Every finding on record at Sienna Nursing and Rehabilitation

Based on interview, and observation, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 02/25/2026 through present date of exit 04/23/2026.This failure could place all residents at risk of not receiving necessary care and services.Findings included:In an interview on 04/23/2026 at 10:24 AM with the Corporate Nurse, he stated he was the Interim DON. He stated he worked 2 days a week, 8-hour shifts, at this Nursing Facility as the DON. He stated he lived close by and was always readily available if needed. He stated he did not believe there was a potential risk for residents not having a full-time DON at the facility. He stated he monitored nurses and residents via online.In an interview on 04/23/2026 at 3:45 PM with the Administrator, he stated the Corporate Nurse was the current DON. He stated he was not aware how many days or hours the DON worked at the facility. He stated he did not believe there was potential risk to residents for not having a full-time DON at the Nursing Facility.In an interview on 04/23/2026 at 10 AM, the Administrator stated the facility did not have a policy for the DON requirement, and the facility followed state regulations.Record review of the Texas State Regulations, it read in part: 483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

Based on observation, interview, and record review the facility failed to ensure the residents right to personal privacy and confidentiality of his or her personal and medical records for 8 of 10 staff (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, RN G). The facility failed to ensure LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, and RN G did not use their personal laptops to access residents' medical records and document care provided without any safeguards in place to ensure security of residents' confidential information. This deficient practice placed residents at risk for having their sensitive patient health information disclosed.Findings include: In an observation on 04/21/2026 at 2:57 PM LVN C was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:19 AM, LVN M was observed completing work on her personal computer. On 04/23/2026 at 10:35 AM, CMA N was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:43 AM, CMA O was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:59 AM, RN H was observed completing work on her personal computer. On 04/23/2026 at 2:42 PM, LVN P was observed completing charting on her personal computer. On 04/23/2026 at 4:45 PM, RN Q was observed completing work on her personal computer. On 04/23/2026 at 4:48 PM, RN G was observed completing work on her personal computer. All staff were briefly interviewed and provided verbal confirmation it was their personal computer, all computers varied in models and customizations (stickers). In an interview on 04/21/2026 at 2:57 PM with LVN C stated the laptop on the medication cart was her personal computer. She stated she had not received instruction from her superiors to bring her own laptop to complete work. She stated she was notified by colleagues to bring her own computer to complete work responsibilities. She stated other staff members used their own personal devices for work but was unable to identify which employees used their own personal device. In an interview on 04/23/2026 at 9:09 AM with the Regional HR Coordinator stated the direct care staff was provided the nurse station computers, kiosks and facility owned tablets/laptops. She stated that all the devices were facility owned and staff should only be using these computers for resident records. She stated there was an additional safety measure that the facility's digital medical record had that restricted access to the database without the network Wi-Fi. She stated that staff should not be using their personal devices to be charting and completing tasks related to work. She stated that personal health information was accessible on the facility's digital medical record to include residents': social security numbers, dates of birth, addresses, phone numbers, insurance numbers, etc. She stated that only company issued laptops should be used to access the facility's digital medical record. She stated that facility should make rounds on staff and monitor for personal equipment use. She stated that personal communication devices are prohibited from use in the facility for work related tasks as outlined in the Employee Handbook topic Personal Communication. She stated department supervisors were responsible for ensuring staff adhered to the Employee Handbook. She stated that the facility could not be aware what the staff was doing with the information and there could be unauthorized downloads of resident personal health information. She stated there was potential for the information to be leaked accidentally or intentionally and the facility was not able to monitor for cybersecurity risks. She stated employees are made aware that personal laptops cannot be used for work upon hire. In an interview on 04/23/2026 at 10:19 AM with LVN M stated she was using her personal computer at the moment. She stated the facility provided a laptop but it stopped working and she notified the previous HR coordinator in October 2025. She added that the HR coordinator she notified quit and nothing was done following this notification. She stated she had not brought it up to any supervisor's attention since then. She stated that the facility's laptop was not turning on or charging properly. She stated that no one instructed her to bring her personal computer and added she did not gain permission or authorization to use her own. She stated she did not know if she could use her own personal device for work related tasks. She stated the only concern with staff using their personal laptop was a HIPAA issue. She stated the information available on a residents' medical chart included: care, physician orders, medical records, care plan, profiles (name, date of birth , insurance, address, phone numbers, social security numbers), and labs. She stated the information on the medical chart was downloadable for staff. She stated she did not know whose responsibility it was to monitor and ensure that staff was not using their personal devices for work. She stated there was only 1 desktop at the nurses station but it had consistent technical issues like disconnecting from the internet. She stated she would like the facility to do something about the computer and laptop issue because it affected how she completed her job. She stated she needed a laptop to review orders and complete documentation. In an interview on 04/23/2026 at 10:35 AM with CMA N stated that when she first started working at the facility a month ago, she was notified by colleagues that she would have to provide her own computer because there was not enough. She stated these were not instructions from her supervisors but from fellow nurses and medication aides. In an interview on 04/23/2026 at 10:43 AM with CMA O stated she had to buy her own laptop because the facility's issued equipment was either scarce or broken. She added she was not instructed by the facility to provide her own laptop. She stated she reported her concerns about limited functional laptops a year ago. She stated she provided a list of equipment needed to the administrator and to the previous DON about 2 months ago. She stated the facility needed approximately 7 laptops to cover the nurses and medication aides on the floor not including the memory care unit. She stated she does not think the equipment at the nurses station was working which included 2 laptops and 1 desktop. She stated the lack of electronic devices had been ongoing for a year. She stated she had not been notified by the facility that it was not permitted for staff to use their personal laptops for work responsibilities. She stated if she could not use her personal device then it affected the residents she cared for because she would not be able to complete her responsibilities. She stated she needed a laptop to access charts, enter records, and review medication orders. She stated she did not see how it affected residents if staff was only using their laptop for their work obligations. She stated that there was no potential for leaks of information and cybersecurity risks. She stated that personal information was on a resident's medical chart to include social security numbers, diagnosis, dates of birth, phone numbers, and more. She stated she would like the facility to provide an issued computer for her to complete her work responsibilities. She stated with the current laptops and computers she could not complete her tasks. She stated she did not know if she could use her personal computer for work per facility policy. In an interview on 04/23/2026 at 10:59 AM with RN H stated she was using her personal computer for work. In an interview on 04/23/2026 at 2:42 PM with LVN P stated she had worked at the facility for 7 years and had used her own laptop for the past 3 years. She stated none of the facility computers worked except for one, but did not know which one was properly functioning. She stated this had been an ongoing issue and there has only been one computer replaced since the Administrator began working. She stated the new computer was the single desktop that was located in the nursing station and was intended to accommodate potentially 4-5 staff members who needed to document and review orders for 3 hallways. She stated if she did not use her personal computer she would not be able to effectively complete her job. She stated the laptop was her personal and the facility had no monitoring or responsibility to fix it if it broke. She stated she would like to have a laptop issued from the facility to complete her job. She stated the laptops in the facility were not operational, do not turn on, or do not properly charge. She stated it was the facility's responsibility to provide equipment to complete her job. In an interview on 04/23/2026 at 2:54 PM with the ADON stated the facility had always struggled with laptops. She stated the facility sent out 10 laptops for repair when the Administrator began and had not been repaired or returned by the IT department handling the repairs. She stated the facility had not had enough laptops for staff since December 2024. She stated she had never instructed staff to bring their own personal laptop to complete work. She added to her knowledge the previous DON and previous Administrators had never provided instruction for staff to bring their personal laptops for work responsibilities. She stated she did not know if there were any firewalls and safeguards for staff who use their personal computer at work. She stated there was a concern for potential to leak resident information if staff were using their personal laptops. She stated to her knowledge there were no information leaks and added she was not sure how it would be monitored. She stated information that could be leaked include medications, diagnosis, social security numbers, dates of birth, addresses, next of kin, phone numbers. She stated it was not permitted per facility policy for staff to use their personal devices for work related responsibilities. She stated she had not instructed any staff member to cease using their personal devices. She stated the alternative was staff would not be able to document and complete responsibilities and tasks. She stated it affected residents by causing potential leak of information. She stated if the facility did not provide equipment it greatly affected the staffs' ability to complete their daily responsibilities and tasks. She stated the Administrator was responsible for creating the work order and ensuring that equipment was working or being fixed. She stated the Administrator created a work order for the 10 laptops sent out in January 2026. In a follow up interview on 04/23/2026 at 4:53 PM, she stated she had a facility issued laptop and desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. In an interview 04/23/2026 at 3:53 PM with the Administrator stated that staff were using facility issued laptops and could not confirm if there were staff members who used their personal laptops. He stated it was okay based on his interpretation of the employee handbook policy for staff to use their personal computers because it was referring to the laptop being used as a communication device and not as a work related device. He stated that the facility had enough computers for staff to be completing their tasks. He stated there were 3 computers for the direct care nurses, a tablet kiosk, and desktops/laptops for the Social Services and ADONs. He stated he did not know if staff were permitted to use the devices issued to the Social Services and ADONs. He stated the medical database included residents' social security numbers, dates of birth, names, phone numbers, diagnosis, medications, orders. He stated he did not know if there was cyber security monitoring in place for staff members that were completing work tasks on their personal computers. He stated he did not have any work orders or documentation for laptops he sent out in January 2026 and added he did not send out any laptops. In an interview on 04/23/2026 at 4:43 PM with RN Q stated she used her own personal laptop to document and review orders for residents in the men's memory care unit. She stated she was never issued a facility laptop and there was no desktop available to her in the memory care unit. She stated the kiosk behind the nurses station in the memory care unit was for CNAs and did not support the access to the medical portal she needed to complete documentation and review orders. She added the kiosk did not properly work and the CNA had a portable tablet kiosk to complete her work issued by the facility. In an interview on 04/23/2026 at 04:48 PM with RN G stated she used her personal laptop to complete documentation and order review. She stated she did receive a facility issued laptop but left it at the main nurses station for others to use in case they did not have a laptop to chart. She stated this was on her own preference to use her personal laptop. She stated she did not gain permission from leadership to use her personal laptop for documentation. She added there was no other facility issued laptop or desktop in the women's memory care unit for staff to complete documentation. She stated the kiosk for the CNA was properly functioning and her CNA had not notified her otherwise. In an interview on 04/23/2026 at 4:55 PM with ADON B stated she had a facility issued laptop and desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. In an interview on 04/23/2026 at 4:57 PM with the Social Services Coordinator stated she had a facility issued laptop and desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. She stated she kept her office locked when not in the room and the desktop had a login only for her to access. Record review of the facility's Employee's Handbook / Policy Review undated, read in part, (General statement) it is the responsibility of the employee to read the Employee Handbook in its entirety and adhere to the instructions found within .Failure to read the handbook is not a reason for not adhering to the policies and will not be allowed as a reason for violating any facility policy (Confidentiality) All information learned while working at the facility is to be kept confidential to each employee when they are not at work, not confidentially speaking with an appropriate employee about the information etc. it is very important to not speak of any information of a resident, co-worker or the facility while out shopping, eating in a restaurant, etc. Facility information should remain in the facility and not the public (Personal Communication) Employees are not permitted to use any form of personal communication devices while at work, unless specified as required use with their job assignment. This includes cell phones, smart phones, laptops, notebooks, notepads, or PDA devices (Computers/ emails / Internet) Employees are not to use the facility computers, internet, or email systems for their own personal entertainment or use. These are intended for business use only

Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 3 of 3 residents (Resident #58, #68, #77) reviewed for respiratory care. - The facility failed on 04/21/2026 to ensure Resident #68's oxygen concentrator was turned on for 3 and a half hours as per vitals collected at 1:30 PM by LNV C.-The facility failed on 04/21/2026 to ensure Residents #58, #68, and #77 had an oxygen in use signage on the doorway entry. This failure placed residents at risk of not receiving respiratory care or the hazards of machine malfunction or accelerating the spread of fire associated with oxygen usage.Findings included: Resident #58 Record review of Resident #58's admission record dated 04/23/2026 revealed a [AGE] year-old male with an initial admission date 01/28/2026. Record review of Resident #58's comprehensive MDS dated [DATE] revealed the resident had a BIMS score of 99 with the significance being the resident was unable to complete the interview. Under Section O (special treatments) the resident was coded for receiving oxygen therapy. Record review of Resident #58's care plan dated 01/28/2026 revealed the resident had a focus area on chronic obstructive pulmonary disease (a progressive, incurable lung disease) with an intervention to give oxygen therapy as ordered by the physician. Record review of Resident #58's physical and history dated 02/16/2026 revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease), malignant neoplasm of lung (cancerous growth in the lung tissue or airways). Record review of Resident #58's orders dated 01/29/2026 revealed the resident had an order for oxygen administration of 2-4 Liters per minute, with a frequency of every shift. In an observation on 04/21/2026 at 10:41 AM revealed there was no oxygen in use sign posted on the Resident #58's doorway while there was an oxygen concentrator in her room. Resident #58 was unavailable for an interview despite numerous attempts on 04/21/2026 at 10:41 AM, 11:48 AM, and 4:06 PM. In an observation on 04/23/2026 at 9:37 AM Resident #58 was observed not on portable oxygen and was ambulating with a walker aid. Resident #58 showed no signs of distress, labored breathing, skin discoloration, or faintness. Resident #68 Record review of Resident #68's admission record dated 04/23/2026 revealed a [AGE] year-old Male with an initial admission date on 04/08/2026. Record review of Resident #68's comprehensive MDS dated [DATE] revealed under section C (cognitive patterns) the resident had BIMS score of 99 due to rarely/never being understood during interviews with the significance being severe cognitive impairment. Under Section O (special treatments) the resident was coded for needing continuous oxygen therapy since admission. Record review of Resident #68's care plan dated 04/09/2026 revealed the resident had a care focus area for oxygen therapy with interventions of monitoring for signs and symptoms of respiratory distress (a critical condition indicating difficulty breathing, characterized by rapid, shallow breaths, wheezing, and the use of muscles) and notify the nurse if the oxygen is off the resident. The resident had an additional care focus area for addressing communication problems. Record review of Resident #68's physical and history dated 04/20/2026 revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease), aphasia following a cerebral infarction (an acquired language disorder caused by a stroke). Orders to monitor Resident #68's oxygen saturation closely were noted in the physical and history. Record review of Resident #68's orders dated 04/08/2026 revealed the resident had an order for oxygen administration of 2-4 LPM, with a frequency of every shift. In an observation on 04/21/2026 at 9:54 AM, Resident #68 was observed lying in bed asleep and not responding to verbal stimuli. Resident #68 had his nasal canula applied properly, but his oxygen concentrator was not on; no vitals had been taken for current oxygen saturation levels per record review of digital health record. Resident #68 did not display any signs of respiratory distress or discoloration in skin. There was no oxygen in use sign posted on Resident #68's doorway. A follow-up observation completed at 11:14 AM revealed no change in Resident #68's condition or in the oxygen concentrator. A follow-up observation at 3:21 PM revealed the oxygen was turned on, and Resident #68 had his cannula administered properly with no signs of respiratory distress or discoloration in skin. Record review of Resident #68's vitals revealed his oxygen saturation level measured at 96% on 04/21/2026 at approximately 1:30PM by LVN C. Resident #77 Record review of Resident #77's admission record dated 04/23/2026 revealed an [AGE] year-old female with an original admission date 10/07/2020 and a readmission [DATE]. Record review of Resident #77's quarterly MDS dated [DATE] revealed under section C (cognitive patterns) revealed the resident had a BIMS score of 15 with the significance being the resident was cognitively intact. Record review of Resident #77's care plan dated 03/20/2026 revealed the resident had a care focus area of Emphysema (characterized by damage to the lung's alveoli [air sacs]) with an intervention to ensure the resident will be free of signs and symptoms of respiratory insufficiency. Record review of Resident #77's physical and history dated 04/03/2026 revealed the resident had a diagnosis of acute on chronic respiratory failure with hypoxemia (abnormally low concentration of oxygen in the blood) with an order to continue oxygen therapy and monitor oxygen saturation closely. Record review of Resident #77's orders dated 03/23/2026 revealed the resident had an order for oxygen administration of 2-4 LPM, with a frequency of every shift. In an observation on 04/21/2026 at 10:12 AM revealed there was no oxygen in use sign posted on Resident #77's doorway while there was an oxygen concentrator in her room. In an interview on 04/21/2026 at 11:15 AM with Resident #77 she stated she did have the oxygen concentrator but did not utilize it because she was getting better and did not need it. She stated she was on oxygen previously but was unable to remember the beginning and end of her treatment. She stated she did not have any difficulty breathing, faintness, and did not display skin discoloration. In an interview on 04/21/2026 at 3:09 PM with LVN C stated she checked Resident #68's oxygen saturation and it was in the 80's when she first measured it at approximately 1:20 PM before oxygen administration. She stated a physical therapist notified her that Resident #68 did not have his oxygen on and proceeded to go check the oxygen concentrator because it was not connected. She stated she did not know why she did not document the oxygen saturation being in the 80's but that she documented the 96% level in his vitals after she administered oxygen therapy. She stated signs and symptoms of a resident without oxygen could be labored breathing and discoloration in fingertips. She stated that healthy oxygen saturation was above 95%. She stated she did not know if the resident required continuous oxygen. She stated she completed her assessment of lungs and heart after the discovery of Resident #68's oxygen concentrator was not working for an unknown amount of time. She stated Resident #68 did not display signs or symptoms of respiratory distress. She stated she checked resident oxygen connections and usage during vital checks, which was usually once per shift. She stated that if a resident did not receive oxygen, they could have difficulty breathing, fall unconscious, and die. She stated the nurses were responsible for checking oxygen saturation and ensuring oxygen concentrators were turned on. She stated the Administrator and ADON oversaw the nurses to ensure tasks were completed. She stated the, oxygen in use and no smoking sign should be posted on the residents' doorway to inform others to not smoke or have fire in the room because it was a hazard with the flow of oxygen. She stated that it was Administrator's and direct care staff responsibility to place signage on residents' doorways. In an interview on 04/21/2026 at 4:27 PM with COTA F stated Resident #68 was non-verbal and would not be able to vocalize if he was in pain or discomfort. She stated that he required yes or no questions to respond to staff. She stated she worked with Resident #68 about 4 times a week for 30 minutes at a time. She stated if he reported or displayed any pain or grimacing, she would alert the nurse immediately. She stated she went to talk to LVN C after initial contact with Resident #68 for his occupational therapy session when she noticed Resident #68's oxygen concentrator was not on at 1:20 PM; she stated Resident #68 was on continuous oxygen based on her previous observation with him. She stated the oxygen saturation was 86% when LVN C initially measured it. She stated LVN C then proceeded to power on the oxygen concentrator at approximately 1:25 PM. She stated LVN C remeasured Resident #68's oxygen saturation, and it increased to the 90s a few minutes after oxygen was readministered. She stated she did not know when the oxygen concentrator stopped working. She stated Resident #68 was more lethargic than usual and was not easily aroused by touch and verbal as before. She stated anyone who goes into the room can turn on the oxygen concentrator and connect the cannula to the resident. She stated that a resident could experience shortness of breath, lethargy, discoloration of extremities, if they were deprived of oxygen from a tank or concentrator. She identified that the nursing department was responsible for monitoring oxygen saturation levels and oxygen related equipment. In an interview on 04/23/2026 at 12:47 PM with CNA E stated as a CNA she can correct the nasal canula and turn on residents' oxygen concentrator. She stated if she discovered a resident with oxygen concentrator turned off she would notify the nurse immediately to measure oxygen saturation levels and turn on the machine. She stated oxygen deprivation symptoms include, skin color change, shortness of breath, labored breathing, and body tremors. She stated the nurse needed to be notified immediately because if the resident was on continuous oxygen, there was potential for injury without it. She stated that nurses usually monitor residents' oxygen concentrators and oxygen tanks. She stated that CNAs during rounds review the resident and ensure the oxygen concentrator was on and the cannula was properly applied. She stated that CNAs make rounds every 2 hours. She stated that if a resident did not have oxygen from 9:54 AM to 1:30 PM, it was an issue. She stated the oxygen use and no smoking signs should be on residents rooms that contained oxygen devices. She stated the signage needed to be posted to notify everyone that there was oxygen in use. She stated it affected residents because staff could not know if there was oxygen in use and added it was a safety concern. In an interview on 04/23/2026 at 3:16 PM with ADON D stated residents who needed continuous oxygen needed to have their oxygen concentrator operational to prevent respiratory distress. She stated it was a concern if the resident did not have their oxygen for 3 and a half hours. She stated that if oxygen saturation levels dropped to 86% respiratory treatment needed to be initiated immediately. She added staff needed to notify the physician, leadership, and provide report to the resident's nurse. She stated staff needed to make rounds every 2 hours to ensure oxygen was being administered for residents on continous oxygen. She stated the nurse needed to turn on the oxygen concentrator because other staff members did not hold the credentials to assess respiratory distress. She stated it would be any non-nurse staff members' responsibility to notify the nurse immediately. She stated that if oxygen saturation continued to decrease after the oxygen was administered, then the resident could be experiencing respiratory failure. She stated that the oxygen concentrator and respiratory assessment completed by the nurse needed to be documented on the resident's profile. She stated that the oxygen use and no smoking signs needed to be posted outside the residents' doorway. She stated if a resident had oxygen devices in their room either in use or not in use, then the sign needed to be up as soon as they received the equipment. She stated that any staff member could place the magnet on the residents' doorway. She stated that if it was not in place then some people could not be aware of which residents had oxygen. She identified herself and all staff members were responsible for ensuring signage was in place. In an interview on 04/23/2026 at 3:30 PM with RN G stated if she located a resident with low oxygen saturation levels she would reapply the oxygen source, complete a respiratory assessment and neurochecks. She stated she would have to discover the reason the oxygen concentrator stopped working to identify the source of the failure and ensure it did not occur again. She stated after that she would document the incident and notify all parties to include the physician, ADON, and resident's family and follow any new orders provided. She stated even if the oxygen saturation levels returned back to optimal (95%) she would still notify all parties and provide report to the resident's nurse and incoming shift nurse. She stated this needed to be followed because a lot of things could go wrong if a resident did not receive oxygen. She stated if oxygen dependent residents did not receive ample oxygen source it could result in brain damage, organ failure, perfusion (failure to deliver oxygenated blood to tissues and organs), lethargy, critical vital signs, and potentially death. She stated the nurses were responsible for tracking and monitoring residents' oxygen levels and ensuring care followed the orders. In an interview on 04/23/2026 at 4:26 PM with the Administrator, he referred to the nursing department for responses regarding oxygen related questions due to limited clinical knowledge on the subject. Record review of the facility's policy titled Oxygen Administration dated 02/13/2007 read in part, Oxygen therapy is also prescribed to ensure oxygenation of all body organs and systems (Goals) The resident will maintain oxygenation with safe and effctive delivery of prescribed oxygen. The resident will maintain an effective breathing pattern with administration of oxygen (Procedures) Become familiar with the type of oxygen administration, medical diagnosis, and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered Turn on oxygen after properly setting for volume and place device in position Place NO SMOKING signs in area when oxygen is administered and stored Document care Record review of the facility's policy titled, Compressed Gases, Safe Handling of dated 12/10/2015 read in part, When cylinders are used in resident rooms appropriate warning signs are to be placed at the entrace of the resident's room. Record review of the facility's last in-service for respiratory distress and oxygen administration reflected it was dated 04/13/2026 for CNAs and 04/14/2026 for nurses.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 4 items served on a sample tray (cold items) reviewed for food and nutrition services. -The facility failed on 04/22/2026 to provide a pudding dessert and tossed salad below 41 F. This failure places residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.Findings include: In an observation completed on 04/22/2026 at 12:31 PM, the facility provided a regular diet sample tray to the survey team to address meal service concerns. The sample tray arrived at the conference room at 12:43 PM, an 11-minute time elapse from the point it left the kitchen steam table. The sides that were intended to be served cold (below 41 F) were measured by the Dietary Manager and read at 53.2 F for a pudding dessert and 69.4 F for a tossed salad. In an interview on 04/22/2026 at 12:35 PM with the Dietary Supervisor I she stated temperatures should be 41 F or below for the cold served items. She stated the salad was in the ice bath and the pudding was in the fridge prior to meal service to maintain the cold serve temperature standard. She stated cold items not held below 41 F could develop bacteria during the resting time. She stated the puddings was stored in the fridge until 10 minutes before serving to residents. She stated she did not know if the puddings were held in the fridge today. She stated the salad was on an ice bath near the steam table before being placed on a resident's tray. She stated the dietary supervisor and manager were responsible for monitoring food temperatures. She stated temperatures were taken daily before meal service to ensure food served was not in the range of 41 F to 140 F. She stated residents could get sick if they received food out of the temperature within the range and could experience an upset stomach. She stated if the food was out of temperature range for a hot item, it should be reheated to 165 F for 15 seconds and for cold items, they should be cooled down to 41 F or below. She stated that cooks and supervisors monitor and measure the temperatures in the daily log daily before meal service;. She provided a record of meal temperatures captured before meal service on 04/22/2026 at 2:00 PM. Record review of the facility's temperature log for lunch on 04/22/2026 revealed the tossed salad measured at 40.8 F and pudding dessert measured at 40.1 F before meal service began. In an interview on 04/23/2026 at 11:31 AM with [NAME] J he stated the temperature danger zone for food was from 43 F to 145 F. He stated that food could develop pathogens and could become spoiled if it was in this range for too long. He stated that hot foods need to be served between 155 F to 175 F. He stated cold foods needed to be served between 31 F to 41 F. He stated the temperatures for the cold items from the lunch sample were not acceptable. He stated he monitored the temperatures before serving on the tray line before every meal service. He stated if food was not in the temperature range, it needed to be heated up or cooled down before being served. He stated cooks and supervisors were responsible for completing temperature logs every day before every meal. He stated if a resident was served food not within the acceptable hot and cold food temperature range they could be served late or they could get sick. He stated he could not remember the last in- service for safe food temperature but suspected it was 2 months ago. In an interview on 04/23/2026 at 2:02 PM with Dietary Supervisor K she stated she measured the food temperatures on the steam table before every meal service for hot and cold served items. She stated the food temperature danger zone for food was 45 F to 140 F. She stated food that entered the danger zone could develop bacteria and it could go bad. She stated hot items needed to be served at 140 F and higher she stated cold items needed to be served at 45 F and below. She stated it affected residents by exposing them to food that could have developed bacteria and the palatability of the food. She identified herself and the cooks were the individuals responsible for completing temperature logs and ensuring food was served with these standards in mind. She stated the temperatures of the cold served items from the test tray were unacceptable. She stated she did not recall the last in- service for food temperature monitoring. Record review of the facility's policy titled, Daily Food Temperature Control dated 2012 read in part, We will assure food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and record on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges (Procedure) Cold foods shall be less than 41 F.

