had no behaviors during her shift. She does not exhibit any signs of discomfort with staff or her roommate.- On 11/07/2025 at 8:30 a.m., LVN E wrote SN called and spoke with resident's RP and informed her that all residents will be moving around to different rooms as the facility has decided to place all females on one hall and all males on the other hall. RP was understanding of change and approved the move to with all belongings.During an interview on 12/10/2025 at 9:40 a.m., LVN A said she was the CN working when Resident #3 reported to AD H Resident #1 had touched her breast inappropriately. LVN A said AD H notified management staff (Administrator, DON and ADON). LVN A said she assessed Resident #3 and did not identify any injuries. LVN A said Resident #3 did not notify her of any sexual abuse incident and Resident #3 was hard to communicate with due to being unable to speak or write after her stroke. LVN A said Resident #3 did indicate Resident #1 had touched her breast without her consent. LVN A said Resident #1 was already on 1:1 monitoring when the incident was reported and Resident #3 could not identify the date her alleged sexual abuse occurred. LVN A said she was not aware of Resident #1 having a history of sexual behaviors. LVN A said Resident #1 stayed on 1:1 monitoring until he was sent out to behavioral hospital for evaluation and upon his return to the facility. LVN A said Resident #1 had recently been placed on 1:1 monitoring while outside of his room and every 15-minute tracking while is his room. LVN A said Resident #1 was waiting for an open bed at an all-male nursing facility. LVN A said she had received training regarding sexual abuse and if it occurred to keep residents safe, the perpetrator should be placed on 1:1 monitoring immediately and administrator, DON, ADON, MD/NP, RP and authorities are notified.During an interview on 12/10/2025 at 1:30 p.m., AD H said she noticed on 11/04/2025 Resident #3 had stayed in her room and not participated in activities for 2-3 days which was out of character for her. AD H said when she started discussing the isolation, Resident #3 expressed to her she had been touched inappropriately on her breast by Resident #1 without her consent on an unidentified date. AD H said she notified the administrator, DON, ADON of her findings. AD H said Resident #3 was upset and withdrawn during the discussion and feels like the allegation was valid. AD H said Resident #3 had returned to participating in facility activities with no recent isolation or withdrawal episodes identified. During an interview on 12/10/2025 at 2:00 p.m., Resident #3 indicated she had been touched on her left breast on top of her clothes by Resident #1 without her consent on an unidentified date. Resident #3 was asked yes or no questions and able to identify locations by pointing or touching. Resident #3 denied any sexual penetration into a body orifice. Resident #3 expressed she currently feels safe at the facility. During an interview on 12/11/2025 at 10:10 a.m., the DON said she investigated the sexual abuse allegations on Resident #1. She said Resident #1 was immediately placed on 1:1 monitoring after the reported incident. She said Resident #1 stayed on 1:1 monitoring until transferred to behavioral hospital for evaluation. She said the NP assessed Resident #1 and ordered Zoloft and Estrace to decrease sexual behaviors. She said Resident #1 was transferred to behavioral hospital on [DATE]. She said Resident #1 admitted to the behavioral hospital staff the inappropriate touching did happen at the nursing facility, but he continues to deny the allegations to the nursing facility staff. She said during the investigation and contact with Resident #1's family she learned he had been incarcerated and had a history of unwanted verbal sexual behaviors. She said the incarceration offense was unknown and the sexual behaviors were not disclosed to facility by family during the admission process. She said Resident #1 did not have any known sexual behavior at the facility prior to this incident. She said Resident #1 returned to the nursing facility on 11/21/2025 from the behavioral hospital and continues to be on 1:1 monitoring while out of his room and every 15-minute tracking while in his room. She said Resident #1 has not had any sexual behavior since his return from behavioral hospital. She said Resident #1 will be transferred to an all-male facility once a bed becomes available. She said Residents #2 and #3 were assessed and monitored after the incidents. She said Residents #2 and #3 were seen by psych services for any effects related to the incidents. She said Resident #2 was known to be attention seeking and flirtatious with other male residents. She said after the reported incidents she visited with residents for safety checks and interviewed residents regarding them feeling safe at the facility and no other residents identified any concerns. She said she in-serviced staff on abuse, neglect, reporting abuse and specific in-service regarding sexual abuse in the nursing home. She said not keeping the residents free from abuse could place them at risk of abuse, physical harm, mental anguish, and emotional distress.During an interview on 12/11/2025 at 10:30 a.m., the ADM said Resident #1 had been at the facility for 1.5 years and he had not exhibited sexual behaviors prior to this incident. He said the facility could not predict he would have sexual behaviors. He said the facility tries to keep all residents safe and free from abuse and neglect. He said as soon as the incident was reported to him, he notified the state agency and began investigating the incident. He said Resident #1 was placed on 1:1 monitoring prior to his transfer to behavioral hospital and upon his return to the facility. He said Resident #1 was pending a transfer to all male facility once a bed becomes available. He said one intervention after the incident was the facility residents (with consent) were moved, and a female hall and male hall was developed. He said facility staff were trained on abuse, neglect and sexual abuse in nursing homes. He said he felt the facility acted quickly and put things in place to prevent continued incidents. He said his expectations were residents were free from abuse and neglect. During an interview on 12/11/2025 at 11:09 a.m., the Psych NP said during her weekly visits to the nursing facility she provided services to Resident #2 and #3 and she did not identify any new concerns following the incidents with Resident #1 in early November 2025. She said both Resident #2 and #3 were being seen prior to incident for depressive episodes but she did not recall any changes or new treatment following the incident. During an interview on 12/11/2025 at 2:41 p.m., the NP said she was aware of Resident #1's allegations of sexual abuse in early November 2025. She said she evaluated Resident #1, initiated 1:1 monitoring, referral to behavioral hospital and started on Estrace 0.5mg daily and Zoloft 25mg daily for sexual behaviors during the transition to behavioral hospital. She said she was not aware of Resident #1 having a history of sexual behaviors and it was not disclosed during admission to nursing facility. She said she had been treating Resident #1 for over a year and she did not recall any sexual behavior reported prior to this incident. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 04/2021 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Record review of Resident #1's 1:1 monitoring with q 15minute documentation tracking log indicated Resident #1 was monitored from 11/03/2025 at 11:45 a.m. until 11/06/2025 at 3:30 p.m. with no new behaviors indicated on tracking log. Record review of Resident #1's 1:1 monitoring with q 15minute documentation tracking log indicated Resident #1 was monitored from 11/21/2025 at 1:00 p.m. until 12/10/2025 at 8:00 a.m. with no new behaviors indicated on tracking log.Record review of Resident #1's Medication Administration Record (MAR) indicated he received Estrace .5mg by month daily (sexual behavior management) starting 11/05/2025 until 11/06/2025 and it was resumed upon his return to the facility on [DATE] until current 12/11/2025. Record reviews of resident safety checks completed with 28 residents revealed they felt safe in the facility.Record review of Resident #2 and Resident #3 psychiatry assessment on 11/09/2025 indicated both residents were receiving treatment for depression with no new or changes to the current treatment plans and both had shown improvement in response process. Record review of Resident #2 and #3 Treatment Administration Record (TAR) indicated both residents were being monitored for following behaviors: afraid/panic, agitated, angry, anxiety, biting, compulsive, continual crying, continual pacing, continual yelling, danger to others, danger to self, delusions, depression, withdrawn, extreme fear, fighting, hallucinations, insomnia, jittery, nervousness, kicking, mood changes, paranoia, pinching, pulling lines, restlessness, scratching, spitting, striking out, hitting, suspiciousness, throwing objects, and uncooperative every shift with no documentation of these behaviors identified since incident. Record review of an in-service record dated 11/03/2025, and titled Preventing Resident Abuse, Sexual Abuse in Nursing homes indicated 48 staff signatures indicating they had been in-serviced.During interviews on 12/10/2025 from 8:30 a.m. though 5:30 p.m. and 12/11/2025 from 8:00 a.m. though 1:30 p.m., 5 LVNs (LVN A, LVN D, LVN E, LVN G, LVN J ), 6 CNA's (CNA F, CNA L, CNA M, CNA N, CNA O, and CNA P), 1 Activity Director (AD H), 1 Activity Assistant (AD assistant Q), 2 Housekeeping staff (Housekeeper R and S), 1 Human Resource staff (HR T) and 1 BOM (BOM B) were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and staying with the aggressor one-on-one until further instruction from the Abuse Coordinator. They identified actions taken during Resident #1's i

Based on interview and record review, the facility failed to report 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 for 3 of the 4 incidents reviewed for reporting. 1. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #1's allegation of inappropriately touching Resident #2 reported on 11/3/2025 and Resident #1 allegation of inappropriately touching Resident #3 reported on 11/04/2025. 2. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #18's allegation of injury of unknown origin on 11/30/2025. This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken.Findings include:Resident #1Record review of Resident #1's admission record, dated 12/10/2025, indicated an [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE]. His diagnoses included mood disorder (mental disorders that primarily affect a person's emotional state), dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities) and high risk of heterosexual behaviors added 11/04/2025.Record review of Resident #1's quarterly MDS dated [DATE] indicated he was intact cognitively with a BIMS score of 15 out of 15 and had no behaviors. He was able to make himself understood and understood others.Resident #2Record review of Resident #2's admission record, dated 12/10/2025, indicated a [AGE] year-old female originally admitted on [DATE]. Her diagnoses included spina bifida (a condition that occurs when the spine and spinal cord don't form properly), anxiety disorder (persistent and excessive worry that interferes with daily activities), depressive episodes, and diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar). Resident #2 discharged on 11/16/2025.Record review Resident #2's admission MDS dated [DATE] indicated she was moderately impaired cognitively with a BIMS score of 09 out of 15 and had inattention and disorganized thinking. She was usually able to make herself understood and usually understood others.Resident #3Record review of Resident #3's admission record, dated 12/10/2025, indicated a [AGE] year-old female originally admitted on [DATE]. Her diagnoses included stroke affecting her right dominant side, aphasia following her stroke (communication disorder that affects her ability to speak, understand, read and write), anxiety disorder (persistent and excessive worry that interferes with daily activities), depressive episodes, and diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar).Record review of Resident #3's annual MDS dated [DATE] indicated she was rarely or never understood and moderately impaired (decisions poor; curs/supervision required) cognitively for daily decision making. She rarely makes herself understood and usually understands others.1.Record review of Resident #1's incident report dated 11/03/2025 authored by BOM B indicated alleged abuse, incident location was in Resident #2's room. Resident #2 reported to BOM B she was touched on her right breast and her cat (peri area) by a male resident (Resident#1). Resident #1 stated that he didn't do anything wrong before he was told what we wanted to question him about. He also stated, that he thought they were asking him about the female resident across the hall because she tried to get his attention and she wasn't covered. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #1's incident report dated 11/04/2025 authored by LVN A indicated alleged abuse, incident location was in Resident #3's room. Resident #3 reported to facility staff member Resident #1 makes her uncomfortable and he had touched her breast without consent. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review completed on 12/10/2025 at 08:32 AM of the TULIP (Texas Unified Licensure Information Portal) reporting system indicated no Provider Investigation Report (Form 3613-A) had been received or uploaded in the system for incidents with allegation of abuse on 11/3/2025 and 11/04/2025. Record review of the Provider Investigation Report (form 3613-A) for the incident with Resident #1's allegation of inappropriately touching Resident #2 on 11/3/2025 was reported on 11/03/2025 indicated it was completed on 11/06/2025. The Provider Investigation Report indicated a thorough investigation of the incident was completed. Record review of the Provider Investigation Report (form 3613-A) for the incident with Resident #1 allegation of inappropriately touched Resident #3 on 11/04/2025 was reported on 11/04/2025 indicated it was completed on 11/07/2025. The Provider Investigation Report indicated a thorough investigation of the incident was completed.2. Record review of Resident #18's admission record, dated 12/10/2025, indicated a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), anxiety disorder (persistent and excessive worry that interferes with daily activities), depressive episodes, disorder of bone density.Record review of Resident #18's annual MDS dated [DATE] indicated she was unable to complete the brief interview for mental status. She had short- and long-term memory problems. She was severely impaired with cognitive skills for daily decision making. She sometimes makes herself understood and usually understands others.Record review of Resident #18's incident report dated 11/30/2025 authored by LVN J indicated injury of unknown origin, incident location was in secure unit reception/lobby area. Resident #18 complaining of stomach pain and transported to local hospital for evaluation. Immediate action taken with administration, DON, ADON, and MD/NP notification. No injuries observed at the time of reported incident. No predisposing environmental, physiological, and/or situational factors indicated. Record review of Resident #18's transfer to hospital summary dated 11/30/2025 indicated the hospital ER CT scan indicated a hip fracture, fecal impaction and distended gallbladder with large gallstones and was being transferred to acute care hospital.Record review completed on 12/10/2025 at 08:32 AM of the TULIP (Texas Unified Licensure Information Portal) reporting system indicated no Provider Investigation Report (Form 3613-A) had been received or uploaded in the system for Resident #18 with allegation of injury of unknown origin on 11/30/2025. Record review of the Provider Investigation Report (form 3613-A) for Resident #18's incident with injury of unknown origin occurred on 11/30/2025 indicated it was completed on 12/03/2025. The Provider Investigation Report indicated a thorough investigation of the incident was completed.During an interview on 12/10/2025 at 11:11 a.m., the ADON said she was the designated representative responsible for completing the Provider Investigation Report (Form 3613-A) and submitting it to the State Agency with 5 working days of the incident. She said the Provider Investigation Report (Form 3613-A) was now in the electronic medical record for completion. She said she completed the Provider Investigation Report (Form 3613-A) in the electronic medical record system for the involved incidents; she just forgot to submit them through the TULIP reporting system. She said I will upload them today into the TULIP reporting system. She said she was responsible for submitting the Provider Investigation Report (Form 3613-A) 5 working days after the incident, initially thought the electronic system would automatically submit the reports once completed but has since learned she must manually upload the report. She said not submitting the Provider Investigation Report (Form 3613-A) timely could delay appropriate corrective actions are to protect residents.During an interview on 12/10/2025 at 11:30 a.m., the Administrator said the ADON was the designated representative responsible for completing the Provider Investigation Reports (Form 3613-A) and submitting it to the State Agency with 5 working days of the incident. He said the Provider Investigation Reports (Form 3613-A) were completed for the incidents involved, which he remembered reviewing them in the electronic medical record. He said the ADON just forgot to upload the information to the TULIP reporting system.Record review of the facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 04/2021, indicated the following: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Results of Investigations: 1. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure Resident #1, and Resident #6 were free from sexual abuse when Resident #6 was observed in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 2. The facility failed to ensure Resident #1 did not touch Resident #2 inappropriately when CNA A witnessed Resident #1 was up behind Resident #2 in dining room/nook area and put his hands on her shoulders and waist and started rubbing his privates against her backside (dry-humping - both residents clothed) on 08/20/2025. 3. The facility failed to ensure Resident #4 was free from physical abuse when Resident #3 picked up silverware from the dining table and hit Resident #4 on top of her right hand on 04/19/2025. 4. The facility failed to ensure Resident #3 & #7 was free from physical and verbal abuse when Resident #3 threw coffee and threatened to kill Res #7. Resident #7 reacted and hit Resident #3 on side of the head with her fist on 05/14/2025. 5. The facility failed to ensure Resident #7 was free from verbal abuse when Resident #3 was cussing at her and calling her an evil bitch and Resident #7 responded she would beat her ass on 05/18/2025. 6. The facility failed to ensure unidentified resident was free from physical abuse when Resident #3 punched an unidentified resident in the chest on 5/27/2025. 7. The facility failed to ensure Resident #5 was free from physical and verbal abuse when Resident #3 was verbally and physically aggressive to Resident #5 and hit her in the face on 6/11/2025. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.The findings included:Resident #6Record review of Resident #6's face sheet, dated 10/21/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 was discharged on 09/25/2025 to a hospital. Resident #6 had diagnoses which included dementia (loss of cognitive functioning), and personal history of traumatic brain injury (sudden injury that causes damage to the brain). Record review of Resident #6's admission MDS Assessment, dated 03/04/2025, indicated she had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, behaviors of rejecting care 1 to 3 days and wandering 4 to 6 days (but less than daily) during the 7 days look back period. No behaviors of abusing others sexually or public sexual acts identified. She required assistance for self-care and was independent with transfers and required supervision with ambulation. Record review of Resident #6's care plan with a target date of 09/08/2025 indicated Resident #6 had an impaired cognitive function/dementia or impaired thought process. Interventions included clear communications, to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #6 had an updated or revised care plan for receiving sexual behaviors from another resident on 03/12/2025. Resident #1Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. 1. Record review of Resident #6's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room. LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Unable to interview Resident #6 she no longer resides at the facility. During an interview on 10/21/2025 at 2:45 p.m. with DS C, he said on 3/12/2025 he was in the secure unit and observed Resident #1 and Resident #6 sitting in the common dining area., Resident #6 had her hand down Resident #1's pants, he immediately notified the CN/LVN K which was nearby, but her back was to Resident #1 and #6 because she was interacting with other residents. He said LVN K intervened and asked Resident #6 to remove her hand from Resident #1's pants. He said Resident #1 got upset and yelled at LVN K, but LVN K removed Resident 6's hand from Resident #1's pants and removed Resident #6 from the situation. He said what he observed was inappropriate touching/sexual abuse and he reported the allegation immediately to the charge nurse/LVN K. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful Resident #2 Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. 2. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera (a female hormone used in men to suppress testosterone production, which can lead to decrease in sexual drive and aggressive behaviors) 150mg/ml and one on one supervision was initiated. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back, and I shouldn't have and stopped when CNA told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. During an observation and interview on 10/20/2025 at 11:30 a.m., Resident #1 was observed ambulating independently in the secure unit hallways and in the outdoor secure area. Resident #1 interviewed regarding the sexually behaviors/allegations, he stated I'm sorry. He would then start asking about needing assistance with banking accounts, financial records and when his family member was arriving at the facility. During an observation and attempted interview on 10/20/2025 at 11:40 a.m., Resident #2 observed sitting in a chair close to dining table and preparing for lunch to be served. Resident #2 with no signs of abuse or fear identified. Resident #2 did not answer interview questions appropriately. During an interview on 10/20/2025 at 3:00 p.m., LVN E said she did not routinely work in the secure unit, she was covering a shift, but she was familiar with the residents on the secure unit. She said she is made aware during shift reports of any resident incidents, behaviors, monitoring required and task due. She said she was not aware of any specific residents on the secure unit currently requiring 1:1 monitoring but due to the cognitive impairment of most of the secure unit residents they must be monitored closely. She said the secure unit has a designated nurse, three CNAs and assistance from restorative aide and activity aide routinely during day shift, so plenty of staff for monitoring. She said as a charge nurse if an abuse allegation is reported to her, she responded immediately, separating involved individuals, and completed head to toe assessment, notified RP, MD, DON, Administrator/AC, hospice (if applicable) and followed orders as received. LVN E said she is aware of Resident #1's sexual behaviors but has not witnessed these behaviors during her assigned shifts. She said Resident #3 did have a history of aggressive behaviors with Resident #4 & #5; Resident #4 has been moved off the secure unit so the two no longer have contact. She said Resident #3 and #5 both still reside on the secure unit and staff attempt to prevent any altercations or interactions between the two. She said they are both up in their wheelchairs in the hallways and that is when the incidents occur due to one being in the path of the other, but staff try to intervene or redirect prior to that occurring. During an interview on 10/20/2025 at 3:30 p.m., CNA A said on 08/20/2025 she was exiting the nurse's office and observed Resident #1 standing behind Resident #2 with his hands on her shoulders moving down to her waist and was rubbing his private area on Resident #2 backside (humping). She said both residents were fully clothed, and she told Resident #1 to stop and immediately hollered for the nurse or assistance. CNA A said she and the nurse separated Resident #1 and Resident #2. CNA A said she was aware that Resident #1 had a history of sexual behaviors with exposing himself, inappropriate touching and masturbating but this was the first incident she witnessed the behaviors involving another resident. She said the incident witnessed was sexual abuse and she reported the incident immediately to the CN/RN D. She said all abuse or neglect allegations are to be reported to CN immediately after intervening and keeping involved residents safe. During an interview on 10/20/2025 at 4:30 p.m., Resident #2's family member said she was notified by facility staff and was aware of the sexual behavior allegation that occurred to Resident #1 back on 08/20/2025. She said she was initially shocked about the incident and felt Resident #2 would be upset about the incident. She said she understood that most of the residents on the secure unit were cognitively impaired and unaware of their actions. She said she was not aware of who the perpetrator was or if he still resided at the facility but she noticed after the incident that Resident #2 would track the younger Caucasian male on the secure unit with her eyes when he got in close perimeter to them but that could be her being protective of a family member. She said she was notified by the facility of incidents and had not noticed any signs of abuse or other fearful behaviors from Resident #2 during unannounced routine visits. An attempted telephone interview on 10/20/2025 at 5:00 p.m. and 10/21/2025 at 9:37 a.m. with RN D, was unsuccessful. During an interview on 10/20/2025 at 5:30 p.m., the DON said she was not the active DON during the incident on 03/12/2025 between Resident #1 and #6 but was active DON and aware of the incident/allegation on 8/20/2025 between Resident #1 and #2 sexual abuse allegations. She said on 08/20/2025 she was made aware of the sexual behaviors from Resident #1, and he was placed on 1:1 monitoring, RP and MD notified, and new orders received for Depo-Provera injection and referral to behavioral hospital. She said both Resident #1 & #2 were assessed by staff with no injuries reported. She said Resident #1 was on 1:1 monitoring until he was transferred to behavioral hospital. She said abuse allegations are to be reported to the Administrator/AC within 24 hours. During an interview on 10/20/2025 at 5:50 p.m., the Administrator said he was aware of the incident between Resident #1 and Resident #6 on 03/12/2025 and it was not reported to the state agency because he considered the incident to be consensual because Resident #1 did not want Resident #6's hand removed. He was unable to provide evidence of how Resident #6 hand got to the location or written consent from responsible party of Resident #1 or Resident #6 due to lack of cognitive ability to consent to consensual sexual contact. He said the incident with sexual behaviors between Resident #1 and #2 on 08/20/2025 was reported to him and he reviewed the incident and identified sexual abuse allegation and reported it to the state agency late. During an observation of the secure unit on 10/21/2025 at 11:20 a.m. to 12:00 noon, 14 residents were observed sitting in the TV/common area watching TV and interacting with staff. Residents were well groomed and appropriately dressed. No indication or signs of abuse or neglect. Residents were transitioned to the dining room for lunch to be served. Observed Resident #2 closely - no indication that she was visually tracking another resident or staff member; she remained in chair with eyes closed and aroused when staff spoke and interacted with her. Resident #3Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Resident #4 Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. 3. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. Record review of Resident #4's progress note/health status note dated 04/22/2025 authored by RN D Resident #4 continues day 3 follow-up status post being hit with a spoon on her right hand posteriorly. No complaints of pain or s/s of pain were observed. Resident doesn't remember being hit. No signs of bruising observed. Record review of Resident#3's progress note/behavior note dated 04/18/2025 authored by LVN K indicated Resident #3 attempted to hit another resident who was wheeling themselves down hallway in wheelchair, resident angrily stated that that lady is following me nurse redirected patient and told resident she was not being followed that she was going in the opposite direction of the other resident. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3; she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand. Record review of Resident #3's progress note/behavior note dated 04/20/2025 authored by LVN K indicated Resident #3 telling other residents that they are trash and that she will call the cops on them staff unable to redirect, resident becomes angry and screams at staff. Record review of Resident #3's progress note/health status note dated 04/22/2025 authored by RN D Resident #3 continues day 3 follow-up status post hitting another resident with a spoon. Resident does not remember hitting anyone. She continues to have episodes of verbal aggression, requiring redirection at times. UA was collected for analysis due to increased aggression. During an observation of the secure unit on 10/20/2025 at 11:25 a.m., Resident #3 was observed up in wheelchair well-groomed with no foul odor. She was maneuvering herself up and down the halls independently. She did not answer interview questions appropriately. During an observation on 10/20/2025 at 1:25 p.m., Resident #4 was observed resting in bed. She was well groomed with no foul odor. She denied abuse by shaking her head no and knotted her head yes when ask is she felt safe at the facility and was pleased with care. During an interview on 10/21/2025 at 2:45 p.m., RN G said she works the night shift on the secure unit. She said Resident #3 did have a history of aggressive behaviors and usually if behavior continued that it could be an indicator of an UTI and she would collect a urinalysis. She said she does not recall witnessing or being involved in incidents with Resident #3 but provided follow up assessments or notes after the incident occurred. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and if staff involved send staff member home. During an interview on 10/22/2025 at 8:00 a.m., CNA F said she worked on the secure unit as a CNA and she had provided care for Resident #3, she said the day of the incident between Resident #3 and Resident #4; Resident #3 was screaming at other residents and she had redirected her and later returned her to the dining room to prepare for supper. She went to get a dinner tray and Resident #3 grabbed the wrapped silverware from the table and hit Resident #4 on top of the right hand. She said she just turned her back long enough to get tray from cart, and she grabbed wrapped silverware and hit Resident #4. She said after the incident Resident #3 was separated from other residents. She said Resident #3 had a history of aggressive behaviors and she usually could be redirected before behaviors escalated. She said Resident #3 usually starts yelling or screaming prior to physical aggression and staff intervene to prevent physical aggression or trigger. She said Resident #4 was moved off the unit so there were no other incidents between her and Resident #3. She said Resident #3 and Resident #5 have a history of altercations because they wheel themselves around the unit and staff try to watch them and make sure that they do not have incident or altercations. Resident #7Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric is indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. 4. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. 5. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. During an observation on 10/20/2025 at 11:00 a.m., Resident #7 was well groomed, and appropriately dressed. Resident #7 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #7 with no signs of abuse or fear of staff identified. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. 6. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Resident #5Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant i

Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure LVN H reported a verbal and physical abuse allegation immediately to the Abuse Coordinator when Resident #3 threw coffee and threatened to kill Resident #7. Resident #7 reacted and hit Resident #3 on side of head with her fist on 05/14/2025. 2. The facility failed to ensure LVN K reported a verbal abuse allegation immediately to the Abuse Coordinator when Resident #3 was cussing at her and calling her an evil bitch and Resident #7 responded she would beat her ass on 05/18/2025. 3. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 picked up silverware from the dining table and hit Resident #4 on top of her right hand on 04/19/2025. The physical abuse allegation was not reported to the state agency. 4. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 punched an unidentified resident in the chest on 5/27/2025. 5. The facility failed to report a physical abuse allegation to the State Agency within 2 hours when Resident #3 was verbally and physically aggressive to Resident #5 and hit her in the face on 6/11/2025. 6. The facility failed to report sexual abuse allegation to the State Agency within 2 hours when it was reported that dietary staff witnessed Resident #6 in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 7. The facility failed to report sexual abuse allegation to the State Agency within 2 hours when on 8/20/2025 at 4:30 p.m. CNA A witnessed Resident #1 was up behind Resident #2 in dining room/nook area and put his hands on her shoulders and waist and started rubbing his privates against her backside (dry-humping - both residents clothed). The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. 8. The facility failed to report neglect allegation to the State Agency within 24 hours when it was reported on 7/13/2025 at 12:30 a.m. Resident #2 had an unwitnessed fall and sustained multiple injuries. The neglect allegation was not reported to the State Agency until 7/14/2025 at 9:44 a.m. greater than 24 hours after the incident occurred. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures could place residents at risk of continued abuse, physical harm, mental anguish, and emotional distress due to violations not being reported as required.Findings included: Resident #3Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Resident #7Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. 1. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. No indication that the physical and verbal altercation was reported to the abuse coordinator. 2. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. No indication that the verbal altercation was reported to the abuse coordinator. During an observation on 10/20/2025 at 11:00 a.m., Resident #7 was well groomed, and appropriately dressed. Resident #7 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #7 with no signs of abuse or fear of staff identified. During an interview on 10/20/2025 at 3:40 p.m., CNA A said she did not recall the incident between Resident #3 and Resident #7 back in May 2025. She said she did not recall Resident #7 having any aggressive behavior but if she was provoked, she may have hit someone. She said Resident #7 is usually quiet and stays to herself. CNA A said that resident to resident altercations, aggressive behaviors, falls, injuries, increase pain are reported to the CN immediately. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. Resident #4 Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. 3. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3, she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand, incident was not witnessed by CNA F due to residents back turned toward CNA A. During an observation of the secure unit on 10/20/2025 at 11:25 a.m., Resident #3 was observed up in wheelchair well-groomed with no foul odor. She was maneuvering herself up and down the halls independently. She did not answer interview questions appropriately. During an observation on 10/20/2025 at 1:25 p.m., Resident #4 was observed resting in bed. She was well groomed with no foul odor. She denied abuse by shaking her head no and nodded her head yes when ask is she felt safe at the facility and was pleased with care. During an interview on 10/21/2025 at 2:45 p.m., RN G said she works the night shift on the secure unit. She said Resident #3 did have a history of aggressive behaviors and usually if behavior continued that it could be an indicator of an UTI and she would collect a urinalysis. She said she does not recall witnessing or being involved in incidents with Resident #3 but provided follow up assessments or notes after the incident occurred. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and if staff involved send staff member home. During an interview on 10/22/2025 at 8:00 a.m., CNA F said she worked on the secure unit as a CNA and she had provided care for Resident #3, she said the day of the incident between Resident #3 and Resident #4; Resident #3 was screaming at other residents and she had redirected her and later returned her to the dining room to prepare for supper. She went to get a dinner tray and Resident #3 grabbed the wrapped silverware from the table and hit Resident #4 on top of the right hand. She said after the incident Resident #3 was separated from other residents. She said Resident #3 had a history of aggressive behaviors and she usually could be redirected before behaviors escalated. She said Resident #3 usually starts yelling or screaming prior to physical aggression and staff intervene to prevent physical aggression or trigger. She said Resident #4 was moved off the unit so there were no other incidents between her and Resident #3. She said Resident #3 and Resident #5 have a history of altercations because they wheel themselves around the unit and staff try to watch them and make sure that they do not have incident or altercations. 4. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Resident #5Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 06/13/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking and had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #5's care plan revision dated 07/08/2024 indicated Resident #5 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #5 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 06/11/2025. 5. Record review of Resident #5's incident report of physical aggression received dated 06/11/2025 indicated Resident #5 mistakenly wheeled her wheelchair into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. RP, MD notified of the incident. No pain or injuries identified at the time of incident. Record review of Resident #3's progress note/incident note dated 06/11/2025 authored by LVN H indicated Resident #3 and Resident #5 were passing in the hallway. Resident #5 gently ran into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. No pain or injuries identified at the time of incident. RP, MD and Psych service notified of the incident. MD increased Depakote to 250mg twice a day and asked to assess for continued aggression and sedation. During an observation on 10/21/2025 at 11:00 a.m., Resident #5 was well groomed, and appropriately dressed. Resident #5 was lying in her bed resting. She was easily aroused but did not respond appropriately to interview questions. Resident #5 with no signs of abuse or fear of staff identified. During an interview on 10/21/2025 at 1:34 p.m., LVN H said she worked part time at the facility and was assigned to work in the secure unit. She said she was familiar with Resident #3 and recalled her to have a history of aggressive behaviors and repeated behaviors with Resident #4, #5 and #7. She said if she witnessed any abuse or aggression that she would separate the residents, provide assessment and contact the RP, Psych services and MD/NP. She said she recalled Resident #3 throwing coffee and threatening Resident #7; Resident #7 reacted by hitting Resident #3, she does not recall reporting the incident to the abuse coordinator. Resident #7 She said she does not recall who Resident #3 punched in the chest on 05/25/2025 but if she had to guess it would be Resident #5 or #7 because of the repeated aggression/altercations between the two. She said Resident #4 was moved off the secure unit so the aggressive behaviors between her and Resident #3 stopped. She said she recalled one incident between Resident #3 and Resident #7 screaming at each other in the hall several months ago but does not recall the outcome of the perpetrator. She said she recalls notifying the Psych services and MD/NP several times regarding aggressive behaviors from Resident #3. She said during the 06/11/2025 incident between Resident #3 and #5 she notified Psych services and MD/NP but then she recontacted MD because Psych services were not providing treatment plan for the aggressive behaviors and she discussed this concern with the MD/NP. She said the MD/NP ordered medication increase of Resident #3's Depakote to 250 mg twice a day and that it seemed to help manage and decrease the aggressive behaviors. She said she does not recall receiving orders for the residents she reported to Psych services or MD/NP for aggressive behaviors to be transferred to behavioral hospital during the aggressive behaviors' incidents. She said all abuse allegations were to be reported to the Administrator immediately after the involved residents were safe. Resident #6 Record review of Resident #6's face sheet, dated 10/21/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 was discharged on 09/25/2025. Resident #6 had diagnoses which included dementia (loss of cognitive functioning), and personal history of traumatic brain injury (sudden injury that causes damage to the brain). Record review of Resident #6's admission MDS Assessment, dated 03/04/2025, indicated she had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, behaviors of rejecting care 1 to 3 days and wandering 4 to 6 days (but less than daily) during the 7 days look back period. No behaviors of abusing others sexually or public sexual acts identified. She required assistance for self-care and was independent with transfers and required supervision with ambulation. Record review of Resident #6's care plan with a target date of 09/08/2025 indicated Resident #6 had an impaired cognitive function/dementia or impaired thought process. Interventions included clear communications, to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #6 had an updated or revised care plan for receiving sexual behavior from another resident on 03/12/2025. Resident #1 Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. 6. Record review of Resident #6's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room,. LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Unable to interview Resident #6; she no longer resides at the facility. During an interview on 10/21/2025 at 2:45 p.m. with DS C, he said on 3/12/2025 he was in the secure unit and observed Resident #1 and Resident #6 sitting in the common dining area, . Resident #6 had her hand down Resident #1's pants, he immediately notified the CN/LVN K which was nearby, but her back was to Resident #1 and #6 because she was interacting with other residents. He said LVN K intervened and asked Resident #6 to remove her hand from Resident #1's pants. He said Resident #1 got upset and yelled at LVN K, but LVN K removed Resident 6's hand from Resident #1's pants and removed Resident #6 from the situation. He said what he observed was inappropriate touching/sexual abuse and he reported the allegation immediately to the charge nurse/LVN K. An attempted telephone interview on 10/20/2025 at 5:10 p.m. and 10/21/2025 at 12:27 p.m. with LVN K, was unsuccessful. Resident #2 Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. 7. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera 150mg/ml and one on one supervision was initiated. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 said stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back and I shouldn't have and stopped when CN told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. During an interview on 10/20/2025 at 3:00 p.m., LVN E interview said she did not routinely work in the secure unit, she was covering a shift, but she was familiar with the residents on the secure unit. She said she is made aware during shift reports of any resident incidents, behaviors, monitoring required and task due. She said she was not aware of any specific residents on the secure unit currently requiring 1:1 monitoring but due to the cognitive impairment of most of the secure unit residents they must be monitored closely. She said the secure unit has a designated nurse, three CNAs and assistance from restorative aide and activity aide routinely during day shift, so plenty of staff for monitoring. She said as a CN if an abuse allegation is reported to her, she responded immediately, separating involved individuals, and completed head to toe assessment, notified RP, MD, DON, Administrator/AC, hospice (if applicable) and followed orders as received. LVN E said she is aware of Resident #1's sexual behaviors but has not witnessed these behaviors during her assigned shifts. She said Resident #3 did have a history of aggressive behaviors with Resident #4 & #5; Resident #4 has been moved off the secure unit so the two no longer have contact. She said Resident #3 and #5 both still reside on the secure unit and staff attempt to prevent any altercations or interactions between the two. She said they are both up in their wheelchairs in the hallways and that is when the incidents occur due to one b

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 residents (Resident's #1, #2, #3, #4, #5, #7, and #8) reviewed for care plans. 1. The facility failed to develop, revise and implement interventions in Resident #1's care plan on 03/12/2025, 07/01/2025 and 08/20/2025 to include interventions to prevent sexual abuse of other residents. 2. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had alleged abuse allegations on 04/19/2025, 05/14/2025, 05/18/2025, 05/27/2025 and 06/11/2025. 3. The facility failed to ensure Resident #8's comprehensive care plan was completed to maintain the resident's highest practicable physical well-being for skin integrity, meeting emotional, intellectual, physical, and social needs, ADL self-care, fall risk and diagnosis within 7 days of comprehensive assessment. 4. The facility failed to develop Resident #4's care plan to address residents' safety after Resident #4 was involved in a resident-to-resident incident on 04/19/2025. 5. The facility failed to develop Resident #7's care plan to address residents' safety after Resident #7 was involved in a resident-to-resident incident on 05/14/2025 and 05/18/2025. 6. The facility failed to develop Resident #5's care plan to address residents' safety after Resident #5 was involved in a resident-to-resident incident on 06/11/2025. 7. The facility failed to develop Resident #2's care plan to address residents' safety after Resident #2 was involved in a resident-to-resident incident on 08/20/2025. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of their needs not being identified and services put in place to address their needs. Findings included: 1. Record review of Resident #1's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), dementia (loss of cognitive functioning), and impulse disorder (conditions that involve difficulties in controlling emotions and behaviors, particularly those that are aggressive or antisocial). Record review of Resident #1's quarterly MDS Assessment, dated 09/09/2025, indicated he was severely impaired cognitively with a BIMS score of 6. He had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring 1 to 3 days during the 7-day look back period. He required supervision assistance for self-care and mobility. Record review of Resident #1's care plan with a revision date of 06/17/2025 indicated Resident #1 had psychosocial wellbeing problems to include disorganized thinking, hallucinations, delusion, verbal aggression, easily annoyed, concentration problems, lack of energy, sleep problems, resist care and wandering related to schizophrenia and insomnia with interventions to include encourage participation from resident who depends on others to make own decision, psych services with continue to monitor patient for changes in mood/behaviors and medication management, and support the resident to set realistic goals. The care plan did not indicate Resident #1 had an updated or revised care plan for sexual behaviors on 03/12/2025, 03/16/2025, 06/30/2025, and 08/20/2025. Record review of Resident #1's progress note/behavior note dated 03/12/2025 indicated DS C alerted LVN K to check on Resident #1 & #6 who was both sitting in dining room, LVN K observed Resident #6's hand down the front of Resident #1's pants and Resident #1 was holding Resident #6's hand and arm in place when LVN K told Resident #6 to remove her hand from Resident #1's pants, Resident #1 would not let go of Resident #6's arm. LVN K had to manually remove Resident #6's hand which was wrapped around Resident #1's penis. Resident #1 became angry yelling at the nurse to leave them alone. Record review of Resident #1's progress note/behavior note dated 03/16/2025 authored by LVN K indicated CNA notified LVN K that Resident #1 entered his room while she was assisting roommate back to bed and was observed by CNA and roommate masturbating, CNA requested Resident #1 to stop, and he became angry and screamed at the CNA. CNA was able to redirect Resident #1. Record review of Resident #1's progress note/health status note dated 06/30/2025 authored by LVN K indicated another resident came and reported to staff that Resident #1 was in the middle of the common area and had exposed his private area and was holding it. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of Resident #1's progress note/behavior note dated 08/20/2025 authored by RN D indicated NP and RP was notified of Resident #1's sexual behaviors and received a new order to send Resident #1 to behavioral center and start Depo-Provera 150mg/ml and one on one supervision was initiated. 2. Record review of Resident #3's face sheet, dated 10/20/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 06/20/2025, indicated she was able to make herself understood and understood others. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days within the 7-day look back period. She required moderate to supervision assistance for self-care and was independent with mobility using a manual wheelchair, required supervision to walk. Record review of Resident #3's care plan revision dated 10/23/2024 indicated Resident #3 had behavior/mod issues and had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with agitation and aggression. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behaviors on 04/18/2025, 04/19/2025, 04/20/2025, 05/14/2025, 05/18/2025, 05/27/2025, and 06/11/2025. Record review of Resident#3's progress note/behavior note dated 04/18/2025 authored by LVN K indicated Resident #3 attempted to hit another resident who was wheeling themselves down hallway in wheelchair, resident angrily stated that that lady is following me nurse redirected patient and told resident she was not being followed that she was going in the opposite direction of the other resident. Record review of Resident#3's progress note/behavior note dated 04/19/2025 authored by LVN K indicated Resident #3 was angry started screaming at 2 other residents CNA F attempted to redirect Resident #3, she remained angry screaming and a few minutes later Resident #3 picked up wrapped silverware from the table and hit Resident #4 on the hand, incident was not witnessed by CNA F due to residents back turned toward CNA A. Record review of Resident #3's progress note/behavior note dated 04/20/2025 authored by LVN K indicated Resident #3 telling other residents that they are trash and that she will call the cops on them staff unable to redirect, resident becomes angry and screams at staff. Record review of Resident #3's progress note/health status note dated 04/22/2025 authored by RN D Resident #3 continues day 3 follow-up status post hitting another resident with a spoon. Resident does not remember hitting anyone. She continues to have episodes of verbal aggression, requiring redirection at times. UA was collected for analysis due to increased aggression. Record review of Resident #3's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #3 threw coffee on Resident #7, called her names and threatened to kill her. Resident #7 struck Resident #3 on the side of her head with her fist. The witnesses to the situation said Resident #3 was not provoked. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. Record review of Resident #3's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 calling her an evil bitch LVN K was able to intervene and separate the residents. Record review of Resident #3's progress note/behavior note dated 05/27/2025 authored by LVN H indicated Resident #3 punched an unidentified resident in her chest. When asked why and what the other resident done to her, she stated, I don't remember, I just have so much anger inside. Record review of Resident #3's progress note/incident note dated 06/11/2025 authored by LVN H indicated Resident #3 and Resident #5 were passing in the hallway. Resident #5 gently ran into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. No pain or injuries identified at the time of incident. RP, MD and Psych service notified of the incident. MD increased Depakote to 250mg twice a day and asked to assess for continued aggression and sedation. 3. Record review of Resident #8's face sheet, dated 10/20/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 09/04/2025. Resident #1 had diagnoses which included muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), pressure ulcer, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin) cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #8's admission MDS Assessment, dated 08/20/2025, indicated he was usually able to make herself understood and sometimes understood others. He had a BIMS score of 00 indicating that he was severely impaired cognitively. He had wandering episodes 1 to 3 days of the 7-day look back period. He required moderate assistance for self-care and moderate assistance with transfers/mobility and maximum assistance with tub/shower transfer and ambulation. He uses a standard wheelchair for mobility. Record reviews of Resident #8's baseline care plan with admission date of 08/07/2025 and completion date of 08/09/2025 to include initial goals, dietary orders, therapy services, safety, ADLs, special treatment, bowel/bladder and skin concerns. No comprehensive care plan was developed prior to Resident #8's discharge on [DATE]. 4. Record review of Resident #4's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's annual MDS Assessment, dated 05/05/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and moderately impaired cognitively for daily decision making. She had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #4's care plan revision dated 01/01/2025 indicated Resident #4 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 04/19/2025. Record review of Resident #4's progress note/health status note dated 04/19/2025 authored by LVN K indicated Resident #4 was sitting in dining room, when Resident #3 became angry and hit Resident #4 on top of the right hand with wrapped silverware. No injury noted RP notified. 5. Record review of Resident #7's face sheet, dated 10/22/2025, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #7's quarterly MDS Assessment, dated 09/04/2025, indicated she was able to make herself understood and understood others. She had a BIMS score of 02 indicating that she was severely impaired cognition. She had inattention behaviors and disorganized thinking, and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily within the 7-day look back period and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4 to 6 days (but not daily) within the 7-day look back period. Record review of Resident #7's care plan revision dated 07/08/2024 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes. Interventions included administering medications as ordered, communicating with resident/family/caregivers regarding resident's capabilities and needs and consulting psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #7 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 05/14/2025 and 05/18/2025. Record review of Resident #7's progress note/behavior note dated 05/14/2025 authored by LVN H indicated just prior to breakfast, Resident #7 had coffee thrown on her by Resident #3. Resident #7 in return struck Resident #3 on the side of her head with her fist. The situation was diffused, and both residents were taken for one on one with aides as a calm down time. We will continue monitoring. Record review of Resident #7's progress note/behavior note dated 05/18/2025 authored by LVN K indicated nurse heard loud voices coming from hallway observed Resident #3 screaming and cursing at Resident #7 stating she would beat her ass, LVN K was able to intervene and separate the residents. 6. Record review of Resident #5's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 06/13/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She had a BIMS score of 99 indicating that she was unable to complete the brief interview for mental status, and severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking and had no indications of behaviors of physical or verbal symptoms directed towards others during the 7-day look back period. Record review of Resident #5's care plan revision dated 07/08/2024 indicated Resident #5 had impaired cognitive function/dementia or impaired thought processes. Interventions included communicating, asking yes or no questions, staff identification and making eye contact, keeping routine consistent, providing homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #5 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 06/11/2025. Record review of Resident #5's incident report of physical aggression received dated 06/11/2025 indicated Resident #5 mistakenly wheeled her wheelchair into Resident #3 resulting Resident #3 becoming verbally and physically aggressive and hitting Resident #5 in the face. Residents separated and placed on 1:1 with CNA. RP, MD notified of the incident. No pain or injuries identified at the time of incident. 7. Record review of Resident #2's face sheet, dated 10/20/2025, indicated an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), hypertension (condition in which the force of the blood against the artery walls is too high) and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's admission MDS Assessment, dated 07/01/2025, indicated she sometimes was able to make self-understood and sometimes understood others. She was not assessed for the brief interview for mental status because she rarely/never understood. She was severely impaired cognitively for daily decision making. She had inattention behaviors and disorganized thinking, but no behaviors symptoms identified within the 7-day look back period. She required moderate assistance and supervision assistance for self-care and supervision with mobility. Record review of Resident #2's care plan revision dated 07/30/2025 indicated Resident #2 had impaired cognitive function/dementia or impaired thought processes r/t dementia. Interventions included to ask yes or no questions, staff identification and make eye contact, keep routine consistent, provide homelike environment, cue, reorientate and supervise as needed, supervision/assistance with decision making, and monitor/document/report as needed any changes in cognitive functions, administer medications as ordered, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving sexual behavior from another resident on 08/20/2025. Record review of Resident #2's progress note/behavior note dated 08/20/2025 authored by RN D indicated Resident #2 was in the secure unit dining room and Resident #1 came up behind Resident #2 and started rubbing his private area on her back side. CNA A intervened immediately and separated the residents. RP, DON and Administrator notified of the incident. Record review of the facility's PIR, dated 08/28/2025, incident category as abuse signed by the ADON on 08/28/2025. The PIR indicated the incident occurred on 08/20/2025 at 4:30 p.m., in the dining room of the secure unit. The PIR indicated CNA A witnessed Resident #1 walked up behind Resident #2, put his hands on her shoulders and was rubbing his private area on her backside. Residents were separated immediately, RN D performed a head-to-toe assessment on both residents, no injury. Resident #2 said stated he didn't hurt me. Resident #1 stated I'm sorry. Investigation summary indicated CNA A intervened immediately and told Resident #1 to stop and he immediately walked off. Resident #2 was unable to be interviewed due to advanced Dementia. Resident #1 stated yes, I rubbed her back and I shouldn't have and stopped when CN told me to. Provider actions taken post-investigation was due to eyewitness and Resident #1 admitting to the situation, the allegation was confirmed. Resident #1 was immediately placed on 1:1 supervision with a new medication prescribed for Depo-Provera and referred to a behavioral hospital. Resident #1 remained on 1:1 monitoring until transferred to behavioral hospital on [DATE]. The sexual abuse allegation was not reported to the State Agency until 8/21/2025 at 11:32 a.m. greater than 2 hours after the incident occurred. During an interview on 10/21/2025 at 3:50 p.m., the ADON/MDS Coordinator said she was responsible for updating resident care plans and she had fallen behind due to her workload. She said the residents that were involved in resident-to-resident altercations should have been discussed during a morning meeting and care plan updated to reflect the resident individualized care and interventions to keep all residents safe. She said if care plans are not updated/revised it does not reflect the current resident's need and care which could result in inappropriate care, accidents or injuries. During an interview on 10/21/2025 at 4:00 p.m., the DON said the ADON/MDS Coordinator was responsible for updating resident care plans. The DON said she and ADON were having to cover floor charge nurse shifts and that some responsibility had fallen behind. She said during IDT care plan meetings and morning stand up meetings, any changes in residents identified that require a care plan revision should have been done then and not delayed. She said residents care plans should be individualized and reflect the residents' needed care and interventions to keep all residents safe. She said if care plans are not updated/revised it does not reflect the current resident's need and care which could result in inappropriate care, accidents or injuries. During an interview on 10/21/2025 at 4:15 p.m., the Administrator said all incidents and allegations are discussed during morning meetings and if care plans need to be updated that the ADON/MDS Contractor was responsible for care plans and interventions updates. He is unsure why the care plans were not updated and if the care plans were not updated or revised, the care plan would not reflect the current resident's needs. He stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. He said the DON should have been assigned the responsibilities of ensuring the care plan was updated. He said not revising care plans could result in inappropriate care, accidents or injuries. Record review of a facility policy revised March 2022, titled, Care Plans, Comprehensive Person-Centered Policy indicated, 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. 12. The interdisciplinary team reviews and updates the care plans; a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met. An Immediate Jeopardy (IJ) was identified on 10/21/2025. The IJ template was provided to the facility on [DATE] at 5:23 pm. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for Immediate Jeopardy for F656 was accepted on 10/22/2025 at 7:05 p.m. and reflected the following: Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors on 10/21/25 by ADON/MDS nurse. ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely manner by the Administrator. Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates. Resident #8 had a baseline care plan completed within 48 hours of admission but discharged on day 14 before another care plan was completed. MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due. DON has reviewed all care plans due dates and none are overdue as of 10/22/25. On 10/22/25 All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate. All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect on 10/22/25. Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior. The administrator will monitor for compliance by being copied on emails to nurse's stations. All charge nurses have been notified of this new system by DON. 6 out of 8 nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions. 46 out of 51 staff were contacted and in-serviced by DON on 10/22/25 on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection. No staff will be allowed to work until this in-service is completed. Monitoring of the Plan of Removal included the following: Record review indicated Residents #1's care plan was updated on 10/21/2025 to include he was at risk for initiating inappropriate sexual behaviors and interventions of monitoring, administering Depo-Provera as prescribed, assist the resident to develop more appropriate methods of coping and interacting such as visiting with other male residents, staff to intervene to protect the rights and safety of others, offer activities, recognize changes in condition and report, notify CN immediately of any inappropriate behaviors and remove resident from area for any signs of inappropriateness such as masturbating in public, exposing self in front of others, do not scold resident. Record reviews of Resident #3's care plan indicated it was updated with resident has potential to be verbally aggressive yelling and cursing at staff/residents related to dementia and poor impulse control on 10/21/2025. Interventions include when resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. Record reviews of Resident #2, #4, #5, and #7 care plans indicated they were updated with safety and goals that residents will remain safe on 10/22/2025. Interventions included encourage use of prescribed safety assistive devices, perform safety risk evaluation on admission and as needed upon change in condition and safety measures including strategies to reduce risk of infection, falls, injuries, incidents and initiate as appropriate. Record reviews of Resident #8's baseline care plan with admission date of 08/07/2025 and completion date of 08/09/2025 to include initial goals, dietary orders, therapy services, safety, ADLs, special treatment, bowel/bladder and skin concerns. No comprehensive care plan developed prior to Resident #8's discharge on [DATE]. Record review of the facility audit completed by the DON she reviewed all care plans due dates, and none are overdue as of 10/22/25. DON reviewed all residents' care plans after adjustments were made, and care plans are accurate on 10/22/2025. Record review of an emails from MDS Coordinator on 10/22/2025 to charge nurses, DON and the Administrator indicating detailed revisions to Resident #1, #2, #3, #4, #5, #7. Record review of in-service dated 10/22/2025 instructed by the DON and MDS Coordinator indicated 6 out of 8 nursing staff were trained on facility policy and procedure for care plans and interventions. Nursing staff will be notified of care plan changes and updates through charge nurse facility emails. Identified Resident #1's care plan updated with inappropriate behaviors with monitoring interventions added, Resident #3 with verbal and physical aggression with new interventions and Resident #2, #4, #5, and #7 with safety care plan and intervention. During an interview on 10/22/2025 at 10:15 a.m. LVN L said she received training regarding care plan revision or updates and that the MDS Coordinator or DON would be emailing/notifying the nursing staff of any changes in resident care plans and that CN should be contacting them for any care plans that need to be updated with changes in the resident's condition and to personalize the care plans to meet the resident's needs. LVN L said she was made aware verbally and electronically (email) of Resident #1 and Resident #3 had updates to their care plans which included the monitoring of Resident #1 and watching Resident #3 was agitated and to intervene before agitation escalates. During an interview on 10/22/2025 at 2:30 p.m., LVN E said she was verbally and electronically notified of updated care plans on Resident #1, #3, #2, #4, #5, and #7. She said Resident #1's care plan had changed, and he is being monitored q 15 minutes to identify any changes in his behaviors and Resident #3's care plan was updated to intervene immediately if agitation identified and the other care plan updates were to ensure residents safety. During interviews conducted on 10/22/2025 at 9:10 a.m. through 10/23/2025 at 10:00 a.m. included LVN E, LVN H, LVN K, LVN L, LVN V, LVN BB, RN MM, and LVN NN. All staff interviewed were able to identify care plans are person centered measures to maintain the resident's highest practicable physical well-being for skin integrity, meeting emotional, intellectual, physical, and social needs, ADL self-care, fall risk and diagnosis MDS. All staff interviewed said resident's care plan should be reviewed and updated when residents have a change in condition, like falls with injuries, unmanaged or repetitive aggressive behaviors. All staff interviewed said the MDS or DON would be notifying charge nurses via email or in person of any care plan updates and/or revision and if charge nurse identifies care plans that need to be revised or updated, they are to notify

41057 Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 6 residents observed for oxygen management. (Residents #1, #6, and #39) 1. The facility failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #1. 2. The facility failed to failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #6. 3. The facility failed on 02/11/2025 to apply clean filters to Resident #39's concentrator and the facility failed to clean the area manufactured to hold the filters in place. These failures could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health. Findings included: 1. Record Review of Resident #1's face sheet dated 02/12/25, indicated he was a [AGE] year-old male admitted on [DATE] and readmitted [DATE] with a diagnosis of chronic obstructive pulmonary disease, COPD (a group of lung disease that cause persistent airflow limitation and breathing problems). Record Review of Resident #1's most recent quarterly MDS assessment dated [DATE] indicated he was severely impaired of cognition. Record Review of Resident #1's care plan revised 11/06/24 indicated he had shortness of breath with interventions of oxygen at 2 liters per minute by nasal canula and to monitor breathing patterns and report abnormalities to the physician. Record Review of Resident #1's Physicians Order Summary dated 02/10/25 indicated he was prescribed oxygen at 2 liters per minute by nasal canula for oxygen saturation (a measure of how well the lungs work) was below 92% as needed for COPD. During an observation on 02/11/25 at 2:30 p.m., Resident #1 was lying in bed wearing oxygen per nasal canula at 2 liters/ minute. The oxygen concentrator was without needed air filters and two separate areas on the oxygen concentrator manufactured to hold the filters were covered with a thick grey powdery, dusty substance. 2. Record review of admission sheet dated 02/10/25 indicated Resident #6 admitted on [DATE] was [AGE] years old with diagnoses including lung cancer, congestive heart failure, and high blood pressure. Record review of physician orders dated 02/10/25 indicated Resident #6 had an order for oxygen supplement at 4 LPM via nasal cannula. May titrate (adjust) to accommodate resident's O2 saturation (how much oxygen is being in the tissues). Keep O2 saturation above 92 % with a start date of 10/31/2024. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #6 received oxygen therapy while she was a resident of this facility and within the last 14 days. Record review of the care plan dated 10/31/24 indicated Resident #6 had cancer in upper lobe of the lung interventions included 02 at 4 LPM per oxygen concentrator via to keep O2 saturation above 92%. During an observation and interview on 02/10/25 at 9:23 a.m., Resident #6 was in her bed, and she was receiving O2 at 4LPM via nasal cannula per oxygen concentrator. The filter in the back of the oxygen concentrator was covered with a thick whitish substance. Resident #6 said the nurse changed the water bottle and tubing; however, she was unsure who cleaned the filter. During an observation and interview on 02/11/25 at 9:15 a.m., LVN B looked at Resident #6's oxygen filter and said the filter needed to be cleaned. She said the dirty filter could lead to infection or prevent the concentrator from working properly. She said the maintenance supervisor or night shift was responsible. During an interview on 02/11/25 at 9:25 a.m., the Maintenance Director said he thought the rental companies serviced the concentrators and he had not serviced the concentrators. During an interview on 02/11/25 at 9:37 a.m., the ADON said she was the infection control nurse. She said the filters on the oxygen concentrator should be cleaned by the night shift weekly. The ADON said if the filter was covered with dust, it could prevent the concentrator from working properly and could cause infections. During an interview on 02/11/25 at 9:39 a.m., the DON said her expectation was for the filters on the concentrator to be cleaned weekly by the night shift. During an interview on 02/12/25 at 9:45 a.m., the Administrator said he expected the equipment to be kept clean and maintained. 3. Record Review of Resident #39's face sheet dated 02/10/25, indicated she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnoses of acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen leading to dangerously low level of oxygen in the blood) and heart failure (chronic condition in which the heart does not pump blood as well as it should). Record Review of Resident #39's most recent annual MDS assessment dated [DATE] indicated she was moderately impaired of cognition and had diagnoses of heart failure and acute respiratory failure with hypoxia. The assessment indicated she received oxygen therapy in the last 14 days. Record Review of Resident #39's care plan revised 01/07/25 indicated she had acute failure with interventions of oxygen at 2 liters per minute by nasal canula as needed and to monitor for signs and symptoms of respiratory distress and report to the physician. Record Review of Resident #39's Physicians Order Summary dated 02/11/25 indicated she was prescribed oxygen at 2 liters per minute by nasal cannula as needed for shortness of breath as of 02/11/25. The resident's previous order was oxygen at 4 liters per minute by nasal cannula with a start date of 10/29/24. During an observation and interview on 02/10/25 at 9:45 a.m., Resident #39 was lying in bed wearing oxygen per nasal canula on at 4 liters/ minute. The oxygen concentrator filter was covered with a thick grey powdery, dusty substance. Resident #39 said she wore her oxygen all the time except when smoking. During an observation and interview on 02/11/25 at 2:30 p.m., LVN A said she was providing care for Resident #1 and #39 today and they were both currently wearing oxygen. LVN A said the filter spaces on the oxygen concentrator of Resident #39 should have been cleaned and dirty filters replaced, and it was not done. She said Resident #1's oxygen concentrator filter should have been cleaned and it was not done. She said the nurses were responsible for ensuring oxygen concentrators had filters and were cleaned and, on the concentrators correctly. She said the night nurses were the back up to double check the oxygen concentrator filters. She said it was overlooked. LVN A said she was educated on ensuring the oxygen concentrator had filters on and the filters were cleaned. LVN A said the resident risk of missing and dirty oxygen concentrator filters was decreased air flow to the concentrator. During an interview on 02/12/25 at 11:02 a.m., the DON said the night nurse was responsible for ensuring oxygen concentrator filters were cleaned or replaced every Sunday night and as needed. She said LVN C was the nurse working on 02/08/25 and should have cleaned Resident #1 and #39's concentrator and filter. The DON said the charge nurse the next shift was the back up to double check and ensure the oxygen concentrators had clean filters. She said all the nurses were educated to ensure all oxygen concentrators have clean filters on them. She said it was overlooked. The DON said the resident risk was possible decreased air flow to the concentrator. The DON said her expectation was all oxygen concentrators have clean filters, be cleaned weekly and as needed and the next shift double check to ensure the oxygen concentrators had clean filters. During an attempted phone interview on 02/12/25 at 11:15 a.m., LVN C called with a message left to return call but did not return call prior to exit. During an interview on 02/12/25 at 11:20 a.m., the Administrator said the charge nurse was responsible for ensuring the oxygen concentrator filters were cleaned and applied to the concentrator. He said the staff were educated to ensure the oxygen concentrator filters were clean, but it was overlooked. He said the resident risk was respiratory illness. The Administrator said his expectation was all oxygen concentrators have filters and be cleaned. Record Review of a facility policy revised October 2010, titled, Oxygen Administration indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration.12. Check the mask, tank, humidifying jar, .to be sure they are in good working order and are securely fastened.15. Periodically check oxygen tubing and delivery device . to ensure cleanliness and change as necessary.2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 02/10/2025 one of six burners did not light when turned on. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 02/10/25 at 8:30 a.m., the DM turned on the gas stove burners with 1 of 6 burners not lighting. The left front burner did not light but no gas was smelled. He said it lit up until now and no staff had informed him the stove was not working. The DM said he thought a pot may have over splashed yesterday evening and blew out the pilot light. The DM said he was responsible for ensuring all equipment in the kitchen worked properly. He said the staff were all educated to inform him or the Maintenance Director if any equipment was not working. He said the resident risk was gas could come out if a knob was hit and the pilot did not light up immediately. The DM said his expectation was all burners to light immediately when turned on and the staff to notify him if they did not. During an interview on 02/10/25 at 8:33 a.m., [NAME] D said all the burners on the gas stove lit the last time he cooked yesterday morning. He said he was not sure why one did not light now. [NAME] D said possibly a splash out of a pot caused the pilot light to go out. [NAME] D said if a burner did not light, he was to notify the DM and Maintenance Director and not use it until fixed. He said all the staff know to notify the DM and Maintenance Director immediately if the burners do not lite and to not use it until the burner was repaired. During an interview on 02/12/25 at 11:00 a.m., the Maintenance Director said the DM was responsible for ensuring all equipment in the kitchen was working properly. He said he was the backup and made weekly rounds. The Maintenance Director said the burners on the stove all lit on 02/07/25 on his last rounds. He said he was educated in maintenance and repairs and could relight the pilot light if needed. The Maintenance Director said the pilot nozzle may have filled up with grease. He said he was notified on 02/10/25 and ordered a part to replace it. He said the resident risk was food could be cooked in a less-than-optimal time because it would take more time to relight the pilot light. He said the gas would shut off if the pilot light was off. The Maintenance Director said he expected the dietary staff to notify him if any equipment was not working so he could repair it. During an interview on 02/12/25 at 11:30 a.m., the Administrator said the DM and Maintenance Director were responsible for ensuring all equipment in the kitchen was in working order. The Administrator said he was ultimately responsible. He said he made weekly rounds with the last round on 02/02/25 and the burners all worked. The Administrator said the pilot nozzle possibly had carbon build up causing it not to light. He said the staff were educated to notify the DM and Maintenance Director of any equipment not working. The Administrator said the resident risk was it would slow down food prep time. He said the gas shuts off when the pilot was off. The Administrator said his expectation was to make the staff report immediately or as soon as possible any equipment not working and the Maintenance Director to repair the nonworking equipment as soon as possible. Record Review of a facility policy revised 2009, titled, Maintenance Service indicated, . Maintenance service shall be provided to all areas of the building, rounds and equipment. The Maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview and record review the facility failed to ensure accurate assessments were completed for 1 of 14 residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure Resident #5's quarterly MDS assessment dated [DATE] was not inaccurately coded for injection and insulin use when Resident #5 had no diagnosis or order for insulin injections. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of Resident #5's face sheet dated 02/12/2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side (left-side paralysis and weakness from a brain bleed), hypertension (high-blood pressure, and anxiety. There was no mention of diabetes or that Resident #5 was diabetic. Record review of Resident #5's care plan dated 10/15/2024 did not indicate any diagnosis of diabetes mellitus or indication of insulin injections being used. Record review of Resident #5's quarterly MDS dated [DATE] indicated she was rarely/never understood and had short-term/long-term memory problems with severely impaired cognition. The same MDS indicated Resident #5 did not have an active diagnosis of diabetes mellitus also under the medications section she received insulin injections during the last seven days but did not indicate hypoglycemic (including insulin) under the section high-risk drug classes: use and indication. Record review of Resident #5's physician orders dated from 10/01/2024 to 2/12/2025 indicated there was no order for insulin or diagnosis of diabetes mellitus during this time. During an observation and interview on 02/12/2025 at 12:18 p.m., Resident #5 was in the dining room, sitting up in a non-emergency medical wheelchair. She was noted to be alert, oriented to person and eating a regular chopped meat textured diet. When Resident #5 was asked about her diet, incomprehensible words were spoken. During an interview on 02/12/2025 at 9:15 a.m., LVN E said Resident #5 did not have a diagnosis of diabetes mellitus and never had received insulin or any type of injections prior to the 10/19/2024 quarterly MDS. LVN E stated the ADON was responsible for completing the MDS and an inaccurate MDS could lead to improper care of the resident. During an interview on 02/12/2025 at 11:15 a.m., the ADON said she was RAC-CT (Resident Assessment Coordinator Certified) for [AGE] years and had been responsible for completing the MDS since January 2025. The ADON said Resident #5 did not have a diagnosis of diabetes and never received insulin injections. When asked about the documentation of insulin and injection use in the quarterly MDS dated [DATE], the ADON said it was coded wrong, and she would fix it. The ADON said the facility used the RAI Version 3.0 Manual as their guideline for completing the MDS accurately. During an interview on 02/12/2025 at 12:45 p.m., the DON said Resident #5's, quarterly MDS dated [DATE] was coded incorrectly for insulin use and injections. The DON said Resident #5 had never had a diagnosis of diabetes and never had an order for insulin or injections prior to the 10/19/2024 quarterly MDS. The DON said incorrectly coding the MDS could lead to inappropriate resident care. Record review of the facility's assessment and care planning policy titled, Comprehensive Assessments, revised dated March 2022, indicated ., Policy Interpretation and Implementation: 1. Comprehensive assessments are conducted in accordance with criteria and timelines established in the Resident Assessment Instrument (RAI) Manual . 8. A significant error is a error in an assessment where: a. the resident' overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and /or results in an appropriate plan of care; and b. the error has not been corrected via submission of a more recent assessment. 9. A significant error differs from a significant change because it reflects incorrect coding of the MDS .

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #6) of 14 residents reviewed for Infection Control. The facility failed to ensure Resident #6 pleural (tissue that lines the chest cavity and covers the lungs) drain bag (this is a flexible tube that drains fluid from the pleural space into in a drainage bag) and the drain port was not on the floor on 02/11/2025. This failure could place residents at risk of cross-contamination and the development of infections. Findings included: Record review of admission sheet dated 02/10/25 indicated Resident #6 admitted on [DATE] was [AGE] years old with lung cancer, congested heart failure (chronic condition in which the heart does not pump well), and high blood pressure. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #6 had long term and short-term memory problems. Resident #6 diagnosis included cancer. She was dependent with ADLs. Record review of the care plan dated 10/31/24 indicated Resident #6 had cancer in upper lobe of the lung with interventions including Enhanced Barrier Precautions related to wound and pleural drain with a start date of 12/13/2024. The goals included Resident #6 will remain free from increased occurrence of infections throughout the review date. The goal was that residents, staff, and family will implement enhanced barrier precautions as directed. Interventions included: ensure residents, family and staff are educated on enhanced barrier precautions protocol. Supplies available to implement precautions. Record review of physician orders dated 02/10/25 indicated Resident #6 had an order to drain the pleural drain bag daily and as needed with a start date of 11/20/24. During an observation on 02/11/25 at 8:30 a.m., Resident #6's pleural drain (this is a flexible tube that drains fluid from the pleural drain bag was on the floor under her bed and the drain port was on the floor. During an interview on 02/11/25 at 8:45 a.m., LVN B said Resident #6 drain bag should not be on the floor to prevent infection and the risk of the tube being pulled out. During an interview on 2/11/25 at 9:37 a.m., the ADON said she was the infection control nurse and the drain bag for Resident #6 should not be on the floor. The drain bag should be kept in the blue bag attached to the bed unless it was being emptied by the nurse to prevent infections and to prevent tube being accidentally pulled out. The ADON said the facility did not have a policy. During an interview on 02/11/25 at 9:39 a.m., the DON said her expectation was for the pleural drain bag to be kept in the blue bag attached to the bed. She said to prevent the drain bag from touching the floor to prevent the spread of germs. Record review obtained per internet at 02/18/25 at https://www.iskushealth.com/wp-content/uploads/2021/12/PleurX-iskus-drainage-guide-complete-2017.pdf indicated . Keep the tip on the PleurX Catheter and the access tip on the drainage line clean. Keep them away from other objects to help avoid contamination.

Based on interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 14 (Resident #1)residents reviewed for accidents/supervision. The facility failed to ensure Resident #1's fall matt was adjacent to her bed on 11/08/24. Resident #1 fell had an unwitnessed fall and sustained a 3 cm laceration above her right eye. This failure could place residents at risk of severe injuries. Findings included: Record review of Resident #1's face sheet dated 12/19/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (brain disorder that destroys memory and thinking skills), dementia (decline in mental abilities), restless leg syndrome (neurological disorder that causes unpleasant or uncomfortable sensations in legs and an irresistible urge to move them), and Parkinson's (brain disorder that causes movement problems). Record review of Resident #1's care plan dated 05/16/24 indicated she was at high risk for falls. Interventions included anticipate and meet Resident #1's needs, ensure call light is in reach, ensure resident is wearing appropriate footwear, follow facility fall protocol, and review information on past falls and attempt to determine cause of falls, and remove any potential cause. The care plan did not include fall matt(s) as interventions. Record review of an incident report dated 10/16/24, completed by LVN B, indicated Resident #1 was found lying on her fall mat. She sustained a small 1 cm skin tear above her right eye. She was assessed with no additional injuries. A steri-strip was applied. The physician was notified. Record review of Resident #1's Fall Risk assessment dated [DATE] indicated she was at high risk for falling. Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had unclear speech, was sometimes able to make herself understood, and usually understood others. She had severe impaired cognitive skills. She was inattentive and had disorganized thinking. She had hallucinations and delusions. She utilized a wheelchair for mobility. She was dependent on staff for all ADLS. Record review of an incident report dated 11/08/24, completed by LVN A, indicated Resident #1 was found on the floor, bleeding from a laceration above her right eye on the brow area. She was assessed with no additional injuries or sign of pain. Resident #1 was transferred to the hospital for evaluation and treatment. The physician, RP and DON were notified. Record review of hospital records dated 11/08/24 indicated Resident #1 sustained a 3 cm laceration above her right eye. She received 5 sutures. Record review of facility investigation dated 11/12/24 indicated the facility would update Resident #1's care plan to include fall mat. During an interview on 12/18/24 at 9:45 a.m., the ADON said Resident #1's diagnoses included Parkinson's. She said Resident #1 was able to roll herself while lying in bed. She said Resident #1 was at risk for falls. She said she thought Resident #1's care plan included a fall mat due to previous falls. She said Resident #1's care plan should have included a fall mat to prevent serious injuries. She said she did not know why Resident #1's fall risk care plan did not include a fall mat. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/19/24 at 11:07 a.m., CNA C said she was aware Resident #1 was supposed to have a fall mat place adjacent to her bed when she was lying in bed. She said she was trained on which residents were at risk for falls and who required fall mats. She said Resident #1's fall mat was moved away from her bed when Resident #1 was transferred to her Geri-chair because the Geri-chair was hard to move over the fall mat. She said she transferred Resident #1 to bed on 11/08/24 and forgot to put the fall mat next to the bed. She said the fall mat was moved away from the bed but was available. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/19/24 at 12:02 p.m., LVN A said Resident #1 had fallen from her bed on 11/08/24 and sustained a 3 cm laceration above her right eye. She said Resident #1 was assessed with no additional injuries. She said Resident #1 was transferred to the hospital for evaluation and treatment. She said the fall mat was folded up at the end of the bed. She said the fall matt was supposed to be on the floor when Resident #1 was lying in bed. She said Resident #1 returned to the facility with 5 sutures above her right eye. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/20/14 at 8:42 a.m., QA LVN D said Resident #1's care plan was not updated to include a fall mat. She said she did not know why the care plan was not updated to include a fall mat. She said she took over updating care plans June 2024 and Resident #1's care plan update was missed. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/20/24 at 11:01 a.m., the Administrator said Resident #1's care plan should have been updated to include a fall mat. He said it was probably a miscommunication that Resident #1's care plan update to include a fall matt was missed. He said residents were at risk of serious injury if the fall mat interventions were not in place as required per the resident care plan. Record review of the facility's Safety and Supervision of Resident Policy dated 2001 (revised July 2017) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training as necessary; d. Ensuring all interventions are implemented; and e. documenting interventions. Record review of facility's Managing Falls and Fall Risk policy dated 2001 (revised March 2018) indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, . 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try and minimize serious consequences of falling.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 14 residents (Resident #2) reviewed for abuse. The facility failed to ensure CNA F did not verbally abuse Resident #2 when she made intimidating remarks at the resident on 08/26/24. The noncompliance was identified as PNC. The noncompliance began on 08/26/24 and ended on 08/26/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of Resident #2's face sheet dated 12/19/24 indicated she was a [AGE] year old female, admitted on [DATE] and her diagnoses included dementia (decline in mental abilities)and schizophrenia (mental disorder characterized by disruptions in thought process. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she sometimes was able to make herself understood or understood others, she had severely impaired skills for daily decision making, she had difficulty focusing attention and had disorganized or incoherent thinking, she rejected care daily, and she utilized a wheelchair for mobility. She required supervision or touching assistance or partial moderate assistance for all ADLS. Record review of Resident #2's care plan dated 08/18/20 indicated Resident #2 had ADL self-care deficit related to dementia. Interventions included assist and supervision for ADLS. Record review of Resident #2's care plan dated 08/18/20 indicated Resident #2 was dependent on staff for meeting emotional, intellectual, physical and social needs related to dementia. Interventions included simple structured activities and visiting with staff and peers. Record review of Resident #2's care plan dated 02/06/24 indicated Resident #2 had behavioral problems that included to severe delusions, moderate disrobing, moderate pacing, and sever resistance to care. Interventions included anticipate and meet Resident #2's needs. Record review of the facility's investigation dated 08/29/24 indicated the facility confirmed Resident #2 was verbally abused by CNA F. Record review of the Administrator's statement dated 08/26/24 indicated At approximately 5:00 p.m. 26 [DATE] I was doing some maintenance work in the restroom between rooms 8-16 and 8-17. I heard someone say, very loudly, I'm sick of you. Get your ass up and get to that dining room. I opened the door to room [ROOM NUMBER]-16 and saw (CNA F) at the bedside of Resident #2 attempting to get her off the bed. I recognized the voice to be (CNA F). I told her I know you were not just speaking to one of my residents like that. (CNA F) began apologizing. I told (CNA F) to clock out and go home immediately and that she was fired. I made sure CNA F left the building and then informed charge nurse of the incident and instructed to assess the resident from head to toe. Record review of CNA F's personnel file indicated she was trained on abuse and resident rights on 05/19/20. CNA F was suspended and terminated on 08/26/24. During an interview on 12/19/24 at 9:19 a.m., CNA F said she got a little loud with Resident #2. She said she did not have the intention to abuse Resident #2 but she (CNA F) was having a bad day and her tone was not a good tone. She denied saying I am sick of you. Get your ass up and get to that dining hall. to Resident #2. She said she was trying to get Resident #2 up for the supper meal. She said Resident #2 had dementia and did not want to get up and out of bed. She said she was trained on abuse and neglect and reporting when she was hired and more than once a year since she was hired. She said she was aware she should not use mean or degrading tones with the residents. During an interview on 12/18/24 at 2:46 p.m., the Administrator said he was the abuse prevention coordinator. He said he was conducting maintenance in the restroom between Resident #2's room and another resident's room. He said he heard someone say I am sick of you. Get your ass up and get to that dining hall. He opened the door and saw CNA F attempting to get Resident #2 off her bed. He said, I know you were no talking to one of my residents like that. The Administrator said he immediately directed CNA F out of the facility and told her she was terminated. He said safe-surveys were conducted and there were no additional residents identified as victims of abuse. He said staff were immediately trained on abuse and neglect and reporting on 08/26/24 and all staff that were not present in the facility were trained prior to their next scheduled shift. He said monitoring to prevent abuse was ongoing by conducting observations and interviews with residents and staff. He said he was in the facility on all shifts. He said there zero tolerance for abuse. He said staff were trained on abuse upon hire, as needed, and annually. Record review of in-service dated 08/26/24 indicated 40 out of 63 staff indicated staff were retrained on abuse and neglect prevention and reporting. Interviews conducted on 12/18/24, 12/19/24 and 12/20/24 with the Administrator, the DON, the ADON, 6 LVN, 6 CNA, 1 medication aide, 2 housekeeping staff, 2 dietary staff, 1 BOM, and 1 maintenance staff who represented all shifts indicated they were able to give examples of abuse and neglect and would report immediately to the abuse coordinator or designee. Interviews conducted with 7 residents indicated there was no concerns of abuse and they would report any abuse to the administrator and DON immediately. They were not afraid of any staff. They had no complaints of staff being rude, using a mean or rude tone or using profanity towards them. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint no required to treat the resident's symptoms

Based on interviews and record review, the facility failed conduct a thorough investigation and to report the results of all investigations to the Administrator or his or her designated representative and to other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 5 residents (Resident #3) reviewed for reporting results of all investigations. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #3's fall. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #3's face sheet dated 12/19/24 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included Alzheimer's (a brain disorder that gradually destroys memory and thinking skills), right femur fracture, and a history of falling. Record review of Resident #3's quarterly MDS dated [DATE] indicated he had unclear speech, was sometime able to make himself understood and sometimes understood others, had severe cognitive impairment, and he did not use a mobility device. Record review of Resident #3's care plan dated 03/28/24 impaired physical mobility related to extremity fracture. Interventions included assist resident with ambulation and transfers. Record review of a progress note dated 03/24/24 at 1:13 p.m. and completed by LVN G indicated Resident #3 was seated in the lounge area. Resident #3 stood up, took a few steps and fell , Staff was not able to prevent the fall. Resident #3 landed on his right hip. Resident #3 was agitated and rolling from side to side. ROM performed and Resident yelled out in pain. The physician was notified. Resident #3 was sent to the ER for evaluation and treatment. Record review of Resident #3's x-ray report dated 03/24/25 indicated an acute impacted subcapital fracture of the right femoral neck (break in the upper part of the thigh bone that can affect the blood supply to the hip joint). Record review of TULIP intake 492332 indicated the facility reported Resident #3's fall and right hip fracture on 03/24/24 at 9:42 p.m. The allegation was noted as Resident Neglect. Record review of an email provided by QA LVN D dated 03/24/24 at 10:18 p.m. from (identifying ticket number)(QA LVN D) Deleting Report noreply Texas Health and Human Services <noreply-hhs-salesforce@partner.hhs.texas.gov> Thank you for contacting TULIP Support Mailbox. Please save this ticket number, which is required for reference until the ticket is resolved. We are working on a resolution and will notify you soon. For enquiries regarding this ticket, please contact the TULIP Support Mailbox, including the assigned Ticket Number: (identifying ticket number) in the subject line. During an interview on 12/19/24 at 11:58 a.m., QA LVN D said the facility did not complete an investigation or submit a 5 day report because the incident was not reportable. She said she contacted TULIP/Salesforce via the portal to indicate the facility made the report in error. She said she when did not hear anything back from TULIP/Salesforce she assumed everything was taken care of the incident was no longer considered reported. She said she did not follow up with TULIP/Salesforce to ensure the self-report was deleted. During an interview on 12/19/24 at , the Administrator said Resident #3's fall was witnessed and not reportable. He said the facility followed the most current LTC provider letter 2024-14 for reporting. He said QA LVN D reported Resident #3's fall in error. He said because Resident #3's fall was witnessed and not reportable, the facility did not complete an investigation or submit a 5 day report. He said he was aware QA LVN D had contacted TULIP/Salesforce to report the error in reporting. He said he was not aware the intake was not deleted. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation policy dated 2001 (revised April 2021), indicated All reports of resident abuse (including injuries of unknown origin) neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 14 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's fall risk care plan accurately addressed and included a fall mat. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #1's face sheet dated 12/19/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (brain disorder that destroys memory and thinking skills), dementia (decline in mental abilities), restless leg syndrome (neurological disorder that causes unpleasant or uncomfortable sensations in legs and an irresistible urge to move them), and Parkinson's (brain disorder that causes movement problems). Record review of Resident #1's care plan dated 05/16/24 indicated she was at high risk for falls. Interventions included anticipate and meet Resident #1's needs, ensure call light is in reach, ensure resident is wearing appropriate footwear, follow facility fall protocol, and review information on past falls and attempt to determine cause of falls, and remove any potential cause. The care plan did not include fall matt(s) as interventions. Record review of an incident report dated 10/16/24, completed by LVN B, indicated Resident #1 was found lying on her fall mat. She sustained a small 1 cm skin tear above her right eye. She was assessed with no additional injuries. A steri-strip was applied. The physician was notified. Record review of Resident #1's Fall Risk assessment dated [DATE] indicated she was at high risk for falling. Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had unclear speech, was sometimes able to make herself understood, and usually understood others. She had severe impaired cognitive skills. She was inattentive and had disorganized thinking. She had hallucinations and delusions. She utilized a wheelchair for mobility. Record review of an incident report dated 11/08/24, completed by LVN A, indicated Resident #1 was found on the floor, bleeding from a laceration above her right eye on the brow area. She was assessed with no additional injuries or sign of pain. Resident #1 was transferred to the hospital for evaluation and treatment. The physician, RP and DON were notified. Record review of hospital records dated 11/08/24 indicated Resident #1 sustained a 3 cm laceration above her right eye. She received 5 sutures. Record review of facility investigation dated 11/12/24 indicated Resident #1's the facility would update Resident #1's care plan to include fall mat. During an interview on 12/19/24 at 9:45 a.m., the ADON said Resident #1's diagnoses included Parkinson's. She said Resident #1 was able to roll herself while lying in bed. She said Resident #1 was at risk for falls. She said she thought Resident #1's care plan included a fall mat due to previous falls. She said Resident #1's care plan should have included a fall mat to prevent serious injuries. She said she did not know why Resident #1's fall risk care plan did not include a fall mat. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/19/24 at 11:07 a.m., CNA C said she was aware Resident #1 was supposed to have a fall mat place adjacent to her bed when she was lying in bed. She said she was trained on which residents were at risk for falls and who required fall mats. She said Resident #1's fall mat was moved away from her bed when Resident #1 was transferred to her Geri-chair because the Geri-chair was hard to move over the fall mat. She said she transferred Resident #1 to bed on 11/08/24 and forgot to put the fall mat next to the bed. She said the fall mat was moved away from the bed but was available. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/19/24 at 12:02 p.m., LVN A said Resident #1 had fallen from her bed on 11/08/24 and sustained a 3 cm laceration above her right eye. She said Resident #1 was assessed with no additional injuries. She said Resident #1 was transferred to the hospital for evaluation and treatment. She said the fall mat was folded up at the end of the bed. She said the fall matt was supposed to be on the floor when Resident #1 was lying in bed. She said Resident #1 returned to the facility with 5 sutures above her right eye. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/20/14 at 8:42 a.m., QA LVN D said Resident #1's care plan was not updated to include a fall mat. She said she did not know the care plan was not updated to include a fall mat. She said she took over updating care plans June 2024 and Resident #1's care plan update was missed. She said residents were at risk of serious injuries if fall mats were not in place. During an interview on 12/20/24 at 11:01 a.m., the Administrator said Resident #1's care plan should have been updated to include a fall mat. He said it was probably a miscommunication that Resident #1's care plan update to include a fall matt was missed. He said residents were at risk of serious injury if the fall mat interventions were not in place as required per the resident care plan. Record review of the facility's Safety and Supervision of Resident Policy dated 2001 (revised July 2017) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training as necessary; d. Ensuring all interventions are implemented; and e. documenting interventions. Record review of facility's Managing Falls and Fall Risk policy dated 2001 (revised March 2018) indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, . 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try and minimize serious consequences of falling. Record review of the facility's Care Planning-Interdisciplinary Team policy dated 2001 (revised March 2022) indicated 1. Resident care plans are developed according to the timeframes and criteria established by S483.21. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 3. The IDT includes but is not limited to: a. the resident's attending physician; b. a registered nurse with responsibility for the resident; c. a nursing assistant with responsibility for the resident; d. a member of the food and nutrition services staff; e. to the extent practicable, the resident and/or the resident's representative; and f. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. 4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 14 residents (Resident #s 1, 2 and 3) reviewed for smoking. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 3. The facility failed to ensure Residents #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 07/26/24, the facility remained out of compliance at a scope of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of harm, severe injury, and possible death. Findings included: Record review of Resident #1's face sheet dated 07/23/24 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included non-st elevation myocardial infarction (hear attack), anxiety (feeling of fear, dread, and uneasiness), paralytic syndrome (neuromuscular weakness that can progress to paralysis), and COPD (chronic obstructive pulmonary disease-restrictive airflow and breathing problems). Record review of Resident #1's annual MDS dated [DATE] indicated she had unclear speech, was sometimes understood, and usually understands others. She had severe impaired cognition (BIMS score of 6). Tobacco use was no. She utilized oxygen therapy. Record review of Resident #1's care plan dated 12/20/23 indicated she was on oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs at 2L continuously. There was no care plan related to tobacco use, smoking, or smoking safety. Record review of Resident #1's progress note dated 03/11/24 at 4:45 p.m., completed by LVN QQ indicated she was informed by the DON Resident #1 received a vape pen from another resident. Resident #1 was caught smoking the vape pen in her bathroom. The content of the vape pen was unknown. Resident was assessed and RP notified. Record review of Resident #2's face sheet dated 07/23/24 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included cerebral infarction (stroke), chronic kidney disease, and major depressive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. He was cognitively intact (BIMS score 14). Record review of Resident #2's care plan dated 05/18/23 indicated Resident #2 was a smoker. Interventions included instruct resident about smoking risks and hazards and instruct resident about facility policy on smoking, locations, times, and safety concerns. Resident #2 was given a letter to show concerns about leaving the facility to smoke unsupervised. He signed the letter, and a copy was put in his clinical records. Resident #2 can sign out to leave the premises and smoke unsupervised. Notify charge nurse immediately if it was suspected Resident #2 has violated the facility smoking policy. Observe clothing and skin for signs of cigarette burns. Resident #2 required supervision while smoking. Resident #2's smoking supplies are stored at the nurses' station. Record review of Resident #2's Smoking-Safety Screen dated 05/30/23 indicated cognitive loss, dexterity problems, smokes 5-10 cigarettes per day, likes to smoke morning, afternoon, evening, and nights and needed the facility to stored lighter and cigarettes. Plan of care was used to assure resident was safe while smoking. Resident #2 was safe to smoke with supervision. Resident #2 had dexterity problems following a CVA. He had cognitive impairment which could impair his safety needs with smoking. There was no Smoking-Safety Screen completed after 05/30/23. Record review of Resident #3's face sheet dated 07/23/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included major depressive disorder, Parkinsonism (a broad term comprising a clinical syndrome and presenting with various neurodegenerative diseases, which manifest with motor symptoms such as rigidity, tremors, bradykinesia, and unstable posture, leading to profound gait impairment), COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety (feeling of fear, dread, and uneasiness), and hypertensive heart disease with heart failure. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and usually understood others. She was cognitively intact (BIMS score 15). Record review of Resident #3's care plan for tobacco use dated 03/21/24 indicated Resident #3 would adhere to the facility smoking policy (revised 07/09/24) and would not suffer injury from unsafe smoking practices (revised 07/09/24). Interventions included conduct Smoking Safety Evaluation upon admission and PRN, orient resident to smoking times and procedures, and Resident #3 required supervision while smoking. Record review of Resident #3's Smoking-Safety Screen dated 03/08/24 indicated Resident #3 smoked 1-2 cigarettes per day and liked to smoke in the afternoon and evening. Resident #3 needed the facility to store lighter and cigarettes. A plan of care was used to assure Resident #3 was safe while smoking. Resident #3 was safe to smoke without supervision. Encouraged Resident #3 to sign self out of nurses' station when smoking without supervision. There was no Smoking-Safety Evaluation completed after 03/08/24. During an interview on 07/23/24 at 11:25 a.m., RN ZZ said she saw Resident #3 pushing Resident #1 toward the front door of the facility to go outside. She said then Resident #3 brought Resident #1 to the station. Resident #1 had burns to her face, hands, and chest. She said she called 911 and the physician. She said Resident #1 was sent to the hospital. She said Resident #2 did not say anything. She said Resident #3 said she was outside with Resident #1. She said Resident #1 said she wanted a cigarette. RN ZZ said Resident #3 reported Resident #2 gave Resident #1 a cigarette. She said Resident #1's oxygen tubing was split into two separate sections. She said she was not aware Resident #3 smoked. She said she thought Resident #2 was an independent smoker. She said she was not aware of a list of smokers. Record review of the progress note dated 07/19/24 at 7:52 p.m., completed by RN ZZ indicated Resident #1 was out back (of the facility). Resident #1 was attempting to smoke a cigarette with her O2 on. The O2 flashed and popped the tube in her nose. Resident #3 was the resident who assisted Resident #1 back into the building after the incident. Record review of Resident #1's Smoking Injury report dated 07/19/24 at 8:10 p.m., completed by RN ZZ indicated Resident #1 was pushed to the nurses' station by Resident #3. She had burns on her face, mouth, nose, cheeks, chin, and chest (8 inches X 6 inches). Her lips were singed, and her right hand had a 3 cm area. Resident #1 indicated It blew up. The ADON called an ambulance. The ambulance arrived and transported Resident #1 to the hospital. Record review of Resident #1's hospital records dated 07/19/24 at 9:32 p.m. indicated Resident #1 presented in respiratory distress with burns to intranasal (nose) and perioral (mouth) region with stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway) and wheezing (high pitched whistle when airway is blocked) . intubated (tube put into windpipe for breathing) for airway protection and expected clinical course with ketamine (anesthetic) and rocuronium (neuromuscular blocker). OG tube (orogastric) also placed. Chest x-ray revealed interstitial edema (form of pulmonary edema). Resident #1 was transferred to burn center for management evaluation. Record review of Resident #1's hospital records dated 07/20/24 indicated Resident #1 reported she had quit smoking (no date noted) and her smoking use included cigarettes. Elevated troponin myocardial injury likely due to acute myocardial injury in setting of severe burns and critical illness. There was 3% partial thickness burn to face/chest. During an interview on 07/23/24 at 11:10 a.m., Resident #2 said he was out back in the garden area of the facility with Resident #1 and Resident #3 He said it was a non-smoking area. He said he knew it was not a smoking area and he should not be smoking there. He said Resident #3 was smoking and got too close to Resident #1 and there was a flash and Resident #1 was on fire. He said he took the oxygen tube off Resident #1 and the fire went out. He denied giving Resident #1 a cigarette. He said he used to go off the facility to smoke but he now had to turn in all his smoking supplies and was only allowed to smoke with supervision. He said he did not give Resident #1 a cigarette. He said he never gave his cigarettes and lighter to the facility and did not sign them out to go smoking. He said he kept them in his room. He said the staff never asked him for his cigarettes or lighter. During an interview on 07/23/24 at 11:30 a.m., Resident #3 said she pushed Resident #1 to the nurses' station from her room. She said LVN WW put a tank of oxygen on Resident #1's chair. She said she informed LVN WW they were going out back of the facility to look at the flowers. She said Resident #2 joined them in the back of the facility. She said she had smoked a cigarette. She said Resident #2 was also smoking. She said she got a cigarette from Resident #2 for Resident #1. She said suddenly Resident #1 exploded and was on fire. She said she did not know how the fire started. She said she did not light the cigarette for Resident #1. She said she pulled the tube from Resident #1 and the fire went out. She said she pushed Resident #1 back into the facility and to the nurses' station. She said she gave all her smoking supplies to the nurse but could not remember which nurse. She said she did not want to talk anymore of the incident and wanted a lawyer. During an interview on 07/23/24 at 9:40 a.m., the Administrator said on 07/19/24, Resident #3 wanted to take Resident #1 outside to enjoy the garden. Resident #2 joined them. Resident #2 was an independent smoker who would sign himself out and go off property to smoke. He joined Resident #1 and #3 in a nonsmoking area. Resident #2 denied giving Resident #1 a cigarette. Resident #3 denied having a cigarette or smoking. Resident #2 said it just exploded and then he said Resident #3 had a cigarette and got too close to Resident #1. There were no staff present. Resident #3 put out the fire and brought Resident #1 back into the facility. RN ZZ assessed Resident #1 with burns to her chest and face and she was sent out to the hospital and then transferred to a secondary hospital burn unit. Since the incident on 07/19/24, the facility's smoking policy changed so no residents were allowed to keep smoking materials in their room and Residents #2 and #3 now required supervision. The facility has started in-services to staff on the new policy. He said all smoking residents were educated on the new policy and signed the new policy. During an observation on 07/23/24 at 10:15 a.m. of the non-smoking area in the back of the facility indicated there was no signage to indicate it was a non-smoking area. There was no signage related to the use of oxygen. During an interview on 07/23/24 at 12:35 p.m., the DON said she was not able to locate any current Smoking-Safety assessments for Residents #1, #2, or #3. During an interview on 07/23/24 at 12:40 p.m., the Administrator said whoever admitted the resident was responsible for doing the initial Smoking-Safety Screen, then it was done as needed. He said he was not aware of who took Resident #3's cigarettes and lighter after the incident on 07/19/24. He said the area where the incident occurred was not a designated smoking area. During an interview on 07/23/24 at 2:00 p.m. CNA YY said she was not aware of who all the smokers were in the facility. She said the residents' cigarettes and lighters were kept at the nurses' station and taken out to the smoking area. She said there was not a list of residents who required supervision while smoking. She said she did not know if Resident #1 or #3 smoked. She said Resident #2 was an independent smoker and kept his cigarettes and lighter in his room. During an interview on 07/23/24 at 2:05 p.m., CNA XX said she would get residents' cigarettes and lighters from the nurses' station and take them out to the smoking area. She said there was not a list of residents who were smokers. She said Resident #2 and one other resident were able to smoke independently and off of the facility property. She said Resident #2 kept his cigarette supplies in his room because he was an independent smoker and did not require supervision. She said she did not know if Resident #1 or #3 smoked. During an interview on 07/23/24 at 2:12 p.m., LVN WW said Resident #1 was at the nurses' station and was having trouble breathing. She said she put the oxygen tank on Resident #1's wheelchair and made sure the cannula was in place. She said Resident #3 indicated they (Resident #1 and Resident #3) were going to sit outside at the back of the facility. She said she was not aware Resident #1 or Resident #3 smoked cigarettes. She said she was not aware of a list of residents who smoked. During an interview on 07/23/24 at 5:51 p.m., the DON said the nurses' station would have a list of residents who smoked and who required supervision or who could smoke independently. She said the nurses would advise the assigned staff of the resident supervision levels for smoking. She said Resident #2 usually kept his cigarettes and lighter. She said she was responsible to make sure the quarterly Smoking-Safety Screen were completed. She said she was not aware the Smoking-Safety Screens were not completed as required. During an interview on 07/23/24 at 6:00 p.m., LVN VV said there was no list for which residents were smokers or who required supervision. She said after the incident on 07/19/24 where Resident #1 caught on fire, all the residents were supervised except one. She said all smoking supplies were supposed to be kept at the nurses' station. She said Resident #2 used to sign out and return his smoking supplies but then he refused. She said she believed the policy allowed him to keep his cigarettes and lighter because he was an independent smoker. During an interview on 07/24/24 at 8:33 a.m. LVN WW said Resident #2 was an independent smoker and did not sign out smoking supplies. She said she was not aware he required supervision. She said she never asked Resident #2 for his cigarettes or lighter. She said after the incident on 07/19/24, Resident #2 required supervision and was a supervised smoker. She said she was not aware of a list of residents who were smokers. She said the smoking supplies were handed to the staff who supervised the residents in the smoking area. She said there was one resident who was allowed to sign himself and his smoking supplies out to smoke off the facility property. She said smoking assessments were done upon admission and as needed if the residents were identified smokers. She said the smoking assessments would be done if they came up due in the electronic record. During an interview on 07/24/24 at 8:40 a.m., LVN WW said Resident #2 was an independent smoker and did not sign out smoking supplies. She said she was not aware he required supervision. She said she never asked Resident #2 for his cigarettes or lighter. She said after the incident on 07/19/24, Resident #2 required supervision and was a supervised smoker. She said she was not aware of a list of residents who were smokers. She said the smoking supplies were handed to the staff who supervised the residents in the smoking area. She said there was one resident who was allowed to sign himself and his smoking supplies out to smoke off the facility property. She said smoking assessments were done upon admission and as needed if the residents were identified smokers. She said the smoking assessments would be done if they came up due in the electronic record. During an interview on 07/24/24 at 8:49 a.m., CNA YY said all smoke breaks were assigned. She said a CNA would supervise at 4:00 p.m. She said the residents smoking supplies were given to them by the nurse. She said Resident #2 never kept his cigarettes or lighter at the nurses' station. She said he was an independent smoker before the incident on 07/19/24 but now had to smoke with supervision. She said she was not aware if Resident #1 or Resident #3 were smokers. During an interview on 07/24/24 at 8:58 a.m., QA TT said Resident #2 was supposed to sign his smoking supplies in and out when he went off the facility property to smoke. She said she did not know why his supplies were not turned in or why he was not signing in and out of the facility. She said Resident #3 denied having cigarettes or smoking. She said all residents who were identified as smokers should have a smoking assessment and a care plan. She said she was working on getting all assessments caught up and completed. She said the assessments were behind due to staff being off. She said the facility brought in a part time MDS nurse who caught up on the MDS assessments but not all other assessments. She said there should be list of residents who smoked. She said if the list of residents who smoked was not posted at the nurses' station, it should be. She said residents were at risk of injuries due to not safe smoking if they did not have assessment or care plans and they were not supervised as required. During an interview on 07/24/24 at 9:15 a.m., the Administrator stated Resident #2 was allowed to keep his cigarettes and lighter on his person because he was an independent smoker. He said the facility tried to keep Resident #2's smoking supplies and Resident #2 would promise to give them back to be kept at the nurses' station, but he would not keep his promise. He said Resident #2 was supposed to sign his smoking supplies in and out of the nurses' station. He said Resident #2 had not signed out of the facility since March 2023 due to being noncompliant and defiant. He said the facility did not have any system in place to protect the other residents from Resident #2's non-compliance or unsafe smoking. He said he would tell Resident #2 to return his smoking supplies but Resident #2 would not return his smoking supplies. He said Resident #2 knew he was not supposed to smoke on the property and smoked in a non-smoking area. He said Resident #3 denied smoking in the non-smoking area on 07/19/24. He said he was not aware of a list of residents who were smokers. He said after the incident on 07/19/24, all cigarettes and smoking paraphernalia were taken from the residents and were kept at the nurses' station. The Administrator said all smoking residents except one were to smoke during the scheduled smoking times. The Administrator said the one resident that did not require supervision could check themselves out and go off the facility premises to smoke. He said smoking was a risk and was unhealthy. During an interview on 07/24/24 at 9:43 a.m., the DON said she was not aware Resident #2 was not signing his smoking supplies in or out. She said she was not aware Resident #3 was a smoker. She said she did not know there was no list of residents who were smokers. She said she was aware the smoking assessments were not current. She said facility was working on making all smoking assessments current and up to date. She said residents were at risk of unsafe smoking if they were not supervised as required. During an interview on 07/24/24 at 1:23 p.m., MDS RR said Resident #2 reported Resident #3 pushed Resident #1 outside to the back garden area. She said the area was a nonsmoking area. She said Resident #2 reported Resident #3 had a lit cigarette and bent down in front of Resident #1 and there was a flash and fire. She said Resident #3 reported it was a freak accident and did not know what happened. MDS RR said resident smoking assessments were supposed to be completed quarterly. She said resident care plans were reviewed and updated quarterly and as needed. She said all smokers should have care plans related to their level of supervision. She said she did not know why the smoking assessments were not current. She said the smoking assessments were not activated in the electronic record and the nurses would not know to do the assessments if they did not populate. She said she had to activate Residents #1, #2, and #3's smoking assessments. She said residents were at risk of serious injury if they were not adequately supervised when they were smoking. She said if their smoking assessments were not completed, and their care plans were not updated the staff would not be aware of their safety needs. During an interview on 07/25/24 at 11:20 a.m., QA TT said Residents #1, #2, and #3 had gone outside to smoke. They did not go to the designated smoking area, but went to the garden area, way in the back. Resident #1 was on oxygen. A spark ignited and Resident #1 got burned. She was sent to the hospital and then transferred to a secondary hospital burn unit. She said none of the residents would say what exactly happened, and it was unknown if Resident #1 had a cigarette or not. Resident #1 had her oxygen tubing on at the time, but it was not hooked up to her concentrator. The Resident returned to the facility on [DATE]. She sustained 2nd and 3rd degree burns to her face and chest. Resident #1 was initially intubated for the edema and received ketamine and Fentanyl (opioid used for pain relief). QA TT said Resident #1 had a hard time communicating. She had a communication board but did not use it. She said all smoke breaks were now supervised and residents were required to sign out. During an observation and interview on 07/25/24 at 11:50 a.m., Resident #1 was sitting in her wheelchair, and had oxygen in place, connected to a concentrator. Resident #1 was noted with contractures to both hands. Resident #1 had a hard time speaking but was able to answer questions. She stated she was outside on 07/19/24 sitting with Resident #2 and Resident #3. She was not in the usual smoking area. She heard a boom and then her shirt caught fire. She was sitting next to Resident #3 who was smoking at the time. Resident #2 was also smoking. She said Resident #2 and Resident #3 put the fire out and she went to the hospital. She did not remember too much after being admitted to the hospital. Resident #1 said she had her oxygen tubing on at the time of the incident, but it was not hooked up to her concentrator. Resident #1 said she smoked a long time ago but was not a smoker and did not have a cigarette at the time of the incident. Resident #1 said she had gone outside with both residents before, but she usually kept her tubing across her lap. She said the cannula was in her nose. She would go outside with them 1-2 times a week. Resident #1 said she had burns above her mouth, directly under her nose, and to her chest. Red areas were noted to Resident #1's upper lip area and under her nose. A dressing was in place to the right upper chest area. QA TT raised the bottom of the dressing where the tape had come loose. Wounds appeared to black in color with some blood noted. Resident #1 said it was very painful and QA TT said she would bring her something for pain. During an observation and interview on 07/25/24 at 12:30 p.m., Resident #2 was sitting in his wheelchair. He had lived in the facility for 1 year. He said on 07/19/24 he went outside to smoke with Residents #1 and #3. They did not go to the designated smoking area, and instead went to the garden area as there was better scenery. Resident #3 was sitting in a chair and lit a cigarette. The minute she started to smoke it he saw a flash of fire. He immediately took Resident #1's oxygen tubing off as it had melted to her face. He said Resident #1's shirt was also on fire. He said he had a Dr. Pepper and a towel he had brought outside. He poured the drink on her shirt and used the towel to put the fire out. He said Resident #1 was crying and in shock. Resident #1 had also burned her hand and nose. He said Resident #3 brought Resident #1 inside the facility. Resident #2 said he now had to smoke at the designated times. Resident #2 said he got a letter from the Administrator stating he had to move out. He said the Administrator said he had given Resident #1 a cigarette. Resident #2 said he did not give her a cigarette, and he was not even smoking at the time. He said Resident #3 was the only one smoking at the time. He said the Administrator just assumed he gave her one. He had never seen Resident #1 smoke since he had been in the facility. He said she must have done it before because she had COPD. Resident #2 said Resident #1 was his girlfriend. Resident #2 said 2-3 months ago he had a vape pen with THC (Tetrahydrocannabinol-a cannabinoid found in cannabis) in it and Resident #1 took a hit. He said the Administrator told him to not do it again. Record review of the facility's Smoking Policy-Residents dated 2001 (revised 2017) indicated . 2. Smoking is only permitted in designated resident smoking areas . 3. Oxygen use is prohibited in smoking areas. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 7. The staff shall consult with the Attending physician and the Director of Nursing services to determine if the safety restriction need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke will be evaluated quarterly, upon significant change (physical or cognitive) and as determined by staff. This was determined to be an Immediate Jeopardy (IJ) on 07/24/24. The Administrator and DON were notified. The Administrator was provided with the IJ template on 07/24/24 at 12:26 p.m. The following plan of removal was submitted by the facility and accepted on 07/26/24 at 9:59 a.m. and included the following: On 22 July 2024 the Administrator implemented a smoking policy which states no resident shall be allowed to smoke on (the facility's) property unsupervised. Residents are to follow posted smoking schedule. This smoking schedule also reflects which staff is responsible for which times. Staff in-service training on this new policy was completed on 25 July 2024 at 6 p.m. Assessment of all residents who smoke or who we think may be sneaking a smoke was completed by QA nurse on 25 July 2024 12:00 noon. Residents were also assessed for the possible need of protective equipment. QA nurse has also updated all resident's care plans to reflect the results of the assessment (completed 26 July 12 noon). QA nurse will ensure quarterly assessments are completed in a timely manner. A list of residents who smoke, along with those that need protective equipment, was posted on top of the smoking box that is carried out to smoking area by supervising staff (24 July 2024). All staff were instructed to read the smoking list that is taped to the lid of the smoking box and put a smoking apron on residents as indicated by said list. Administration has reiterated to residents, who often leave facility grounds, the policy that they must sign out before leaving and sign back in upon return. All residents who have been identified as smokers have signed acknowledgement of their understanding of this policy on 23 July 2024 at 12 noon. Smoking questionnaire, as of 24 July 2024 12 noon, is now a part of admission package to determine if the resident may be a smoker. Care plan team has updated resident #2's care plan to reflect he is no longer allowed to keep smoking material on his person or in his room. Resident #2 has been instructed to sign himself out when he leaves the building and sign himself in upon his return. Resident #1 and #3 have been assessed as smokers. Residents #1 and #3's care plans have been updated to reflect the fact that they may try to sneak around and smoke. On 24 July 2024 administration implemented a policy that all smoking on the facility property will be supervised. All staff has been instructed on smoking safety and supervision (completed 25 July 2024 at 6 p.m. by DON and Admin) to ensure that hazardous materials are kept away from the designated smoking area. All staff has been instructed by the DON and the Administrator to request the return of smoking material that any resident checks out upon resident's return to facility (completed 25 July 2024 at 6 p.m.). All staff has been instructed by the DON on smoking safety and supervision (completed 25 July 2024 at 6 p.m.) to ensure that hazardous materials are kept away from designated smoking area. New policy compliance will be monitored by the Administrator, the DON, the QA Nurse as well as the weekly QA Rounds team. On 07/26/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observations of a facility smoking area on 07/26/24 at 4:00 p.m. and 7:00 p.m., there was one staff with residents. Two residents had on a smoking apron. Staff lit residents' cigarettes with lighter. No residents retained smoking paraphernalia. There was a box with residents' smoking materials. There was a list of resident smokers taped to top of the box of residents' smoking materials that included who required safety interventions (protective apron). During an interview on 07/26/24 at 3:45 p.m., the DON said staff were in-serviced on the facility's smoking policy. She said shifts have changed recently to 6a-6p and 6p-6a for nurses and CNAs. She said residents who smoked were instructed on the revised Smoking Policy. During an interview on 07/26/24 at 4:10 p.m., QA TT said in-services were conducted with staff and residents. She said Smoking Assessments were updated on smokers and done on residents suspected of smoking. She said she reviewed and updated the care plans based on the Smoking Assessment. During interviews conducted on 07/26/24 from 4:45 p.m. through 6:15 p.m. with the facility staff from all shifts (CNA A, CNA B, CNA C, NA D, DA E, DA F, RN G, CNA H, LVN I, CNA J, CNA K, and Maintenance Director L) indicated they were aware of the facility smoking policy, knew which residents required smoking protection (aprons), were aware residents were required to turn in smoking paraphernalia, and would report any resident to the charge nurse if they were non-compliant with return of smoking paraphernalia. They were able to explain the importance of assessing each resident for smoking safety, ensuring all residents adhered to the smoking policy and smoking contracts, and knew the consequences of non-compliance, ensuring residents do not keep their own smoking materials or smoke unsupervised, ensuring the families of residents who smoked complied with all smoking rules, posting all designated smoking hours to ensure each resident was available during those times, ensuring residents on oxygen or those with roommates on oxygen did not keep lighters in their rooms, and reporting any non-compliance with the smoking policy to management. They were of where the list of smokers was (on the box of resident smoking materials). During an interview on 07/26/24 at 6:20 p.m., Resident #2 said he was aware of the new smoking policy, smoking schedule, supervision, wearing a protective apron, and signing out to smoke off the premises. He said cigarettes and lighters we [TRUNCATED]

Based on observation, interview, and record review, the facility failed to follow Federal, State, and Local laws and regulations regarding smoking, smoking areas, and smoking safety for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for smoking safety. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Residents #2 and Resident #3 were supervised while they were smoking. 3. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 07/26/24, the facility remained out of compliance at a scope of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking. Findings included: Record review of Resident #1's face sheet dated 07/23/24 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included non-st elevation myocardial infarction (hear attack), anxiety (feeling of fear, dread, and uneasiness), paralytic syndrome (neuromuscular weakness that can progress to paralysis), and COPD (chronic obstructive pulmonary disease-restrictive airflow and breathing problems). Record review of Resident #1's annual MDS dated [DATE] indicated she had unclear speech, was sometimes understood, and usually understands others. She had severe impaired cognition (BIMS score of 6). Tobacco use was no. She utilized oxygen therapy. Record review of Resident #1's care plan dated 12/20/23 indicated she was on oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal prongs at 2L continuously. There was no care plan related to tobacco use, smoking, or smoking safety. Record review of Resident #1's progress note dated 03/11/24 at 4:45 p.m., completed by LVN QQ indicated she was informed by the DON Resident #1 received a vape pen from another resident. Resident #1 was caught smoking the vape pen in her bathroom. The content of the vape pen was unknown. Resident was assessed and RP notified. Record review of Resident #2's face sheet dated 07/23/24 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included cerebral infarction (stroke), chronic kidney disease, and major depressive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. He was cognitively intact (BIMS score 14). Record review of Resident #2's care plan dated 05/18/23 indicated Resident #2 was a smoker. Interventions included instruct resident about smoking risks and hazards and instruct resident about facility policy on smoking, locations, times, and safety concerns. Resident #2 was given a letter to show concerns about leaving the facility to smoke unsupervised. He signed the letter, and a copy was put in his clinical records. Resident #2 can sign out to leave the premises and smoke unsupervised. Notify charge nurse immediately if it was suspected Resident #2 has violated the facility smoking policy. Observe clothing and skin for signs of cigarette burns. Resident #2 required supervision while smoking. Resident #2's smoking supplies are stored at the nurses' station. Record review of Resident #2's Smoking-Safety Screen dated 05/30/23 indicated cognitive loss, dexterity problems, smokes 5-10 cigarettes per day, likes to smoke morning, afternoon, evening, and nights and needed the facility to stored lighter and cigarettes. Plan of care was used to assure resident was safe while smoking. Resident #2 was safe to smoke with supervision. Resident #2 had dexterity problems following a CVA. He had cognitive impairment which could impair his safety needs with smoking. There was no Smoking-Safety Screen completed after 05/30/23. Record review of Resident #3's face sheet dated 07/23/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included major depressive disorder, Parkinsonism (a broad term comprising a clinical syndrome and presenting with various neurodegenerative diseases, which manifest with motor symptoms such as rigidity, tremors, bradykinesia, and unstable posture, leading to profound gait impairment), COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety (feeling of fear, dread, and uneasiness), and hypertensive heart disease with heart failure. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and usually understood others. She was cognitively intact (BIMS score 15). Record review of Resident #3's care plan for tobacco use dated 03/21/24 indicated Resident #3 would adhere to the facility smoking policy (revised 07/09/24) and would not suffer injury from unsafe smoking practices (revised 07/09/24). Interventions included conduct Smoking Safety Evaluation upon admission and PRN, orient resident to smoking times and procedures, and Resident #3 required supervision while smoking. Record review of Resident #3's Smoking-Safety Screen dated 03/08/24 indicated Resident #3 smoked 1-2 cigarettes per day and liked to smoke in the afternoon and evening. Resident #3 needed the facility to store lighter and cigarettes. A plan of care was used to assure Resident #3 was safe while smoking. Resident #3 was safe to smoke without supervision. Encouraged Resident #3 to sign self out of nurses' station when smoking without supervision. There was no Smoking-Safety Evaluation completed after 03/08/24. During an interview on 07/23/24 at 11:25 a.m., RN ZZ said she saw Resident #3 pushing Resident #1 toward the front door of the facility to go outside. She said then Resident #3 brought Resident #1 to the station. Resident #1 had burns to her face, hands, and chest. She said she called 911 and the physician. She said Resident #1 was sent to the hospital. She said Resident #2 did not say anything. She said Resident #3 said she was outside with Resident #1. She said Resident #1 said she wanted a cigarette. RN ZZ said Resident #3 reported Resident #2 gave Resident #1 a cigarette. She said Resident #1's oxygen tubing was split into two separate sections. She said she was not aware Resident #3 smoked. She said she thought Resident #2 was an independent smoker. She said she was not aware of a list of smokers. Record review of the progress note dated 07/19/24 at 7:52 p.m., completed by RN ZZ indicated Resident #1 was out back (of the facility). Resident #1 was attempting to smoke a cigarette with her O2 on. The O2 flashed and popped the tube in her nose. Resident #3 was the resident who assisted Resident #1 back into the building after the incident. Record review of Resident #1's Smoking Injury report dated 07/19/24 at 8:10 p.m., completed by RN ZZ indicated Resident #1 was pushed to the nurses' station by Resident #3. She had burns on her face, mouth, nose, cheeks, chin, and chest (8 inches X 6 inches). Her lips were singed, and her right hand had a 3 cm area. Resident #1 indicated It blew up. The ADON called an ambulance. The ambulance arrived and transported Resident #1 to the hospital. Record review of Resident #1's hospital records dated 07/19/24 at 9:32 p.m. indicated Resident #1 presented in respiratory distress with burns to intranasal (nose) and perioral (mouth) region with stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway) and wheezing (high pitched whistle when airway is blocked) . intubated (tube put into windpipe for breathing) for airway protection and expected clinical course with ketamine (anesthetic) and rocuronium (neuromuscular blocker). OG tube (orogastric) also placed. Chest x-ray revealed interstitial edema (form of pulmonary edema). Resident #1 was transferred to burn center for management evaluation. Record review of Resident #1's hospital records dated 07/20/24 indicated Resident #1 reported she had quit smoking (no date noted) and her smoking use included cigarettes. Elevated troponin myocardial injury likely due to acute myocardial injury in setting of severe burns and critical illness. There was 3% partial thickness burn to face/chest. During an interview on 07/23/24 at 11:10 a.m., Resident #2 said he was out back in the garden area of the facility with Resident #1 and Resident #3 He said it was a non-smoking area. He said he knew it was not a smoking area and he should not be smoking there. He said Resident #3 was smoking and got too close to Resident #1 and there was a flash and Resident #1 was on fire. He said he took the oxygen tube off Resident #1 and the fire went out. He denied giving Resident #1 a cigarette. He said he used to go off the facility to smoke but he now had to turn in all his smoking supplies and was only allowed to smoke with supervision. He said he did not give Resident #1 a cigarette. He said he never gave his cigarettes and lighter to the facility and did not sign them out to go smoking. He said he kept them in his room. He said the staff never asked him for his cigarettes or lighter. During an interview on 07/23/24 at 11:30 a.m., Resident #3 said she pushed Resident #1 to the nurses' station from her room. She said LVN WW put a tank of oxygen on Resident #1's chair. She said she informed LVN WW they were going out back of the facility to look at the flowers. She said Resident #2 joined them in the back of the facility. She said she had smoked a cigarette. She said Resident #2 was also smoking. She said she got a cigarette from Resident #2 for Resident #1. She said suddenly Resident #1 exploded and was on fire. She said she did not know how the fire started. She said she did not light the cigarette for Resident #1. She said she pulled the tube from Resident #1 and the fire went out. She said she pushed Resident #1 back into the facility and to the nurses' station. She said she gave all her smoking supplies to the nurse but could not remember which nurse. She said she did not want to talk anymore of the incident and wanted a lawyer. During an interview on 07/23/24 at 9:40 a.m., the Administrator said on 07/19/24, Resident #3 wanted to take Resident #1 outside to enjoy the garden. Resident #2 joined them. Resident #2 was an independent smoker who would sign himself out and go off property to smoke. He joined Resident #1 and #3 in a nonsmoking area. Resident #2 denied giving Resident #1 a cigarette. Resident #3 denied having a cigarette or smoking. Resident #2 said it just exploded and then he said Resident #3 had a cigarette and got too close to Resident #1. There were no staff present. Resident #3 put out the fire and brought Resident #1 back into the facility. RN ZZ assessed Resident #1 with burns to her chest and face and she was sent out to the hospital and then transferred to a secondary hospital burn unit. Since the incident on 07/19/24, the facility's smoking policy changed so no residents were allowed to keep smoking materials in their room and Residents #2 and #3 now required supervision. The facility has started in-services to staff on the new policy. He said all smoking residents were educated on the new policy and signed the new policy. During an observation on 07/23/24 at 10:15 a.m. of the non-smoking area in the back of the facility indicated there was no signage to indicate it was a non-smoking area. There was no signage related to the use of oxygen. During an interview on 07/23/24 at 12:35 p.m., the DON said she was not able to locate any current Smoking-Safety assessments for Residents #1, #2, or #3. During an interview on 07/23/24 at 12:40 p.m., the Administrator said whoever admitted the resident was responsible for doing the initial Smoking-Safety Screen, then it was done as needed. He said he was not aware of who took Resident #3's cigarettes and lighter after the incident on 07/19/24. He said the area where the incident occurred was not a designated smoking area. During an interview on 07/23/24 at 2:00 p.m. CNA YY said she was not aware of who all the smokers were in the facility. She said the residents' cigarettes and lighters were kept at the nurses' station and taken out to the smoking area. She said there was not a list of residents who required supervision while smoking. She said she did not know if Resident #1 or #3 smoked. She said Resident #2 was an independent smoker and kept his cigarettes and lighter in his room. During an interview on 07/23/24 at 2:05 p.m., CNA XX said she would get residents' cigarettes and lighters from the nurses' station and take them out to the smoking area. She said there was not a list of residents who were smokers. She said Resident #2 and one other resident were able to smoke independently and off of the facility property. She said Resident #2 kept his cigarette supplies in his room because he was an independent smoker and did not require supervision. She said she did not know if Resident #1 or #3 smoked. During an interview on 07/23/24 at 2:12 p.m., LVN WW said Resident #1 was at the nurses' station and was having trouble breathing. She said she put the oxygen tank on Resident #1's wheelchair and made sure the cannula was in place. She said Resident #3 indicated they (Resident #1 and Resident #3) were going to sit outside at the back of the facility. She said she was not aware Resident #1 or Resident #3 smoked cigarettes. She said she was not aware of a list of residents who smoked. During an interview on 07/23/24 at 5:51 p.m., the DON said the nurses' station would have a list of residents who smoked and who required supervision or who could smoke independently. She said the nurses would advise the assigned staff of the resident supervision levels for smoking. She said Resident #2 usually kept his cigarettes and lighter. She said she was responsible to make sure the quarterly Smoking-Safety Screen were completed. She said she was not aware the Smoking-Safety Screens were not completed as required. During an interview on 07/23/24 at 6:00 p.m., LVN VV said there was no list for which residents were smokers or who required supervision. She said after the incident on 07/19/24 where Resident #1 caught on fire, all the residents were supervised except one. She said all smoking supplies were supposed to be kept at the nurses' station. She said Resident #2 used to sign out and return his smoking supplies but then he refused. She said she believed the policy allowed him to keep his cigarettes and lighter because he was an independent smoker. During an interview on 07/24/24 at 8:33 a.m. LVN WW said Resident #2 was an independent smoker and did not sign out smoking supplies. She said she was not aware he required supervision. She said she never asked Resident #2 for his cigarettes or lighter. She said after the incident on 07/19/24, Resident #2 required supervision and was a supervised smoker. She said she was not aware of a list of residents who were smokers. She said the smoking supplies were handed to the staff who supervised the residents in the smoking area. She said there was one resident who was allowed to sign himself and his smoking supplies out to smoke off the facility property. She said smoking assessments were done upon admission and as needed if the residents were identified smokers. She said the smoking assessments would be done if they came up due in the electronic record. During an interview on 07/24/24 at 8:40 a.m., LVN WW said Resident #2 was an independent smoker and did not sign out smoking supplies. She said she was not aware he required supervision. She said she never asked Resident #2 for his cigarettes or lighter. She said after the incident on 07/19/24, Resident #2 required supervision and was a supervised smoker. She said she was not aware of a list of residents who were smokers. She said the smoking supplies were handed to the staff who supervised the residents in the smoking area. She said there was one resident who was allowed to sign himself and his smoking supplies out to smoke off the facility property. She said smoking assessments were done upon admission and as needed if the residents were identified smokers. She said the smoking assessments would be done if they came up due in the electronic record. During an interview on 07/24/24 at 8:49 a.m., CNA YY said all smoke breaks were assigned. She said a CNA would supervise at 4:00 p.m. She said the residents smoking supplies were given to them by the nurse. She said Resident #2 never kept his cigarettes or lighter at the nurses' station. She said he was an independent smoker before the incident on 07/19/24 but now had to smoke with supervision. She said she was not aware if Resident #1 or Resident #3 were smokers. During an interview on 07/24/24 at 8:58 a.m., QA TT said Resident #2 was supposed to sign his smoking supplies in and out when he went off the facility property to smoke. She said she did not know why his supplies were not turned in or why he was not signing in and out of the facility. She said Resident #3 denied having cigarettes or smoking. She said all residents who were identified as smokers should have a smoking assessment and a care plan. She said she was working on getting all assessments caught up and completed. She said the assessments were behind due to staff being off. She said the facility brought in a part time MDS nurse who caught up on the MDS assessments but not all other assessments. She said there should be list of residents who smoked. She said if the list of residents who smoked was not posted at the nurses' station, it should be. She said residents were at risk of injuries due to not safe smoking if they did not have assessment or care plans and they were not supervised as required. During an interview on 07/24/24 at 9:15 a.m., the Administrator stated Resident #2 was allowed to keep his cigarettes and lighter on his person because he was an independent smoker. He said the facility tried to keep Resident #2's smoking supplies and Resident #2 would promise to give them back to be kept at the nurses' station, but he would not keep his promise. He said Resident #2 was supposed to sign his smoking supplies in and out of the nurses' station. He said Resident #2 had not signed out of the facility since March 2023 due to being noncompliant and defiant. He said the facility did not have any system in place to protect the other residents from Resident #2's non-compliance or unsafe smoking. He said he would tell Resident #2 to return his smoking supplies but Resident #2 would not return his smoking supplies. He said Resident #2 knew he was not supposed to smoke on the property and smoked in a non-smoking area. He said Resident #3 denied smoking in the non-smoking area on 07/19/24. He said he was not aware of a list of residents who were smokers. He said after the incident on 07/19/24, all cigarettes and smoking paraphernalia were taken from the residents and were kept at the nurses' station. The Administrator said all smoking residents except one were to smoke during the scheduled smoking times. The Administrator said the one resident that did not require supervision could check themselves out and go off the facility premises to smoke. He said smoking was a risk and was unhealthy. During an interview on 07/24/24 at 9:43 a.m., the DON said she was not aware Resident #2 was not signing his smoking supplies in or out. She said she was not aware Resident #3 was a smoker. She said she did not know there was no list of residents who were smokers. She said she was aware the smoking assessments were not current. She said facility was working on making all smoking assessments current and up to date. She said residents were at risk of unsafe smoking if they were not supervised as required. During an interview on 07/24/24 at 1:23 p.m., MDS RR said Resident #2 reported Resident #3 pushed Resident #1 outside to the back garden area. She said the area was a nonsmoking area. She said Resident #2 reported Resident #3 had a lit cigarette and bent down in front of Resident #1 and there was a flash and fire. She said Resident #3 reported it was a freak accident and did not know what happened. MDS RR said resident smoking assessments were supposed to be completed quarterly. She said resident care plans were reviewed and updated quarterly and as needed. She said all smokers should have care plans related to their level of supervision. She said she did not know why the smoking assessments were not current. She said the smoking assessments were not activated in the electronic record and the nurses would not know to do the assessments if they did not populate. She said she had to activate Residents #1, #2, and #3's smoking assessments. She said residents were at risk of serious injury if they were not adequately supervised when they were smoking. She said if their smoking assessments were not completed, and their care plans were not updated the staff would not be aware of their safety needs. During an interview on 07/25/24 at 11:20 a.m., QA TT said Residents #1, #2, and #3 had gone outside to smoke. They did not go to the designated smoking area, but went to the garden area, way in the back. Resident #1 was on oxygen. A spark ignited and Resident #1 got burned. She was sent to the hospital and then transferred to a secondary hospital burn unit. She said none of the residents would say what exactly happened, and it was unknown if Resident #1 had a cigarette or not. Resident #1 had her oxygen tubing on at the time, but it was not hooked up to her concentrator. The Resident returned to the facility on [DATE]. She sustained 2nd and 3rd degree burns to her face and chest. Resident #1 was initially intubated for the edema and received ketamine and Fentanyl (opioid used for pain relief). QA TT said Resident #1 had a hard time communicating. She had a communication board but did not use it. She said all smoke breaks were now supervised and residents were required to sign out. During an observation and interview on 07/25/24 at 11:50 a.m., Resident #1 was sitting in her wheelchair, and had oxygen in place, connected to a concentrator. Resident #1 was noted with contractures to both hands. Resident #1 had a hard time speaking but was able to answer questions. She stated she was outside on 07/19/24 sitting with Resident #2 and Resident #3. She was not in the usual smoking area. She heard a boom and then her shirt caught fire. She was sitting next to Resident #3 who was smoking at the time. Resident #2 was also smoking. She said Resident #2 and Resident #3 put the fire out and she went to the hospital. She did not remember too much after being admitted to the hospital. Resident #1 said she had her oxygen tubing on at the time of the incident, but it was not hooked up to her concentrator. Resident #1 said she smoked a long time ago but was not a smoker and did not have a cigarette at the time of the incident. Resident #1 said she had gone outside with both residents before, but she usually kept her tubing across her lap. She said the cannula was in her nose. She would go outside with them 1-2 times a week. Resident #1 said she had burns above her mouth, directly under her nose, and to her chest. Red areas were noted to Resident #1's upper lip area and under her nose. A dressing was in place to the right upper chest area. QA TT raised the bottom of the dressing where the tape had come loose. Wounds appeared to black in color with some blood noted. Resident #1 said it was very painful and QA TT said she would bring her something for pain. During an observation and interview on 07/25/24 at 12:30 p.m., Resident #2 was sitting in his wheelchair. He had lived in the facility for 1 year. He said on 07/19/24 he went outside to smoke with Residents #1 and #3. They did not go to the designated smoking area, and instead went to the garden area as there was better scenery. Resident #3 was sitting in a chair and lit a cigarette. The minute she started to smoke it he saw a flash of fire. He immediately took Resident #1's oxygen tubing off as it had melted to her face. He said Resident #1's shirt was also on fire. He said he had a Dr. Pepper and a towel he had brought outside. He poured the drink on her shirt and used the towel to put the fire out. He said Resident #1 was crying and in shock. Resident #1 had also burned her hand and nose. He said Resident #3 brought Resident #1 inside the facility. Resident #2 said he now had to smoke at the designated times. Resident #2 said he got a letter from the Administrator stating he had to move out. He said the Administrator said he had given Resident #1 a cigarette. Resident #2 said he did not give her a cigarette, and he was not even smoking at the time. He said Resident #3 was the only one smoking at the time. He said the Administrator just assumed he gave her one. He had never seen Resident #1 smoke since he had been in the facility. He said she must have done it before because she had COPD. Resident #2 said Resident #1 was his girlfriend. Resident #2 said 2-3 months ago he had a vape pen with THC (Tetrahydrocannabinol-a cannabinoid found in cannabis) in it and Resident #1 took a hit. He said the Administrator told him to not do it again. Record review of the facility's Smoking Policy-Residents dated 2001 (revised 2017) indicated . 2. Smoking is only permitted in designated resident smoking areas . 3. Oxygen use is prohibited in smoking areas. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 7. The staff shall consult with the Attending physician and the Director of Nursing services to determine if the safety restriction need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke will be evaluated quarterly, upon significant change (physical or cognitive) and as determined by staff. This was determined to be an Immediate Jeopardy (IJ) on 07/24/24. The Administrator and DON were notified. The Administrator was provided with the IJ template on 07/24/24 at 12:26 p.m. The following plan of removal was submitted by the facility and accepted on 07/26/24 at 9:59 a.m. and included the following: On 22 July 2024 the Administrator implemented a smoking policy which states no resident shall be allowed to smoke on (the facility's) property unsupervised. Residents are to follow posted smoking schedule. This smoking schedule also reflects which staff is responsible for which times. Staff in-service training on this new policy was completed on 25 July 2024 at 6 p.m. Assessment of all residents who smoke or who we think may be sneaking a smoke was completed by QA nurse on 25 July 2024 12:00 noon. Residents were also assessed for the possible need of protective equipment. QA nurse has also updated all resident's care plans to reflect the results of the assessment (completed 26 July 12 noon). QA nurse will ensure quarterly assessments are completed in a timely manner. A list of residents who smoke, along with those that need protective equipment, was posted on top of the smoking box that is carried out to smoking area by supervising staff (24 July 2024). All staff were instructed to read the smoking list that is taped to the lid of the smoking box and put a smoking apron on residents as indicated by said list. Administration has reiterated to residents, who often leave facility grounds, the policy that they must sign out before leaving and sign back in upon return. All residents who have been identified as smokers have signed acknowledgement of their understanding of this policy on 23 July 2024 at 12 noon. Smoking questionnaire, as of 24 July 2024 12 noon, is now a part of admission package to determine if the resident may be a smoker. Care plan team has updated resident #2's care plan to reflect he is no longer allowed to keep smoking material on his person or in his room. Resident #2 has been instructed to sign himself out when he leaves the building and sign himself in upon his return. Resident #1 and #3 have been assessed as smokers. Residents #1 and #3's care plans have been updated to reflect the fact that they may try to sneak around and smoke. On 24 July 2024 administration implemented a policy that all smoking on the facility property will be supervised. All staff has been instructed on smoking safety and supervision (completed 25 July 2024 at 6 p.m. by DON and Admin) to ensure that hazardous materials are kept away from the designated smoking area. All staff has been instructed by the DON and the Administrator to request the return of smoking material that any resident checks out upon resident's return to facility (completed 25 July 2024 at 6 p.m.). All staff has been instructed by the DON on smoking safety and supervision (completed 25 July 2024 at 6 p.m.) to ensure that hazardous materials are kept away from designated smoking area. New policy compliance will be monitored by the Administrator, the DON, the QA Nurse as well as the weekly QA Rounds team. On 07/26/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observations of a facility smoking area on 07/26/24 at 4:00 p.m. and 7:00 p.m., there was one staff with residents. Two residents had on a smoking apron. Staff lit residents' cigarettes with lighter. No residents retained smoking paraphernalia. There was a box with residents' smoking materials. There was a list of resident smokers taped to top of the box of residents' smoking materials that included who required safety interventions (protective apron). During an interview on 07/26/24 at 3:45 p.m., the DON said staff were in-serviced on the facility's smoking policy. She said shifts have changed recently to 6a-6p and 6p-6a for nurses and CNAs. She said residents who smoked were instructed on the revised Smoking Policy. During an interview on 07/26/24 at 4:10 p.m., QA TT said in-services were conducted with staff and residents. She said Smoking Assessments were updated on smokers and done on residents suspected of smoking. She said she reviewed and updated the care plans based on the Smoking Assessment. During interviews conducted on 07/26/24 from 4:45 p.m. through 6:15 p.m. with the facility staff from all shifts (CNA A, CNA B, CNA C, NA D, DA E, DA F, RN G, CNA H, LVN I, CNA J, CNA K, and Maintenance Director L) indicated they were aware of the facility smoking policy, knew which residents required smoking protection (aprons), were aware residents were required to turn in smoking paraphernalia, and would report any resident to the charge nurse if they were non-compliant with return of smoking paraphernalia. They were able to explain the importance of assessing each resident for smoking safety, ensuring all residents adhered to the smoking policy and smoking contracts, and knew the consequences of non-compliance, ensuring residents do not keep their own smoking materials or smoke unsupervised, ensuring the families of residents who smoked complied with all smoking rules, posting all designated smoking hours to ensure each resident was available during those times, ensuring residents on oxygen or those with roommates on oxygen did not keep lighters in their rooms, and reporting any non-compliance with the smoking policy to management. They were of where the list of smokers was (on the box of resident smoking materials). During an interview on 07/26/24 at 6:20 p.m., Resident #2 said he wa [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure resident's environment remained free of accident hazards for 1 of 18 residents reviewed for accident hazards. (Resident #51) The facility did not secure Resident #51 in the facility van in a manner to prevent an accident. Facility staff were not trained how to properly secure residents in the van and the facility did not complete safety checks on the facility van. Resident #51 sustained a head injury while being transported in the facility van and was taken to the emergency room where he died . An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures affected Resident #51 and could place the other wheelchair-bound residents who had the potential to ride the facility van at risk for severe injury or death. Findings included: Review of Physician orders dated [DATE] indicated Resident #51 was admitted [DATE], was [AGE] years old and had diagnoses of major depressive disorder, [CONDITION(S)], heart failure, [CONDITION(S)], and end stage renal disease. A Minimum Data Set (MDS) dated [DATE] indicated Resident #51 required extensive and physical assistance for activities of daily living skills (ADLS) including transfers and locomotion off unit. The MDS indicated the resident required a wheelchair. Resident #51 received hemodialysis 3 times per week. An incident note dated [DATE] at 4:15 p.m. indicated Resident #51 was placed in the facility van following [CONDITION(S)]. When leaving from red light a few seconds later the nurse heard a thump and resident hollered out. When the nurse looked up into the rear-view mirror, the front of resident chair was raised upward, and back of resident head was against the back metal ramp of van that was folded up. Resident was not alert or oriented at this time and began to vomit while he was attempting to slump over. Resident had a small hematoma located to posterior head with a slight abrasion to his head, resident was slow to responding and vomiting. ADON was notified via phone and instructed to take resident to hospital. During an observation and interview on [DATE] at 1:00 p.m., LVN A who was driving the van on the [DATE] incident regarding Resident #51 and this surveyor went to parking lot to look in facility van. The van was an older model van with side sliding doors to both sides of van and a rear entry door with a fold up metal wheelchair ramp. It has the capacity to hold one wheelchair. LVN A said on [DATE], she positioned Resident #51 in facility van through the rear entrance. She locked the wheelchair and applied the safety strap hooks to the back two areas of the wheelchair. She then folded the floor ramp and closed back door and went to the sliding side doors and repeated steps on the front 2 straps for the wheelchair. She said she then applied the upper torso seatbeat across resident's chest area and clamped into place. She said she always puts the straps on back of wheelchair and then proceeds to apply to the front area of the wheelchair. She said a few seconds after leaving the [CONDITION(S)] center, when she pulled away from the red light, she heard a noise and Resident #51 shouted out. She pulled the facility van over to assist the resident. She said the front right side of his wheelchair was tilted upward with the right front tie-down strap loosened while still attached to wheelchair. She said the shoulder strap across his upper torso had locked up (tightened). She said his head was against the wheelchair ramp and that he began vomiting. She also stated the right arm rest of his wheelchair had come loose. She said the right front track anchored to the floor of the van where the strap attached was loose. This surveyor checked the right front track and it moved freely, while the remaining three did not. She then put armrest of wheelchair back in place and tightened the right front tie-down strap. She said she notified the facility and was instructed to transport resident to local ER for evaluation. When asked if the wheelchair had been properly secured in the facility van, would this incident have occurred, and LVN A responded No. An emergency room Visit Note dated [DATE] indicated Resident #51 was seen by ER provider at 1:43 p.m. following transportation by facility van. The note indicated the following: *Stated complaint: Fall. *Chief Complaint: head injury. *Initial comments described Resident #51had fallen backwards and hit his head. Patient has been extremely obtunded in the last 10 minutes since hitting his head. *Patient's blood pressure is 79 systolic here. Patient is not answering any questions. .*Comments: Around 3:15 p.m. patient had a course of agonal respirations. Patient is in PEA (pulseless electrical activity). Bedside ultrasound shows minimal cardiac activity. I (ER pprovider) pronounced the patient deceased at 3:25 p.m. Patient no longer in PEA and no cardiac activity seen on bedside ultrasound .*Disposition: Clinical Impressions: Primary Impression: Cardiopulmonary arrest Additional impressions: [CONDITION(S)] (end stage renal disease Head injury . During a second observation and interview with LVN A on [DATE] at 2:15 p.m., she said she had transported residents on several occasions. She said she had received training sometime around the first of the year maybe, and again following the incident with Resident #51. Along with 2 additional surveyors on the team and the administrator, LVN A then demonstrated to surveyors how she secured Resident #51 in the van while using his wheelchair obtained from his former room. This surveyor sat in the wheelchair throughout the demonstration. When securing the back of the wheelchair, she secured 2 of the strap belts to the frame of the wheelchair just below the seat. She then went to the side door of the facility van and secured the front 2 strap belts on the frame between the seat and the wheels on each side. She said she would also add the shoulder seat belt across the front upper torso of residents. LVN A demonstrated placement of Resident #51's head on the frame of the wheelchair ramp. She said he sustained a nickel sized hematoma (knot) to the back of his head from hitting the ramp. She also said he had a small abrasion to the area and added that it did not break the skin. A typed list provided by the DON on [DATE] at 3:40 p.m. indicated 13 different residents had ridden in the facility van since [DATE]. Also provided on this page were a list of 9 staff members who had driven the facility van within the last 3 months. LVN A was listed as one who had driven the facility van in the past 3 months. An electronic form provided by the DON on [DATE] at 3:40 p.m. indicated in-service topics dated [DATE] through [DATE]. The topic section gave no indication of lecture or demonstration training of the facility van, mechanics of safety checks, or resident safety. When surveyor asked for documentation of how drivers were trained for the facility van and securing wheelchairs, the DON said this was all the documentation available regarding training for the facility van. She said they inserviced staff on [DATE] after the incident with Resident #51. An in-service record was provided by DON on [DATE] at 3:40 p.m. with the content description listed as how to properly secure a wheelchair into a wheelchair van. How-to video. This in-service was dated as performed [DATE]. The comment section listed youtube .com/watch? v-FoB.1ulskkE is a video step by step. Four employees signed form as participants. Attachments included an undated 3-page handout titled How to secure Wheelchair into a Van obtained from website movemobility.ca/about. The following was included in the handout: *The securement system is built directly into the floor of a wheelchair accessible vehicle, and it keeps the wheelchair locked in place to keep the passenger safe while the vehicle is in use. Wheelchairs that are not secured properly can result in movement in the vehicle while it is in motion; this is unsafe during normal driving conditions and is even more dangerous in the event of a sharp turn, sudden stop, crash or other precarious driving conditions; *Restraints/belts are in a four-point strap system (two at the front and two at the back) and it is necessary to use all four restraints that are provided. The purpose of the restraints is to keep a wheelchair in place; *Secure the front restraints/belts first to the solid portion of the frame of the wheelchair with the straps at a 45-degree angle, tighten the restraints while keeping the front brakes on until the front restraints are tightened. Then, secure the rear restraints to the solid part of the wheelchair frame at a 45-degree angle; *Conclusion-most wheelchair transportation injuries are the result of improper wheelchair securement. Proper wheelchair securement can save lives and prevent serious injuries. The administrator, DON and other department heads were notified on [DATE] at 11:40 a.m., an Immediate Jeopardy (IJ) situation identified due to the above failures, the IJ template was provided and a POR (plan of removal) was requested. During this notification of the Immediate Jeopardy, the DON said staff were trained re: facility van. She said she had provided an (electronic) in-service records the previous day ([DATE]). This surveyor reminded her of receiving in-service record on [DATE] and asking her if the topic of the facility van was discussed with staff, to which she had replied yes. This surveyor told her it was not documented on the referenced electronic in-service record and the nursing rule if it wasn't documented, it wasn't done, to which she replied, 'Just because it's documented doesn't mean it was done either. During this IJ notification, the administrator and DON said the van had been inspected when it returned to the facility on [DATE]. They had found nothing out wrong with van. This surveyor reviewed a note from Resident #51's electronic record entered by the administrator. The note was dated [DATE] at 4:30 p.m. It said inspected facility van with DON. Nothing significant looked out of place. This surveyor asked about checking the lift and tie-down system. Informed him the entry should have been more descriptive. Also during this time, surveyor asked regarding a checkist of inspecting facility van to ensure proper mechanics of the handicap system. The administrator said there was a checklist. The checklist provided by the facility titled Monthly Vehicle Inspection Checklist included the following checks: *windshield condition; *window condition/operation; *hi-beam lights; *low beam lights; *tail lights; *brake lights; *turn signals; *emergency flashers; *license plate lights; *back-up light; *back-up alarm; *wiper blades/operation; *emergency brake; *horn; *seats; *seat belts; *rearview mirrow; *side mirrors; *fire extinguisher; *first aid kit; *spare tire; and *tire tools. There was no mention for ensuring the safety of the van, lift and tie down system. The facility's Plan of Removal was accepted on [DATE] at 10:28 a.m. and included: [DATE] Immediate action need to be taken so no other residents sustain minor or life-threatening injury while being transported. Plan of Action To date, the facility has, in relation to preventing other Residents from sustaining minor or life threatening injury related to Resident transportation: * Facility van's inspection * Assistant Director of Nursing, Director of Nursing, and the Administrator each inspected the vehicle once it returned to the facility, nothing noticed to be defective * The following items were checked for mechanical deficiencies and abnormalities (none noted): * Wheelchair ramp * Rear and side doors * Seat belt * All four wheelchair retractors (Q'Straint) * Retractor straps and hooks * Facility van placed out of operation * Van will remain out of operation until it has been thoroughly inspected and cleared by a licensed mechanic or replaced; in the meantime, Residents can be transported to appointments by family members/responsible parties or nonemergency medical transportation services (NEMT) * Developed Wheelchair Van Instruction and Checkoff procedure, see enclosure To further keep Residents from injury while being transported the following courses for improvement are implemented: *Facility implements new drivers training effective [DATE], training overview enclosed * Director of Nursing is appointed to serve as the facilities' transportation director and will oversee training on transportation and driver(s); both the Securement 101 and Securement 102 are completed on [DATE] * Securement 101 is designed to provide a comprehensive introduction to wheelchair securement best practices. Through a series of four lessons, transportation providers will learn how to operate a variety of 4-point securement systems currently available and understand how to properly secure passengers with special needs and their wheelchairs. Each lesson concludes with a quiz, highlighting levels of competence. Once the course has been successfully completed, students will receive a certificate of completion that is valid for two years. Supervisors will be able to track their students' progress and see which topics require more attention. This course is ideal for new hires as well as refresher training for more experienced drivers and safety trainers. * To successfully complete this course, students must pass a test with a score of at least 75% * Securement 102 is designed for transportation directors, supervisors, and trainers who can help implement the troubleshooting techniques and best practice recommendations within their agencies. * To successfully complete this course, students must pass a test with a score of at least 75% * Driver's training includes: * Classroom instruction will be provided by the facility and consists of the following: * QTraining Aqademy - Securement 101 to be taken by all drivers * Learning objectives for Securement 101 include1: * Understand the liability inherent in transporting passengers in wheelchairs, and ways to mitigate that risk and improve passenger safety. * Compare and differentiate between the various types of wheelchair securement equipment, occupant securements, and accessories. * Apply the 3 essential principles needed to properly secure a wheelchair. * Apply the 3 essential principles needed to properly secure a wheelchair passenger using the occupant securements. * Differentiate between WC19 compliant wheelchairs and Non-WC19 wheelchairs, and how to approach securement with both types of wheelchairs. * Understand and avoid common securement pitfalls, problems, and errors that lead to most wheelchair incidents. * To successfully complete this course, students must pass a test with a score of at least 75% * Review Texas Department of Transportation training on collisions (TxDOT), topics include: * Avoid a collision * What to do after a crash * When to call police * When to move your vehicle * What to do after a car accident (Progressive Insurance) 1 https://training.qstraint.com/courses/securement-101-basic-wheelchair-securement-training/ * Road tests will be overseen by the Director of Nursing, and consist of the following: * Skills checkoff and demonstrations, to include: * Open and closing of doors * Use of wheelchair ramp * Securement of the wheelchair and warnings * Use of retractors and tie downs * Use of seatbelt(s) * Securement of the passenger and warnings * Placement of wheelchair in vehicle * Release of the passenger and warnings * Maintenance and care items * Proper use of [NAME] Vehicle Maintenance Checks and Services Checklist * Discuss what to do in an emergency * How to fill out insurance paperwork * No driver shall be allowed to transport a Resident without successful completion of this training * Vehicle Maintenance Checks and Services * New vehicle checklist was developed, tested , and implemented by Director of Operations and Business Office Manage on [DATE], see enclosure * Vehicles are checked weekly by the Maintenance Supervisor/designee * A pre-use and post-use inspection are completed for every use by the driver and turned into the Charge Nurse once returned. On [DATE] at 9:00am, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: The administrator and DON had completed the Securement 101 classes on [DATE] and verbalized knowledge of safe securement of residents during facility van transports. The DON also completed Securement 102 0n [DATE]. The administrator confirmed the facility van remained out of operation and all current or pending transports would be completed by family members/responsible parties or nonemergency medical transportation services. Administrator stated all van driver training will be completed and skills check offs done by the DON. The DON confirmed she was the facility's transportation director and will oversee training on transportation and drivers. On [DATE] at 9:00am, the administrator was informed the IJ was removed, however, the facility remained out of compliance as a scope of pattern and severity of no actual harm with a potential for more than minimal harm as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. During the exit on [DATE] at 3:30 p.m., the facility was asked for any additional information related to accidents and hazards. No new additional information was provided. Facility provided a third copy of Resident #51's clinical record.