Based on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/21/2026 to ensure a moldy tomato was not stored in the walk-in fridge.- The facility failed on 04/21/2026 to ensure different produce were not stored in the same bag (tomato with green onions).- The facility failed on 04/21/2026 to ensure a bag of green onions, bologna sandwiches, and hardboiled eggs in the walk-in fridge were labeled.- The facility failed on 04/21/2026 to ensure a box of chicken thighs was not leaking fluids, labeled, and was stored to maintain a temperature below 41 F. This failure had the potential to place residents at risk for foodborne illness.Findings included: During an observation and brief interview of the initial tour of the kitchen which began on 04/21/2026 at 8:35 AM with Dietary Supervisor I revealed at 8:41 AM, a tomato that had developed mold was stored in an unlabeled bag and shared the same space with green onions. At 8:45 AM, a bag of hard-boiled eggs with varying age with signs of spoilage, was discovered without a label; a bag of green onions that were showing signs of spoiling (lack of firmness, discoloration, and fluid build-up) was unlabeled; and a bag of bologna sandwiches were unlabeled. At 8:50 AM, a box of chicken thighs was discovered to be leaking in the walk-in fridge and presented with excessive fluid build-up and unlabeled. The Dietary Supervisor I stated she transferred the chicken thighs from the freezer to the walk-in fridge to defrost on 04/17/2026 at approximately 12:00 PM. She added it was her intention to cook them on 04/20/2026. The chicken thighs were removed from the fridge by [NAME] J, and a temperature check was requested of the chicken thighs. At 8:54 AM, 2 different chicken thighs were tested from the box and measured at 45 F by [NAME] J with Dietary Supervisor I and Dietary Supervisor K present during reading and acknowledged of results. Follow up observation of the kitchen on 04/22/2026 at 10:30 AM revealed no additional findings. In an interview on 04/23/2026 at 11:06 AM with Dietary Aide L she stated her responsibilities were to set up the drink area, clean the milk container, and prepare the dessert and beverages for the next day. She stated she goes into the fridge to obtain snacks. She stated if she found moldy, unlabeled, or mixed items she needed to throw them away because it was cross contamination. She stated it was a daily chore for Dietary Supervisor K to review all the ingredients in the kitchen. She stated if this was not completed the residents could get sick or bugs could get in the fridge. She stated she did not know the temperature at which poultry needed to be stored in the fridge. She stated she did not know the range for food temperature danger zone. She stated the last in-service received for sanitary and food storage was in March/April 2026. She stated the dietary staff were responsible for ensuring the kitchen upheld sanitary and safe serving conditions, and the Dietary Supervisors were responsible for ensuring it was being completed by dietary staff. In an interview on 04/23/2026 at 11:23 AM with [NAME] J he stated it was not appropriate for spoiled, unlabeled, and mixed items to be in the walk-in fridge. He stated labels needed to be used to inform staff when the item can last be used. He stated he checked the ingredients in the walk-in fridge every time he entered the fridge. He stated the temperature for the fridge was checked twice a day by cooks and dietary supervisors. He added the Dietary Supervisors were responsible for checking the contents of the fridge. He stated that it was checked at least once a day. He stated that everyone was responsible for ensuring items were labeled in the walk-in fridge. He stated if there was an unlabeled item, staff had to pull it out and label it for 4 days ahead. He stated the temperature of the chicken thighs was 45 F. He stated that the temperature of the chicken thighs needed to be 41 F or below because it could grow bacteria otherwise. He stated the chicken thighs were discarded the same day. He stated that the fluid buildup was a sanitary concern and was a cross-contamination issue for the kitchen. He stated the last in-service he received for food storage and sanitary conditions was on 4/14/2026. He stated that residents could get sick and experience diarrhea if staff did not adhere to standards. In an interview on 04/23/2026 at 1:25 PM with Dietary Supervisor I she stated the concerning observations from the initial kitchen tour included the chicken thighs temperature while in the walk-in fridge and the box they were stored in was leaking, the storage and labeling of hardboiled eggs, tomatoes, and bologna sandwiches, separate storage of food items, and discarding moldy food immediately. She stated that Dietary Supervisor K was responsible for ensuring the walk in storage was meeting sanitary and storage regulations. She stated the routine was for Dietary Supervisor K to complete a review every morning and ensure it was up to standard. She stated that the walk through was completed before surveyor's arrival at 8:35 AM. She stated cooks and dietary aides were responsible for labeling and dating items. She stated that staff were trained to notify supervisors of ingredient concerns and discard the produce. She stated the last in-service for storage and sanitation was 2 weeks ago. She stated she felt she had enough staff members to complete all kitchen operations and maintain regulation standards. She stated that the kitchen conditions on 04/21/2026 affected residents to include changing the menu on short notice and possibly becoming sick from the food item. She identified all dietary staff were responsible for ensuring food was nutritive, sanitary, and stored in healthy conditions. She stated initial findings were below standards of food and service. She stated the chicken thighs should have been 41 F or below and added anything higher than this temperature was potential for bacterial growth. In an interview on 04/23/2026 at 1:47 PM with Dietary Supervisor K she stated the discrepancies in the kitchen from the initial kitchen tour included the mixed vegetables, chicken thighs conditions and temperature, vegetables quality, unlabeled items, and improper storage practices. She stated these were concerns with cross contamination and could result in the residents developing a food borne illness. She stated her responsibilities were to make meal tickets, monitoring staff to ensure adherence to temperature standards and cooking procedures, washing dishes, and monitoring staff's utilization of protective equipment. She stated she completed a walkthrough of the freezers and fridges every day when she gets to work. She stated she began the walkthrough before the surveyor completed an initial kitchen tour on 04/21/2026 and added she missed the opportunity to address the surveyor's findings in the walk-in fridge at the start of her shift at 6:00 AM. She stated she did not finish the walkthrough due to other responsibilities taking precedence. She stated that all dietary staff were responsible for adhering to storage and safe handling standards. She stated that staff were trained to discard all food that was unlabeled, aged, or spoiled. She stated that it affected residents by not presenting a healthy and safe environment for residents' meals. She stated residents could develop food-borne illnesses. She stated she could not remember the last in-service she provided to her staff for food storage or sanitation. Record review of the facility's policy titled, Food storage and Supplies dated 2012 read in part, All facility storage areas will be maintained in an orderly manner that preserves the conditions of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects (Procedure) Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received . Any product with a stamped expiration date will be discarded once that date passes On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food spoil If food has developed such spoilage characteristics, it should not be eaten If perishable foods are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated bacteria can grow and food becomes spoiled and should not be served However, if possible food spoilage is observed prior to the best by date, the product will be discarded Frozen items that should be thawed before preparation should be stored under refrigeration until thawed, and should be dated with the date removed from the freezer

Based on interviews and record review, the facility failed to employ a qualified social worker on a full-time basis with a facility of more than 120 beds for 1 of 1 Social Workers reviewed. -The facility failed to ensure social services were directed by a qualified individual on 4/23/26 in a facility with 138 total capacity. This failure placed residents at risk of receiving services from a staff member not qualified to identify as a social worker.Findings included: During record review of personnel files on 04/23/2026 at 8:35 AM, it was revealed the Social Services Coordinator did not complete her bachelor's degree in social work nor did she possess licensure from the Texas State Board of Social Worker Examiners. In an interview on 04/23/2026 at 8:36 AM with the Regional HR Coordinator stated the previous Social Worker passed away in May 2025 and the facility went 8 months without a Social Service department. She stated the facility did not have a policy on Social Services qualifications but followed the regulation for qualifications for a Social Worker. She stated the Social Services Coordinator did not have a social work degree or license but had relevant course work that was adjacent. She stated she was aware that a facility with a capacity of 120 beds or more required a full-time social worker with qualifications. She stated the facility needed to adhere to the state regulation standard which required the Social Services Coordinator to possess a license from the Texas Board of Social Work Examiners. She stated that the Administrator was responsible for hiring decisions and Corporate decides the continuation. She stated it was the divisional HR chain of command and higher ups to monitor and address license concerns with the facility and its employees. She clarified that the facility HR coordinator was only responsible for monitoring and checking for license renewals. She stated that residents have not been affected because the previous 8 months the facility did not have a social services department and added the alternative would be not having a social service department. In an interview on 04/23/2026 at 12:00 PM with the Social Services Coordinator she stated she did not have a license in Social Work. She stated she had her bachelor's degree in human services. She stated that she did not know the State regulation requirements for the Social Worker qualifications in a nursing facility. She stated she had never worked in a nursing facility before. She stated her previous experience was as an advocate related services and completed tasks such as locating in network providers, providing meal service programs, advocating, setting appointments for members, attending meetings, and ensure medication compliance. She stated the Regional HR Coordinator was responsible for adhering to Texas regulation for hiring qualified staff. She stated that it affected residents if the Texas regulation was not adhered to because it was a liability. She stated she was not notified of concerns from corporate personnel regarding qualifications in her role. She stated her responsibilities in her current role were to complete care plans, BIMS, grievances, Patient Healthcare Questionnaire-9s (tool used for screening and measuring depression severity), contact family for concerns, set up appointments for eye exams, dental services, and podiatry appointments. She added that she completed social assessments and managed room changes for residents. She stated that she did not have any concerns about her roles/responsibilities in her position or concerns about being qualified. She addressed her badge displayed the title Social Worker, and clarified it was created by the Regional HR Coordinator. In an interview on 04/23/2026 at 4:15 PM with the Administrator he stated he was aware the Social Services Coordinator did not possess the qualifications to be a licensed Social Worker. He stated the facility was not within compliance of the regulation for the requirement to have a qualified full-time Social Worker for a facility with 138 bed capacity. He stated he was aware of the Social Services Coordinator educational background and credentials before hiring an proceeded with employment offer. He stated the Social Services Coordinator would be enrolling in classes to become a licensed Social Worker. He was provided an image of the Social Services Coordinator badge that read Social Worker and added he was not aware. Record review of the Texas Administration Code Rule S554.703 dated 03/11/2024 read in part, A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners A qualified social worker is an individual who is licensed, including a temporary or provisional license, by the Texas State Board of Social Worker Examiners as prescribed by Texas Occupations Code, Chapter 505 Record review of the Texas Occupations Code Chapter 505, Section 505.351. updated 09/01/2019 read in part, (Subchapter G, License Requirements) A person may not use or cause to be used the title 'social worker,' 'licensed baccalaureate social worker,' 'licensed master social worker,' 'licensed clinical social worker,' 'licensed social worker,' or any combination, variation, or abbreviation of those titles, as a professional or business identification, representation, asset, or means of obtaining benefit unless the person holds an appropriate license issued under this chapter .

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in fridge cooling system and 7 of 10 employees (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q) not having access to facility issued laptops and desktops.-The facility failed to ensure water was not pooling under the walk-in fridge cooling system.-The facility failed to ensure laptops intended for nursing staff use were working. This failure placed residents at risk for delay in care and foodborne illnesses.Findings included: During an observation, brief interview, and record review of the initial tour of the kitchen on 04/21/2026 at 8:49 AM with Dietary Supervisor I, it was observed a small puddle of water was developing on the floor directly underneath the cooling system of the walk-in fridge. She stated she could not recall how long the walk-in fridge cooling system had been leaking for and added that she already submitted a work order to maintenance for it. A copy of the work order was requested from Dietary Supervisor I but was not fulfilled due to her not being able to find the work order. Temperature logs for the walk-in fridge did not show any variation of temperature exceeding range above 40 F for the previous 2 weeks. In an interview on 04/23/2026 at 11:15 AM with Dietary Aide L stated walk-in fridge cooling system had been leaking for a couple of weeks. She stated sometimes it leaked and sometimes it stopped. She stated it had never affected the temperature for the walk-in fridge. She stated she notified her manager in March 2026 when she noticed water pooling underneath it. She stated the Maintenance man came and fixed it in March of 2026. She stated that if equipment stopped working, she was trained to notify the supervisor immediately because something could go bad or conditions could get worse. She stated if the equipment was not working then the temperatures could be off then the residents could be served food that was spoiled. In an interview on 04/23/2026 at 11:36 AM with [NAME] J stated that the kitchen equipment worked fine except the walk-in fridge was leaking water from the cooling system. He stated he was made aware of the kitchen leak on 4/21/2026 and prior to that there were no issues. He stated it was not acceptable for the walk-in fridge to have an active leak. He stated it could raise the temperature of the walk-in fridge. He stated the PVC pipe was fixed and insulated by maintenance on 04/21/2026. He stated it affected residents because the food could not be stored in the fridge until it was fixed because of the potential for temperature issues. He stated if he discovered faulty equipment, he would report it to the supervisor immediately to ensure it was fixed. He stated all dietary staff were responsible for reporting equipment issues to the Dietary Supervisors. He stated he did not receive training on reporting broken equipment. In an interview on 04/23/2026 at 1:34 PM with Dietary Supervisor I stated she was made aware of the walk-in fridge leaking from the cooling system about 3 months ago and the previous maintenance man applied foil tape and minimized the leak. She stated that it had been difficult to maintain the fridge temperature below 40 and she noticed that it rose to 41 or 42. She stated she was not aware if this had affected the produce or meat within the walk-in fridge. She stated she was completing on going monitor and suspected that the walk-in door was not being properly closed by dietary staff. She stated the door does close all the way on its own and needed to be pressed hard because of the mechanism on the handle. She stated she believed she told the previous Maintenance worker verbally about the leak thus she did not have a documented workorder to provide. She stated the current maintenance applied the insulation on 04/22/2026. She stated there had been no leaks since 04/21/2026 She stated it was not okay for the walk-in fridge to have a leak due to safety and sanitary issues. She stated that if equipment was properly functioning, it should not be leaking. She stated staff was trained to notify maintenance or supervisor for equipment issues immediately. She stated that if further concerns rose with leaking or temperature, she will notify maintenance. She stated the current Maintenance Supervisor had been working at the facility for a week. In an interview on 4/23/2026 at 4:20 PM, the Administrator stated the copper pipe from the cooling fan in the walk-in fridge was producing condensation and attributed the puddle of water on the floor to it. He stated there was no leak in the walk-in fridge and there was nothing wrong with the fridge cooling system. He stated insulation was placed to resolve the water that was dripping from excess condensation. He stated no work order existed for the walk-in fridge cooling system because it did not need repair. Record review of invoice from a local HVAC dated 07/22/2025 read in part, The tech checked all of the AC units and made sure they had freon and were working properly. Record review of a facility generated maintenance review dated 04/16/2026 read in part, Food preparation Equipment: Inspect kitchen small appliances Steps: Conduct safety and operations inspections Visually inspect all appliances for damage. Inspect electric cords and connections. Test functionality of appliance and proper operation of all controls. Lubricate per manufacturer's spec as needed (Notes) 'Had no issue everything was in working condition.' In an observation on 04/21/2026 at 2:57 PM LVN C was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:19 AM, LVN M was observed completing work on her personal computer. On 04/23/2026 at 10:35 AM, CMA N was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:43 AM, CMA O was observed completing work on her personal computer during medication administration. On 04/23/2026 at 10:59 AM, RN H was observed completing work on her personal computer. On 04/23/2026 at 2:42 PM, LVN P was observed completing charting on her personal computer. On 04/23/2026 at 4:45 PM, RN Q was observed completing work on her personal computer. All staff were briefly interviewed and provided verbal confirmation it was their personal computer, all computers varied in models and customizations (stickers). In an interview on 04/21/2026 at 2:57 PM with LVN C stated the laptop on the medication cart was her personal computer. She stated she had not received instructions from her superiors to bring her own laptop to complete work. She stated she was notified by colleagues to bring her own computer to complete work responsibilities. She stated other staff members used their own personal devices for work but was unable to identify which employees used their own personal device. In an interview on 04/23/2026 at 9:09 AM with the Regional HR Coordinator stated the direct care staff was provided the nurse station computers, kiosks and a facility owned tablets/laptops. She stated that all the devices were facility owned and staff should only be using these computers for work responsibilities. She stated that staff should not be using their personal devices to be charting and completing tasks related to work. She stated that only company issued laptops should be used to access the facility's digital medical record and facility Wi-Fi. She stated that department heads should make rounds on staff and monitor for personal equipment use. She stated that personal communication devices are prohibited from use in the facility for work related tasks as outlined in the Employee Handbook topic Personal Communication. She stated department supervisors were responsible for ensuring staff adhered to the Employee Handbook. She stated employees are made aware that personal laptops cannot be used for work upon hire. In an interview on 04/23/2026 at 10:19 AM with LVN M stated she was using her personal computer at the moment. She stated the facility provided a laptop but it stopped working and she notified the previous HR coordinator in October 2025. She added that the HR coordinator she notified quit and nothing was done following this notification. She stated she had not brought it up to any supervisor's attention since then. She stated that the facility's laptop was not turning on or charging properly. She stated that no one instructed her to bring her personal computer and added she did not gain permission or authorization to use her own. She stated she did not know if she could use her own personal device for work related tasks. She stated she did not know whose responsibility it was to monitor and ensure that staff was not using their personal devices for work. She stated there was only 1 desktop at the nurses station but it had consistent technical issues like disconnecting from the internet. She stated she would like the facility to do something about the computer and laptop issue because it affected how she completed her job. She stated she needed a laptop to review orders and complete documentation. In an interview on 04/23/2026 on 10:35 AM with CMA N stated that when she first started working at the facility a month ago, she was notified by colleagues that she would have to provide her own computer because there was not enough facility laptops. She stated these were not instructions from her supervisors but from colleagues. In an interview on 04/23/2026 at 10:43 AM with CMA O stated she had to buy her own laptop because the facility's issued equipment was either scarce or broken. She added she was not instructed by the facility to provide her own laptop. She stated she reported her concerns about limited functional laptops a year ago. She stated she provided a list of equipment needed to the Administrator and to the previous DON about 2 months ago. She stated the facility needed approximately 7 laptops to cover the nurses and medication aides on the floor not including the memory care unit. She stated she does not think the equipment at the nurses station was working which included 2 laptops and 1 desktop. She stated the lack of electronic devices had been ongoing for a year. She stated she had not been notified by the facility that it was not permitted for staff to use their personal laptops for work responsibilities. She stated if she could not use her personal device then it affected the residents she cared for because she would not be able to complete her responsibilities. She stated she needed a laptop to access charts, enter records, and review medication orders. She stated she would like the facility to provide an issued computer for her to complete her work responsibilities. She stated with the current laptops and computers she could not complete her tasks. She stated she did not know if she could use her personal computer for work per facility policy. In an interview on 04/23/2026 at 10:59 AM with RN H stated she was using her personal computer for work. In an interview on 04/23/2026 at 2:42 PM with LVN P stated she had worked at the facility for 7 years and had to use her own laptop for the past 3 years. She stated none of the facility computers worked except for one, but did not know which one was properly functioning. She stated this had been an ongoing issue and there has only been one computer replaced since the Administrator began working in January 2026. She stated the new computer was the single desktop that was located in the nursing station and was intended to accommodate potentially 4-5 staff members who needed to document and review orders for 3 hallways. She stated if she did not use her personal computer she would not be able to effectively complete her job. She stated she would like to have a laptop issued from the facility to complete her job. She stated the laptops in the facility were not operational, do not turn on, or do not properly charge. She stated it was the facility's responsibility to provide equipment for her to complete her job. In an interview on 04/23/2026 at 2:54 PM with ADON D stated the facility had always struggled with laptops. She stated the facility sent out 10 laptops for repair when the Administrator began (January 2026) and had not been repaired or returned by the IT department yet. She stated the facility did not have enough laptops for staff since December 2024. She stated she had never instructed staff to bring their own personal laptop to complete work. She added to her knowledge the previous DON and previous Administrators had never provided instruction for staff to bring their personal laptops for work responsibilities. She stated she had not instructed any staff member to cease using their personal devices. She stated the alternative was staff would not be able to document and complete responsibilities and tasks. She stated if the facility did not provide equipment it greatly affected the staffs' ability to complete their daily responsibilities and tasks and tend to residents' needs. She stated the Administrator was responsible for creating the work order and ensuring that equipment was working or being fixed. She stated the Administrator created a work order for the 10 laptops sent out in January 2026. In a follow up interview on 04/23/2026 at 4:53 PM, she stated she had a facility issued laptop and desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. In an interview 04/23/2026 at 3:53 PM with the Administrator stated that staff were using facility issued laptops and could not confirm if there were staff members who used their personal laptops. He stated it was okay based on his interpretation of the employee handbook policy for staff to use their personal computers because it was referring to the laptop being used as a communication device and not as a work related device. He stated that the facility had enough computers for staff to be completing their tasks on facility issued laptops instead of personal devices. He stated there were 3 computers for the direct care nurses, a tablet kiosk, and desktops/laptops for the Social Services and ADONs. He stated he did not know if staff were permitted to use the devices issued to the Social Services and ADONs. He stated he did not have any work orders or documentation for laptops he sent out in January 2026 and added he did not send out any laptops. In an interview on 04/23/2026 at 4:43 PM with RN Q stated she used her own personal laptop to document and review orders for residents in the men's memory care unit. She stated she was never issued a facility laptop and there was no desktop available to her in the memory care unit. She stated the kiosk behind the nurses station in the memory care unit was for CNAs and did not support the access to the medical portal she needed to complete documentation and review orders. She added the kiosk did not properly work and the CNA had a portable tablet kiosk to complete her work issued by the facility. In an interview on 04/23/2026 at 4:55 PM with ADON B stated she had a facility issued laptop and desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. In an interview on 04/23/2026 at 4:57 PM with the Social Services Coordinator stated she had a facility issued desktop in her office. She added she was the only one permitted to access these devices and staff were not permitted to complete work related responsibilities on it. She stated she kept her office locked when not in the room and the desktop had a login only for her to access. Record review of the facility's Employee's Handbook / Policy Review undated, read in part, (General statement) it is the responsibility of the employee to read the Employee Handbook in its entirety and adhere to the instructions found within .Failure to read the handbook is not a reason for not adhering to the policies and will not be allowed as a reason for violating any facility policy (Personal Communication) Employees are not permitted to use any form of personal communication devices while at work, unless specified as required use with their job assignment. This includes cell phones, smart phones, laptops, notebooks, notepads, or PDA devices (Computers/ emails / Internet) Employees are not to use the facility computers, internet, or email systems for their own personal entertainment or use. These are intended for business use only Record review of the facility policy titled Dietary Preventive Maintenance dated 2003 read in part, The Maintenance Supervisor is responsible for ensuring mechanical and electrical operations of the kitchen. The dietary personnel will be responsible for advising the Maintenance Supervisor in writing of needed repairs. The Maintenance Supervisor will complete the dietary Preventative Maintenance log on a monthly basis to ensure maintenance of dietary equipment. Written documentation will be maintained by the facility of preventative maintenance and corrective actions.