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents reviewed for supervision. (Resident #6) The facility did not develop and implement interventions to prevent Resident #6 from eloping from the facility. The resident had exit seeking behaviors and impaired safety awareness. The resident found outside the fence of the secure unit on 1/15/21. On 1/30/21, the resident was found approximately 0.3 miles from the facility at an intersection by a staff member returning from a lunch break. This failure could place residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 2/26/21. While the IJ was removed on 3/1/21, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Physician orders dated 2/26/21 indicated Resident #6, admitted [DATE], was [AGE] years old with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, and bi-polar disorder. Admission orders dated 12/23/20 indicated an order to refer Resident #6 to psychiatric care for evaluation and treatment. An MDS dated [DATE] indicated Resident #6 had severe cognitive impairment, was ambulatory, and required supervision with most of his activities of daily living. The behavior section of the assessment indicated the resident wandered 4 to 6 days a week, but less than daily and there was no impact placing the resident at risk of getting to a potentially dangerous place. The baseline care plan dated 12/23/20 did not address wandering or elopement risk. A review of the clinical record from 12/23/20 to 2/26/21 indicated no elopement risk assessments in the medical record. A nursing progress note dated 12/26/20, completed by LVN S indicated Resident #6 was walking throughout the secure unit seeking an exit. He tried each door of the facility, pushed on the exits and was redirected by staff. A nursing progress note dated 12/27/20 at 11:31 a.m., completed by LVN S indicated Resident #6 was actively seeking an exit. A nursing progress note dated 12/28/20 at 4:41 a.m., completed by LVN T indicated Resident #6 was seeking an exit to find his car. A nursing progress note dated 12/28/20 at 4:45 p.m., completed by LVN F indicated Resident #6 had been agitated at times telling staff these people need to be fed. The LVN offered a snack and water but he refused. The note indicated the resident was exit seeking, attempting to open exit doors and was redirected. A nursing progress note dated 12/30/20 at 4:16 a.m. completed by LVN U indicated Resident #6 was wandering throughout the secure unit and the secure courtyard during the night shift. A nursing progress note dated 12/30/20 at 2:13 p.m. completed by LVN S indicated Resident #6 wandered throughout the facility and courtyard frequently checking gates and doors for an exit. A nursing progress note dated 1/5/21 at 8:05 a.m., completed by LVN S indicated Resident #6 was actively seeking an exit, stating he needed to go to work. Staff repeatedly redirected him to return to his room, or to wear a mask while outside of his room. He was very anxious and nervous. He approached the nurse and stated, watch your coins. They will disappear.' He was looking around, wringing his hands. A nursing progress note dated 1/9/21 at 11:41 p.m., completed by LVN T indicated Resident #6 was always seeking an exit. The note indicated staff attempted to redirect Resident #6 without success. A progress note dated 1/13/21 at 4:55 p.m., completed by LVN S indicated Resident #6 continued to seek an exit. When staff attempted to redirect him back to his room, he said the city was supposed to be calling him about moving those cars and needed to get through those doors to take care of business. The note indicated the resident was very determined and could not be redirected from his purpose. A facility incident report dated 1/15/21 indicated Resident #6 was found outside the facility by the dumpsters by dietary staff. The report indicated predisposing factors included active exit seeker. An incident progress note dated 1/15/21 at 1:53 p.m. completed by ADON A indicated dietary personnel told ADON A Resident #6 was outside. The note indicated the resident was outside by the dumpsters in the back of the facility and he asked the nurse how to get to a local city. The note indicated the resident was escorted into the facility and was unable to verbalize how he got out of the facility. The facility called the family member to inform her of the elopement and she told them he was just trying to get home. During an interview on 02/26/21 at 10:00 a.m., ADON A said Resident #6 was found outside the secure unit courtyard by the facility dumpsters by dietary staff on 01/15/21. She said there was no investigation completed into how the resident got outside the fence of the secure unit. She said she reported the elopement to the administrator. During an interview on 02/26/21 at 10:40 a.m., ADON A said she did not complete Resident #6's care plans. She said she was behind due to the COVID pandemic and the death of the facility's owner. During an observation on 2/26/21 at 10:05 a.m., the secure courtyard had a gate on the west side of the building outside of A-hall exit door (exit door from secure unit leading into courtyard). The keypad to open the gate was located inside the building on A-hall near the solarium. The keypad was not visible from the nurse station. A nursing progress note dated 1/19/21 at 4:30 p.m. completed by GVN V indicated Resident #6 had refused his prescribed evening medication. He was wandering and actively attempting to leave the facility stating he had to go get the baby. The note indicated the resident attempted to climb the fence surrounding the secure unit patio. Staff attempted to redirect him by providing a snack and water, but he continued to pace to and from doors to find an exit. A wandering risk assessment completed 1/25/21 for Resident #6 indicated the assessment was the one-month assessment. Section H. Complete at 1 month, quarterly, annually, with sig (significant) change and adhoc (as needed) indicated no entry as to any episodes of wandering in the past three months or six months. A nursing progress note dated 1/27/21 at 5:15 p.m. completed by LVN S indicated Resident #6 was repeatedly walking the fence line, examining the gates and crevices on the fence. He pushed on the boards, reached up and tried to pull on the top railing of the fence. He would walk back indoors and walk the hallway, then return outside and walk all along the fence again. An incident progress note dated 1/30/21 at 1:16 p.m., completed by LVN F indicated the nurse received a phone call from CNA E stating she had Resident #6 in her car. The note indicated CNA E picked the resident up on a local street where she saw him walking when she was driving back from lunch. Resident #6 was escorted into building. During an interview on 02/26/21 at 12:35 p.m., LVN F said she recalled she saw Resident #6 walking around the courtyard of the secure unit at the 1:00 p.m. smoke break on 1/30/21. She said she received a call from CNA E at approximately 1:40 p.m. on 01/30/21 and CNA E said she had Resident #6 in her car. She said she was not aware Resident #6 had exited the secure unit of the facility or how he had exited the secure unit of the facility. She said she was aware he was constantly walking, wandering, or exit seeking at the locked back gate of the fence surrounding the secure unit courtyard. An incident report dated 1/30/21 indicated CNA E picked Resident #6 on a local street when she was returning from lunch. There was no evidence of any investigation conducted. During an interview on 2/26/21 at 11:24 a.m., CNA E said she left the facility for lunch on 1/30/21 around 1:00 p.m. She said she did not see Resident #6 on the road when she left. She said on her way back she saw Resident #6 down by the stop sign at the end of the road. She said she thought it may be about ½ a mile to the stop sign from the facility. She said she called the facility then put the resident in her car and took him back to the facility. During an interview on 02/26/21 at 12:30 p.m., CNA E said she did not recall if she saw Resident #6 or what he was doing prior to leaving the facility for her lunch meal on 01/30/21. She said she was aware he was usually walking, wandering, or exit seeking. During an observation on 2/26/21 at 3:50 p.m., the intersection where Resident #6 was found on 1/30/21 was a two-lane through road with no sidewalk or shoulder and used for people living in the residential area and to connect the center of the town to a highway. An incident Audit Report dated 2/14/21 completed by RN P indicated the care plan was revised on 2/5/21. A review of the clinical record from 12/23/20 to 2/26/21 indicated the comprehensive care plan was not updated to include wandering or elopement risk. During an observation on 2/26/21 at 2:50 p.m., Resident #6 was sitting on his bed with his daughter at his bedside. He was not able to recall any elopements. During an interview on 02/26/21 at 12:33 p.m., Medication Aide M said she administered Resident #6's 12:00 p.m. medications 01/30/21. She said she did not know where he was or what he was doing after he received his medications. She said she was aware he was constantly walking, wandering, or exit seeking. During an interview on 3/1/21 at 11:10 a.m., LVN S said Resident #6 was exit seeking since he admitted . She said he used to be in construction and would get up early in the mornings. She said he would try to open all the exits. She said when he was outside, he would try to open the gate. During an interview on 2/26/21 at 10:00 a.m., ADON A said Resident #6 eloped from the facility on 1/30/21. She said a CNA was driving back to the facility from lunch and found him down the road from the facility. She said the staff on the secure unit did not know he had gotten out of the facility. She said the resident was placed on every 15-minute checks and was still on the 15-minute checks. During an interview on 2/26/21 at 10:40 a.m., ADON A said there was no formal investigation completed when Resident #6 eloped from the facility either time. She said there was not a care plan to address the wandering or elopement of Resident #6. She said at the time of the elopements, the keypad to open the gate was a two-digit keypad. She said the administrator accidentally opened the gate just by pushing random buttons on 2/9/21. She said they called the Fire [NAME] on 2/11/21 to ask about installing a box over the keypad until a new upgraded keypad could be ordered. She said the new keypad was ordered on 2/12/21 and installed on 2/24/21. During an interview on 2/26/21 at 1:05 p.m., ADON A said nothing was done after the first elopement because they thought it was a fluke. The Wandering and Elopements policy revised March 2019 indicated Policy Interpretation and Implementation - 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. The administrator was notified on 2/26/21 at 1:05 p.m., an Immediate Jeopardy situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 2/27/21 at 8:06 a.m. and included: Based on the Need for Immediate Action section in the IJ Template provided to me via email from Texas HHSC February 26, 2021, at 1427 stating the following: Immediate action needs to be taken to keep residents on the secure unit safe and prevent injury or death related to residents leaving the secure area. To date, the facility has, in relation to keeping Residents on the secure unit safe and prevent injury or death related to Residents leaving the secure area: * 12/23/20: Resident admitted with ICP in place; Wandering Risk Assessment completed, (Wandering Risk Assessment addressed elopement risks); Behaviors and Side Effects monitored and documented every shift, demonstrating interventions to address elopement risk (specifically: redirection, activity, engagement, 1:1 monitoring, removing Resident from area) * 12/26/20: 72 hour Wandering Risk Scale completed (this scale addresses elopement risks); Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift * 1/15/21: Resident's first exit * 1/25/21: One Month Wandering Risk Scale completed; Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift * 1/30/21: Resident's second exit; Q15 Minute Monitoring initiated in addition to Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift * 2/2/31: Resident referred to Senior PsychCare * 2/4/21: Administrator and Maintenance Supervisor discuss gate during weekly Touch Base, Maintenance Supervisor believe gate is being open from within A/B Nurses Station (release button), recommends signage and education of staff * 2/5/21: Memory Care Community becomes COVID free * 2/8/21: Administrator discusses gate with A/B ADON during weekly Touch Base; Administrator identifies the problem (assessed that Resident has figured out that by touching a series of buttons, the lock on the gate will be released), findings discussed with Nursing and Maintenance; look into reprogramming keypad with more extensive code * 2/9/21: Resident seen by Senior Psych Care; Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift; A/B ADON and Administrator further discuss gate solutions * 2/11/21: Administrator and Maintenance Supervisor further discuss gate during weekly Touch Base, Administrator directs Maintenance Supervisor and A/B ADON to get code A Family Caring for Families Since 1965 [NAME] Acres Health & Rehabilitation Newton, Texas www.ShadyAcresCares.com changed today or call to get support in to replace the keypad; investigation reveals that the problem cannot be fixed without outside professional intervention; Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift * 2/12/21: Call placed to the Fire [NAME] in reference to lockbox; lockbox protecting the keypad is authorized and installed; new keypad order and service requested with RF Technologies * 2/19/21: new keypad received at facility, despite historic icy conditions; Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift * 2/22/21: Resident again seen by Senior Psych Care * 2/23/21: keypad installed, preventing Resident from opening the locked gate; Behaviors and Side Effects with staff interventions and Resident response continue to be documented every shift To further keep Residents on the secure unit safe and prevent injury or death related to Residents leaving the secure area, the facility shall: * In-service Memory Care Community staff on exit-seeking care with the St. Joseph's Healthcare, [NAME] Seniors Mental Health Outreach Program: Working With A Resident Who Is Exit-seeking: A Learning Module For Long-term Care Staff * All Memory Care Community staff on shift are in-serviced February 26, 2021 and sign off on their training * All Memory Care Community staff not currently at work (next rotation starts Monday March 1, 2021) are in-serviced and sign off on their training no later than March 1, 2021 * [NAME] Acres will continue to assess Residents for elopement risks at admission via the Wandering Risk Assessment ([NAME] Acres' Wandering Risk Assessment addresses elopement risks), this is followed up by a 72 hour Wandering Risk Assessment, one month Wandering Risk Assessment, and quarterly Wandering Risk Assessment; Charge Nurses are responsible for completing these assessments and it will be verified by the ADONs * All Memory Care Community Residents will have their care plans audited no later than February 27, 2021 by the A/B ADON; any Resident with a determined risk for elopement will have an updated care plan no later than March 1, 2021 * Newly installed keypad will be monitored by Memory Care Community Charge Nurses and findings discussed with A/B ADON; any urgent matter will immediately be relayed to Administration; these findings will further be discussed and reviewed during the weekly QAPI Meetings A Family Caring for Families Since 1965 [NAME] Acres Health & Rehabilitation Newton, Texas www.ShadyAcresCares.com These findings and courses for improvements will be discussed by the facility QAPI Committee. Continued recommendations for improvement shall be supervised and delivered from QAPI to the facility Administrator, following their monthly meetings (SAHR QAPI is scheduled to meet every Wednesday at 1245). QAPI will supervise this plan and review these findings and remain involved in ensuring the facilities adherence with all federal and state regulations. The owners of [NAME] L. Hines, Inc (BDA of [NAME] Acres Health & Rehabilitation), shall ensure these steps are followed by providing oversight supervision of facility staff, to include the Administrator. Enclosures (1) 1. Link to training: https://brainxchange.ca/Public/Files/Education/Education-Module_Exit-seeking.aspx On 3/1/21 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: An in-service dated 2/26/21 indicated staff were in-serviced regarding working with residents who are exit seeking and to monitor all exits and keypads every two hours. Reviewed 3 medical records of residents residing on the secure unit. The records had updated wander risk assessments and updated care plans as needed. 2 LVNs, 1 GVN, 3 CNAs, 1 NA, 1 housekeeping staff, and the social worker, were interviewed and were able to verbalize the appropriate interventions to deal with residents who were elopement risk and to monitor all exit to ensure they were in good working order. Reviewed the door/keypad monitoring logs implemented on 2/26/21. They had all been completed every two hours. Resident #6 continued to be monitored every 15 minutes. During an interview on 3/1/21 at 2:15 p.m., ADON B said she found an elopement risk assessment she would upload into PCC to have available. The form will be used the same as the wandering risk assessment. On 3/1/21 at 2:26 p.m., the DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure resources were utilized effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for the facility. The administrator did not initiate an emergency evacuation or have resources available to evacuate residents and staff during a mandatory evacuation of the local county. An Immediate Jeopardy (IJ) was determined to have existed from 8/26/20 to 8/27/20. While the IJ was removed on 8/27/20, the facility remained out of compliance at a scope of widespread with a potential for more than minimal harm. Findings included: An Order of Mandatory Evacuation dated 8/25/20 at 5:00 p.m. indicated a mandatory evacuation was declared due to the imminent threat of being in the path of a weather event that could potentially cause widespread or severe damage, injury or loss of life and property. The Shady Acres Health & Rehabilitation (SAHR) Emergency Preparedness and Response Plan June 2020 indicated .i) Evacuation i) SAHR will evacuate to (1) Autumn Leaves Nursing and Rehabilitation Center,(NAME) Texas in a city-wide emergency . iii) Decision to evacuate residents to a receiving facility will be determined by the Administrator. A room roster dated 8/26/20 indicated the following: *4 residents were at risk for elopement, *15 residents were wandering risk, *39 residents were high risk for falls, *6 residents were low risk for falls, *13 residents were moderate risk for falls, *28 residents were in a chair most of the time, *8 residents were ambulatory with assistance or assistance device, *4 residents were bedfast most of the time, *19 residents were independent with ambulation During observations on 8/31/20 at 11:45 a.m., while traveling to the facility, the local town had numerous trees and limbs down, there were linemen working to restore power to the city. There were numerous emergency management trucks and vans set up in the town approximately 1/2 mile from the facility. During an interview on 8/31/20 at 12:00 p.m., the administrator said on 8/25/20 the local judge ordered a mandatory evacuation for the county. The administrator indicated he did not plan on evacuating the residents or staff; they were going to shelter in place. The administrator said the judge said the facility was excluded from the mandatory evacuation order for the local county. He said the judge did not provide him any documentation. He indicated the residents and staff were evacuated on 8/26/20 prior to the storm after HHSC got involved. He indicated the facility required assistance with transportation and receiving facilities for the residents and staff. The administrator indicated placement had to be obtained for 49 residents due to the facility on ly having a contract with a facility which could only take 11 residents. The administrator said the current census was 12, the others are starting to return to this facility. During an interview on 8/31/20 at 1:34 p.m., the County Judge said there was a mandatory evacuation issued for the county of on 8/25/20 due to the hurricane. He said the administrator asked if in his opinion they would be ok if they didn't evacuate, he said he thought they would probably be ok, but it was a mandatory evacuation order. The judge said he informed the administrator there would not be city or county support, he said the fire department or ambulances might not be able to provide services, if the storm hits this area. He said the administrator asked for a document to exclude them from the evacuation, he said he did not provide an exclusion document. During an interview on 8/31/20 at 1:50 p.m., the EMC with SEMAC said the emergency plan was activated due to the facility not evacuating earlier when the evacuation was ordered. He said they were notified by HHSC of the facility needing assistance with evacuation. The facility needed transportation and placement for some of the residents. During an interview on 8/31/20 at 2:00 p.m., Housekeeper A said the evacuation on 8/26/20 was last minute and she herself did not have time to evacuate after getting the residents out. She indicated she thought the facility was going to shelter in place for the hurricane. During an interview on 8/31/20 at 2:10 p.m., Housekeeper B said on 8/26/20 her responsibility was to pack residents with 2 changes of clothes and toiletries for the evacuation. During an interview on 8/31/20 at 2:45 p.m., CNA G, CNA H, CNA K, and Housekeeper L said on 8/26/20 they were sheltering in place but then they evacuated. They all indicated they had been trained about disasters and sheltering in place. The administrator and DON were notified on 8/26/20 at 08:29 p.m., an IJ situation was identified due to the above failure. The administrator was provided the IJ documentation via email on 8/31/20 at 1:20 p.m. The facility's Plan of Removal was accepted on 9/1/20 at 2:45 p.m., and included the following interventions: The facility shall immediately initiate the facility's emergency preparedness/disaster plan to evacuate residents from the local area when ordered to do so. The facility shall obey all mandatory evacuation orders issued by the County Judge. Failure to do so can lead to Immediate Jeopardy to the health and safety of the residents of the facility. The facility will take immediate action and update their emergency plan (SAHR Emergency Preparedness and Response Plan) in accordance with the comprehensive risk mitigation assessment based on the location to include monitoring and complying with local laws and ordinances. This was completed on 31 [DATE]. The following is immediately added to the facility emergency plan: (1) SAHR will fully comply with all mandatory evacuation orders, local laws, ordinances and orders signed into effect by any City or local county official (2) EPC will monitor local news, media and official publication outlets for any updates released from City and/or County officials Revisions to the emergency plan completed on 31 [DATE]. The facility also developed a written policy and procedure (attached) that directs the adherence to local laws and ordinances. This policy and procedure was completed on 31 [DATE]. In accordance with 19.1914 TAC, section (e), facility staff are provided a copy of the changed plan, new policy, and inserviced on their responsibilities. All employees, with personal email addresses on file, are emailed a copy of the updated emergency plan and new policy and procedure; this is completed 01 SEP 20. All employees on staff are in-serviced on the updates; this is completed 01 SEP 20. All staff not currently at work or not allowed to clock in until they have been in-serviced and signed off on their training. These findings and courses for improvements will be discussed by the facility QAPI Committee. Continued recommendations for improvement shall be supervised and delivered from QAPI to the facility Administrator, following their monthly meetings (SAHR QAPI is scheduled to meet every second Wednesday at 1245). QAPI will supervise this plan and review these findings and A Family Caring for Families Since 1965 Shady Acres Health & Rehabilitation Newton, Texas www.ShadyAcresCares.com remain involved in ensuring the facilities adherence with all City and County laws and ordinances. The owners of(NAME)L.(NAME) Inc (DBA of Shady Acres Health & Rehabilitation), shall ensure these steps are followed by providing oversight supervision of facility staff, to include the Administrator. Enclosures (3) 1. Shady Acres 2 IJ template 8.26.20 2. SAHR Emergency Preparedness and Response Plan 3. Policy Subject: Adherence to Local Laws, Ordinances, and Orders On 09/1/20 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Inservices dated 9/1/20 indicated all staff on duty were retrained about the mandatory evacuation orders and from now on they would evacuate when it is a mandatory evacuation. During interviews of staff to validate the POR as follows: During interviews on 9/1/20 indicated 22 (4 housekeepers, 3 LVNs, 2 Med aides, 3 dietary, 5 CNAs, 1 administrator, 2 office staff, 1 DON, and 1 Activity person) staff members working the day and evening shifts had been retrained and were able to voice if there is a mandatory evacuation order will evacuate the residents and not shelter in place. During an interview on 9/1/20 at 3:20 p.m., the administrator, DON and ADON said the rest of the staff will be retrained before their next shift to work The facility revised their policy as indicated: Shady Acres Health & Rehabilitation (SAHR) Emergency Preparedness and Response Plan Warning: dated August, 2020 indicated . i) EPC shall be notified of an emergency by the county EMC ii) EPC monitors local, regional, and national news outlets daily (1) SAHR will fully comply with all mandatory evacuation orders, local laws, ordinances and orders signed into effect by any City of(NAME)or(NAME)County official. (2) EPC will monitor local news, media and official publication outlets for any updates released from City and/or County officials iii) Serious weather reports/potentials (regarding a disaster or potential disaster) will be briefed in weekly meetings or via email. During the exit conference the facility was asked for additional information related to these findings. Additional information was provided as follows: a copy of the mandatory evacuation order. On 9/1/20 at 1:20 p.m., the administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, resident and staff interviews, and medical record review, the facility failed to assure the staff developed and implemented a person-centered, comprehensive plan of care to address the aggressive behaviors of 1 of 5 sample residents (Resident (R) 2) in order to protect the health and well-being of the additional 27 residents who resided on the secure unit. R2 was found to have slammed a door in the face of supplemental resident R7 on 2/12/17; subsequently, R7 suffered a fractured clavicle (a bone in the shoulder) and expressed continued fear of R2. Between 2/12/17 and 3/14/17, R2 exhibited additional aggressive behaviors on 9 different occasions toward supplemental residents R6, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility's failure to develop specific, person-centered approaches to address R2's aggressive behavior toward other residents was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., R2 was discharged from the facility to a mental health center and would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. Findings include: Review of R2's Admission Record, dated 8/13/15, indicated the facility admitted the resident on 7/31/15 with [DIAGNOSES REDACTED]. R2 was [AGE] years old. Review of R2's quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, with an Assessment Reference Date (ARD) of 2/3/17, documented R2 had impaired short-term and long-term memory (Sections C0700 and C0800) and moderately impaired cognitive skills for decision-making (Section C1000). R2 did not exhibit any physical or verbal behavioral symptoms toward others or other behavioral symptoms (Section E0200). She also did not exhibit any mood symptoms of depression (Section D0500). R2 was able to ambulate independently (Section G0300) and had no limitations in her mobility (Section G0400). R2 received antipsychotic, antianxiety, and antidepressant medications daily (Section N0410). Review of R2's Care Plan, dated 4/4/16, documented, The resident is/has potential to be physically aggressive, hitting, scratching (related to) poor impulse control. The resident's goals included: .will demonstrate effective coping skills . and .will not harm self or others The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc Monitor (every) shift. Document observed behavior and attempted interventions in behavior log .Monitor/document/report PRN (as needed) any (signs and symptoms) of resident posing danger to self and others .(and) When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of a Psychosocial Note for R2, dated 2/13/17 at 9:05 a.m., documented, This resident is noncompliant with (the Brief Interview for Mental Status). In general this resident is noncompliant. She is not social with other residents. She is primarily focused on receiving pain meds and smoking. This resident is unable to make informed decisions and is very difficult to redirect during an anger outburst. (Social worker) will continue to monitor resident's behavior. On 3/14/17 at 12:40 p.m., an interview was attempted with R2; however, she refused to be interviewed. Between 2/12/17 and 3/14/17, R2 was involved in 10 physical and/or verbal altercations with supplemental residents R6, R7, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility failed to implement sufficient interventions to ensure the safety of residents on the secure unit (cross-reference F323: Accidents and Supervision). Review of R2's Care Plan addressing her aggression and behavioral symptoms indicated the staff had not updated the care plan since 4/4/16. The care plan did not include specific interventions to address the resident's behaviors that were tailored to the resident's past interests, current preferences, hobbies, interests, and needs. During an interview on 3/14/17 at 3:30 p.m. with the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the DON was asked about additional interventions to keep the residents on the secure unit safe. The DON stated, Staff has done (every) 15-minute monitoring of her location. Staff is doing close observation of her when she is out of her room. Her roommate was removed from the room. The DON added that R2 is a danger to others; we can't keep others safe here. The ADON stated the resident's behaviors escalated when she doesn't get the medication she wants. She added, When staff tells her no, that's when she really becomes aggressive. The ADON stated she would expect specific non-pharmacological interventions documented in the care plan, and R2 usually was responsive to smoking and coffee breaks as a way to redirect her. The ADON confirmed these interventions should have been incorporated in the care plan. Though R2's 4/4/16 Care Plan directed staff to administer medications as ordered, assess and anticipate the resident's needs, monitor and document behaviors, and engage the resident calmly in conversation to redirect aggressive behaviors, these interventions were proven ineffective at managing R2's behavior. Moreover, the effective interventions the staff identified (offer coffee or smoking) were not included in the plan of care. The intervention implemented repeatedly after several separate incidents, every 15-minute checks, had also proven to be ineffective. There were no person-centered approaches developed that would aid the staff in managing R2's aggressive behaviors and/or assist staff in prevention of aggression. Though staff identified the resident's aggression stemmed from not getting the medication or cigarettes she requested, there were no specific behavioral interventions designed to address the root cause of her aggression.

Based on observations, resident and staff interviews, policy review, and medical record review, the facility failed to assure person-centered care was assessed, planned, and provided for 1 of 5 sample residents (Resident (R) 2) in order to protect the health and well-being of the additional 27 residents who resided on the secure unit. R2 was found to have slammed a door in the face of supplemental resident R7 on 2/12/17; subsequently, R7 suffered a fractured clavicle (a bone in the shoulder) and expressed continued fear of R2. Between 2/12/17 and 3/14/17, R2 exhibited additional aggressive behaviors on 9 different occasions toward supplemental residents R6, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility's failure to ensure specific, person-centered approaches were implemented to address R2's aggressive behavior toward other residents was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., R2 was discharged from the facility to a mental health center and would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. Findings include: Review of R2's Admission Record, dated 8/13/15, indicated the facility admitted the resident on 7/31/15 with [DIAGNOSES REDACTED]. R2 was [AGE] years old. Review of R2's quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, with an Assessment Reference Date (ARD) of 2/3/17, documented R2 had impaired short-term and long-term memory (Sections C0700 and C0800) and moderately impaired cognitive skills for decision-making (Section C1000). R2 did not exhibit any physical or verbal behavioral symptoms toward others or other behavioral symptoms (Section E0200). She also did not exhibit any mood symptoms of depression (Section D0500). R2 was able to ambulate independently (Section G0300) and had no limitations in her mobility (Section G0400). R2 received antipsychotic, antianxiety, and antidepressant medications daily (Section N0410). Review of R2's Care Plan, dated 4/4/16, documented, The resident is/has potential to be physically aggressive, hitting, scratching (related to) poor impulse control. The resident's goals included: .will demonstrate effective coping skills . and .will not harm self or others The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc Monitor (every) shift. Document observed behavior and attempted interventions in behavior log .Monitor/document/report PRN (as needed) any (signs and symptoms) of resident posing danger to self and others .(and) When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of a Psychosocial Note for R2, dated 2/13/17 at 9:05 a.m. documented, This resident is noncompliant with (the Brief Interview for Mental Status). In general this resident is noncompliant. She is not social with other residents. She is primarily focused on receiving pain meds and smoking. This resident is unable to make informed decisions and is very difficult to redirect during an anger outburst. (Social Worker) will continue to monitor resident's behavior. On 3/14/17 at 12:40 p.m., an interview was attempted with R2; however, she refused to be interviewed. Between 2/12/17 and 3/14/17, R2 was involved in 10 physical and/or verbal altercations with supplemental residents R6, R7, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility failed to implement sufficient interventions to ensure the safety of residents on the secure unit (cross-reference F323: Accidents and Supervision). Review of R2's Care Plan addressing her aggression and behavioral symptoms indicated the staff had not updated the care plan since 4/4/16. The care plan did not include specific interventions to address the resident's behaviors that were tailored to the resident's past interests, current preferences, hobbies, interests, and needs. During an interview on 3/15/17 at 8:25 a.m. the DON stated that R2 was placed on every 15-minute checks from 2/12/17 to 2/13/17; from 2/22/17 to 2/24/17; and from 3/1/17 to 3/3/17. Though many of the incidents (above) occurred while R2 was on the every 15-minute checks, the facility failed to identify the checks were not effective at curbing R2's aggressive behaviors and failed to implement other, more effective interventions to keep the residents on the secure unit safe. During an interview on 3/14/17 at 3:30 p.m., with the Administrator, the DON, and the Assistant Director of Nursing (ADON), the Administrator stated R2 had been given a 30-day eviction notice on 2/17/17 due to her aggressive and inappropriate behaviors and threatening other residents. He stated the resident's responsible party and Adult Protective Services had been contacted, but neither had provided any assistance. He stated the Ombudsman and Sheriff had also been contacted for legal advice in the matter. The Administrator stated the facility social worker was attempting to find alternate placement for the resident, but so far, she had not been accepted anywhere. When asked about additional interventions to keep the residents on the secure unit safe, the DON added, Staff has done (every) 15-minute monitoring of her location. Staff is doing close observation of her when she is out of her room. Her roommate was removed from the room. The DON added that R2 is a danger to others; we can't keep others safe here. The Administrator stated he would have liked to drop R2 off at her responsible party's doorstep, but I was told I can't do that. He added, If there was somewhere for her to go, I'd take her right now. We're without resources. We're in a quandary. The ADON stated the resident's behaviors escalated when she doesn't get the medication she wants. She added, When staff tells her no, that's when she really becomes aggressive. The ADON stated she would expect specific non-pharmacological interventions documented in the care plan, and R2 usually was responsive to smoking and coffee breaks as a way to redirect her. The ADON confirmed these interventions should be incorporated in the care plan. On 3/15/17 at 9:30 a.m., the DON and Administrator were alerted to the presence of an immediate jeopardy situation. The Administrator exclaimed angrily, This is ridiculous! If you were so concerned about the safety of our residents, you would be over there yourself supervising them. We've done everything we can short of dumping her, which is also against the law. When asked to elaborate on the interventions that had been tried and failed, the Administrator was unable to provide any more information. During an interview on 3/14/17 at 1:43 p.m., Nurse Aide (NA) 3 stated, (R2) mostly keeps to herself but becomes agitated when things don't go her way. She stated the staff would attempt to redirect R2 when she was aggressive, but this usually was not effective. During an interview on 3/15/17 at 9:56 a.m., NA1 stated, R2 was easily agitated, especially when she could not get her way. She stated R2 was aggressive toward other residents and staff. NA1 stated when R2 was agitated, she would tell her to calm down, but this was not usually effective. NA1 added R2 enjoyed smoking and getting coffee, and sometimes these distractions worked to redirect her from her agitation. During an interview on 3/15/17 at 10:03 a.m., Licensed Vocational Nurse (LVN) 1 stated R2 often wants controlled medication and gets very agitated if she doesn't get it. When I turn her down, she gets angry and asks more times. LVN1 stated when R2 became aggressive, she would tell her to lie down, try to redirect her, or try to tell her that her behavior was not appropriate and she cannot continue it. She stated R2 was not always responsive to this rationalization or to redirection. During an interview on 3/15/17 at 10:22 a.m., NA2 stated when R2 was aggressive she would take the resident out of the way and tell (R2) she can't do it. NA2 also stated it worked better to offer to take R2 outside to smoke than to reason with her. Though R2's 4/4/16 Care Plan directed staff to administer medications as ordered, assess and anticipate the resident's needs, monitor and document behaviors, and engage the resident calmly in conversation to redirect aggressive behaviors, these interventions were proven ineffective at managing R2's behavior. Moreover, the effective interventions the staff identified (offer coffee or smoking) were not included in the plan of care. The intervention implemented repeatedly after several separate incidents, every 15-minute checks, had also proven to be ineffective. There were no person-centered approaches developed that would aid the staff in dealing with R2's aggressive behaviors and/or assist staff in prevention of aggression. Though staff identified the resident's aggression stemmed from not getting the medication or cigarettes she requested, there were no specific behavioral interventions designed to address the root cause of her aggression. During an interview on 3/14/17 at 3:30 p.m. with the Administrator, the DON, and the ADON, the ADON stated the facility should have developed a series of effective non-pharmacological approaches specifically tailored to R2's behaviors, needs, and interests; those approaches should have been included on the care plan.

Based on observations, resident and staff interviews, policy review, and medical record review, the facility failed to ensure aggressive behaviors by 1 of 5 sample residents (Resident (R) 2) were addressed and sufficient interventions were implemented to keep the additional 27 residents who resided on the secure unit safe from further potential harm. R2 was found to have slammed a door in the face of supplemental resident R7 on 2/12/17; subsequently, R7 suffered a fractured clavicle (a bone in the shoulder) and expressed continued fear of R2. Between 2/12/17 and 3/14/17, R2 exhibited additional aggressive behaviors on 9 different occasions toward supplemental residents R6, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility's failure to ensure residents were protected from further aggressive behaviors from R2 was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., the facility discharged R2 to a mental health center. R2 would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. Findings include: A. Facility Overview The facility had a total census of 74 residents. The Room Roster provided by the Assistant Director of Nursing (ADON) on 3/14/17 at 10:20 a.m. documented 28 residents resided on the secure unit, a locked unit designated for the care of residents with dementia. During the initial tour of the facility on 3/14/17 beginning at 9:45 a.m., the ADON listed and discussed 22 residents with a primary [DIAGNOSES REDACTED]. The secure unit consisted of one long hallway of resident rooms with the day room, dining room, and nurses' station located in the middle of the hallway. There was a fenced-in courtyard and residents could freely access the courtyard. From the nurses' station window, only a small amount of the dining room and the day room were visible; staff could not see either end of the hall where resident rooms were located. A review of the facility's Special Care Unit .Policies and Procedures, revised 10/19/98, indicated, We believe that residents with progressive, irreversible, untreatable, and ultimately fatal dementia diseases have many needs created by their dementing condition .While it is important to be cognizant of individual differences and needs among dementia persons, it is equally important for staff to provide interventions that address fundamental basic, self-care, and survival needs of dementia residents .These guidelines along with the facility's other policies and procedures provide an organizational framework which should maximizes (sic) the resident's functional independence and provide a safe and secure environment for quality of care and living experience .Special Care Unit residents will be allowed to wander from room to room or as they please as the unit has been made safe for wandering to occur. A review of the facility's Behavioral Assessment, Intervention, and Monitoring policy, revised March 2015, indicated, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm .Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms B. R2 Background Review of R2's Admission Record, dated 8/13/15, indicated the facility admitted the resident on 7/31/15 with [DIAGNOSES REDACTED]. R2 was [AGE] years old. Review of R2's quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, with an Assessment Reference Date (ARD) of 2/3/17, documented R2 had impaired short-term and long-term memory (Sections C0700 and C0800) and moderately impaired cognitive skills for decision-making (Section C1000). R2 did not exhibit any physical or verbal behavioral symptoms toward others or other behavioral symptoms (Section E0200). She also did not exhibit any mood symptoms of depression (Section D0500). R2 was able to ambulate independently (Section G0300) and had no limitations in her mobility (Section G0400). R2 received antipsychotic, antianxiety, and antidepressant medications daily (Section N0410). Review of R2's Care Plan, dated 4/4/16, documented, The resident is/has potential to be physically aggressive, hitting, scratching (related to) poor impulse control. The resident's goals included: .will demonstrate effective coping skills . and .will not harm self or others The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc Monitor (every) shift. Document observed behavior and attempted interventions in behavior log .Monitor/document/report PRN (as needed) any (signs and symptoms) of resident posing danger to self and others .(and) When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of a Psychosocial Note, dated 2/13/17 at 9:05 a.m., documented, This resident is noncompliant with (the Brief Interview for Mental Status). In general this resident is noncompliant. She is not social with other residents. She is primarily focused on receiving pain meds and smoking. This resident is unable to make informed decisions and is very difficult to redirect during an anger outburst. (Social Worker) will continue to monitor resident's behavior. On 3/14/17 at 12:40 p.m., an interview was attempted with R2; however, she refused to be interviewed. Observation on 3/14/17 at 1:43 p.m. revealed R2 walked outside into the courtyard where two other residents were present. There was no staff outside to supervise. Observation on 3/14/17 at 4:03 p.m. revealed R2 walked through the hallway to her room. She passed two residents in the doorway between the day room and her residential hallway. The charge nurse was in the nurses' station and the nurse aides were in residents' rooms providing assistance. Observation on 3/14/17 at 4:33 p.m. revealed R2 again walked through the hallway very near three residents. The staff was not in the area to supervise and R2 was not visible from the nurses' station window. C. Altercation 1 Review of R7's Admission Record, dated 3/14/17, indicated the facility admitted the resident on 10/4/16 with [DIAGNOSES REDACTED]. R7 was [AGE] years old. Review of R7's quarterly MDS assessment, with an ARD of 1/13/17, documented R7 had impaired short-term and long-term memory (Sections C0700 and C0800) and severely impaired cognitive skills for decision-making (Section C1000). She was rarely/never able to make herself understood or understand others (Sections B0700 and B0800). Review of R7's 10/27/16 Care Plan, revised 2/13/17, documented R7 is a wanderer (related to) dementia and has impaired cognitive function/dementia or impaired thought processes (related to) Alzheimer's Disease. The resident's goals included: (R7's) safety will be maintained . and (R7) will demonstrate happiness with daily routine The interventions included distracting her from wandering, providing structured activities, identifying a pattern of wandering, monitoring for fatigue and weight loss, and providing a homelike environment. Review of an Incident Note, dated 2/11/17 at 8:00 a.m., documented, .this charge nurse observes (sic) a large hematoma to right temporal region of her head. Resident denies fall, denies headache at this time. Resident complains of right shoulder pain. Resident's shoulder of her clothing pulled to the side with observance of another hematoma to right shoulder joint. Resident complains of pain with ROM (range of motion) to right shoulder joint. Resident unable to give a description at this time. Review of R7's Health Status Note, dated 2/12/17 at 10:46 a.m., documented, .follow up (after) observance of contusion/hematoma to right temporal region of the skull and contusion/hematoma to right shoulder. Resident observed to have facial grimaces upon assessment at this time today. Resident continues to complain of pain to right shoulder as well as limited ROM due to intensity of pain. Resident medicated with PRN (as needed) pain medication per MAR ('Medication Administration Record'). Resident notified that xrays (sic) have been ordered and she will be having them done today .Resident states, 'that girl .you know who, she slammed the door in my face and then, then all of this.' Resident notified that if she sees the girl who caused this injury to her to point her out. Resident states, 'ok, I will.' Review of R7's Health Status Note, dated 2/12/17 at 10:51 a.m., documented, Resident is supervised with ambulation to the lunch table at this time when she points to peer resident (R2) who is sitting at her seat in the dining room and states, 'that's her, that's the girl who did this to me.' Resident notified that we would keep an eye on her and the DON was notified. Review of R7's Health Status Note, dated 2/12/17 at 1:39 p.m., documented, Rec'd (received) .results from xray (sic) of right shoulder. Xray (sic) results state acute fracture of distal right clavicle. Review of R2's Behavior Note, dated 2/12/17 at 10:34 a.m., documented, Peer resident (R7) stated, That lady slammed the gray double door in my face upon seeing resident (R2). When questioning (R2), she stated, 'She came in my room and I don't like her. I shut the (door) on her.' When advising resident that she caused injury to peer resident (R7), resident stated 'I don't care. I'll do it again if she comes in my room.' When attempting to continue conversation, resident turned away and stated, 'I don't like you either' and ceased talking. Review of R7's Care Plan, updated on 2/13/17, documented the focus, (R7) has a right clavicle fracture (related to) physical assertion (sic) of other resident. The goals were related to the fracture healing without complications. The interventions included: anticipate and meet her needs, encourage deep breathing and relaxation, follow physician orders [REDACTED]. The care plan did not address strategies for ensuring R7 was safe around R2 and easing R7's fears of R2 after the incident. Review of R2's Q (Every) 15 Minute Checks records indicated she was placed on every 15-minute tracking from 2/12/17 to 2/13/17, when she was discharged to a behavioral health hospital for evaluation. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the plan of care after the incident or put in any other interventions in place to ensure the safety of the residents on the secure unit. Review of a Provider Investigation Report with Cover Sheet, dated 2/17/17, documented under Provider Action Taken Post-Investigation, Frequent monitoring of resident (R7) and wandering .Resident (R2) returned to facility on 2/15/17 with medication changes and no behaviors reported at (behavioral hospital). Frequent monitoring of (R2) for any follow up incidents or aggressive behaviors. 30 day eviction notice issued to (R2's) family on 2/17/17. During an interview on 3/14/17 at 4:33 p.m., R7 stated, I am afraid of the girl that hurt me. She slammed the door and almost killed me. Hit me right here (pointed to chest). She scares me, and I don't go near her. I mostly stay in my room because I'm afraid of her. D. Altercation 2 Review of R9's Admission Record, dated 3/14/17, indicated the facility admitted the resident on 1/25/17 with [DIAGNOSES REDACTED]. Review of R9's admission MDS assessment, with an ARD of 2/7/17, documented R9 had impaired short-term and long-term memory (Sections C0700 and C0800) and moderately impaired cognitive skills for decision-making (Section C1000). He was sometimes able to make himself understood or understand others (Sections B0700 and B0800). Review of R9's 2/22/17 Care Plan documented R9 had a potential to be physically aggressive (related to) cognitive impairment and R9 had impaired cognitive function/dementia or impaired thought processes. Review of a Behavior Note for R2, dated 2/12/17 at 9:45 a.m., documented, Resident heard screaming down the hall. This charge nurse and (nurse aides) on staff rush (sic) to her room to see what is wrong. Resident is observed holding the front of peer resident's (R9) walker stating while screaming, 'He's trying to come in my room! He tried to hit me with his walker.' Peer resident successfully redirected at this time. (R2) notified that peer resident (R9) is unaware that the room he is attempting to enter is not his. Resident observed to turn and slam the door at this time. Review of a Behavior Note for R9, dated 2/12/17 at 10:00 a.m., documented, A resident heard screaming down the hall. This charge nurse and (nurse aides) on staff rush (sic) to B hall to what is wrong. Resident is observed standing in peer resident's door way with peer resident's (R2) holding the front of (R9's) walker stating while screaming, 'He's trying to come in my room! He tried to hit me with his walker.' (R9) successfully redirected at this time. R9 ambulates (sic) down the hall with assistance of rollator walker singing and humming loudly at this time, 'You can't go down there. They won't let you in. HEYYHAYY!' R9 successfully redirected at this time to coffee social with peer residents participating. An incident report/investigation into the above altercation was requested, but had not been provided by the facility as of the survey exit on 3/16/17 at 12:30 p.m. Review of R2's Q (Every) 15 Minute Checks records indicated R2 continued on every 15-minute checks from 2/12/17 to 2/13/17. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the plan of care after the incident or put in any other interventions in place to ensure the safety of the residents on the secure unit. E. Altercation 3 Review of R8's Admission Record, dated 3/14/17, indicated the facility admitted the resident on 1/8/16 with [DIAGNOSES REDACTED]. Review of R8's annual MDS assessment, with an ARD of 1/6/17, documented R8 had severely impaired cognition (Section C0500). He was usually able to make himself understood and understand others (Sections B0700 and B0800). Review of R8's 5/2/16 Care Plan documented he was at risk for elopement due to wandering related to dementia and he had impaired cognitive function due to dementia. Review of an Incident Note for R2, dated 2/12/17, 1:02 p.m., documented, Resident approaches this charge nurse while passing cigarettes out for smoke break and screams, 'I NEED A DAMN CIGARETTE,' while this charge nurse is lighting peer resident's cigarette. (R8) as soon as peer resident (R8) steps away to seat himself for smoking activity (R2) grabs this charge nurse in the face, takes eye glasses and bends them up. Resident then grabs this charge nurses (sic) hair and shirt pulling her downward, all objects that this charge nurse is holding falls to the ground. (R2) then begins to kick report book, paperwork, and peer residents (sic) cigarettes while walking off to the entrance of the building. Resident was attempted to be redirected with no success at this time. Review of an Incident Report, dated 2/12/17, documented under Immediate Action Taken, Resident was attempted to be redirected with no success at this time. Review of R2's Q (Every) 15 Minute Checks records and Care Plan, dated 4/4/16, indicated that although R2 continued on every 15-minute checks, there was no evidence documented that the staff implemented any new interventions or updated R2's care plan. F. Altercation 4 Review of a Behavior Note for R2, dated 2/12/17 at 4:11 p.m., documented, (R2) walked through dining room and turned to another (resident) and said, 'I ought to push you out of my chair.' (R2) instructed by this nurse to keep walking and not to speak to others in that way. The Behavior Note did not include identification of the victim of R2's aggression. An incident report/investigation into the above altercation was requested, but had not been provided by the facility as of the survey exit on 3/16/17 at 12:30 p.m. Review of R2's Q (Every) 15 Minute Checks records indicated R2 continued on every 15-minute checks from 2/12/17 to 2/13/17. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the plan of care after the incident or put in any other interventions in place to ensure the safety of the residents on the secure unit. G. Altercation 5 Review of R11's Admission Record, dated 3/15/17, indicated the facility admitted the resident on 8/3/15 with [DIAGNOSES REDACTED]. Review of R11's quarterly MDS assessment, with an ARD of 2/9/17, documented R11 had minimally impaired cognition (Section C0500). She was usually able to make herself understood and understand others (Sections B0700 and B0800). Review of R11's Care Plan, revised 8/16/16, documented she was dependent on staff for meeting emotional, intellectual, physical, and social needs (related to) Dow[DIAGNOSES REDACTED]. She had a potential to be physically aggressive and had impaired cognitive function. Review of a Health Status Note for R2, dated 2/23/17 at 8:05 p.m., documented, This (nurse) observed resident kick at another resident in the dinning (sic) room and brushed up against the other resident buttocks with her foot. No injuries to report. This (nurse) separated both residents. Review of R2's Q (Every) 15 Minute Checks records indicated she was on every 15-minute checks from 2/22/17 to 2/24/17 related to an elopement attempt. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the plan of care after the incident or put in any other interventions in place to ensure the safety of the residents on the secure unit. H. Altercation 6 Review of R10's Admission Record, dated 3/15/17, indicated the facility admitted the resident on 7/27/16 with [DIAGNOSES REDACTED]. Review of R10's quarterly MDS assessment, with an ARD of 2/3/17, documented R10's cognition was intact (Section C0500). He was usually able to make himself understood and understand others (Sections B0700 and B0800). He experienced delusions (Section E0100). Review of R10's Care Plan, revised 11/25/16, documented he was at risk for elopement due to wandering and he had impaired cognitive function related to dementia. Review of an Incident Note for R2, dated 2/27/17 at 11:12 a.m., documented, Resident aggressively approached another one of her peers (R10) that was sitting in a chair in the dinning (sic) room and stated get out of my damn chair as she was leaning/standing over peer. Charge nurse .placed her arm between the two residents and backed up resident then resident raised her arm/fist to strike charge nurse. (The charge nurse) blocked the hit then removed resident from the dinning (sic) room and the other peers. Then resident ambulated to her room. Review of R2's Q (Every) 15 Minute Checks records indicated R2 was not on every 15-minute checks during this incident, and the checks were not reinstated following the incident. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the plan of care after the incident or put in any other interventions in place to ensure the safety of the residents on the secure unit. I. Altercation 7 Review of R12's Admission Record, dated 3/16/17, indicated the facility admitted the resident on 4/6/16 with [DIAGNOSES REDACTED]. Review of R12's quarterly MDS assessment, with an ARD of 1/12/17, documented R12 had severely impaired cognition (Section C1000) and was rarely/never able to make herself understood or understand others (Sections B0700 and B0800). R12 was totally dependent on staff with locomotion and most activities of daily living (Section G0110). Review of R12's 5/31/16 Care Plan documented R12 had a potential to be physically aggressive, a potential to wander aimlessly, impaired cognitive function, and a communication problem related to dementia. Review of a Behavior Note for R2, dated 3/1/17 at 3:05 p.m. documented, .resident stated to (nurse aide (NA) 4) that she is going [***] ing crazy and her roommate gets on her nerves because she grits her teeth and screams. Reported that Resident (sic) also stated she is going to beat the[***]out of her roommate. Roommate removed from room and up in geri-chair in living room. (Administrator) notified of resident's statement. (Administrator) stated that due to statement being a terroristic threat and her previous behaviors to notify family to pick up resident for permanent discharge or she would be arrested. Review of R2's Q (Every) 15 Minute Checks records indicated she was placed on every 15-minute checks from 3/1/17 to 3/3/17; however, a review of R2's Care Plan, dated 4/4/16, indicated no evidence of new interventions implemented following this incident. J. Altercation 8 Please see R8's identification information under Section E above. Review of a Behavior Note for R2, dated 3/12/17, 4:11 p.m., documented, Resident out to smoke with supervision with other peers and resident was (sic) aggressively stated to another peer (R8), 'give me your cigarette because you wont (sic) finish it, you will throw it away.' Removed peer from resident and resident went inside building. (R8) stated to this (nurse), 'why does she always bully people?' No injuries to report at this time. Peer stated he was OK. This (nurse) ambulated with peer into the building. (R8) stated to the (nurse), 'walk me to the couch, She is some(thing) else.' Will continue to monitor. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the care plan following this incident. There was no evidence the facility implemented new interventions following this incident to promote safety of the residents on the secure unit. R2 was not on every 15-minute checks during this incident, and the checks were not reinstated following the incident. K. Altercation 9 Review of R6's Admission Record, dated 3/14/17, indicated the facility admitted the resident on 1/26/11 with [DIAGNOSES REDACTED]. Review of R6's annual MDS assessment, with an ARD of 1/20/17, documented R6 had impaired short-term and long-term memory (Sections C0700 and C0800) and severely impaired cognitive skills for decision-making (Section C1000). She was rarely/never able to make herself understood or understand others (Sections B0700 and B0800). Review of R6's Care Plan, revised 5/11/16, documented she had a potential to be verbally aggressive, had impaired cognitive function, and had a communication problem due to dementia. Review of a Behavior Note for R2, dated 3/13/17 at 5:03 p.m., documented, Resident lunged at another peer resident (R6) very agitated yelling at peer stated screaming 'shut up' because peer was crying as she ambulated out of dining room. No physical contact was observed, resident was yelling at peer in her face. Removed resident (R6) from area. No injuries to report at this time. Review of R2's Care Plan, dated 4/4/16, indicated the staff did not update the care plan following this incident. There was no evidence the facility implemented new interventions following this incident to promote safety of the residents on the secure unit. R2 was not on every 15-minute checks during this incident, and the checks were not reinstated following the incident. L. Altercation 10 Please refer to R11's identification information in Section G above. Review of a Health Status Note for R2, dated 3/14/17 at 6:30 p.m., documented, (R2) was sitting at dining table waiting to eat supper when another resident (R11) walked by her, (R2) stated, She's a fat pig, she makes me sick. During an interview on 3/15/17 at 2:16 p.m., R11 stated she was afraid of R2 because she said mean things and she was afraid of getting hurt by her. She stated she felt unsafe around R2 and R2 continued to say mean things to her, like calling her a 'fat pig.' During an interview on 3/14/17 at 4:50 p.m., the DON stated the facility had re-started every 15-minute checks to ensure safety for residents on the secure unit after discussion about concerns with the survey team. She stated the 15-minute checks were to continue until R2 was discharged from the facility. R2's care plan was not updated following the above incident, nor were any new interventions implemented. M. Facility Failures 1. Failure to Implement New Interventions R2's Care Plan addressing her aggression and behavioral symptoms had not been updated since 4/4/16. The care plan did not include specific interventions to address the resident's behaviors (cross-reference F309: Care and Services). The DON stated on 3/15/17 at 8:25 a.m. that R2 was placed on every 15-minute checks from 2/12/17 to 2/13/17; from 2/22/17 to 2/24/17; and from 3/1/17 to 3/3/17. Though many of the incidents (above) occurred while R2 was on the every 15-minute checks, the facility failed to identify the checks were not effective at curbing R2's aggressive behaviors and failed to implement other, more effective interventions to keep the residents on the secure unit safe. During an interview on 3/14/17 at 3:30 p.m., with the Administrator, the DON, and the ADON, the Administrator stated R2 had been given a 30-day eviction notice on 2/17/17 due to her aggressive and inappropriate behaviors and threatening other residents. He stated the resident's responsible party and Adult Protective Services had been contacted, but neither had provided any assistance. He stated the Ombudsman and Sheriff had also been contacted for legal advice in the matter. The Administrator stated the facility social worker was attempting to find alternate placement for the resident, but so far, she had not been accepted anywhere. When asked about additional interventions to keep the residents on the secure unit safe, the DON added, Staff has done (every) 15-minute monitoring of her location. Staff is doing close observation of her when she is out of her room. Her roommate was removed from the room. The DON added that R2 is a danger to others; we can't keep others safe here. The Administrator stated he would have liked to drop R2 off at her responsible party's doorstep, but I was told I can't do that. He added, If there was somewhere for her to go, I'd take her right now. We're without resources. We're in a quandary. The ADON stated the resident's behaviors escalated when she doesn't get the medication she wants. She added, When staff tells her no, that's when she really becomes aggressive. The ADON stated she would expect specific non-pharmacological interventions documented in the care plan, and R2 usually was responsive to smoking and coffee breaks as a way to redirect her. The ADON confirmed these interventions should be incorporated in the care plan. On 3/15/17 at 9:30 a.m., the DON and Administrator were alerted to the presence of an immediate jeopardy situation. The Administrator exclaimed angrily, This is ridiculous! If you were so concerned about the safety of our residents, you would be over there yourself supervising them. We've done everything we can short of dumping her, which is also against the law. Wh(TRUNCATED)