Based on observation, interview and record review, the facility failed to immediately inform the resident's physician and their representative when there was a significant change in the resident's physical, mental or psychosocial status for 1 of 3 residents (Resident #68 reviewed for change in condition. -The facility failed to ensure LVN C reported Resident #68's oxygen being disconnected for unknown number of hours and oxygen saturation of 86% to the physician on 04/21/2026. This failure places residents at risk for experiencing a worsening condition and leaving the resident without appropriate treatment following a change in condition. Findings included: Resident #68 Record review of Resident #68's admission record dated 04/23/2026 revealed a [AGE] year-old Male with an initial admission date on 04/08/2026. Record review of Resident #68's physical and history dated 04/20/2026 revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease), aphasia following a cerebral infarction (an acquired language disorder caused by a stroke). Orders to monitor Resident #68's oxygen saturation closely were noted in the physical and history. Record review of Resident #68's comprehensive MDS dated [DATE] revealed under section C (cognitive patterns) the resident had BIMS score of 99 due to rarely/never being understood during interviews with the significance being severe cognitive impairment. Under section GG (functional abilities) the resident was coded as dependent on staff for all bed mobilities and transfers. Under Section O (special treatments) the resident was coded for needing continuous oxygen therapy since admission. Record review of Resident #68's care plan dated 04/09/2026 revealed the resident had a care focus area for oxygen therapy with interventions of monitoring for signs and symptoms of respiratory distress (a critical condition indicating difficulty breathing, characterized by rapid, shallow breaths, wheezing, and the use of muscles) and notify the nurse if the oxygen is off the resident. The resident had an additional care focus area for addressing communication problems. Record review of Resident #68's physician order dated 4/8/2026 for oxygen at 2-4 Liters per minute with a frequency of everyday and every shift for diagnosis of chronic obstructive pulmonary disease (a progressive, incurable lung disease). In an observation on 04/21/2026 at 9:54 AM, Resident #68 was observed lying in bed asleep and not responding to verbal stimuli. Resident #68 had his nasal canula applied properly, but his oxygen concentrator was not on; no vitals had been taken for current oxygen saturation levels as per documentation on digital health record. Resident #68 did not display any signs of respiratory distress or discoloration in skin. A follow-up observation completed at 11:14 AM revealed no change in Resident #68's condition or in the oxygen concentrator. A follow-up observation at 3:21 PM revealed the oxygen was turned on and Resident #68 had his cannula administered properly with no signs of respiratory distress or discoloration in skin. Record review of Resident #68's vitals revealed his oxygen saturation level measured at 96% on 04/21/2026 at approximately 1:30PM by LVN C. In an interview on 04/21/2026 at 3:09 PM with LVN C stated she checked Resident #68's oxygen saturation and it was in the 80's when she first measured it at approximately 1:20 PM before oxygen administration. She stated a physical therapist notified her that Resident #68 did not have his oxygen on and proceeded to go check the oxygen concentrator because it was not connected. She stated she did not know why she did not document the oxygen saturation being in the 80's but that she documented the 96% level in his vitals after she administered oxygen therapy. She stated that healthy oxygen saturation was above 95%. She stated she did not know if the resident required continuous oxygen. She stated she completed her assessment of lungs and heart after the discovery of Resident #68 with no signs or symptoms of respiratory distress. She stated she did not report the event to the charge nurse, physician, or the ADON about Resident #68's oxygen saturation. She stated this was because his oxygen levels returned to normal, and assessment showed no findings. She stated she did not know if she had to notify the physician, ADON, or the charge nurse. In an interview on 04/21/2026 at 4:27 PM with COTA F stated Resident #68 was non-verbal and would not be able to vocalize if he was in pain or discomfort. She stated that he required yes or no questions to respond to staff. She stated she went to talk to LVN C after initial contact with Resident #68 for his occupational therapy session when she noticed Resident #68's oxygen concentrator was not on at approximately 1:20PM; she stated Resident #68 was on continuous oxygen based on her previous observation with him. She stated the oxygen saturation was 86% when LVN C initially measured it. In an interview on 04/23/2026 at 3:16 PM with ADON D stated residents who were dependent on oxygen needed to have it applied to prevent respiratory distress. She stated it was a concern if Resident #68 did not have his oxygen for possibly 4 hours. She stated that if the oxygen drops to 86% saturation, respiratory treatment needed to be made, staff needed to notify the physician, herself, and provide report to the nurse. She stated the physician needed to be notified in case they needed to provide new orders for Resident #68. In an interview on 04/23/2026 at 3:30 PM with RN G She stated she would have to discover the reason the oxygen concentrator stopped working to identify the source of the failure and ensure it did not occur again. She stated after that she would document the incident and notify all parties to include the physician, ADON, and resident's family and follow any new orders provided. She stated even if the oxygen saturation levels returned back to normal levels (95%) she would still notify all parties and provide report to the resident's nurse and incoming shift nurse. She stated this needed to be followed because a lot of things could go wrong if a resident did not receive oxygen. She stated if oxygen dependent residents did not receive ample oxygen source it could result in brain damage, organ failure, perfusion (failure to deliver oxygenated blood to tissues and organs), lethargy, critical vital signs, and potentially death. She stated it was the nurse's responsibility to provide notification to the physician and resident's family with a change in condition. She stated that oxygen being disconnected for an unknown length of time and 86% oxygen saturation was considered a change of condition. Record review of nursing progress notes revealed no respiratory assessment or notification to the physician was completed by LVN C on 04/21/2026. Record review of the facility's policy titled Notifying the Physician of Change in Status dated 03/11/2013 read in part, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record The nurse is responsible, however, for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor Record review of the facility's last in-service for notifying the physician of change in status reflected it was dated 02/13/2026.

Based on observation, interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed. The facility failed to maintain evidence demonstrating the results of grievances prior to 2/13/2026. This failure could place residents at risk of not having their grievances properly resolved, tracked, and documented for future review.Findings include: An observation made on 04/21/2026 at approximately 1:30 PM revealed that the grievance binder provided did not have any documentation of grievances prior to 2/13/2026. In an interview on 04/23/2026 at 11:48 AM with the Social Services stated she began at the facility in February 2026 and there was no grievance documentation that she located upon taking office. She added that she did not discard anything. She stated she began taking grievances in February 2026 and utilizing a tracking binder. She stated prior to February 2026 she does not know how grievances were being tracked. She stated it was a requirement and facility policy to keep track of the grievances. She stated that grievances needed to be monitored to ensure resolution, follow-up, documentation, and to help track trends. She stated that she did not know how long the grievances needed to be documented for. She identified herself as the individual responsible for tracking and documenting grievances that were completed. She stated that if this was not completed then it affected residents by not addressing their concerns and there could be no change to the issue. She stated she had not provided any in service for reporting or completing grievances for staff or residents. She stated she was not made aware of any grievance handling concerns from residents or staff before she began working on February 2026. She stated the facility's previous Social Worker unexpectedly passed away in the middle of 2025 and was previously the grievance coordinator. In an interview on 04/23/2026 at 12:35 PM with CNA E stated she has worked at the facility for 6 years. She stated the Administrator was the grievance coordinator. She stated that ADON and DON monitored and tracked grievances. She stated that she was not sure if there was a grievance binder where they would be filed. She stated that complaints needed to be tracked and monitored to fix and adjust as the residents identified. She stated it was an issue if the grievances were only documented from February 2026 onward because there was no documentation of concerns or resolutions before then. She stated that all staff were responsible for ensuring they were aware of the grievance system in place and communicating it amongst leadership. In an interview on 04/23/2026 at 1:08 PM with LVN M stated she did not know who monitored and tracked all grievances. She stated that prior to February 2026 the grievances were being completed via paper. She stated either the DON or Administrator would have the binder for grievances prior to February 2026. She stated it was important to track and monitor to ensure it was completed, resolved, and for tracking trends. She stated she does not know how it was being tracked and monitored now. She stated she did not remember the last training/in-service she received for grievances. She stated she did not know how grievances were being handled from June 2025 to January 2026. In an interview on 04/23/2026 at 3:05 PM with the ADON stated she did not play any role on how grievances were handled. She stated the grievances were the responsibility fromof the previous Social Worker who passed away in May 2025. She stated after this, the grievance responsibility transferred to the two Interim Administrators the facility had before January 2026. She added that the grievance coordinator responsibility was then transferred to the current Administrator and now was assigned to the current Social Services. She stated that it was concerning if their furthest back grievance was February 2026 because how does the facility know previous grievances were taken care of. She stated there was no way to determine if previous grievances were resolved or corrected. In an interview on 04/23/2026 at 4:03 PM with the Administrator stated the only documentation of grievances in place was what was provided on 04/21/2026. He stated he did not locate another binder of grievances from his predecessors, nor did the Social Services locate a grievance binder from her predecessor. He stated there was a concern for the missing grievance documentation before January 2026. He stated it was important to have the grievances for the past 3 years because it was regulation. He stated that it assisted in trending and tracking residents' concerns. He identified the current grievance coordinator was Social Services. He stated that everyone was responsible for monitoring and tracking grievances. Record review of the facility policy titled Grievances dated 11/2/2016 read in part, The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have (Procedure) The grievance official of this facility is the administrator or their designee. The grievance official will: Oversee the grievance process, receive and track grievances to their conclusion All written grievances will include: the date the greivance was received Maintaining evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision .

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #12) reviewed for ADL care. -The facility failed on 04/21/2026 to ensure Resident #12's fingernails were trimmed. This failure could place residents who required assistance with ADL's at risk for unmet needs.Findings included: Record review of Resident #12's admission sheet dated 04/23/2026 revealed a [AGE] year-old female with an original admission date on 06/18/2020 and a readmission date on 02/26/2021. Record review of Resident #12's comprehensive MDS dated [DATE] revealed under section C the resident had a BIMS score of 15 with the significance being cognitively intact. Under section GG the resident was coded for needing setup or clean-up assistance for personal hygiene. Record review of Resident #12's care plan dated 04/02/2026 revealed the resident had a focus area for ADL self-care performance deficits with interventions to include assist with personal hygiene as required and to check nail length during bathing and trim on bath day or as necessary. Record review of Resident #12's physical and health dated 04/15/2026 revealed the resident was diagnosed with neuropathy (damage to nerves outside the brain and spinal cord causing numbness, tingling, and stabbing pain in the hands and feet) and reported pain in joints to the physician during visit. In an interview and observation on 04/21/2026 at 3:23 PM with Resident #12 she stated that her nails were long and usually asked the therapy department to cut her nails because she was not diabetic. She stated she received assistance for bathing, and staff had not offered to trim her nails on her most recent shower day. She stated she would like her nails to be cut because they were getting long. She stated she had not scratched or hurt herself while her nails were in their current condition. It was observed that her fingernails were measuring more than 1 inch in length, and added it was not her preference. She was unable to recall when the last time was she had her nails trimmed. In an interview on 04/23/2026 at 12:26 PM with LVN C she stated that CNAs and nurses could cut the nails for residents and added if a resident was diabetic the nurse would have to complete it. She stated nails were reviewed during changing, medication pass, and showers. She stated there was potential for it to be addressed a minimum of 3 times a day. She stated a resident could scratch themselves, hurt others, tear skin, and stated it was an infection control issue. She stated that there was not a nail trimming day or schedule to her knowledge. She stated she did not know how supervisors monitored for the completion of these tasks by CNAs and nurses. She stated it was not appropriate for residents' nails to be an inch and a half long if it was not their preference. She stated she received nail trimming training a week ago. In an interview on 04/23/2026 at 12:41 PM with CNA E she stated CNAs and nurses could provide nail trimming. She stated hygiene related ADLs were reviewed a minimum of 2-3 times a day per staff member during rounds, call light responses, changing, transfers, showers, and medication pass. She stated anyone could notify the CNAs and nurses about a resident's lengthy nails. She stated they do not cut residents' nails very often because some residents refused and the facility was short staffed. She stated shower schedules were not being adhered to. She stated it was hard to complete tasks because of the acuity of residents and the ratio of employees to residents. She stated there were no injuries related to staff shortages. She stated it affected a resident if they had long nails because they could scratch tender skin or develop ingrown nails. She stated an inch and a half of nail length was considered long and needed to be addressed, care planned or serviced. She stated she did not recall the last in- services she received for ADLs. In an interview on 04/23/2026 at 3:10 PM with ADON D she stated that staff provided ADLs with transfer, feeding, nail trimming, changing beds, and incontinences. She stated CNAs and nurses complete fingernail trimming and added it was a monthly routine. She stated staff should cut the nails or offer to cut them for the resident when it was observed the resident had lengthy nails. She stated that it affected the residents because it did not fulfill their wish to have a nail trim. She stated there was potential to scratch themselves or have skin integrity compromised. She identified herself and ADON B were responsible for ensuring staff were completing ADLs for residents. She stated she did not recall the last in-service or training for ADLs but would look for in-service logs; later provided on 04/23/2026 at 4:55 PM. Record review of the facility's policy titled Nail Care undated read in part, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity issues, to prevent infection, and injury from scratching by fingernails It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath (Goals) nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions Record review of the most recent in-service for nail care was completed on 02/11/2026. Record review of the facility's latest nail care / refusal sheet dated 04/17/2026 revealed that Resident #12 was not on the list for residents who received nail care on the listed date.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #6) of 8 residents reviewed for falls.The facility failed to ensure Resident #6 was assessed by a nurse immediately after her fall on 03/13/2026.This failure could affect residents by placing them at risk of potential medical complications related to changes in condition.Findings include:Record review of Resident #6's admission record dated 04/23/2026 revealed a [AGE] year-old female with initial admission date 12/09/2025, and readmission date 04/04/2026.Record review of Resident #6's health and physical dated 03/13/2026, revealed a medical history of Anxiety (frequent thoughts and feelings of worry or nervousness that affect everyday life tasks), Type 2 Diabetes Mellitus (a condition that happens when the body does not properly use blood sugar), and Schizophrenia (severe mental disorder that affects how the person thinks, feels, and behaves, often leading to hallucinations, or delusions, meaning seeing or hearing things that are not real). The health and physical noted it was a PRN visit for post-fall examination. It was noted Resident #6 was observed with redness and swelling to her chin. Bruises to bi-lateral, or both, knees. It was noted X-rays were ordered for her chin and both knees.Record review of Resident #6's Quarterly MDS dated [DATE] revealed there was no BIMS score as Resident #6 was noted to be never or rarely understood. Under Section GG-Functional Abilities, Resident #6 was noted to be completely dependent with ADLs and mobility, meaning the helper does all the work to complete the task while the resident does none of the effort.Record review of Resident #6's care plan with revision date 04/17/2026, revealed the resident was at risk for falls related to her Dementia diagnosis, wandering, anti-anxiety/antidepressant medication use, and poor safety awareness. Interventions included for staff ensuring a safe environment and educating Resident #6 about safety reminders and what to do if a fall occurs.Record review of Resident #6's Event Nurses' Note- Fall, dated 03/13/2026, it was noted: During AM rounds, resident was noted with redness to bilateral knees, noted with a knot to her right side of forehead and has a red swollen chin. During report, nurse did not get any report of incident. ADON notified, ADON contacted night CNA, he voiced she had a fall and picked her up from the floor, and was on her knees when found and forgot to report it to PM nurse. Vital signs were taken; the Physician and Responsible Party were notified on 03/13/2026.Record review of Resident #6's Patient Report, Mandible (jawbone), partial, dated 03/13/2026, had noted findings with no fracture or loose teeth seen. No acute findings.Record review of Resident #6's Patient Report, Left Knee, dated 03/13/2026, noted no acute findings.Record review of Resident #6's Patient Report, Right Knee, dated 03/13/2026, noted no acute findings.Record review of Resident #6's Neurological assessment dated [DATE], revealed Resident #6 was monitored from 06:30 AM to 2:15 PM, starting with every 15 minutes the first hour, every 30 minutes the second hour, and every 1 hour for four hours. Resident #6 was also noted to be monitored at 10PM-6AM shift, and 6AM-2pm shift the following day. There were no acute findings noted.In an observation on 04/22/2026 at 10:15 AM, Resident #6 was observed in her wheelchair with a dark brown scab on her right-side forehead, no redness, swelling, or bruising observed on her forehead or chin. Resident #6 was unable to answer this State Surveyor's questions coherently. Resident #6 was observed interacting with other residents and staff. Resident #6 did not display physical symptoms of pain, including grimacing or guarding. In an interview on 04/23/2026 at 10:25 AM with the Corporate Nurse, he stated he was not aware of Resident #6's fall incident that happened on 03/13/2026. He stated it was the Nursing Facility expectation for CNAs to remain with the residents if found on the floor and notify the nurse immediately. He stated this was protocol so the nurse could assess the resident before moving them, to prevent further injury.In an interview on 04/23/2026 at 11:57 AM with CNA R, he stated it was approximately 4:45 AM- 5 AM when he found Resident #6 on 03/13/2026. He stated Resident #6 was unable to state what happened to her. He stated he looked at Resident #6 and she appeared fine. He stated he was unable to locate the assigned nurse, so he moved Resident #6 back into her bed. CNA R stated he was trained and aware he was not to move any residents that experienced a fall until a nurse had assessed the residents. He stated he forgot to report it to the nurse until he was called by the ADON that morning. He stated it was expectation for CNAs to not to move residents after they fall until a nurse assessed them to prevent further injury. He also stated nurses need to assess residents for possible changes in alertness. He stated he was provided a verbal warning and in-service training for falls relating to the incident.In an interview on 04/23/2026 at 2:15 PM with the ADON, she stated she called CNA R on 03/13/2026 after being notified by the morning nurse of Resident #6's observed physical changes such as the redness and swelling of the chin. She stated CNA R reported finding Resident #6 on the floor that morning but failed to notify any of the nurses or nursing supervisors. She stated he had forgotten to report it to the nurse. She stated CNAs were expected to not move any residents after a fall until a nurse assessed the resident. She stated this was expectation because of potential further harm to residents. She stated a 1 to 1 was completed with CNA R, and he was provided a verbal warning and in-service training for falls.In an interview on 04/23/2026 at 3:44 PM with the Administrator, he stated it was expectation for CNAs to wait for the assigned nurse to assess residents after a fall. He stated that was the Nursing Facility's protocol. He stated there was possible risks to residents if CNAs failed to report falls to the assigned nurse or Nursing Supervisor. The Administrator did not want to elaborate on what the possible risks were to residents.Record review of the facility's Fall Policy, with no date, read in part under procedure: In instances where fall risk measures do not prevent a fall, the residents will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. It continued, The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #10) reviewed for infection control in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #10. These failures could place resident's at risk for cross contamination and the spread of infection. Finding included: Record review of Resident #10's electronic admission record dated 04/22/2026 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and constipation. He was [AGE] years of age. Review of Resident #10's care plan revised on 10/30/2025 indicated in part: Resident has bowel incontinence. Resident will not have any complications related to bowel incontinence. Check him frequently and assist with toileting as needed. Provide pericare after each incontinent episode. Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated in part: Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Observation on 04/21/2026 at 11:54 AM CNA A performed incontinent care for Resident #10. CNA A put on a pair of clean gloves and then undid the resident's brief. The CNA then took some wet wipes and wiped Resident #10's scrotum and penis. CNA A then turned the resident on his side and took some more wipes and wiped the resident's rectal area. The resident had had a bowel movement, so the CNA took some extra wipes and wiped the bowel movements from the resident's bottom. CNA A then removed the soiled brief and while still wearing the same gloves she took a clean brief and fastened it to Resident #10. The CNA then assisted the resident on his back and was done with the care. Interview on 04/21/2026 at 2:28 PM CNA A said that she should have changed her gloves before she took the clean brief and fastened it to the resident. The CNA said that she had gotten nervous when she had performed incontinent care for Resident #10. CNA A said that if she did not change her gloves after they became contaminated it could have led to infections and cross contamination. Interview 04/23/2026 at 2:42 PM the DON said what it was expected for the CNAs to remove their gloves once they became contaminated. The DON said the CNAs were then supposed to sanitize their hands before putting a new pair of gloves on. The DON said if the CNAs did not change their gloves there was a possibility of the spread of fecal matter and the spread of germs. The DON said they monitored staff by conducting periodic training and they also performed proficiencies for CNAs on a yearly basis. Interview on 04/23/2026 at 3:46 PM the Administrator said that he agreed with what the DON had said regarding the expectation of the CNAs changing their gloves after they became contaminated. The Administrator said that he was not a clinical nurse so he would agree with what the DON had said regarding the possible outcomes if the CNA had not changed her gloves. Record review of the facility policy titled Personal/Perineal Care dated 05/11/2022 indicated in part: An incontinent resident of urine and/or bowl should be identified, assessed and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Start: perform hand hygiene - [NAME] (put on) gloves and all other PPE per standard precautions - gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - clean to dirty. Doffing and discarding of gloves are required if visibly soiled. Always perform hand hygiene before and after glove use. Note skin changes and apply moisture barrier cream as directed. Doff (take off) gloves and PPE and perform hand hygiene. Record review of the facility's undated policy titled Infection Control indicated in part: The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Facility assessment/Infection prevention and control assessment tool for long term care facilities. At least annually and on an as-needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain an efficient and up to date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need.

Based on observation, interview, and record review, the facility failed to post, in a form and manner accessible and understandable to residents and, resident representatives: a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, and the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 2 of 5 (400-hall/Male Memory Care Unit, and 500-hall/Female Memory Care Unit) halls reviewed for posting of required information. The facility failed to post a written description of a resident's legal rights in an accessible area for the residents, including information about pertinent state client advocacy groups such as the State Survey Agency and the Ombudsman.This failure could place residents at risk of lack of knowledge of who to contact should they require advocacy, investigation, and not knowing their rights or how to exercise their rights. Findings included:In an observation on 04/22/2026 at 12 PM in the secured female Memory Care Unit, there were no postings regarding Resident Rights and state client advocacy groups.In an observation on 04/22/2026 at 12:10 PM in the secured male Memory Care Unit, there were no postings regarding Resident Rights and state client advocacy groups.In an interview on 04/23/2026 at 10:19 AM with CNA T, she stated there were no postings in the Memory Care Units. She stated the contact information for the Administrator was posted in all the Residents' rooms, and they could contact him for concerns. She stated there was not information in the memory care units regarding contacting the State Agency and/or the Ombudsman.In an interview on 04/23/2026 at 11:33 AM with RN U, she stated the purpose of the postings of the residents' rights and state client advocacy groups was for residents or their families to contact another party to resolve concerns. She stated residents and their families had the right to contact the State Agency or the Ombudsman if they felt the Nursing Facility was not addressing their concerns or attempting to resolve their issues. She stated the potential risk of residents not having contact information to the State Agency, or the Ombudsman included potential neglect.In an interview on 04/23/2026 at 3:41 PM with the Administrator, he stated there were no written postings regarding resident rights including information about the State Agency, or the Ombudsman in the memory care units. He stated his phone number was posted in the residents' rooms, and they were able to contact him for concerns. He stated he did not believe there were no potential risks of not having the posted information in the memory care units for the residents.Record review of the facility's Resident Rights policy, with no date, read in part under Information and Communication: 5. The facility must post, in a form and manner accessible and understandable to residents, and resident representatives: A. A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit.

Based on observation, interview, and record review the facility failed to ensure the residents had the right to examine the results of the most recent survey of the facility and the facility failed to post the results of the most recent survey in a place that is readily accessible to residents, family members, legal representatives of residents, and the public for 1 of 1 survey results binder reviewed. -The facility failed to ensure the annual survey results binder was accessible for residents, family members, and staff on 04/22/2026 at 11:30 AM. This failure placed residents, family members, and legal representatives of the residents at risk of not being informed of the facility's survey and investigation results causing.Findings included: During an observation conducted on 04/22/2026 at 11:30 AM, the annual survey results binder was not locatable in an easily accessible area near the entrance or nurse's station. On 04/22/2026 at 11:32 AM, The Administrator obtained the survey results binder from a cabinet located outside his office doorway. There was no sign postage that alerted passersby that the survey results binder was in the cabinet. In an interview on 04/22/2026 at 11:33 AM with The Administrator stated the binder was inside the cabinet by the front entrance with no sign postage or notice of survey results binder. He stated it was accessible because anyone could open the cabinet and locate the survey results binder inside. He stated that there were issues of residents taking it to their rooms and using it as a coloring book when he first began working at the facility in January 2026. He stated that he did not know if the binder needed to be out in the open or if it was fine to be in the cabinet. He stated he would need to review policy and regulation to see if there was placement required for it. He stated he did not see anything wrong with the placement of the survey results binder being inside the cabinet. In a follow-up interview on 04/23/2026 at approximately 3:50 PM the administrator stated there was no facility policy for the annual survey results binder. In an interview on 04/22/2026 at 11:37 AM with CNA stated the binder was located in the front in a basket by administrator's office. She stated it should be on top of the cabinet but there were residents who messed with it and altered the contents. She stated that it was a resident's right to look at it. She stated it was not acceptable for the binder to be tucked away in the cabinet and it needed to be out at all times for the public to access. She stated the contents included compliance with the state survey and investigation results. She stated it was HR or The Administrator's responsibility to update it and to ensure it was accessible at all times. She stated that residents and families would not know where it was and the information it contained if it was not in plain sight. She stated that it was a resident's right to have access and read it without asking for the information. She stated the last in service she received for resident rights was a week ago with education and comprehension evaluation. In a confidential group interview on an undisclosed date and time, 8 of the 10 residents that attended did not know where the survey results binder was located and what the contents of the binder were. In an interview on 04/23/2026 at 10:14 AM with LVN stated she had been a nurse for 7 years and worked at the facility for 3 years. She stated that the survey results binder used to be on the wall near the nurses station but she does not know where it was relocated to. She stated if a resident asked her to help them locate it she would notify her superiors. She stated that the results have to be in the open and accessible for anyone to obtain. She stated it was not acceptable for the binder to be in the cabinet without signage. She stated that everyone had the right to review the survey results binder to include family, residents, and visitors. She stated she did not know who was in charge of updating it or placing it in an open and accessible location. She stated the contents of it included the failures, facility's corrections, and results of the survey. She stated if it was not accessible then the residents and visitors would not have knowledge as to what the survey team's findings were. In an interview on 04/23/2026 at 2:48 PM with The ADON stated the survey results binder was in the front of the building in the basket, but sometimes it has to be placed in the cabinet because residents would take it. She stated it was not acceptable for the binder to be in the cabinet without the signage posting for it. She stated it contained the results of the annual survey and investigations and identified The Administrator was responsible for updating it. She stated it was a resident's right to have access to the results. She stated it affected residents and family because they could miss out on findings discovered by the state on the facility. She stated she had not provided an in service or training to staff regarding contents of the binder and where it could be located. Record review of the facility's Resident Rights policy, with no date, under Information and Communications, read in part: 10. The resident had the right to- a. examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. It continued to read, 11. The facility must- a. Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. And, C. Post notice of the availability of such reports in areas of the facility prominent and accessible to the public.

Based on observation and interview the facility failed to ensure the daily nursing staffing was posted as required for 3 of 3 days in that, The facility did not post the daily staffing in a prominent place readily accessible to residents and visitors.This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.Findings include:In an observation on 04/22/2026 at 11:25 AM, the staffing schedule and census was posted in the main Nurse's station behind the desk, and by the backwall, not accessible to residents in wheelchairs or residents with visual impairments. The nurse's station area had 2 open walkways located on each side of the desk serving as the Nurse's station, with only Nursing Facility staff walking through and behind the desk. In an interview on 04/22/2026 at 11:29 AM with CMA N, she stated the schedule staffing information was only located in the main nurse's station behind the desk. She stated there was no staffing schedule in either memory care unit. She stated the purpose of the staffing schedule was for residents and staff to be aware of the census and what units staff were assigned to.In an interview on 04/23/2026 at 10 AM with RN S, she stated the staffing schedule was only located behind the main Nurse's station. She stated she did not believe residents were able to observe the schedule information because it was located on the wall behind the Nurse's station. She stated the purpose of the staffing schedule was for staff and residents to see the amount of staffing coverage.In an interview on 04/23/2026 at 10:19 AM with CNA T, she stated the staffing schedule and census information was located at the main Nurse's station, located behind the desk. She stated she did not think residents or visitors were able to observe the information from the nurse's station, and the residents or visitors were not allowed behind the desk. She stated she did not believe it was readable because of the location of the postage being behind the desk of the Nurse's station. In an interview on 04/23/2026 at 3:39 PM with the Administrator, he stated the ADONs currently assisted with posting daily census and staffing schedule. He stated the purpose of the census and staffing schedule being posted was for everyone to be aware of the resident census and staffing census. He stated he believed residents and visitors were able to observed the information and did not see potential risks of not having the information readily visible and accessible.On 04/23/2026 at 9:00 AM, the Administrator stated the facility did not have a policy for scheduled staffing, and the facility followed state regulations.Record review of Texas State Regulations, read in part: 483.35(g)(2) Posting Requirements (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents, staff, and visitors.

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) of four residents reviewed for nutrition. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 11.47% weight loss in 80 days. He had an active decline in his weight from 12/1/25 - 02/18/26. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization. Findings included: Review of Resident #1's admission record on 2/18/2026 reflected he was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), diabetes mellitus (a group of metabolic diseases characterized by high blood sugar levels), dementia (decline in mental ability), anxiety disorder (mental health condition characterized by excessive fear). Review of Resident #1's admission MDS assessment, dated 12/8/26, reflected a BIMS score of 2, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he required Setup or clean-up assistance with eating. Section K (Swallowing/Nutritional Status) reflected that he was on regular diet. Section K0300 (Weight Loss) reflected that he had no weight loss, and he was not on physician- prescribed weight-loss program. Review of Resident #1's care plan revised 12/4/2026 reflected that Resident#1 was at risk for malnutrition. The interventions included: Determine food preferences as needed, monitor and document amount consumed, monitor weight per facility protocol, serve diet as ordered, notify physician for any negative findings. Review of Resident #1's weights reflected an active decline in his weight from 12/10/25 - 2/18/26. Resident #1 weight on 12/1/25 reflected 191.8 pounds, on 12/10/2026 185.6 pounds, and a weight of 169.80 pounds on 02/18/26. Review of Resident #1's Nutrition Assessment, dated 12/16/2025 and documented by the RD, reflected the following: Height:69.0, Weight: 185.6. Diet order was regular, and texture Order was Regular, and that Residents#1 Food Intake was 25-100%. Review of Resident #1's meal intake for documentation for January and February reflected he consumed 25-100% of his meals. Record review of Resident #1's weight watchers' assessment dated [DATE] revealed resident had a 14.4-pound weight loss. Interventions included red glass initiated and 2 cal supplement with each med pass. Record review of the list of residents on the red cup program (a program in which residents received a red cup at meals to alert staff that they were at risk for weight loss/malnutrition) did not include Resident #1. Record review of Resident #1's order summary for January 2026 revealed no supplement or red glass program in physician orders. Record review of Resident #1's order summary for February 2026 revealed no supplement until 2/13/2026. On 2/13/2026 an order for Boost twice daily was implemented. No red glass program in physician orders. During an observation on 2/18/2026 at 12:35pm during lunch meal Resident#1 only took two bites of his food that was served at lunch and kept leaving the table. Resident#1 declined offer for alternative food from CNA A. Resident #1 accepted a boot supplement. During an interview on 2/18/2026 at 3:58 PM with the DM revealed that the DON was responsible for monitoring residents' weight loss, dietary recommendations, and also which residents needed to be on the Red Glass program . The program alerts staff to pay attention to the resident on the program to monitor their intake closely. She stated that if a resident were placed on the red glass program the charge nurse would send a communication slip to dietary. She stated that the DON reports to the dietician and she monitors weight loss and decides if a supplement is needed. DM stated Resident #1 was not on the snack list but kitchen does send extra snacks. DM was not aware of Resident #1's weight loss. During an interview on 2/18/2026 at 4:10pm with the Director of Nursing she stated she recently became aware of Resident #1's weight loss, as she was the individual who entered weights into the electronic charting system. She stated that she has been in this position for a week and did implement a supplement for Resident #1 on 2/13/2026. She stated she felt as though Resident #1 should have weekly weights as well as supplements for extra nutrition. She also stated Resident #1 should have been placed on the facility's Red Glass program. DON stated Resident #1 did not have a decline because of the weight loss. The Director of Nursing stated a negative outcome of weight loss could be impaired skin integrity, decreased nutritional status. During an interview on 2/18/2026 at 4:15pm with RN D she stated Resident #1 has had some weight loss and does not eat well. RN D stated if Resident #1 does not eat they offer alternatives and snacks. RN D stated staff visualize how much residents eat and enter the consumption into electronic health record. RN D stated CNA's notify nursing if someone eats less than they normally do or if a resident doesn't eat at all. RN D stated resident did not have a decline due to weight loss. During an interview on 2/18/2026 at 4:46pm with OTA she stated Resident #1's fine motor skills were intact and he did not require assistive devices while eating. OTA stated Resident #1 has not declined and is still at his prior level of function. During an interview on 2/18/2026 at 4:55pm with ADON she stated she entered a weight watcher assessment for Resident #1 on 1/15/2026 and intended to put interventions in place of red glass program and 2 cal supplement with each med pass. ADON stated that she forgot to enter it into the physician orders to implement these interventions. ADON stated a negative outcome of not implementing physician orders for weight loss could be continued weight loss. ADON stated that they just got a DON and she had been trying to balance completing all the tasks. During an interview 2/19/26 at 11:00 AM with the Dietician (RD), she stated she completed an assessment on Resident #1 on admission [DATE] and recommended house supplements three times daily. RD stated these should have been entered into the electronic health record as a physician order. She stated she receives a monthly report on weight loss and Resident #1 was not on the list she received in January 2026. RD stated interventions for weight loss program include red glass program, weight watchers, fortified food, snacks, and supplements. RD stated effectiveness of interventions are monitored by monitoring weights and sometimes lab work. She stated Resident #1 could definitely be put on a supplement and/or increased weights for additional weight support. She stated she does not necessarily monitor the facility's Red Glass program; she was not sure who monitored this program. RD stated the risk of not carrying out these interventions could be continued weight loss, loss of lean muscle mass, and pressure wounds. RD stated Resident #1 has not had any negative outcomes due to weight loss and was still above his ideal body weight. During an interview on 02/19/2026 at 11:45AM with a CNA C who was assigned to Resident #1's care, she stated she could not tell that Resident #1 had lost weight. CNA C stated that the resident required set up at meals but can feed himself with a lot of encouragement. CNA C stated if residents don't eat, they offer health shakes. She also stated Resident#1 was not on the red cup program and that staff was required to pay extra attention to resident on the Red Cup program. CAN C stated Resident #1 has not had a decline in function due to the weight loss. During an observation on 2/19/2026 at 12:10PM during lunch meal Resident #1 would not stay seated at table and kept rolling away despite staff encouragement to eat. Did not observe an alternative or supplement offered at this time. During an interview on 2/19/2026 at 2:07PM with Nurse Practitioner she stated she last assessed Resident #1 on 2/18/2026 and she was unaware of the weigh loss and felt like if he lost that much weight she would have known. NP stated she should have been notified of the weight loss. NP stated they can use appetite stimulants for weight loss. NP stated Resident #1 was still functioning the same and it did not cause him harm as she did not see a decline. She said the risk for harm with weight loss differs for every resident. NP did state that due to dementia and the disease process some weight loss is expected. Review of the Facility' Resident Weight policy reflected that the following assessments and Recognition:Nursing Policy & Procedure Manual undatedAll residents will be weighed by the 10th of the month and their weights documented correctly. Appropriate actions regarding significant changes will be carried out.Procedure:1. Weights shall be obtained and documented at admission, readmission, and monthly unless ordered otherwise by the physician, or unless dictated more frequently by the residents' condition. Factors indicating the need for more frequent weights include significant weight loss, drastic decrease in food consumption, prolonged nausea, vomiting, or diarrhea, significant weight gain, swelling or edema, poor appetite during adjustment period to the facility, recent change from tube feeding to oral intake, or pressure ulcers that are not resolving as expected.The Dietary Profile will be completed upon admission and quarterly thereafter by the dietary manager. The Nutrition Risk Assessment form will be completed by the Registered Dietitian upon admission, annually, and updated if the resident has a significant change. The RD and dietary manager will also chart in the dietary Progress Notes as needed regarding visits, nutritional issues, updates to food preferences, etc.4. All residents must be weighed as indicated, unless otherwise ordered by the attending physician. Pre-medicate resident for pain or discomfort, as per physician's orders, as needed prior to weighting.7. Significant Weight LossThe facility reviews resident weights after monthly weights are obtained, to determine residents with significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months. The weight change will be recorded on the appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the designated location. The physician and family will be notified. In addition, an acute care plan for weight loss will be initiated and the clinical record reviewed for possible need of a significant change of condition MDS assessment. Assess the resident for possible reason for weight loss to include:9. All significant weight changes will be referred to the Regional Dietitian on the next visit. The Regional Dietitian will generate a copy of the facility weight report and can review the weight watchers' forms in PCC. The Regional Dietitian will complete an assessment on all significant weight losses. The Regional Dietitian will review all facility interventions, and will make appropriate recommendations, which will be approved by the physician, if necessary.

Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 5 (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for sufficient staffing related resident-to-resident altercations and 1:1 monitoring. 1. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring from a previous altercation on 05/25/2025. 2. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. 5. The facility failed to ensure Hall 400 (male secured unit) had sufficient staff to provide 1:1 monitoring for Resident #1 on 05/25/2025 from 10:00pm-6:00am. 6. The facility failed to ensure Hall 500 (female secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/04/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. 7. The facility failed to ensure Hall 500 (male secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/08/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025 at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 06/20/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dining room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident ##1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, CMA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she 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, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dining room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 and Secure Hall 400 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they are responsible for multiple halls. Review of the facility daily staff schedule, dated 05/25/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with one (1) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on 05/25/2025 from 10:00pm-6:00am, revealed it was signed LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/04/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-K and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 2:00pm-10:00pm, was signed by one of the CNAs (CNA-K) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/04/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/08/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-N and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 from 2:00pm-10:00pm, was signed by one of CNAs (CNA-L) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/08/2025, revealed during the 10:00pm to 6:00am shift, there was (2) CNA (CNA-O and CNA-P) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on Secure Hall 400 and Resident #2 on Secure Hall 500 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. During an interview on 06/20/2025 at 10:15pm, with CNA-O who worked 10pm-6am stated that he worked many shifts alone and he was responsible for covering Secure Hall 400 and Secure Hall 500 at the same time. He stated he also worked alone when residents were on 1:1 monitoring. He stated 1:1 monitoring should be where the staff is within arm's length of the resident, but that was not possible when he was the only CNA and was responsible for both halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 means that 1 staff is with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. During an interview on 06/23/2025 at 8:00pm, the ADO stated the facility did not have a staffing policy. This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue to monitor with random interviews and weekly skin assessments, and address if issues are identified. Primary contact for each resident on the secure unit to be contacted on 6/23/2025 by the DON/Compliance Nurse [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for resident-to-resident altercations. 1. The facility failed to prevent supervision of Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient supervising staff to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 5. The facility failed ensure Hall 500 (female secured unit) had sufficient supervising staff to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025 at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm at a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 12/13/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:35 pm, signed by DON: .Resident saw another resident enter his room, he walked to his room and yelled at the other resident. When other resident did not move out fast enough, he punched other resident in the face. Another resident was walking backward, and this resident shoved him causing a fall. No injuries to Resident #1. Stated not in pain. Other resident was sent to the emergency room after hitting head on floor. Initial Treatment/New Orders: skin assessed. 1:1 monitoring, referral to impatient psyc notified: psych center 05/25/2024 at 4:45pm .Interventions 1 on 1 supervision, Redirection. 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dinning room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident ##1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, CMA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident, but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she 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, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dinning room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 and Secure Hall 400 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they are responsible for multiple halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 means that 1 staff is with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. During an interview on 06/23/2025 at 8:00pm, the ADO stated the facility did not have a policy regarding accidents and hazards. This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue to monitor with random interviews and weekly skin assessments, and address if issues are identified. Primary contact for each resident on the secure unit to be contacted on 6/23/2025 by the DON/Compliance Nurse to inquire about any concerns related to resident safety/abuse. These will be reviewed by the DON/Facility Administrator, Regional Compliance Nurse, and ADO for follow up and to address concerns identified. All resident responsible party contacts will be initiated/completed by 6/23/2025. Trauma informed assessment (to determine historical or present trauma based on resident perspective) completed by Compliance, DON and ADON on residents in the secured unit with history of physical aggression and assessment were completed on 06/22/2025. No trauma was identified during these assessments. On 6/23/2025, skin assessments were completed by DON and Compliance Nurse to assess for signs of physical trauma. Off cycle QAPI done with Dr. medical director via telephone on 06/22/25 by facility DON. No recommendation made by the medical director at this time. The following in-services were initiated by Facility DON on 06/22/25. Any staff member who is not present during the in-service will not be allowed to assume their duties until in-service. All in-services sent via staffing application to all staff on 06/22/25. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Management of aggressive behavior One-to-one monitoring Prevention of Resident-to-Resident physical Abuse On 6/23/2025, 1:1 in-service for Administrator by ADO regarding staffing adjustment as needed based on acuity to maintain resident safety. After receiving education, a handout is given to the staff members to have on their person in case a question arises and random interviews with staff members are ongoing to assess understanding. These will be completed by DON/Compliance team/ADO. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/23/2022 at 7:00 PM through 06/24/2022 at 10:30 AM revealed: Review of facility documents revealed written interviews by the DON with Resident #2, Resident #1, and Resident #7, with no concerns voiced. Review of facility fax receipts revealed referrals were faxed on 06/21/2025 to 6 different facilities for Resident #2. Review of facility documents revealed 9 staff were interviewed by DON for Resident #2, 5 staff were interviewed for Resident #7, 4 staff were interviewed for Resident #1, and 2 staff were interviewed for Resident #9. The questions asked where: Are you aware of any triggers for resident? What time of day are her behaviors worst? Is there anything they like? Are there any recommendations to improve care? And are there any co[TRUNCATED]