Based on observations, resident and staff interviews, and medical record review, the facility failed to administer the facility in a manner to effectively maintain the highest practicable well-being of each resident. The facility failed to ensure aggressive behaviors by 1 of 5 sample residents (Resident (R) 2) were addressed and sufficient interventions were implemented to keep the additional 27 residents who resided on the secure unit safe from further potential harm. R2 was found to have slammed a door in the face of supplemental resident R7 on 2/12/17; subsequently, R7 suffered a fractured clavicle (a bone in the shoulder) and expressed continued fear of R2. Between 2/12/17 and 3/14/17, R2 exhibited additional aggressive behaviors on 9 different occasions toward supplemental residents R6, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility's failure to administer the facility in a manner to ensure residents were protected from further aggressive behaviors from R2 was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., the facility discharged R2 to a mental health center. R2 would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. Findings include: Review of R2's Admission Record, dated 8/13/15, indicated the facility admitted the resident on 7/31/15 with [DIAGNOSES REDACTED]. R2 was [AGE] years old. Review of R2's quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, with an Assessment Reference Date (ARD) of 2/3/17, documented R2 had impaired short-term and long-term memory (Sections C0700 and C0800) and moderately impaired cognitive skills for decision-making (Section C1000). R2 did not exhibit any physical or verbal behavioral symptoms toward others or other behavioral symptoms (Section E0200). She also did not exhibit any mood symptoms of depression (Section D0500). R2 was able to ambulate independently (Section G0300) and had no limitations in her mobility (Section G0400). R2 received antipsychotic, antianxiety, and antidepressant medications daily (Section N0410). Review of R2's Care Plan, dated 4/4/16, documented, The resident is/has potential to be physically aggressive, hitting, scratching (related to) poor impulse control. The resident's goals included: .will demonstrate effective coping skills . and .will not harm self or others The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness .Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc Monitor (every) shift. Document observed behavior and attempted interventions in behavior log .Monitor/document/report PRN (as needed) any (signs and symptoms) of resident posing danger to self and others .(and) When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. On 3/14/17 at 12:40 p.m., an interview was attempted with R2; however, she refused to be interviewed. Observation on 3/14/17 at 1:43 p.m. revealed R2 walked outside into the courtyard where two other residents were present. There was no staff outside to supervise. Observation on 3/14/17 at 4:03 p.m. revealed R2 walked through the hallway to her room. She passed two residents in the doorway between the day room and her residential hallway. The charge nurse was in the nurses' station and the nurse aides were in residents' rooms providing assistance. Observation on 3/14/17 at 4:33 p.m. revealed R2 again walked through the hallway very near three residents. The staff was not in the area to supervise and R2 was not visible from the nurses' station window. Between 2/12/17 and 3/14/17, R2 was involved in 10 physical and/or verbal altercations with supplemental residents R6, R7, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility failed to implement sufficient interventions to ensure the safety of residents on the secure unit (cross-reference F323: Accidents and Supervision). Review of R2's Care Plan addressing her aggression and behavioral symptoms indicated the staff had not updated the care plan since 4/4/16. The care plan did not include specific interventions to address the resident's behaviors that were tailored to the resident's past interests, current preferences, hobbies, interests, and needs (cross-reference F309: Care and Services). During an interview on 3/15/17 at 8:25 a.m., the DON stated that R2 was placed on every 15-minute checks from 2/12/17 to 2/13/17; from 2/22/17 to 2/24/17; and from 3/1/17 to 3/3/17. Though many of the incidents (above) occurred while R2 was on the every 15-minute checks, the facility failed to identify the checks were not effective at curbing R2's aggressive behaviors and failed to implement other, more effective interventions to keep the residents on the secure unit safe. During an interview on 3/14/17 at 3:30 p.m. with the Administrator, the DON, and the Assistant Director of Nursing (ADON), the Administrator stated R2 had been given a 30-day eviction notice on 2/17/17 due to her aggressive and inappropriate behaviors and threatening other residents. He stated the resident's responsible party and Adult Protective Services had been contacted, but neither had provided any assistance. He stated the Ombudsman and Sheriff had also been contacted for legal advice in the matter. The Administrator stated the facility social worker was attempting to find alternate placement for the resident, but so far, she had not been accepted anywhere. When asked about additional interventions to keep the residents on the secure unit safe, the DON added, Staff has done (every) 15-minute monitoring of her location. Staff is doing close observation of her when she is out of her room. Her roommate was removed from the room. The DON added that R2 is a danger to others; we can't keep others safe here. The Administrator stated he would have liked to drop R2 off at her responsible party's doorstep, but I was told I can't do that. He added, If there was somewhere for her to go, I'd take her right now. We're without resources. We're in a quandary. On 3/15/17 at 9:30 a.m., the DON and Administrator were alerted to the presence of an immediate jeopardy situation. The Administrator exclaimed angrily, This is ridiculous! If you were so concerned about the safety of our residents, you would be over there yourself supervising them. We've done everything we can short of dumping her, which is also against the law. When asked to elaborate on the interventions that had been tried and failed, the Administrator was unable to provide any more information. On 3/15/17 at 11:40 a.m., the Administrator provided a copy of his license, and stated he did not have a job description when one was requested. The facility's administration failed to ensure new interventions after R2's continued aggressive behaviors to ensure the residents on the secure unit were protected from additional injuries. The facility's administration also failed to promote a safe, homelike milieu for the 27 additional residents in the secure unit, which negatively affected the residents' quality of life and overall well-being.

Based on observations, resident and staff interviews, policy review, and medical record review, the facility failed to ensure the Medical Director was responsible for implementation of resident care policies and coordination of medical care to address the aggressive behaviors 1 of 5 sample residents (Resident (R) 2) and protect the safety of the additional 27 residents who resided on the secure unit from further potential harm. R2 was found to have slammed a door in the face of supplemental resident R7 on 2/12/17; subsequently, R7 suffered a fractured clavicle (a bone in the shoulder) and expressed continued fear of R2. Between 2/12/17 and 3/14/17, R2 exhibited additional aggressive behaviors on 9 different occasions toward supplemental residents R6, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility's failure to ensure the Medial Director oversaw implementation of resident care policies and the coordination of medical care for R2 in order to protect residents from further aggressive behaviors was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., the facility discharged R2 to a mental health center. R2 would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. Findings include: Between 2/12/17 and 3/14/17, R2 was involved in 10 physical and/or verbal altercations with supplemental residents R6, R7, R8, R9, R10, R11, and R12, and 1 unidentified resident. The facility failed to implement sufficient interventions to ensure the safety of residents on the secure unit (cross-reference F323: Accidents and Supervision). Review of R2's Care Plan addressing her aggression and behavioral symptoms indicated the staff had not updated the care plan since 4/4/16. The care plan did not include specific interventions to address the resident's behaviors that were tailored to the resident's past interests, current preferences, hobbies, interests, and needs (cross-reference F309: Care and Services). The facility did not demonstrate adequate indications for R2's use of the PRN Klonopin (an [MEDICAL CONDITION] medication also used to manage anxiousness) and [MEDICATION NAME] (an antianxiety medication) or describe R2's behaviors in a meaningful way. The staff administered PRN medications for inappropriate reasons, such as upset stomach, demanding medication, threatening staff, or continuously requesting the medication (cross-reference F329: Unnecessary Drugs). During an interview on 3/14/17 at 3:30 p.m., with the Administrator, the DON, and the Assistant Director of Nursing (ADON), the Administrator stated R2 had been given a 30-day eviction notice on 2/17/17 due to her aggressive and inappropriate behaviors and threatening other residents. He stated the resident's responsible party and Adult Protective Services had been contacted, but neither had provided any assistance. He stated the Ombudsman and Sheriff had also been contacted for legal advice in the matter. The Administrator stated the facility social worker was attempting to find alternate placement for the resident, but so far, she had not been accepted anywhere. When asked about additional interventions to keep the residents on the secure unit safe, the DON added, Staff has done (every) 15-minute monitoring of her location. Staff is doing close observation of her when she is out of her room. Her roommate was removed from the room. The DON added that R2 is a danger to others; we can't keep others safe here. The Administrator stated he would have liked to drop R2 off at her responsible party's doorstep, but I was told I can't do that. He added, If there was somewhere for her to go, I'd take her right now. We're without resources. We're in a quandary. On 3/15/17 at 9:30 a.m., the DON and Administrator were alerted to the presence of an immediate jeopardy situation. The Administrator exclaimed angrily, This is ridiculous! If you were so concerned about the safety of our residents, you would be over there yourself supervising them. We've done everything we can short of dumping her, which is also against the law. When asked to elaborate on the interventions that had been tried and failed, the Administrator was unable to provide any more information. During an interview on 3/16/17 at 11:25 a.m., the Administrator stated the staff discussed R2's behavioral symptoms in their morning team meetings on Monday, Wednesday, and Friday and also during the quarterly QAA meetings. The Administrator stated the interventions attempted to protect the secure unit residents and address R2's behaviors included: implementing periodic every 15-minute checks, moving her roommate, trying different activities, and making medication adjustments. He stated the first step was sending R2 to the behavior hospital, which sent her back to the facility with medication changes. The Administrator stated the police were called numerous times to threaten or scare her, but this had proved ineffective. He added the Ombudsman and Adult Protective Services had been consulted as well. The Administrator was asked what recommendations were made in the QAA Committee regarding R2's behaviors, and how the interventions were evaluated and revised when proven ineffective, but he did not offer any additional information. The ADON stated she had identified during the QAA process that PRN medications were being given for inappropriate indications for use, and education was done with the nursing staff. She stated, however, that R2's inappropriate reasons for PRN medication use had not been identified and addressed. During an interview on 3/16/17 at 9:33 a.m., the Medical Director stated R2 had a history of [REDACTED]. He stated she suffered a stroke in the community prior to admission to the facility, which caused a greater amount of cognitive impairment ([MEDICAL CONDITION]), paranoia, and aggression. He stated R2 was treated with various medications to help stabilize her mood and had been sent to the behavioral hospital in February 2017 for medication adjustments. The Medical Director stated several psychiatrists and counselors had attempted to speak with R2 without success, but stated this was over a series of years. The Medical Director stated that he, along with the facility's interdisciplinary team, had looked at roommate selection, medication regimen, other medical symptoms, and social factors affecting R2's behaviors, but had not found any successful interventions. He stated in order to keep residents safe on the secure unit, the staff were to separate her from certain individuals that she clashed with. The Medical Director added, I think her needs could be best met somewhere else. Safety is a concern. Anytime you have behavioral issues, you are subject to triggers or changes in behaviors. Staff needs to be able to recognize these triggers and try to minimize risk to other individuals, but there is always a risk. The Medical Director also stated during his visits with R2, he rarely reviewed the Medication Administration Record [REDACTED]. He stated he discussed PRN usage with the staff in general terms and had dialogue with the patient, if possible. He stated the reasons given for use of the PRN medications were not always appropriate (such as an upset stomach), and he would expect further documentation of the resident's signs of distress that warranted the medication.

Based on resident and staff interviews, record reviews, and review of facility policies and procedures, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) Committee that systematically reviewed the quality of care and services provided to residents to identify deficient practices and develop and implement plans of action to correct those deficient practices to enhance the quality of care and quality of life for residents. This deficient practice had the potential to affect all 74 residents of the facility. Specifically, the QAA Committee failed to: 1. Ensure the 27 residents who resided in the facility's secure unit were protected from the aggressive actions of 1 resident (Resident (R) 2). Between 2/12/17 and 3/14/17, R2 was involved in 10 physical and/or verbal altercations with supplemental residents R6, R7, R8, R9, R10, R11, and R12, and 1 unidentified resident. The failure to implement sufficient interventions to ensure the safety of residents on the secure unit resulted in the determination that an immediate jeopardy situation existed since 2/17/17 when the facility discovered that R2 was physically aggressive to R7, causing a fractured clavicle (bone in the shoulder). R2 remained on the secured unit from 2/17/17 until the IJ was identified on 3/15/17, thus continuing to place R7 and the other residents on the secured unit at risk for harm. 2. Ensure the facility's undated QAA (also known as QA) policy entitled, .Quality Assurance/Peer Review Policy and Procedure, was updated. 3. Ensure the QAA Committee identified deficient practice regarding proper hand-washing before serving residents their meals and that residents were served the proper portion size for a mechanically altered meal. 4. Ensure the staff developed and revised person-centered approaches to effectively manage the behaviors of 1 resident (R2) out of a sample of 5 residents. 5. Ensure the staff followed the guidance included in the Resident Assessment Instrument (RAI) Manual 3.0 to develop a care plan for R3 related to the use of an antipsychotic medication, and develop a nutritional care plan for R5. 6. Ensure R3 received a comprehensive medical evaluation to rule out medical reasons for a change in mental status prior to receiving an order for [REDACTED]. 7. Ensure that the Consultant Pharmacist identified 2 irregularities with medication administration for 2 residents, R3 and R2. 8. Ensure the staff provided R4 with a nutritional supplement per physician's orders [REDACTED].>9. Ensure that blood draws and a urinalysis were completed in a timely manner per physician order [REDACTED].>Findings include: 1. The facility's failure to develop, implement, and maintain an effective QAA program to ensure residents were protected from further aggressive behaviors from R2 was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus immediate jeopardy was identified on 3/15/17. The immediate jeopardy was determined to first exist on 2/12/17, when the facility discovered R2 was aggressive with R7, causing a broken clavicle. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 3/15/17 at 9:30 a.m. The facility provided an acceptable plan for removal of the immediate jeopardy on 3/15/17 at 11:41 a.m. The facility's plan documented: The facility identifies that Resident #2 has the potential to affect the safety of 27 residents on the secure unit. On February 17, 2017 a 30-day Eviction Notice was issued to the Responsible Party with eviction date on/or before March 18, 2017. The Social Worker began locating alternate placement for Resident #2 without success. During this time, Resident #2 has been monitored by the secure unit staff and placed on (every) 15 minute monitoring as needed in regards to behaviors. On March 1, 2017, the facility Administrator contacted the Newton County Police Chief to discuss the eviction and alternate placement possibilities within accordance the State Law. The facility's local mental health authority, (name of center), was contacted on March 2, 2017. Case Worker assessed resident and was unsuccessful in locating a mental health facility to admit resident #2. The Social Worker presented Resident #2 family with a list of potential facilities for them to contact personally. Responsible Party refused to answer or return calls to Social Worker and when contacted, Responsible Party has refused to pick up resident for eviction discharge. Social Worker has also made multiple attempts to also contact (Adult Protective Services) without a return phone call. Social Worker has also been in contact the state Ombudsman with updated information regarding Resident #2's Eviction Notice. Ombudsman has also been unsuccessful in locating alternate placement for resident. On March 15, 2017, Resident #2 is currently under (every) 15 minute location monitoring by secure unit staff. Resident has immediately been placed under (one-to-one) staff supervision until resident is discharged from facility. Responsible party was called by Social Worker at 10:20 a.m. and a detailed message was left stating that resident and belongings needed to be picked up immediately. Newton County Sheriff's Department was contacted by the Administrator at 10:30 a.m. to again discuss the current situation and State Laws regarding discharge and mental health placement. Resident #2 is to remain on (every) 15 minute location tracking and (one-to-one) staff supervision until eviction date on/or before March 18, 2017. Secure Unit staff is to be in-serviced on Resident to Resident Altercations and review facility policy and procedures prior to beginning scheduled work shift within the next 3 days. The facility Director of Operations (DOO) has contacted the Newton County Judge and Precinct #3 Justice of the Peace in regards to Involuntary Mental Health Warrant. The DOO has also left messages with the City Manager and the Newton County Sheriff. The DOO is scheduled to meet with Precinct 3 Justice of the Peace at noon today to discuss Mental Health Warrant. If Resident #2 remains in the facility after March 18, 2017, Justice of the Peace will continue working on an Involuntary Mental Health Warrant for removal from facility. The survey team validated the immediate jeopardy was removed on 3/15/17 at 3:40 p.m. following the facility's implementation of the plan for removal of the immediate jeopardy. On 3/16/17 at 7:38 p.m., the facility discharged R2 to a mental health center. R2 would not be returning to the facility. The deficient practice remained at a G (isolated actual harm) scope and severity following the removal of the immediate jeopardy. 2. Review of the facility's undated QA policy entitled, .Quality Assurance/Peer Review Policy and Procedure, indicated: a. There was no evidence in the policies that identified data collection methods and systems, which would include adverse monitoring of an event(s). b. There was no evidence in the policies that identified feedback from the direct care staff, clinical staff, residents or their representatives, and how this information would impact possible improvement in resident care. c. There was no evidence in the policies and procedures that identified how the committee would monitor and evaluate high risk situations, and how the facility would track these situations and monitor the outcomes. d. There was no evidence in the policies and procedures that clearly identified performance improvement measures and how these measures would determine success for the facility. 3. The facility failed to ensure the staff served food to the residents in a sanitary manner, and served chopped meat according to portion size. During an interview on 3/16/17 at 10:26 a.m. the Dietary Manager (DM) stated that she had recently lost long term employees and that the staff observed on 3/14/17 were new. She stated that she constantly provided education to the staff. She stated that she had attempted to serve the residents from the steam table in the main dining room as a part of culture change. She stated that the steam table should have been covered, the staff should have washed their hands prior to donning gloves and serving the residents, and the staff should have used a scoop to provide the proper serving size for the residents who received chopped meat. (Refer to F371.) 4. The facility failed to assure the staff assessed, care planned, and provided for person-centered care for 1 of 5 sample residents (R2) in order to protect the health and well-being of the additional 27 residents who resided on the secure unit. During an interview on 3/14/17 at 3:30 p.m. with the Administrator, the DON, and the Assistant Director of Nursing (ADON), the ADON stated she would expect specific non-pharmacological interventions documented in the care plan, and R2 usually was responsive to smoking and coffee breaks as a way to redirect her. The ADON confirmed these interventions should have been incorporated in the care plan. (Refer to F279, F280, F309, and F323.) 5. The staff failed to follow the guidance included in the Resident Assessment Instrument (RAI) Manual 3.0 to develop a care plan for R3 related to the use of an antipsychotic medication, and to develop a nutritional care plan for R5. During an interview on 3/15/17 at 11:29 a.m., the MDS Coordinator stated that care plans are updated during care plan meetings and upon a change in the resident's condition. The MDS Coordinator acknowledged that in the case of R3's antipsychotic medication, this was not done. The MDS Coordinator stated that she would correct the care plan. (Refer to F279.) 6. The facility failed to ensure that R3 received a comprehensive medical evaluation to rule out medical reasons for a change in mental status prior to receiving an order for [REDACTED]. a. Regarding R3: During an interview on 3/15/17 at 9:25 a.m., the ADON and the DON both confirmed there was no additional documentation that showed R3 had a history of [REDACTED]. During a telephonic interview on 3/15/17 at 10:29 a.m., R3's primary care physician (PCP) stated the resident had a history of [REDACTED]. The PCP confirmed during this interview that he had ordered laboratory and other diagnostic testing in conjunction with the order for [MEDICATION NAME] (an antipsychotic medication). During a telephonic interview 3/16/17 at 11:00 a.m., the facility's Consultant Pharmacist stated the facility should look at other means before starting a resident on an antipsychotic medication. b. Regarding R2: During an interview on 3/14/17 at 3:30 p.m. with the Administrator, the DON, and the ADON, the ADON stated when the nursing staff administers PRN anti-anxiety medications they should look for signs of severe anxiety and document those signs in the notes. The DON stated she would expect non-pharmacological interventions to be attempted and documented prior to the administration of a PRN medication. The ADON stated the facility should have developed a series of effective non-pharmacological approaches specifically tailored to R2's behaviors, and those approaches should have been included on the care plan. (Refer to F329.) 7. The facility failed to ensure the Consultant Pharmacist identified 2 irregularities with medication administration for 2 residents, R3 and R2. a. Regarding R3: Per clinical record review of the Medication Administration Records (MARs) for 12/24/16 forward until 3/15/17, the MARs indicated that R3 received [MEDICATION NAME] twice a day on a routine basis rather than on as as needed basis as ordered. During an interview on 3/15/17 at 10:50 a.m. the DON confirmed that the Consultant Pharmacist did not identify that the staff incorrectly administered R3's [MEDICATION NAME] twice daily on a routine basis rather than on an as needed basis as ordered. During a telephonic interview on 3/16/17 at 11:00 a.m., the Consultant Pharmacist stated that he should have noted this as an irregularity. b. Regarding R2: The documentation did not demonstrate adequate indications for use of the PRN Klonopin (an [MEDICAL CONDITION] medication also used to manage anxiousness) or describe R2's behaviors in a meaningful way. The staff administered PRN Klonopin for inappropriate reasons, including upset stomach, demanding medication, threatening staff, or continuously requesting the medication. During an interview on 3/16/17 at 11:00 a.m., the Consultant Pharmacist stated he sometimes reviewed nursing documentation regarding the reason for administration of PRN medications, but sometimes he just discussed PRN usage with the nursing staff and did not review the nurses' notes. He stated he had not identified an issue with R2's indications for use of PRN Klonopin and [MEDICATION NAME]. (Refer to F428.) 8. The facility failed to ensure the staff provided R4 with a nutritional supplement per physician's orders [REDACTED]. Observations of 2 meals on 3/14/17 and 1 meal on 3/15/17 revealed the staff failed to provide R4 a Boost supplement with his meal. During an interview on 3/16/17 at 10:34 a.m. the DM stated R4 was supposed to receive the Boost supplement at every meal. She stated it should be on his diet card, but confirmed it was not. She stated the kitchen staff should provide the Boost on the beverage cart with each meal. The DM stated there was no documentation or tracking of whether residents received and/or consumed nutritional supplements. (Refer to F325.) 9. The facility failed to ensure R3 received blood draws and a urinalysis in a timely manner per physician's orders [REDACTED]. a urinalysis (UA). Review of the lab results for these tests indicated the blood draws were not collected until 12/28/16 and the urine sample was not collected until 12/29/16. A review of the lab results reported on 12/28/16 and 12/29/16 indicated several lab values were out of the reference ranges for normal results. During an interview on 3/17/17 at 12:59 p.m., the DON stated that laboratory tests and UAs are typically completed by the next morning. The DON confirmed the clinical record contained no documentation to show the staff notified R3's physician of the delay in obtaining the blood draws and UA collection. (Refer to F502.) During an interview on 3/16/17 at 11:25 a.m. with the Administrator, the DON, and the ADON, the administrative staff stated that all department heads are involved in the QA meetings. The Administrator stated in addition to the quarterly QA meetings, they have QA meetings 3 days a week. The ADON clarified that the QA meetings conducted each Monday, Wednesday, and Friday were stand-up meetings. The ADON stated that the participants in the stand-up meetings discussed behaviors all of the time. When the Administrative staff were asked if they conduct root cause analysis or identify possible deficient practice and were action plans developed as a result, the Administrator said that he does a root cause analysis all of the time. Review of the facility's policy and procedure entitled, .Quality Assurance/Peer Review Policy and Procedure identified the Purpose of the QA committee as .to evaluate Resident care at all Facilities including: nursing services, qualification of patient care rendered by a nurse or under her supervision, the merits of any complaint or allegation to TDHS (Texas Department of Health Services) survey/complaint investigation or report, and manage facility and corporate civil liabilities via incident investigation, document production protection and legal evaluation of resident care and resident care improvement via Quality Assurance/Peer Review evaluation pursuant to the authority under Texas Occupation Code Title 3 Section 303.0001 et. Seq .The committee evaluations of resident care also include committee recommendations and actions regarding employee training, supervision, education and employment status .