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 resulting in a skin tear to her arm for Resident #5 on 06/04/2025. 4. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #5 by slapping her across the face on 06/08/2025. 5. The facility failed ensure Hall 500 (female secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #6 resulting in a skin tear to the cheek for Resident #6, while Resident #2 was supposed to be on 1:1 monitoring on 06/08/2025. 6. The facility failed to ensure Hall 400 (male secured unit) had sufficient staff to provide 1:1 monitoring for Resident #1 on 05/25/2025 from 10:00pm-6:00am. 7. The facility failed to ensure Hall 500 (female secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/04/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. 8. The facility failed to ensure Hall 500 (male secure unit) had sufficient staffing to provide 1:1 monitoring for Resident #2 on 06/08/2024 from 2:00pm-10:00pm, and from 10:00pm-6:00am. An Immediate Jeopardy (IJ) situation was identified on 06/22/2025. The IJ template was provided to the facility at 4:05 pm. While the IJ was removed on 06/24/2025 at 10:30 am, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm at a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for resident-to-resident altercations and serious harm in the event of an emergency, hospitalizations, and even death. Findings included: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 12/15/2023, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, heart failure, and alcohol dependence. Review of Resident #1's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: no antipsychotic, antianxiety, or antidepressant medications. Review of Resident's #1's Care Plan, last review 06/10/2025, revealed in part: Focus: Resident demonstrates physical behaviors hits other residents and staff, revised on 04/14/2025. Goal: Resident will not harm self or others through the review date, revised on 06/10/2025. Interventions: 1:1 supervision as needed, revised on 12/13/2024. Further review of care plan revealed no interventions added since 12/13/2024. Review of Resident #1's progress notes revealed: 05/25/2025 10:35 pm, signed by DON: .Resident saw another resident enter his room, he walked to his room and yelled at the other resident. When other resident did not move out fast enough, he punched other resident in the face. Another resident was walking backward, and this resident shoved him causing a fall. No injuries to Resident #1. Stated not in pain. Other resident was sent to the emergency room after hitting head on floor. Initial Treatment/New Orders: skin assessed. 1:1 monitoring, referral to impatient psyc notified: psych center 05/25/2024 at 4:45pm .Interventions 1 on 1 supervision, Redirection. 05/25/2025 10:45 pm, signed by DON: .CMA-A walking into the dining room, heard two residents having a verbal altercation then saw Resident #1 hit another resident in the face. When the other resident was swinging back, he slid out of his chair onto the floor .Initial Treatment/New orders: skin assessed, 1:1 monitoring, send referral to inpatient psych . notified psych center 05/25/2025 at 6:50pm .Interventions 1 on 1 supervision, Redirection. 05/27/2025 at 1:00 pm, signed by ADON: Resident #1 was transferred to a hospital on [DATE] at 1:00 PM related to resident had aggressive behaviors and was sent to psych facility for evaluation and treatment. Resident #3 Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with initial admit date of 02/20/2024, to Hall 400 (male secured locked unit) with diagnoses which included: explosive disorder, depression, and dementia. Review of Resident #3's Quarterly MDS assessment, dated 05/22/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. E0900. Wandering: behavior not exhibited. Section N: Medications: antidepressant medications. Review of Resident's #3's Care Plan, last review 05/29/2025, revealed in part: Focus: Resident is at risk for wandering, revised on 02/21/2024. Goal: Resident's safety will be maintained through the review date, revised on 05/29/2025. Interventions: Distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 02/21/2024. Identify pattern of wandering, revised on 02/21/2024. Further review of care plan revealed no interventions regarding wandering added since 02/21/2024. Review of Resident #3's progress notes revealed: 05/25/2025 4:53 pm, signed by RN-B: Resident #3 was transferred to a hospital on [DATE] PM related to resident altercation on another resident. Resident was knocked to the ground and hit his head on the found resident sent out for further Evaluation. 05/25/2025 10:58 pm, signed by DON: .Resident wandered into another resident's room. Other resident came in starting verbal altercation. When this resident did not move fast enough the other resident punched him in the face. The resident was backing up trying to exit room and fell landing on left lateral. 911 was called immediately. Skin assessed and previous left elbow skin tear was bleeding and noted to be bigger in size. No pain .Physician notified on 05/25/2025 6:45 PM . Review of the Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 4:20 pm, Resident #3 went into Resident #1's room. Staff heard yelling and saw Resident #1 hit and push Resident #3. Resident #3 fell to the floor and hit his head on the floor and sent to emergency room to be further evaluated. Resident #3 had laceration to back of heat with hematoma, no bleeding, no signs of infection, closed with 3 staples, measurements 1.5x2x0.5cm, hematoma measures 4x5x0.5cm, hematoma to left side of head measurements 3x3cm, bruises to bilateral upper extremities, reopened skin teas to left elbow with part of skin fold missing, no bleeding, no signs of infection, measurements 2x2.5x0.1cm, no other skin issues noted at this time. Facility initiated one on one monitoring with Resident #1. Contacted psych services. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed 2 CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the 2 CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Resident #4 Review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with initial admit date of 03/25/2024, to Hall 400 (male secured locked unit) with diagnoses which included: personality change, depression, and dementia. Review of Resident #4's Quarterly MDS assessment, dated 05/30/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 physical behavioral symptom directed towards others. Section N: Medications: antidepressant medications. Review of Resident's #4's Care Plan, last review 06/19/2025, revealed in part: Focus: Resident has a potential for trauma that may have a negative impact. The trauma is related to physical altercation, revised on 05/26/2025. Goal: Staff will assist in avoiding triggers through next review date. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediate to the nurse. Record review of Resident #4's progress notes revealed: 05/25/2025 11:09 pm, signed by DON: .The fall caused a skin tear to left elbow. Size of the skin tear in cm: 0.5 x 0.5. New/bleeding, a verbal altercation between this resident and another resident was overheard. CMA- A walked into dining room and saw another resident hit this resident in the face, when Resident #4 tried to swing back he slid out of his chair. Upon assessment a skin tear to the left elbow was noted. Stated it did not hurt . Review of the Provider Investigation Report, dated 05/31/2025, revealed: on 05/25/2025 at 6:30 pm, Resident #1 slapped Resident #4 and when Resident #4 tried to swing back he slid out of his chair. Upon his assessment a skin tear to the left elbow was noted, measurements 0.8x0.7x0.1cm. Facility initiated one on one monitoring with Resident #1. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 05/25/2025 at the time of the incident, revealed (2) CNAs (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with a census of 19 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #1 revealed 1:1 monitoring started on 05/25/2025 at 4:45 pm and was signed by the (2) CNA's (CNA-C and CNA-D) assigned to Hall 400 (male secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 1:35 pm, the DON stated that both secure units were always staffed with 2 CNA's each on all shifts except night shift which had 1 CNA per unit. She stated that if a resident was placed on 1:1 monitoring, an additional staff was added making 3 CNAs or 2 CNAs on 10:00pm-6:00am shift. During an interview on 06/20/2025 at 12:45 pm, CNA- C stated she was on shift on Secure Hall 400 at the time of these incidents with Resident #1. She stated on 05/25/2025, there was only herself and 1 other staff to supervise the 19 residents plus provide 1:1 monitoring with Resident #1 that required the resident to always be within arm's reach. She stated the locked unit was also having issues with the locked doors on the unit not functioning; therefore, they also had to monitor the doors, the residents, and provide 1:1 of Resident #1 within arm's reach. She stated that Resident #1 was placed on 1:1 monitoring but no extra staff was sent. She stated that at the time of the second incident Resident #1 was in the dining room and no staff was present. She stated she worked the secure unit alone often and had never been given extra staff when residents were placed 1:1 monitoring requiring residents to be within arm's reach. During an interview on 06/20/2025 at 8:00 pm, LVN-G stated she was responsible for Secure Hall 400 and Secure Hall 500 on 05/25/2025 from 2pm-10pm. She stated she was on Secure Hall 500 at the time of the first incident. She stated she was back on Secure Hall 500 when the 2nd incident happened. She stated Resident #1 was supposed to be on 1:1 monitoring because of the previous incident, when the 2nd incident happened, and she did not know why he was not. She stated there were only 2 CNAs covering Secure Hall 400 at the time and that there was no way that the LVN could help with 1:1 monitoring because she was responsible for both secure halls. During an interview on 06/20/2025 at 8:15 pm, MA-A stated he was working on 05/25/2025 at time of both incidents and stated that he was in a resident's room during the 1st incident with Resident #3 and did not see that incident, but he knew that he was placed on 1:1 monitoring. He stated that he was walking down the hall, when the 2nd incident happened and heard Resident #1 yelling then he spotted Resident #1 in the dining room with no staff present and saw him slap Resident #4. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 02/09/2024, to Hall 500 (female secured locked unit) with diagnoses which included: traumatic brain injury, anxiety, depression, and dementia. Review of Resident #2's Quarterly MDS assessment, dated 05/20/2025, revealed a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: - Presence and Frequency: 1 other behavioral symptom not directed towards others. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #2's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors attempts to hit other residents, revised on 04/09/2025. Goal: Resident will not harm self or others through the review date, revised on 05/22/2025. Interventions: When she 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, revised on 11/18/2024. Record review of Resident #2's progress notes revealed: 06/04/2025 11:13 am, signed by LVN-E: .resident started being anxious and agitated. resident grabbed another resident arm causing a skin tear . resident is currently on 1:1 for monitoring .: 06/08/2025 12:19 pm, signed by LVN-F: . nurse was called by resident in hallway, that resident has just slapped another resident across the face. psych facility contacted, and 1:1 supervision. 06/08/2025 1:09 pm, signed by LVN-F . resident was grabbing another female resident by her cheeks and would not let her go, staff intervened but resident would not let other resident go. Resident #5 Review of Resident #5's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with initial admit date of 06/10/2020, to Hall 500 (female secured locked unit) with diagnoses which included: anxiety, Alzheimer's, and mood disorder. Review of Resident #5's Annual MDS assessment, dated 06/04/2025, revealed a BIMS score of 99 which indicated resident was unable to complete the interview. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms: behavior not exhibited. Section N: Medications: antianxiety and antidepressant medications. Review of Resident's #5's Care Plan, last review 04/10/2025, revealed in part: Focus: Resident has a history of trauma that may have a negative impact. The trauma is related to getting scratched, revised on 06/05/2025. Goal: Maintain resident safety and integrity during post trauma episode, using appropriate interventions, revised on 06/05/2025. Interventions: Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse, revised on 06/05/2025. Record review of Resident #5's progress notes revealed: 06/05/2025 10:38 am, signed by LVN-E: . resident received a skin tear due to another resident grabbing her arm. Physician notified on 06/04/2025 at 10:10am. 06/08/2025 12:29pm, signed by LVN-F: . Resident voices she was slapped across the face by the other female resident. Review of the Provider Investigation Report, dated 06/11/2025, revealed: On 06/04/2025 at 10:00am, Residents were sitting at the table in dining room when Resident #2 reached over and grabbed Resident #5's arm causing a skin tear. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/04/2025 at the time of the incident, revealed (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:15am-2:00pm, was signed by the (1) CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. During an interview on 06/19/2025 at 2:00pm, CNA-J said she was on shift on Secure Hall 500 at the time of this incident with Resident #2 on 06/04/2025. She stated there was supposed to always be 2 CNAs, but she worked many times by herself. She stated that when a resident is placed on 1:1 monitoring the 2 CNAs on shift rotated and monitored them as close as possible. She stated it was very rare that a third CNA was sent. She stated she had worked on the floor multiple times alone with a resident on 1:1 monitoring. She stated when a resident was 1:1 the staff was supposed to be within arm's length of them at all times and must follow them wherever they go. She stated she could not remember specific dates or incidents because there were so many incidents and 1:1 monitoring that she couldn't remember them all. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] to Hall 500 (female secured locked unit) with diagnoses which included: explosive disorder, Alzheimer's, and seizures. Review of Resident #6's Quarterly MDS assessment, dated 05/26/2025, revealed a BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS revealed: Section E: Behavior: E0100 no potential indicators of psychosis. E0200. Behavioral Symptoms- Presence and Frequency: 1 physical behavioral symptom director towards others. Section N: Medications: no antianxiety, antipsychotic, or antidepressant medications. Review of Resident's #6's Care Plan, last review 05/22/2025, revealed in part: Focus: Resident has potential to demonstrate physical behaviors, revised on 02/16/2024. Goal: Resident will demonstrate effective coping skills through the review date, revised on 05/22/2025. Interventions: Assess and anticipate her needs: food, thirst, toileting needs, comfort level, body positioning, pain, revised on 08/29/2023. Record review of Resident #6's progress notes revealed: 06/08/2025 1:28pm, signed by LVN-F: . Resident was in her wheelchair looking outside, when the other female resident came up to her and grabbed her face and started being combative, nurse/aide intervened but other resident would not let her go. Review of the Provider Investigation Report, dated 06/13/2025, revealed: On 06/08/2025 at 12:00pm, Resident #2 hit Resident #5 with no injuries. She then grabbed Resident #6 by the face causing a very small scratch to her cheek. Resident #2 was placed on 1:1 monitoring. Investigation Findings: Confirmed. Review of the facility daily staff schedule, dated 06/08/2025 at the time of the incident, revealed (1) CNA (CNA-M) and a float CNA (CNA-J) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the 1:1 monitoring sheet for Resident #2 on 06/08/2025 revealed 1:1 monitoring was not initiated until 1:00 pm after the 2nd incident. 1:1 monitoring sheet was signed by RN-B who was assigned as a nurse for Hall 100 and Hall 200. During an interview on 06/21/2025 at 9:00 am, LVN-F stated she was responsible for Secure Hall 500 on 06/08/2025 from 2pm-10pm. She stated that Resident #2 was supposed to have been placed on 1:1 monitoring after the 1st incident but there was no staff available. She stated Resident #1 and Resident #6 were in the dining room alone when she heard Resident #6 screaming. She stated the LVNs cannot provide 1:1 monitoring because they were responsible for multiple halls. Review of the facility daily staff schedule, dated 05/25/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with one (1) of the 36 requiring 1:1 monitoring. Review of the 1:1 monitoring sheet for Resident #1 on 05/25/2025 from 10:00pm-6:00am, revealed it was signed LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 2:00pm-10:00pm, was signed by one of the CNAs (CNA-K) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/04/2025, revealed during the 10:00pm to 6:00am shift, there was (1) CNA (CNA-H) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #2 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. Review of the facility daily staff schedule dated 06/08/2025 from 2:00pm-10:00pm, revealed (2) CNA (CNA-N and CNA-L) assigned to Hall 500 (female secured locked unit) with a census of 16 residents with known behaviors. Further review of staff schedule revealed no additional designated CNA for 1:1 monitoring for Resident #1 per the facility in-service and DON's interview. Review of 1:1 monitoring sheet for Resident #2 on 06/08/2025 from 2:00pm-10:00pm, was signed by one of CNAs (CNA-L) assigned to Hall 500 (female secured locked unit) with no evidence of an additional designated CNA for 1:1 monitoring for Resident #2 per the facility in-service and DON's interview. Review of the facility daily staff schedule, dated 06/08/2025, revealed during the 10:00pm to 6:00am shift, there was (2) CNA (CNA-O and CNA-P) assigned for Secure Hall 400 and Secure Hall 500 for 36 residents with (2) of the 36 requiring 1:1 monitoring. Review of 1:1 monitoring sheet for Resident #1 on Secure Hall 400 and Resident #2 on Secure Hall 500 on 06/04/2025 from 10:00pm-6:00am, revealed it was signed by LVN-I who was assigned as the nurse for Secure Hall 500, Secure Hall 400, and hall 100. During an interview on 06/20/2025 at 10:15pm, with CNA-O who worked 10pm-6am stated that he worked many shifts alone and he was responsible for covering Secure Hall 400 and Secure Hall 500 at the same time. He stated he also worked alone when residents were on 1:1 monitoring. He stated 1:1 monitoring should be where the staff was within arm's length of the resident, but that was not possible when he was the only CNA and was responsible for both halls. During an interview on 06/20/2025 at 12:30pm, the ADON stated the secured units were supposed to be staffed with 2 CNAs each during the day and 1 CNA each on 10pm-6 am shift. She stated when a resident was placed 1:1 monitoring, and additional staff member was supposed to be designated for that resident. She stated they pull staff from other departments such as dietary and housekeeping to perform 1:1 monitoring. She stated 1:1 meant that 1 staff was with that resident at all times. The ADON stated that on the night shift, if there was only 1 CNA assigned to both secure units, the LVN would stay on the opposite unit and monitor it. She stated resident were usually asleep on that shift, so she felt that 1 person on each unit was enough even when a resident was on 1:1 monitoring. During an interview on 06/20/2025 at 3:30pm, the DON stated that she was not aware of any times that there was not a designated staff for residents on 1:1 monitoring. She stated did not know how Resident # 1 and Resident #2 were able to get into 2nd altercations while on 1:1 monitoring. She stated she felt the facility was doing a good job preventing altercations and injuries. She stated that she did not feel that the facility was short staffed. Review of the facility document dated 05/25/2025 titled In-service training report, reflected: Subject: 1:1 Monitoring. When a resident is on 1:1 monitoring, the person designated to monitor has to be with that resident at all times. Not just with in eyesight. Not in the same room as them. Not having him in an area where all employees can keep an eye out. There needs to be one designated person who will be filling out the monitoring sheet that is within arm's length. This is so we can quickly intervene, if needed. Review of facility policy titled, Abuse/Neglect; not dated, revealed, in part: The resident has 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, and any physical or chemical restraint not required to treat the residents medical symptoms . This was determined to be an Immediate Jeopardy (IJ) on 06/22/2025 at 4:05pm. The Regional Compliance Nurse, Director of Nurses, and Assistant Director of Nurses were notified. The Regional Compliance Nurse was provided with the IJ template on 06/22/2022 at 4:05 PM. The following Plan of Removal was accepted on 06/23/2025 at 6:20 PM and included: Interventions: Any resident that resides in the secure unit that has the potential for resident-to-resident altercation can be affected by deficient practices. Alleged perpetrator Resident #2 was interviewed by DON on 06/22/26 @ 6:15pm with no concerns voiced by resident and placed on 15-minute checks for resident safety and the safety of other resident in the secure unit and continued for at least 24 hours. Resident #1 was interviewed on 06/23/25 by DON and voiced no concerns and did not recall being aggressive with any other resident. Resident #7 was interviewed on 06/23/25 by DON and resident did not voice any concerns and could not recall being aggressive with any other resident. Resident #8 is not at the facility for an interview on 06/23/25 and Resident #9 is not at the facility for an interview on 06/23/25. Abuse prevention in-service for all facility staff initiated in house and completed by Admin/DON/Compliance Nurse on 06/22/2025 and for staff that is not present during the in-services will be sent the in-service via staffing application and they be not be allowed to assume duties until in-service prior to them clocking in for their shift and all new staff or agency staff will be in-services on abuse prior to them starting their position. All in services to be completed by 6/23/2025. Immediate psychiatric services on call for residents that trigger through trauma informed assessments on the secure unit completed on 06/22/2025. Referrals sent out by DON and will be followed up by DON for Resident #2 have been sent out to other skilled nursing facility and Behavioral Hospitals. and Resident #8 referral was sent to a facility and accepted and admitted [DATE], Resident #9 referred to a facility and accepted and admitted on [DATE]. Resident #1 referral sent to psych hospital and accepted and admitted 05/2725 and return 06/03/25. All direct care staff that were work at the time of the incident in the secured unit working with Resident #2 have been interviewed by DON on 06/22/25 and no root cause could be determined for her behaviors. Staff was able to state regarding Resident #1 resident is very territorial and does not like resident entering his room and resident was transition to long term community in a private room and have decrease behaviors and for Resident #9 no root cause was determined for his behavior. For Resident #7 no root cause was determined for his behavior. Resident #8 no root cause was determined for his behaviors. Facility will ensure adequate staffing to manage acuity based on the 24-hour report in Point Click Care, Real Time systems monitoring and current census. The administrator will maintain adequate staff for resident safety per acuity. Staffing will be reviewed during stand-up Meetings at 8:30 AM and stand-down meetings at 4PM to ensure there is adequate staffing for the secure units. During both meetings the team will review, and the Administrator/designee will adjust staffing to maintain resident safety based on acuity based on the 24-hour report in PCC, Real Time Systems monitoring and current census. If one on one is required additional staff member will be added and not substituted with the current staff in the units to ensure adequate staffing to protect residents from further incidents. The facility administrator/designee will decide and assure staff are assigned to the 1:1 resident. The Administrator/DON will check in with assigned staff frequently to assure that 1:1 monitoring is ongoing. Resident interviews on the secure units have been completed by DON, compliance, ADON, on 06/22/25. No concerns from residents were voiced. On 6/23/2025 Skin assessments were completed, and no visible signs of physical abuse were noted. We will continue [TRUNCATED]

Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 9 (06/04/25, 06/05/25, 06/06/25, 06/13/25, 06/14/25, 06/15/25, 06/16/25, 06/18/25, 06/19/25) of 20 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 06/04/25, 06/05/25, 06/06/25, 06/13/25, 06/14/25, 06/15/25, 06/16/25, 06/18/25, and 06/19/25. This failure leaves residents without the nursing administrative oversight that only the DON can provide. Findings include: Review of the daily staffing schedule revealed DON worked as a charge nurse on 06/04/25, 06/05/25, 06/06/25, 06/13/25, 06/14/25, 06/15/25, 06/16/25, 06/18/25, and 06/19/25. During an interview on 06/20/2025 at 3:30 PM, the DON stated she was responsible for monitoring her staff and ensuring things were done correctly. She stated she had been working night shift as the charge nurse because a night nurse had recently quit. She stated no-one else had been designated to perform her duties while she had not been able to. The DON stated that working the night shifts have not interfered with performing her DON duties. She stated she was not aware of the regulation stating that she could not work the floor. Policy for RN/DON coverage was requested on 06/23/2025 but wasn't provided. Review of document titled, Job Description Director of Nursing dated 2014, revealed: The following is a non-exhaustive criterion that relates to the job of a Director of Nursing, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for Director of Nursing. and are related to the functions that are essential to the job of a Director of Nursing. Knowledge Base: Working knowledge of nursing home regulations. Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with The Company, local, state, and federal regulations. Manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines. Augment floor staffing if needed .

Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #44) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #44 who resided in the secure unit. As a result, he eloped from the facility and was located approximately 20 minutes later after he had crossed a 5-lane street. Resident #44, who was diagnosed with dementia, had attempted on 2 other occasions to elope from the secure unit through a resident room window. On the third attempt he went out a resident's window and out the back gate of the secure unit due to the gate magnetic locking mechanism not aligning up correctly. It was determined a past non-compliance Immediate Jeopardy existed from 09/18/22 to 09/19/22. The Immediate Jeopardy was determined to have been removed due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk for elopement that could result in injury, impairment or even death. Findings included: Review of Resident #44's admission record dated 09/27/22 revealed he was an [AGE] year old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and dementia. Record review of Resident #44's MDS dated [DATE] indicated in part: BIMS = 12 indicating the resident was moderately impaired. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? Indicated the resident Behavior present, fluctuates (comes and goes, changes in severity) Wandering - Presence & Frequency =. 3. Behavior of this type occurred daily. Functional Limitation in Range of Motion. No impairment. Mobility Devices = None. Record review of Resident #44's care plan dated 09/19/22 indicated in part: FOCUS: Resident is at risk for wandering related to dementia. GOAL: Resident will not leave facility unattended through the review date. INTERVENTIONS: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Monitor location every 15 min. The resident will reside in the secure unit. Record review of the facility's provider investigation report dated 09/20/2022 and completed by the previous facility Administrator L indicated in part: Incident date 09/18/22, Resident involved: Resident #44. Description of allegation: Resident eloped from secure unit. Resident left out of another resident's room window and went out the back gate and left the facility grounds. Investigation summary: Resident left facility approx. 1345PM (1:45pm), resident exited the facility from another resident's room window. The resident pushed open the back gate and left the facility grounds. Facility gate was not appropriately secured due to the magnets not lined up and touching. Resident was identified walking across the street. Staff brought resident back to the facility at 14:05PM (2:05pm). Resident was combative with staff. The resident was placed 1:1 monitoring and referrals have been sent out to behavioral hospitals transfer. Investigation findings = confirmed. Record review of Resident #44's nurses notes indicated in part: 6/8/2022 22:20 (10:20pm) resident was found by staff trying to get out of his bedroom window. staff that witness stated that resident was about halfway out of the window. this nurse went into resident's room and resident had his window propped up. resident stating that it is too hot in his room right now that is why his window is open. window was closed and resident became upset at staff. 9/4/2022 17:00 (5:00pm) This nurse observed res walking outside in memory care courtyard, upon attempting to redirect res back inside, this nurse noted a window open, and screen removed, res refused to come back inside, attempted x3 to notify family member of elopement attempt. one on one care provided at this time, no injury noted. Record review of CNA B's undated statement indicated in part: I left the hall at 1:35pm [on 09/18/22] to throw my trash. Walked back at 1:40pm into hall 400 noticed another resident coming out of Resident #44's room I thought that was weird. I asked the resident what he was doing? He said he was checking to see if Resident #44 was in there. I checked to see if he was on his bed didn't see him, so I went to the dining room he wasn't there. I told CMA E what was going on. He got up fast we went back to check his room and bathroom he wasn't there. We started checking every room. Didn't find him. CMA E went report it to head of nursing I kept looking we checked back door. Back gate was open. Record review of CMA E's undated statement indicated in part: I did my last hourly check at before I took Resident #44 and other residents at 1:05pm [on 09/18/22]. We came back at 1:25 I went to the nurses station at 1:35, CNA B told me she was going to throw the trash I said ok. She came back at 1:40 and she told me should couldn't find Resident #44. I got up and started checking rooms from the opposite sides of the hall after we met, I went to the nurses station and told them I was missing Resident #44. I return to the hall and opened the emergency exit to check back gate. The alarm went off for the inside door but the gate going to the alley was not locked. I went back inside to turn off the alarm. And started double checking my hall. Then I called DON. During an observation and interview on 09/25/22 at 09:44 AM Resident #44 was in his room awake and alert and ambulating in his room. The resident was asked if he recalled getting out of the facility and he stated yes, he had done that because he wanted to go back home to Seminole. Resident said his family member had just dumped him here and did not want to come pick him up. The resident said none of his children wanted to come and take him home and that was the reason he had gotten out. The resident said he was going to contact the police for them keeping him here. Resident #44 said he had gotten out through a window and then opened the gate door and that was how he got out. During an interview on 09/26/22 at 12:02 PM, CMA D said at one time the back gate located outside the men's unit appeared to be secured with a plastic bag and was not working well, she said she did not recall reporting it. CMA D said the day (09/18/22) that Resident #44 had eloped from the facility she had last seen him at about 1:21 PM because that was when CMA E had brought the resident back inside from smoking in the back patio. CMA D said at about 1:45 PM she heard from facility staff the resident was missing and that some aides had spotted the resident outside by the school. CMA D said she and one of the nurses got in her car and went to assist with getting the resident into her car. CMA D said at the time they got the resident into her car he had already walked about 3 blocks away from the facility. During an interview on 09/27/22 at 11:42 AM, CNA B said she was working 6am-2pm on 09/18/2022 in the men's secure unit on the day Resident #44 had eloped from the facility. CMA B said before she left to take the trash out, she had seen Resident #44 sitting down in the secure unit dining room. CNA B said she told CMA E she was going to take the trash out, said CMA E was sitting at the nurses station when she told him she was leaving to take the trash out. CNA B said when she came back, she noticed another resident coming out of Resident #44's room so she asked him what he was doing and he said he was checking to see if Resident #44 was in his room. CNA B said she looked in the room and did not see Resident #44. She said she asked CMA E where Resident #44 was, and they started looking for him and that's when they noticed he was missing. CNA B said CMA E opened the back door and they noticed that the gate door could be opened by simply pushing it as it was not locked so they assumed the resident went out that way. During an interview on 09/28/22 at 03:02 PM, the DON and ADON, said that as far as they knew Resident #44 had gotten out through one of the resident's windows in the secure unit and had forced open the back gate [on 09/18/22]. They said that along with the regional compliance nurse they had checked the back gate on that day and found that it was not locking. They said they had aligned the locking magnets on the gate and it worked again. They said that as far as they knew the gate was working before Resident #44 eloped. The DON said there was no documentation or plan on checking the gate to make sure it was closing prior to the elopement on 09/18/2022 but that now they had implemented something to check it. The DON said the gate had been repaired the following day [on 09/19/22]. During an observation on 09/28/22 at 03:32 PM, the secure unit back gate was inspected and the gate was noted to have been replaced as the gate appeared new and was functioning properly when inspected with the facility maintenance man. During an observation on 09/28/22 at 03:42 PM, a video recording that was on file of the facility's video camera showed the day (09/18/22) when the Resident #44 eloped through the back gate. The video showed where Resident #44 approached the gate and started to push it open but then the video stopped and started again and at that time the resident was gone, later on the video CMA E is seen coming out to check the gate and pushes it open, the gate did not appear to be locked at the time CMA E came to check it. (Note: CMA E was not available for in person interview as he was not working. An attempt was made to interview via telephone on 09/28/22, but he did not return voice message.) During an observation on 09/28/22 at 03:54 PM, revealed the street the resident crossed before being found was a 5 lane street which was located in front of the facility. Facility implemented actions: The gate and magnets were replaced on 09/19/22. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. All the windows in the men's secure unit have locks on them that allowed the windows to open only 6 inches. This was verified by surveyor during an observation on 09/25/22. The men's and women's secure unit initiated a resident head count on an hourly basis and kept a log where they document the count. This was verified by surveyor during an observation on 09/25/22. The facility conducted training and in-services on how monitor residents with exiting behaviors and what to do when a resident is missing. This was verified on 10/10/22 by surveyor during interviews of 2 LVNS, 4 CNAs and activity director and they understood the training. The facility placed Resident #1 on a one to one with a facility staff continuously with the resident. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. The facility initiated back gate checks twice a day daily to make sure the gate was functioning correctly and documenting the checks. This was verified by surveyor during an observation and record review of the document which indicated the gate was checked twice a day daily by the Maintenance man on 10/10/22. The facility placed an aide in the hall to monitor the residents if they were not busy, they were to sit in the hall. This was verified by surveyor during an observation on 09/25/22 and 10/10/22. Facility Administrator, DON and ADON stated they had included Resident #1's elopement issues in their plans and QA meetings. Record review of the facility's policy titled Wandering and elopement and dated March 2019 indicated in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. Record review of the facility's policy titled SecureCare environment admission criteria and process and dated February 2007 indicated in part: The goal of the SecureCare environment is to meet the individual needs of the residents with dementia related illnesses. The SecureCare environment will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. The secured care unit may be used to keep residents who are a high risk for elopement safe from exiting the facility. On 10/10/22 at 4:45pm the Administrator and DON were notified of the Past Non-Compliance IJ existing from 09/18/22 - 09/19/22 and the template was provided.

Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse for 1 (Resident #1) of 4 residents reviewed for abuse. The facility failed to follow their policy and procedure for the locked unit that provided monitoring and supervision of residents to prevent elopement, and accounting of all residents on all units, which would have alerted staff of a missing resident. On 07/19/22 at 1:45p.m., Resident #1 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . While the Charge nurse was doing rounds at 3:15 p.m. a resident alerted the Charge nurse that she saw Resident #1 laying on the ground outside in the courtyard. The resident was found unconscious and rushed by ambulance to local hospital. Staff were unaware resident was not on the unit for approximately 111 minutes. Staff did not follow policy and procedures to ensure all residents on locked unit were accounted for. An Immediate Jeopardy (IJ) was identified on 7/22/2022. While the IJ was removed on 7/23/2022, the facility remained out of compliance, at a level of Isolated Actual Harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed residents at risk for not being provided services that are necessary to avoid injury, harm or death. Findings included: Record review of Resident #1's electronic Face sheet revealed a [AGE] year-old male admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed: Brief Interview for Mental Status (BIMS) of 3. No signs of acute changes in mental status from resident baseline. No behavioral symptoms exhibited. Active neurological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #1's progress notes dated 7/19/2022 at 4:26 PM RN-E was doing rounds on 500 hall, when she looked through the blinds and saw this resident lying in the sun, face up. Nurse started yelling to other nurses to call 911 and rushed out to resident. Resident was unresponsive, body was heated, and he had apparently been outside for a while. BP-95/57mmHg, pr-89, RR-24, 911 arrived in 6 minutes and resident was taken to the ER. Record review of Resident #1 Secure Care Environment Screening Tool dated 5/3/2022, completed by LVN-O, stated: Does the resident continue to exhibit exit seeking behavior? Answer, YES. Record review of Resident #1 care plan dated 6/5/2022 states resident resides on the male secured unit with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 7/20/2022 at 11:32 a.m., ERN-A stated the resident was admitted to the hospital emergency room around 4:11 pm 7/19/2022. She stated Resident #1 was nonresponsive and had an internal temperature of 107 degrees. She stated he had very shallow breathing and was intubated. She stated he had [CONDITION(S)] on the back of his heels, right collar bone, right arm, and left arm. She stated she was told the resident was taken outside of the facility in a wheelchair and left outside by accident. She stated later the DON of the facility called stating the resident got outside the facility and was not noticed missing for a while. According to weather history report (https://www.wunderground.com/history/daily/KMAF/date/2022-7-19 accessed on 8/11/22) the temperature on 07/19/22 in the city where this facility is located were 1:53 p.m. - 101 degrees Fahrenheit 2:53 p.m. - 103 degrees Fahrenheit 3:53 p.m. - 105 degrees Fahrenheit During an interview on 7/20/2022 at 12:45 p.m., ICUN-B stated Resident #1 was sedated and resting at this time. He stated the resident was still intubated and the plan was to see if Resident #1 woke up today. He stated the resident was in acute [CONDITION(S)], intubated, and had multiple [CONDITION(S)] on his body. He stated the worst [CONDITION(S)] are located on the backs of the resident's heels, which at this time have formed very large blisters. During an interview on 7/20/2022 at 1:35 pm, NCNA-C stated she was working on the day of the incident on 7/19/2022. She stated she heard somehow Resident #1 got outside. She stated the last time she saw him on the unit was right at 1:30 p.m. when she took the residents out for their smoke break, she stated she cannot remember if he went out with the smokers or not. She stated that the aids are to round every 2 hours on the hallway to check all residents. During an observation on 7/20/2022 at 1:40 p.m., on hallway 400 (male locked unit) the door at the end of the hallway had direct access to the outside courtyard that sits between hallway 400 and hallway 500. NCNA-C put in the code and opened the door, allowing it to shut by itself. The door looked to be slightly open, NCNA-C pushed on the door to access the outside and the alarm went off. NCNA-C stated she had never had any issues with this door not working or not beeping if a resident tried to leave. During an interview on 7/20/2022 at 1:45 pm LVN-D stated she was not at the facility the day of the incident on 7/19/2022. She stated she was required to round every 2 hours but really tried to go around her unit once an hour. She stated that Resident #1 had two spots he liked to stay. She stated he would sit in a chair in the dining room or be up near the double doors that exit the unit. She stated she is not sure how the resident got outside. She stated that he could have gone out with the smokers or with an aid. She stated if he tried to walk out the door by himself, the alarm would have triggered. Request for work orders/tickets for faulty back door requested 7/21/2022, no work orders/tickets were submitted for male unit security door in the past 3 months. During a phone interview on 7/20/2022 at 2:15 p.m., RN-E stated she was the charge Nurse for both Hallway 400 and 500. She stated she got to work right at 2pm. She stated she started her rounds because she rounds every two hours. She stated she was not sure how Resident #1 got outside. She stated the facility let her know they have a video showing Resident #1 walk out of the locked door in the back of the unit at 1:40 p.m. She stated the resident does wander but never tried to go outside. She stated at 3:45 pm she was on hall 500 (women's locked unit) rounding and she stated she heard another resident stating that someone was laying down outside. She stated she saw Resident #1 on the ground near the concrete structure in between halls 400 and 500 outside laying in the grass. She stated she started screaming for help and they got outside and started putting water on the resident. During an interview on 7/20/2022 at 2:25 p.m., ADMIN-F stated she tried to access the cameras on the locked unit, but it was faulty and did not record. During record review and observation on 7/20/2022 at 3:45 p.m., the outside cameras were on, but no video footage was saved from the date of the incident on 7/19/2022. During a phone interview on 7/20/2022 at 3:10 p.m., NCNA-G stated the activity director came around 1:40 p.m. and got a few residents. She stated she and NCNA-C must have assumed that Resident #1 went off of the unit with the activity director. She stated she should have double checked before she left for the day at 2:25 p.m. but didn't. She stated t she normally worked the 500 hall, (women's), and that the men are calmer and doesn't try to elope or go for the back security door. She stated Resident #1 was not an elopement risk, he was actually a very sweet, gentle resident, who just wandered up and down the hallway. She stated the door alarm was annoying and was very loud because she has heard it before. She stated the security alarm never went off on Tuesday, 7/19/2022. She stated she saw NCNA-C take Residents #2, #3, and #4 out for their smoke break around 1:22 p.m., but RN-M brought the residents back into the facility around 1:35 p.m. She stated she had no idea how Resident #1 got outside. She stated the last time she saw Resident # 1 was at 1:40 pm on 7/19/2022 when she went to check on him. She stated that if she would have done her rounding before end of shift this would not have happened, she stated she assumed Resident #1 was off the unit instead of verifying. During an interview on 7/20/2022 at 3:15 pm AA-U stated she did go to hall 400 around 1:40 pm to get a couple of the residents of the unit to participate in activities in the dining room. During an interview on 7/20/2022 at 3:21 pm ADON-H stated her only assumptions was that Resident #1 exited through the security door that did not lock and the alarm didn't trigger. She stated the checks in place for the Residents on the locked unit were not done properly and instead of checking for each resident before end of shift, her staff made assumptions. She stated if her staff had made their proper checks and rounded like they were supposed to this incident would not have occurred. During an interview on 7/20/2022 at 5:30 p.m., LVN-L said he was not working the day of the incident 7/19/2022 and, today 7/20/2022 was his first day back. He stated he was given a head count sheet and was told to fill this out during his shift. He stated he was not in-serviced on anything, and his assumption was that he was to fill this out during his shift because of the incident that occurred with Resident #1. He stated Resident #1 did wander but he never saw the resident go to the back security door and push on it or try to exit the unit. He stated, I would call him a wanderer not an eloper. Nurse stated that the alarm was very loud. He stated if Resident #1 tried to exit through the back door, the alarm would have gone off. He stated an employee would have had to put the code in to turn the alarm off. During an observation on 7/20/2022 at 5:35 p.m., with LVN-L, Investigator had LVN-L enter code to open back security door. Investigator pushed door open and let door slam shut on its own, door had small gap where it did not completely close. Investigator waited 5-10 seconds, saw on security system that door showed to be locked and pushed door back open, the security alarm went off and LVN-L had to put code in to turn alarm off. During an observation on 7/20/2022 at 5:45 p.m., AMD-Q was fixing the back security door. Installed new arm that made the door close 100% instead of leaving a small gap but the alarm would still go off. During a Phone interview on 7/20/2022 at 6:15pm with NCNA-G stated that NCNA-C took the residents out at 1:25 pm on 7/19/2022 for their smoke break, but RN-M brought the residents back in. She stated that she last saw Resident #1 around 1:40 pm when she changed him on 7/19/2022 and left him in his room. During a record review of Resident #1's Task notes dated 7/19/22, revealed there was no documentation of any task of helping, changing, moving, or seeing the resident any time after 1:25 p.m. based on nurses/aid notes in system. During a Phone interview on 7/21/2022 at 10:15 a.m., RN-M stated she took Residents #2, #3, and #4 out for their smoke break early at 1:22 p.m. on 7/19/2022. She stated the aids would take the residents to smoke at times if she was busy. During an interview on 7/21/2022 at 10:25 am NCNA-C stated that NCNA-G took the smokers out at 1:20 pm on 7/19/2022 and then RN-M joined them a few minutes later. She stated aids don't usually take the smokers out unless the charge nurse is busy. During an interview on 7/22/2022 at 1:25 pm DON stated that all residents on hall 400 are both wanders and elopement risk, that is why they are on the unit. She stated that her expectation of all her aids and nurses is to round on all residents every two hours. She stated that every resident should be accounted for every 2 hours, visually seen. She stated if the blinds had been opened or her staff would have done their rounding properly the incident would have never occurred. She stated that she could not find the exact policy that stated every 2 hours of rounding, but it is an expectation of hers for all of her staff. During an interview on 7/22/2022 at 1:45 p.m., LVN-O stated that all residents on hall 400 are wanders and elopement risk. She stated the difference between wandering and elopement was, wandering was when residents walk around a lot on the unit. She stated the definition of elopement was residents who are actively trying to go through the locked doors either the secure door at the end of the hallway to go outside or the double secure doors to get off the unit. She stated, well . none of the residents try to get through the locked doors. Request for policy/procedure that stated round, and resident counts done every 2 hours requested 7/23/2022, no policy/procedure was provided by the time of exit. Record review of Abuse/Neglect policy dated 3/29/2018 states: The resident has the right to be free from abuse, neglect. misappropriation of resident property, and exploitation as defined in this subpart. 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish. or emotional distress. An Immediate Jeopardy was identified on 7/22/2022 at 3:27 p.m. due to the above failures. The ADO-P, DON-N, ADMIN-F, ADON-H were informed of the IJ. The Administrator was provided with the IJ template on 7/22/2022 at 3:27 p.m. The Plan of Removal was accepted on 7/23/2022 at 1:07 PM and reflected the following: Interventions: Resident #1 was transferred to the hospital There were no other residents noted to be left alone/unattended outdoors of the secure unit on 7/19/22. In-Services Starting 7/19/22 secure unit staff were in-serviced by the DON/ADON on the following (staff not in-serviced as of 7/22/22 will not be allowed to assume their duties in the secure unit until they have been in-serviced). Additionally, new hires and agency will be in-serviced during orientation on systems below. Administrator and DON will audit 5X per week to ensure compliance of in-services and systems below. o Check the outdoors portion of the secure unit at least every 30 minutes to ensure that no resident is outdoors unsupervised. o Blinds to the secure unit will be left open so the outside area can be monitored by staff. o Perform a headcount at least every hour of all residents in the secure unit. The head count will be documented in log by the charge nurse. Sign out/in binder will be kept at nurse's station. This includes the start of shift change. o Secure unit residents will be signed out/in when taken out of the unit. This includes the therapy/activity department. o Staff will not use the exit door of the men's secure unit to smoke. Secure unit exit doors will only be used for emergencies. o Residents of the secure unit will smoke in the facility's designated area. Residents must be signed out by the charge nurse. Once completed, residents will be returned to their secure unit and the charge nurse will sign them in. o Re-education on maintenance care: the use and how to submit tickets. New hires will be oriented during orientation. On 7/19/22 the area maintenance director did the following: o Inspected the magnetic lock of the door opening to the outside was engaging properly. On 7/20/22 o As a precaution the door closure was replaced, and a stop alarm was added to the door. The medical director was notified of this plan on 07/19/2022 and an off cycle QAPI plan was initiated regarding this event. Monitoring: The DON and or designee will monitor that headcount, 30 min outdoor checks, and sign in/out sheets are used properly and completed at least 5 times per week. If the maintenance director is not available, the administrator or designee will monitor that the door opening to the outdoors is functioning properly at least 3 times per week. During daily rounds, the administrator, DON, and/or designee will ensure that the secure unit dining rooms are open, and staff are able to see outdoors; that the staff are not using the door to smoke; or any other unauthorized use. If a resident cannot be located in the secure unit, check the sign out/in binder. If the resident has not been signed out, notify the administrator and DON and start a search for the resident to verify their location immediately. At least 1 person will search all areas of the secure unit while, simultaneously, someone begins to search outside. If, after a search of the facility and grounds, police are notified, the admin will direct staff to begin searching the perimeter of the facility and work outwards. Questionaries will be completed by HR to ensure retention of in-services. Monitoring of the facility Plan to address the immediacy through interviews and record reviews between 7/22/2022 to 7/23/2022 revealed: Record review of in-services and logs on 7/23/2022 at 10:45 am sign in sheet, head count, blinds being opened (21 employee signatures, dated 7/19/2022 to 7/23/2022), the security door is off limits and not to be opened, log of resident going off unit to smoke at 8:30 was signed out and back in for the resident being taken off the unit to go smoke in the smoke area outside and returned to the unit at 8:50/signed back in (18 employee signatures, dated 7/19/2022). During an observation on 7/23/2022 at 10:55 group of staff being in-serviced at the nurse's station being led by DON covering locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. The group was in-serviced for all the non-locked units. The DON then went to each locked unit and in-serviced the employees individually on the locked unit. During an interview and record review on 7/23/2022 at 11:05 am LVN-O stated that she has been educated. She stated for her unit, the back security door is an emergency exit only. She stated the head count sheet, which she does every 30 minutes is to now be done every hour. She stated that if a resident is not accounted for, they are to inform the DON/Admin immediately and start searching by unit. She stated she is to do outside checks every 30 minutes. She stated that if a resident ever leaves the unit they are to sign out (which she showed this document and headcount document, both with no concerns noted). She stated she does feel with these preventatives' measures in place, an incident like this would not occur again. During an interview on 7/23/2022 at 11:42 am CS-R stated she worked the day of the incident but was on hallway 500 and left at 1:30 pm. She stated that this was her first day back and she was part of the in-service that started at 10:55 am. She stated it covered locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. She stated she does feel the new procedures in place would prevent an incident like this to occur again. Record review on 7/23/2022 of binder with audit logs of at 30-minute intervals starting at 8:30 am on 7/23/2022 outside checks performed by nursing staff, last notated at 11:30 am. Record review on 7/23/2022 of Questionnaire completed by LVN-T and CS-R that covered all in-services. Consisted of 9 questions, signature by employee and dated. Reviewed by DON on 7/23/2022. 1. When you take a resident out of the secure unit what do you need to do? 2. What do you do if you are not able to locate a resident from the unit? 3. How often should a head count in the secure unit be done and by who? 4. Should the exit back door at the secure unit be used? 5. Where is the secure unit smokers designated smoking area located at? 6. Should the blinds in secure units be open or closed? 7. Should the dining room doors be closed in the secure unit? 8. What should you do if you find something that needs to be repaired in the facility? 9. How often should the outdoor smoking designated area be monitored? During a phone interview on 7/23/2022 at 12:45 pm NCNA-S stated she was in-serviced a couple days ago on locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. She stated she just got called and they did an in-service with her over the phone over maintenance logs and how to submit tickets. During a phone interview on 7/23/2022 at 12:56 pm LVN-T stated the facility did just call her over the phone and did an in-service on maintenance log/submitting ticket. She stated it was how to put in a service order and what to look for when it comes to maintenance on each unit. She stated she worked the night shift of 7/19/2022 the date the incident occurred, and she was in-serviced that night over locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. The ADO-P, DON-N, ADMIN-F, ADON-H were informed the Immediate Jeopardy was removed on 7/23/2022 at 1:07 PM. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to provide supervision on 07/19/22 between 1:40 p.m. and 3:45 p.m., when Resident #1 who had a diagnosis of dementia and history of wandering, was found lying on the ground outside in the courtyard of the secured unit. Resident #1 was found unconscious and rushed by ambulance to a local hospital. The facility's failure to provide adequate supervision resulted in Resident #1 being left outside in the courtyard unattended during 104-degree Fahrenheit temperatures for approximately two hours and further resulted in Resident #1 being found unresponsive, transported to the emergency room , assessed to have a core temperature of 107 degrees and multiple blisters in different sites, had blisters bilaterally on the heels which were ruptured. Resident #1 was admitted to the ICU unit with a diagnosis Hyperthermia associated with heat, acute renal failure, and was intubated/unconscious. An Immediate Jeopardy (IJ) was identified on 7/22/2022. While the IJ was removed on 7/23/2022, the facility remained out of compliance, at a level of Isolated Actual harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect residents that were identified as an elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. The findings include: Record review of Resident #1 electronic Face sheet revealed [AGE] year-old male admitted [DATE] with a diagnosis of lack of coordination, Hypertension, Dementia, and [CONDITION(S)]. Record review of Resident #1 quarterly Minimum Data Set (MDS) dated [DATE] revealed: Brief Interview for Mental Status (BIMS) of 3, suggest severe cognitive impairment. No signs of acute changes in mental status from resident baseline. No behavioral symptoms exhibited. Record review of Resident #1's progress notes dated 7/19/2022 at 4:26 PM RN-E was doing rounds on 500 hall, when she looked through the blinds and saw this resident lying in the sun, face up. Nurse started yelling to other nurses to call 911 and rushed out to resident. Resident was unresponsive, body was heated, and he had apparently been outside for a while. BP-95/57mmHg, pr-89, RR-24, 911 arrived in 6 minutes and resident was taken to the ER. Record review of Resident #1's care plan dated 6/5/2022 stated resident resides on the male secured unit with diagnosis of dementia, with lack of safety awareness and wandering with exit seeking behaviors. Goals, revealed in care plan, if resident is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system, etc. During a phone interview on 7/20/2022 at 11:32 a.m., ERN-A stated the resident was admitted to the hospital emergency room around 4:11 pm on 7/19/2022. She stated Resident #1 was nonresponsive and had an internal temperature of 107 degrees. She stated he had very shallow breathing and was intubated. She stated he had [CONDITION(S)] on the back of his heels, right collar bone, right arm and left arm. She stated she was told the resident was taken outside of the facility in a wheelchair and left outside by accident. She stated later the DON of the facility called stating the resident got outside the facility and was not noticed missing for a while. According to weather history report (https://www.wunderground.com/history/daily/KMAF/date/2022-7-19 accessed on 8/11/22) the temperature on 07/19/22 in the city where this facility is located were 1:53 p.m. - 101 degrees Fahrenheit 2:53 p.m. - 103 degrees Fahrenheit 3:53 p.m. - 105 degrees Fahrenheit During an interview on 7/20/2022 at 12:45 p.m., ICUN-B stated Resident #1 was sedated and resting at this time. He stated the resident was still intubated and the plan was to see if Resident #1 woke up today. He stated the resident was in acute renal failure, intubated, and had multiple [CONDITION(S)] on his body. He stated the worst [CONDITION(S)] are located on the backs of the resident's heels, which at this time have formed very large blisters. Record review of a hospital progress note dated 7/21/2022 at 4:01 p.m., indicated right heel unstageable, left heel Deep tissue injury (DTI), Cleaned then apply [MEDICATION(S)] to xeroform and place on wound then cover with dry dressing. Nursing to change daily. Wound care to check patient daily. During an interview on 7/20/2022 at 1:35 p.m., NCNA-C stated she was working on the day of the incident on 7/19/2022. She stated she heard somehow Resident #1 got outside. She stated the last time she saw him on the unit was right at 1:30 p.m. when she took the residents out for their smoke break, she stated she cannot remember if he went out with the smokers or not. She stated that the aids are to round every 2 hours on the hallway to check all residents. She stated Resident #1 doesn't go outside much. She stated he wanders and walks the halls but that was about it. She stated, I would not consider him an elopement risk. She stated during her entire shift on 7/19/2022 she never heard the exit door alarm go off. During an observation on 7/20/2022 at 1:40 p.m., on hallway 400 (male locked unit) the door at the end of the hallway had direct access to the outside courtyard that sits between hallway 400 and hallway 500. NCNA-C put in the code and opened the door, allowing it to shut by itself. The door looked to be slightly open, NCNA-C pushed on the door to access the outside and the alarm went off. NCNA-C stated she had never had any issues with this door not working or not beeping if a resident tried to leave. During an interview on 7/20/2022 at 1:45 p.m., LVN-D stated she was not at the facility the day of the incident on 7/19/2022. She stated she was required to round every 2 hours but really tried to go around her unit once an hour. She stated that Resident #1 had two spots he liked to stay. She stated he would sit in a chair in the dining room or be up near the double doors that exit the unit. She stated that she is not sure how the resident got outside. She stated that he could have gone out with the smokers or with an aid. She stated if he tried to walk out the door by himself, the alarm would have triggered. She stated that he had never tried to exit the unit. She stated he wandered but he was not an elopement risk. She stated he was one of the better residents honestly, one you don't really have to worry about. During a phone interview on 7/20/2022 at 2:15 p.m., RN-E stated she was the charge Nurse for both Hallway 400 and 500. She stated she got to work right at 2pm. She stated she started her rounds because she rounds every two hours. She stated she was not sure how Resident #1 got outside. She stated the facility let her know they have a video showing Resident #1 walk out of the locked door in the back of the unit at 1:40 p.m She stated the resident does wander but never tried to go outside. She stated at 3:45 pm she was on hall 500 (women's locked unit) rounding and she stated she heard another resident stating that someone was laying down outside. She stated she saw Resident #1 on the ground near the concrete structure in between halls 400 and 500 outside laying in the grass. She stated she started screaming for help and they got outside and started putting water on the resident. During an interview on 7/20/2022 at 2:25 p.m., ADMIN-F stated she tried to access the cameras on the locked unit, but it was faulty and did not record. During record review and observation on 7/20/2022 at 3:45 p.m., the outside cameras were on, but no video footage was saved from the date of the incident on 7/19/2022. During a phone interview on 7/20/2022 at 3:10 p.m., NCNA-G stated the activity director came around 1:40 p.m. and got a few residents. She stated she and NCNA-C must have assumed that Resident #1 went off of the unit with the activity director. She stated she should have double checked before she left for the day at 2:25 p.m. but didn't. She stated t she normally worked the 500 hall, (women's), and that the men are calmer and doesn't try to elope or go for the back security door. She stated Resident #1 was not an elopement risk, he was actually a very sweet, gentle resident, who just wandered up and down the hallway. She stated the door alarm was annoying and was very loud because she has heard it before. She stated the security alarm never went off on Tuesday, 7/19/2022. She stated she saw NCNA-C take Residents #2, #3, and #4 out for their smoke break around 1:22 p.m., but RN-M brought the residents back into the facility around 1:35 p.m. She stated she had no idea how Resident #1 got outside. She stated the last time she saw Resident # 1 was at 1:40 pm on 7/19/2022 when she went to check on him. During an interview on 7/20/2022 at 3:21 p.m., ADON-H stated her only assumptions was that Resident #1 exited through the security door that should have alarmed, that did not lock, and the alarm did not trigger. During an interview on 7/20/22 at 4:30 p.m., CNA-I working hall 400, stated she was not in-serviced on: if you can't find a resident do not assume they are in activities/therapy, if you are taking residents off the unit for any reason they must be signed out, smoking or going out the back door on men's unit is not allowed or you must clear it with the DON, a head count sheet should be completed every hour and turned into the DON, when she came into work today. During an interview on 7/20/22 at 4:45 p.m., NCNA-J working hall 500, stated she was not in-serviced on: if you can't find a resident do not assume they are in activities/therapy, if you are taking residents off the unit for any reason they must be signed out, smoking or going out the back door on the men's unit is not allowed or you much clear it with DON, and a head count sheet that should be completed every hour and turned into the DON, when she came into work today. During an interview on 7/20/22 at 4:55 p.m., CNA-K working hall 500, stated she was not in-serviced on: if you can't find a resident do not assume they are in activities/therapy, if you are taking residents off the unit for any reason they must be signed out, smoking or going out the back door on men's unit is not allowed or you much clear it with DON, and a head count sheet that should be completed every hour and turned into the DON, when she came into work today. During an interview on 7/20/2022 at 5:30 p.m., LVN-L said he was not working the day of the incident 7/19/2022 and, today 7/20/2022 was his first day back. He stated he was given a head count sheet and was told to fill this out during his shift. He stated he was not in-serviced on anything, and his assumption was that he was to fill this out during his shift because of the incident that occurred with Resident #1. He stated Resident #1 did wander but he never saw the resident go to the back security door and push on it or try to exit the unit. He stated, I would call him a wanderer not an eloper. Nurse stated that the alarm was very loud. He stated if Resident #1 tried to exit through the back door, the alarm would have gone off. He stated an employee would have had to put the code in to turn the alarm off. During an observation on 7/20/2022 at 5:35 p.m., with LVN-L, Investigator had LVN-L enter code to open back security door. Investigator pushed door open and let door slam shut on its own, door had small gap where it did not completely close. Investigator waited 5-10 seconds, saw on security system that door showed to be locked and pushed door back open, the security alarm went off and LVN-L had to put code in to turn alarm off. During an observation on 7/20/2022 at 5:45 p.m., AMD-Q was fixing the back security door. Installed new arm that made the door close 100% instead of leaving a small gap. During a Phone interview on 7/20/2022 at 6:15 p.m., NCNA-G stated that NCNA-C took the residents out at 1:25 p.m. on 7/19/2022 for their smoke break, but RN-M brought the residents back in. She stated she last saw Resident #1 around 1:40 pm when she changed him on 7/19/2022 and left him in his room. During a record review of Resident #1's Task notes dated 7/19/22, revealed there was no documentation of any task of helping, changing, moving, or seeing the resident any time after 1:25 p.m. based on nurses/aid notes in system. During a Phone interview on 7/21/2022 at 10:15 a.m., RN-M stated she took Residents #2, #3, and #4 out for their smoke break early at 1:22 p.m. on 7/19/2022. She stated the aids would take the residents to smoke at times if she was very busy. She stated Resident #1 was a very nice guy and does wander but never tried to elope or exit through the secured doors. During an interview on 7/21/2022 at 10:25 a.m., NCNA-C stated that NCNA-G took the smokers out at 1:20 p.m. on 7/19/2022 and then RN-M joined them a few minutes later. She stated aids don't usually take the smokers out unless the charge nurse was busy. During an interview on 7/22/2022 at 1:25 p.m., the DON stated that all residents on hall 400 are both wanders and elopement risk, that was why they are on the unit. She stated she is not exactly sure how the resident got out of the facility. She stated the secure door at the end of hall 400 had an alarm and should have gone off. She stated she has never had this happen before and her nurses/aids should be round/checking on all residents every 2 hours. She stated the dinning room on hall 400 has about 7 windows that were all closed because the sun made the room to hot. She stated its required to keep those windows open at all times, but for some reason on this day the blinds were shut. During an interview on 7/22/2022 at 1:45 p.m., LVN-O stated that all residents on hall 400 are wanders and elopement risk. She stated the difference between wandering and elopement was, wandering was when residents walk around a lot on the unit. She stated the definition of elopement was residents who are actively trying to go through the locked doors either the secure door at the end of the hallway to go outside or the double secure doors to get off the unit. She stated, well . none of the residents try to get through the locked doors. An Immediate Jeopardy was identified on 7/22/2022 at 3:27 p.m. due to the above failures. The ADO-P, AMD-Q, DON-N, ADMIN-F, ADON-H were informed of the IJ. The Administrator was provided with the IJ template on 7/22/2022 at 3:27 p.m. The Plan of Removal was accepted on 7/23/2022 at 1:07 PM and reflected the following: Interventions: Resident #1 was transferred to the hospital There were no other residents noted to be left alone/unattended outdoors of the secure unit on 7/19/22. In-Services Starting 7/19/22 secure unit staff were in-serviced by the DON/ADON on the following (staff not in-serviced as of 7/22/22 will not be allowed to assume their duties in the secure unit until they have been in-serviced). Additionally, new hires and agency will be in-serviced during orientation on systems below. Administrator and DON will audit 5X per week to ensure compliance of in-services and systems below. o Check the outdoors portion of the secure unit at least every 30 minutes to ensure that no resident is outdoors unsupervised. o Blinds to the secure unit will be left open so the outside area can be monitored by staff. o Perform a headcount at least every hour of all residents in the secure unit. The head count will be documented in log by the charge nurse. Sign out/in binder will be kept at nurse's station. This includes the start of shift change. o Secure unit residents will be signed out/in when taken out of the unit. This includes the therapy/activity department. o Staff will not use the exit door of the men's secure unit to smoke. Secure unit exit doors will only be used for emergencies. o Residents of the secure unit will smoke in the facility's designated area. Residents must be signed out by the charge nurse. Once completed, residents will be returned to their secure unit and the charge nurse will sign them in. o Re-education on maintenance care: the use and how to submit tickets. New hires will be oriented during orientation. On 7/19/22 the area maintenance director did the following: o Inspected the magnetic lock of the door opening to the outside was engaging properly. On 7/20/22 o As a precaution the door closure was replaced, and a stop alarm was added to the door. The medical director was notified of this plan on 07/19/2022 and an off cycle QAPI plan was initiated regarding this event. Monitoring: The DON and or designee will monitor that headcount, 30 min outdoor checks, and sign in/out sheets are used properly and completed at least 5 times per week. If the maintenance director is not available, the administrator or designee will monitor that the door opening to the outdoors is functioning properly at least 3 times per week. During daily rounds, the administrator, DON, and/or designee will ensure that the secure unit dining rooms are open, and staff are able to see outdoors; that the staff are not using the door to smoke; or any other unauthorized use. If a resident cannot be located in the secure unit, check the sign out/in binder. If the resident has not been signed out, notify the administrator and DON and start a search for the resident to verify their location immediately. At least 1 person will search all areas of the secure unit while, simultaneously, someone begins to search outside. If, after a search of the facility and grounds, police are notified, the admin will direct staff to begin searching the perimeter of the facility and work outwards. Questionaries will be completed by HR to ensure retention of in-services. Monitoring of the facility Plan to address the immediacy through interviews and record reviews between 7/22/2022 to 7/23/2022 revealed: Record review of in-services and logs on 7/23/2022 at 10:45 am sign in sheet, head count, blinds being opened (21 employee signatures, dated 7/19/2022 to 7/23/2022), the security door is off limits and not to be opened, log of resident going off unit to smoke at 8:30 was signed out and back in for the resident being taken off the unit to go smoke in the smoke area outside and returned to the unit at 8:50/signed back in (18 employee signatures, dated 7/19/2022). During an observation on 7/23/2022 at 10:55 group of staff being in-serviced at the nurse's station being led by DON covering locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. The group was in-serviced for all the non-locked units. The DON then went to each locked unit and in-serviced the employees individually on the locked unit. During an interview and record review on 7/23/2022 at 11:05 am LVN-O stated that she has been educated. She stated for her unit, the back security door is an emergency exit only. She stated the head count sheet, which she does every 30 minutes is to now be done every hour. She stated that if a resident is not accounted for, they are to inform the DON/Admin immediately and start searching by unit. She stated she is to do outside checks every 30 minutes. She stated that if a resident ever leaves the unit they are to sign out (which she showed this document and headcount document, both with no concerns noted). She stated she does feel with these preventatives' measures in place, an incident like this would not occur again. During an interview on 7/23/2022 at 11:42 am CS-R stated she worked the day of the incident but was on hallway 500 and left at 1:30 pm. She stated that this was her first day back and she was part of the in-service that started at 10:55 am. She stated it covered locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. She stated she does feel the new procedures in place would prevent an incident like this to occur again. Record review on 7/23/2022 of binder with audit logs of at 30-minute intervals starting at 8:30 am on 7/23/2022 outside checks performed by nursing staff, last notated at 11:30 am. Record review on 7/23/2022 of Questionnaire completed by LVN-T and CS-R that covered all in-services. Consisted of 9 questions, signature by employee and dated. Reviewed by DON on 7/23/2022. 1. When you take a resident out of the secure unit what do you need to do? 2. What do you do if you are not able to locate a resident from the unit? 3. How often should a head count in the secure unit be done and by who? 4. Should the exit back door at the secure unit be used? 5. Where is the secure unit smokers designated smoking area located at? 6. Should the blinds in secure units be open or closed? 7. Should the dining room doors be closed in the secure unit? 8. What should you do if you find something that needs to be repaired in the facility? 9. How often should the outdoor smoking designated area be monitored? During a phone interview on 7/23/2022 at 12:45 pm NCNA-S stated she was in-serviced a couple days ago on locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. She stated she just got called and they did an in-service with her over the phone over maintenance logs and how to submit tickets. During a phone interview on 7/23/2022 at 12:56 pm LVN-T stated the facility did just call her over the phone and did an in-service on maintenance log/submitting ticket. She stated it was how to put in a service order and what to look for when it comes to maintenance on each unit. She stated she worked the night shift of 7/19/2022 the date the incident occurred, and she was in-serviced that night over locked doors, missing residents, blinds on the locked units, headcount sheets, sign in/out of resident sheets, and facility checks. The ADO-P, DON-N, ADMIN-F, ADON-H were informed the Immediate Jeopardy was removed on 7/23/2022 at 1:07 PM. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews, observations and record reviews the facility failed to ensure residents were free from neglect for 1 (Resident #1) of 5 residents whose care was reviewed for neglect. The facility failed to provide necessary staff and specialized bandages (Unnaboot dressing) to ensure correct wound care treatments were conducted; The facility failed to ensure staff were trained and oversight was provided for residents with specialized dressings; The facility failed to ensure the process for wound care orders from the wound care clinic (WCC) was effective. Resident #1 received the wrong wound care between 8/27/19 and 9/23/19 because the facility failed to identify if new recommendations were made. On 9/23/19 Resident #1 was admitted to the hospital with [REDACTED]. The physician recommended amputation of the lower leg. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/27/2019. While the IJ was removed on 09/30/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing [MEDICAL CONDITION] (infection of the blood), severe pain, dismemberment including amputation, or death. Findings Included: FACILITY CLINICAL RECORD Record review of Resident #1's Resident Face Sheet dated 1/9/17 documented she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented, in part: She scored a 2 of 15 on her mental status exam indicating severe cognitive impairment. She showed signs of [MEDICAL CONDITION] that included inattention and disorganized thinking that fluctuated. Her depression screening indicated she had no indicators of depression. She showed no indicators of [MEDICAL CONDITION]. She had no behaviors documented. Her Activities of Daily Living (ADL) status indicated: she needed total assistance of one person for bed mobility, locomotion, dressing, toilet use, personal hygiene, and showering. Resident #1 needed total assistance of two staff for transfers. She needed supervision for eating. She had no range of motion impairments identified and used a wheelchair. She had active [DIAGNOSES REDACTED]. The MDS documented she received no scheduled or as needed pain medications. Her pain interview indicated she experienced no pain. There were no other health conditions or problems conditions identified. She was not identified as life expectancy of less than six months. She was at risk for developing pressure ulcers but had none at the time of the assessment. She did [MEDICAL CONDITION] the second or third degree. Identified treatments included a pressure reducing device for the bed, application of non-surgical dressings, and application of appointments or medications. Review of Resident #1's Care Plan Summary reviewed 6/5/19 documented she needed extensive assistance of two staff for all ADLs. She had wounds to the left lower extremity and was at risk for pressure ulcers. Review of the Nursing Assistant Care Plan dated 8/1/19 documented that her skin was not intact, and she had lower extremity impairment. Review of the Care Plan updated on 9/2/19 documented she had healing left lateral extremity (LLE) burns. The identified goal was the area will heal without complications. Identified approaches included perform treatments per order, if no improvement for two weeks report to medical doctor. Review of Physician Telephone Orders documented: 6/11/19 Wound Care to evaluate and treat on healing third-[MEDICAL CONDITION] left lower extremity. 7/17/19 Treatment left lower leg: cleanse with normal saline and 4 x 4, pat dry with 4 x 4, wrap with Unnaboot and Coban every other day. (There was no Telephone Order for 8/23/19 indicating new wound care orders). Review of the printed (existing) Wound Treatment Flowsheets (TAR) for (MONTH) 2019 documented: Order - treatment to LLE: cleanse with normal saline and 4 x 4, pat dry with 4 x 4, apply on Unnaboot and Coban; every other day and as needed. The TAR documented the order was discontinued on 8/19/19 Review of the hand written (new) Wound TAR for (MONTH) 2019 documented: Order beginning 8/19/19 for LLE- cleanse with normal saline and 4 x 4, pat dry with 4 x 4, apply all the Unnaboot and Coban toes to knee; once a week and as needed if draining. The order was initialed as completed by the treatment nurse on 8/19/19 and 8/22/19. The WCC did the wound care on 8/27/19. Review of the (MONTH) 2019 TAR documented: Order treat wounds at LLE: cleanse with normal saline and 4 x 4, pat dry with 4 x 4's, apply Unnaboot and Coban. The frequency had handwritten changed to every week and as needed. Treatments were shown to be completed on 9/4/19 (by Licensed Vocational Nurse (LVN A)), 9/9/19, 9/16/19 and 9/19/19 (by LVN A). The WCC completed the wound care on 9/23/19. Review of the Nurses Notes documented: 7/16/19 at 3:24 p.m.: resident returned from wound care appointment. No distress noted. Denies pain. 8/27/19 at 5:00 p.m.: resident returned from doctor appointment with no new orders. No distress noted. Denies pain. Able to voice needs. Eat meals in dining room. (There was no indication if the doctor's appointment was the WCC or another doctor.) 8/28/19 at 6:20 a.m. and 9:30 a.m. showed no indication new wound care orders had been made. 9/15/19 at 8:00 p.m. documented client has a wound care consult at the hospital to be set up. (There were no other notes written between 9/15/19 and 9/23/19.) 9/23/19 at 5:00 p.m. documented: received report that resident went to wound care. Notified at this time resident was admitted to hospital from wound care. 9/23/19 untimed note: called family and notified Doctor of self report. Review of the 24-hour Nurse to Nurse shift report dated 8/27/19 documented no mention of Resident #1 going to the WCC or any new wound care orders. WOUND CARE CLINIC (WCC) Review of Resident #1's WCC records dated 8/6/19 documented: History of Present Illness: changing Unnaboot every other day. Looks like she has more skin. Physician order [REDACTED]. Keep dressing dry and intact. Apply Unnaboot, wrap with Kerlix gauze and secure with Coban, slit cut at top of Unnaboot due to tightness, remove and reapply every other day. Notes: wound care instructions to follow dermatologist, lower leg improved. Orders sent with nurse to facility. Review of Resident #1's WCC records dated 8/19/19 documented: History of Present Illness: wound looks clean and smaller. Physician order [REDACTED]. Order sent with nurse to facility. Discharge Instruction Details: Apply complete Unnaboot from toes to knee, wrap with Coban 4 x 5 from toes to knee. Change every other day due to drainage or once a week if tolerated well. Facility Caregiver given a copy Review of Resident #1's WCC records dated 8/27/19 documented: History of Present Illness: Unnaboot was tight and difficult to remove. The dressing was stuck to wounds. Wounds look about the same. Dermatologist is still overseeing the Unnaboots. Physician order [REDACTED]. Wound care order applied [MEDICATION NAME] to entire leg, wrap lightly with Kerlix and lightly with Coban or #5 netting every day. Other: No Unnaboot unless otherwise ordered by dermatologist. So tight I could not remove easily and did not want to tear her skin, [MEDICAL CONDITION] noted above wrap. Wound unchanged. (The WCC orders did not document the orders they were sent back with the caregiver or sent to the facility.) Review of the fax confirmation report dated (MONTH) 29, 2019 at 11:50 a.m. sent by the WCC documented the results were busy and the fax could not have gone through to the facility. Review of Resident #1's WCC records dated 9/23/19 documented: Physician order [REDACTED]. Rapid response called and patient taken to ER in [MEDICAL CONDITION] called. Called facility to report to DON (Director Of Nurses). Assessment Notes: constricture and bruising below knee where Unnaboot was too tight. [MEDICAL CONDITION] foot, Unnaboot stopped at ankle. Review of a note provided to the WCC (writer unknown) on 9/23/19 documented: I took over treatments last week. The most current orders I found and have from y'all are Unnaboot every week. I realized the resident has not been to your wound care center since 8/27/19. It seems her wound stays really moist and the nurses during the day have to reinforce due to drainage. If orders changed and not sent back to facility with resident, please fax to facility. Observation on 9/26/19 at 10:50 a.m. the Wound Care Center showed surveyors the wound care pictures on their camera. Picture #1 showed Resident #1's knee; the knee was swollen and there was a clear straight indention where the compression bandage started; the calf was appeared approximately 1/3rd the size of the knee. Picture #2 showed the entire leg: there were clear lines where the bandage had compressed from the knee to the ankle; there was visible black bruising on the top of the bandage at the knee, the knee and foot were swollen with the ankle/calf visibly compressed. Picture #3 showed an angle view of Resident #1's foot/ankle: the compression line was very clear, Resident #1's foot was swollen from ankle to toes. During an interview on 9/26/19 at 10:17 a.m. WCC-RN [NAME] said she was the nurse manager over the WCC and was working 9/23/19. She said she was aware of Resident #1 and her care. WCC-RN [NAME] said on 8/27/19 the WCC said they would not see Resident #1 until she followed up with the dermatologist and the vascular specialist. She said the WCC thought the wound care orders were detrimental and wanted it re-assessed. WCC-RN [NAME] said they WCC did not see Resident #1 between 8/27/19 and 9/23/19. WCC-RN [NAME] said the facility had a Treatment Nurse that had been coming with the residents and the resident's leg was improving. WCC-RN [NAME] said Resident #1's treatment had been recommended by a dermatologist. She said since the wound was improving the WCC recommended the dressing changed be decreased from every other day to once a week to be completed by the Treatment Nurse at the facility. WCC-RN [NAME] said the last time they saw Resident #1 on 8/27/19 they asked that asked the facility not to place the Unnaboot again because the leg was bleeding. WCC-RN [NAME] said, I did remove it 8/28/19 and it was very tight. She said at that time the WCC recommended Resident #1 needed [MEDICATION NAME] and Kerlix until she was seen by the dermatologist. WCC-RN [NAME] said the facility sent orders with the resident after the resident was seen. She said if there was not a care giver they would fax over the orders. WCC-RN [NAME] showed surveyor the fax cover sheet sent 8/27/19 that read busy on the top of it. She acknowledged it was possible the facility did not get the orders. WCC-RN [NAME] said they worked with all kinds of agencies who were able to call and get clarification orders. WCC-RN [NAME] confirmed she worked 9/23/19. She said she went into the room and saw the Unnaboot dressing started at the ankle and went to the knee. She said Resident #1's foot was swollen three times what it normally was. She said, the calf was 21.5 centimeters in diameter (slightly larger than a 12-ounce soda can) and was bright red and bleeding. Her foot was huge and there was an indention and bruising from the wrapping. RN [NAME] said whoever came with Resident #1 on 9/23/19 put a hand-written note on the desk for her saying they were reinforcing the dressing and not changing it. She said when the WCC was taking off the dressing the staff were just cutting and cutting - there was layer of layer of wrapping. WCC-RN [NAME] said they took pictures of it but had not uploaded it into her medical record yet. WCC-RN [NAME] said she was trying to take the dressing off when Resident #1 slumped over. She said another nurse took off the dressing and Resident #1 started bleeding when they cut the dressing off. WCC-RN [NAME] said Resident #1's blood pressure was 95/56; her pulse was 118; and her respirations were 20. She said the doctor had to hold WCC-Resident #1 to get a pulse ox reading and it was. WCC-RN [NAME] said Resident #1 was hypotensive and hypoxic. She said she made the decision to send Resident #1 to the emergency room via the hospital's special response team. WCC-RN [NAME] said the hospitalization was easily avoidable. She said I don't care they're not a specialist - a nurse would know not to wrap that way. The foot ankle being wrapped could have been avoided. You can look it up. The way the wrap was placed it could have been avoided. During an interview on 9/26/19 at 10:17 a.m. the WCC Doctor said Resident #1's leg had been bad since the start. He said once the dermatologist took over the wound care orders the WCC just kept an eye on things because they did not want to get orders mixed up. He said, when they got the resident it was wrapped in multiple layers of gauze that caused the dressing to constrict further. The WCC-MD said once the boot dressing was applied it was designed to tighten as it dried and squeeze out fluid (he squeezed his hands together). He said his recommendation was to amputate the leg. He said the clinic could not rub the scissors across her skin to cut off the bandage because the skin would peel back like hide. HOSPITAL Review of Resident #1's emergency room (ER) Physician Notes dated 9/23/19 documented: Muscular-skeletal - the patient's left lower extremity looks awful. From the knee down the patient has open maceration with exposed underlying tissue. Their circumference of the leg is much smaller than the right and looks like it has been wrapped heavily in a compressive bandage for a long time. The patient has 4+ [MEDICAL CONDITION] of the foot. Medical Decision Making - the patient has an awful looking lower left leg. I wonder if she needs amputation. Emergency Department Disposition - she was admitted to the hospital. Review of the hospital's Consultation Note dated 9/23/19 at 5:11 p.m. documented: History of present illness: [AGE] year-old female presented with a complaint of weakness. ER Doctor evaluated her and noted her left lower extremity from the knee to the ankle is macerated circumferentially and does not appear to be healing well. It appears this may be the source of [MEDICAL CONDITION]. ER Doctor called consultant to consider above the knee amputation. Consulting physician explained indications would be if there's any osteo[DIAGNOSES REDACTED], if this was the source [MEDICAL CONDITION] and chronic/non-healing, and if the patient's lifestyle is limited by the non-healing large wound to the left lower extremity. Muscular-skeletal: left lower extremity shows from the knee to the ankle to be much smaller and caliber than the contralateral (other side). Her left foot is markedly swollen likely due to limited venous and lymphatic drainage. There are islands of fresh skin mixed with open granulation tissue on the left lower leg circumferentially. Review of the Hospital History and Physical dated 9/23/19 at 7:49 PM documented: History of present illness - today patient was at the wound care clinic, she collapsed, a rapid response was called, and she was brought to the emergency room . In the emergency room she was found to be essentially not very communicative except for severe pain. According to the son she does not like to talk to anybody usually. In the emergency room it was found that she has significant alterations and infection of the left lower extremity from the knee all the way down. There is extensive areas of simple bleeding and bruising from the left lower extremity. Seems to be very tender upon touch. Patients son stated that since (YEAR) her left lower extremity has been managed by the wound care at the nursing home, she has improved gradually and there were areas of healing to the extent that was only a small ulcer left. And later on, it would get worse again and flare up an infection would involve the left lower extremity. This is an ongoing issue with this patient for the past three years. Physical exam- examination of the left lower extremity does reveal alterations, areas of bleeding. There are areas of intermittent healing ulcers, as well as areas of normal looking skin. The left ankle is definitely swollen. Assessment and plan -[MEDICAL CONDITION] most probably due to left lower extremity infection and ulceration. Possibly significant vascular compromise in the left lower extremity. Patient is being managed currently with antibiotics as well as IV fluids. Review of the Hospital Discharge Documentation dated 9/26/19 documented: Primary Discharge Diagnosis -[MEDICAL CONDITION], left lower extremity [MEDICAL CONDITION]. Hospital course - patient was admitted through the emergency room , she was essentially not very cooperative and not wanting to talk too much. She was found to have left lower extremity [MEDICAL CONDITION] from the knee all the way down to the ankle. She had ankle [MEDICAL CONDITION] as well. But overall her condition is not very good. Case was discussed with the patient's son. Doctor did ask him about his preference of surgery versus hospice. He stated that hospice has been considered in the past. Upon further evaluation and considerations, it seems that above the knee amputation will not add much quality of life to the patient's life except will probably cause more pain related to surgery. She is already in some degree of pain because of the [MEDICAL CONDITION] of the left lower extremity. It was elected to discharge the patient back to the nursing home with hospice service. Right lower extremity without significant [MEDICAL CONDITION] and/or ulceration. Left lower extremity is definitely with significant [MEDICAL CONDITION] as well as some degree of alterations were areas of normal skin. Condition on Discharge - guarded and she was to return back to the nursing home with a hospice service consult. During an interview on 9/26/19 at 9:52 a.m. hospital Licensed Vocational Nurse (LVN) C said Resident #1 looked awful. She said the WCC had pictures in the chart of her leg. Hospital LVN C said Resident #1 had a large amount of drainage from her leg. Hospital LVN C said the doctor wanted to amputate Resident #1's leg but the hospital was unable to reach the family and the hospital was concerned she would not make it through the surgery. Hospital LVN C said Resident #1's admitting [DIAGNOSES REDACTED].#1 had [MEDICAL CONDITION] literally from knee to ankle. Observation and interview on 9/26/19 at 9:55 a.m. Hospital LVN C said she could not find a pulse in Resident #1's left foot because it was too swollen. Hospital Registered Nurse (RN) D said she could not find a pedal pulse either. Resident #1 had 3+ [MEDICAL CONDITION] to the left foot (indentation where skin was depressed by finger for up to 30 seconds). Resident #1 was in bed dressed in a hospital gown; she either ignored or was not aware of other people in the room with her unless that person was touching her left leg. Resident #1 was in a hospital gown, her leg was uncovered, resting on a paper pad. Resident #1's left leg had open shallow wounds with serosanguineous (clear) fluid weeping from it from her knee to her ankle. The wounds were shallow with a dark red base. Some yellow tissue with irregular margins. The wounds on the back of Resident #1's leg had sanguineous (red) drainage in an approximately quarter sized area. Hospital RN D picked up Resident #1's leg to show drainage; the pad showed drainage from the ankle the length of the pad to the knee. Hospital RN D said she changed the paper pad approximately three minutes prior and the pad already had enough drainage on it that it stuck to leg. Hospital RN D placed a cloth pad that would not stick to wounds underneath the leg. During an interview on 9/25/19 at 10:54 a.m. the Administrator said there was no formal Treatment Nurse but they had some as-needed nurses coming in to do treatments. The Administrator said the facility received a call from the WCC on 9/23/19 that LVN A put the Unnaboot on wrong and the hospital said it was too tight. The Administrator said the WCC manager at the hospital said the resident's dressing was put on very tight and she was being admitted to the hospital. Administrator said she went to the hospital. She said Resident #1's leg was not infected but acknowledged it was very bloody. Surveyor requested the WCC orders/notes provided to the facility. During an interview on 9/25/19 at 2:10 p.m. the Administrator said she called WCC for copies of orders for the Unnaboot. The Administrator said the WCC wanted the Unnaboot discontinued on 8/27/19 and the order was communicated on 8/27/19 discharge notes. The Administrator said the facility never got the change in orders. The Administrator said the previous Treatment nurse was instructed to get a follow up appointment with the dermatologist to get the Unnaboot discontinued and did not follow through. The Administrator acknowledged Resident #1 was receiving the wrong wound care because the order did not get communicated to the facility and they were unaware of it. The Administrator said usually when a resident went to the WCC they returned with a report that documented order changes. During an interview on 9/25/19 at 3:34 p.m. the previous Treatment Nurse (RN B) confirmed she was the last Treatment Nurse. She said she took over as Treatment Nurse in (MONTH) 2019 and her last day was 8/22/19. RN B said she remembered Resident #1. She said Resident #1 had an un-healing wound on her left calf that had been there 2 -3 years. RN B said she went to the WCC appointments with the residents, so she would know changes. RN B said the orders were an Unnaboot dressing toes to knee. She said the wounds started improving the WCC Doctor said they could change it to once a week. She said she did not remember the date but it was right before she quit. RN B said the WCC told her to use the entire boot and do it loosely because it constricts. She said as far as she knew a follow up appointment with the dermatologist was never made. RN B said the Unnaboot order was still in use when she left the facility. She said she did not know who took over doing treatments when she left. During an interview on 9/26/19 at 2:15 p.m. RN F said she only worked at the facility for a week on the 2 p.m. - 10 p.m. shift. She confirmed she worked with Resident #1. She said it looked like Resident #1 had a wound infection so the facility sent her to the WCC. She said the hospital then called to say they were admitting her. RN F acknowledged she saw Resident #1's dressing. She said the wrap started at the ankle and extended to right below her knee. RN F said she was pretty sure the dressing was dated 9/19/19. RN F said on Sunday night (9/22/19 the night before Resident #1 was admitted to the hospital) she wanted to change the dressing because it was seeping through but was told not to touch it and the wound care nurse would take care of it. RN F said she reinforced the dressing on the medial area with 4 X 4 dressings where it was draining and wrapped with Kerlix. She said she elevated the leg and Resident #1 said she was not in any pain. RN F described Resident #1's foot as slightly swollen with no pitting. RN F said she did not have any training on the Unnaboot dressing until 9/23/19. RN F repeated, I really wanted to change the dressing, but I was told no. It just looked so Nasty. During an interview on 9/26/19 at 2:25 p.m. LVN G said she had worked for the facility before but had only been back 3 weeks. She said when Resident #1's drainage seeps through the dressing the staff reinforced it and wrapped it with gauze. LVN G said as far as she knew LVN A took care of the wound care. She said Resident #1's Unnaboot was changed once a week. LVN A confirmed she worked the morning of 9/23/19 (the WCC appointment/ hospital admission). She said Resident #1 was up in her Geri chair that morning. LVN G said she did not notice any swelling to Resident #1's foot but there was some bloody drainage. LVN G remembered the dressing being applied above the toes and ended below the knee. She said LVN A placed a handwritten note with Resident #1's demographics to go with her with some questions. She said the only in-service she had on the Unnaboot dressing was 9/23/19 During an interview on 9/26/19 at 2:25 p.m. the previous Treatment Nurse (RN B) said the usual process for wound care from the WCC was: the WCC would give the order, the nurse would write a Telephone Order, put it in the clinical record, and then write the order on the TAR. She said the paper copy of the WCC orders would go in the TAR book and it would stay there indefinitely. She said all the orders she received were filed in the TAR book. RN B said no one trained her on how to apply the Unnaboot dressings. She said she originally watched another nurse at a doctor's appointment apply it and imitated what she did. RN B said when she took Resident #1 to the WCC they said she needed to use the whole roll of dressing but the toes to knee was perfect. She said she believed there was vague directions on the side of the box. RN B said the dermatologist instructed her to go toe to knees. The previous Treatment Nurse (RN B) acknowledged she did not communicate those instructions to anyone because she was the only one doing treatments. She said she was doing most of the weekend treatments as well. She said she did not remember telling the previous Assistant Director of Nurses (pADON) the instructions. She said she never found the dressing applied incorrectly. RN B said in general she did not train staff to do treatments because it was only her and the pADON who did treatments. She said she did question if the 2 p.m. - 10 p.m. or 10 p.m. - 6 a.m. shift needed to be trained but was told it would be fine. She said two nurses shadowed her on learning how to do treatments on the weekend. RN B said minor dressing changes supplies were left out for the nurses and if there was an emergency they would call her or the pADON to do it. She said saline, gauze and the island dressings were left out for the charge nurses. During an interview on 9/26/19 at 2:46 a.m. the previous Assistant Director of Nurses (pADON) said her last day at the facility was 9/17/19. She said she did not remember when the Treatment Nurse (RN B) walked out. She said once the treatment nurse left she (the pADON) did treatments on Mondays including measurements and skin assessments. She said LVN A did treatments Tuesday through Friday while acting as a charge nurse once RN B was gone. She said she had finally found a nurse to do treatments on the weekends. She said in her opinion the skin system was probably not working because she had to work on the floor too much and was unable to keep up with the assessments. She said the residents were getting the treatments as ordered by the physician when she left. She said she did not know what happened after she left. The pADON said she remembered Resident #1. She said Resident #1 had the third-[MEDICAL CONDITION]. She said when Resident #1 was admitted both legs were burned but they got the right leg healed up. She said Resident #1 was going to wound care and it was looking better. She said Resident #1 had an appointment to see the vascular specialist but they had to reschedule because family was not present to sign the initial paperwork. The pADON said RN B went with resident to the WCC and RN B told her (pADON) that the WCC doctor changed the treatment from every other day to weekly. The pADON said the Unnaboot dressing was a gauze that was tightly woven and impregnated with [MEDICATION NAME] or zinc. She said it was a wet dressing so it needed Kerlix on top of it. She said it was a normal treatment for [REDACTED]. She said to apply it you started at the tips of the toes and worked up. The pADON added if the dressing was not started at the toe it would cut off circulation and you could not start mid-foot. She said to apply they needed to wrap lightly, not tightly all the way to the knee and repeat with Kerlix and Coban. She said she gave a training on it a long time ago but did not remember when. The pADON said she showed the staff to start at the toes and work and apply it lightly. She said she did not remember when she told them. The pADON said when a resident's dressing was soiled or something the staff needed to call her and if she was not available to reinforce the dressing until she was able to get there and change the dressing. She said the nurses had access to ABD pad and wrap with Kerlix or Coban. She said the staff (unidentified) called in the beginning of (MONTH) to report Resident #1 was bleeding through the dressing and she told them to put a towel underneath until she could get there. The pADON said Resident #1 did not frequently bleed through the dressing. The pADON said it depended on what kind of day Resident #1 was having if she would allow the wound care or not. She said Resident #1 was on pain medication. Interview on 9/26/19 at 3:32 p.m. the current Assistant Director of Nurses (ADON) said Charge Nurses did not have access to the treatment cart (meaning even if they wanted the to the nurses did not have access to the appropriate supplies to do correct wound care). She said that was going to have to change because the pADON lived close and could go change the dressing on demand and she would not be able to. She added she did not know if there was even an Unnaboot (dressing) in the Treatment cart. The ADON opened the treatment cart and found an Unnaboot dressing. Observation and interview on 9/26/19 at 3:32 p.m. of the Unnaboot bandage instructions on the outside of the box showed: The bandage provide mild compression. A picture showed the bandage was to be applied from the toes to the knee. The directions read: 1. position the foot at a right angle, so the foot is perpendicular to the leg. Begin wrapping without pressure just above the toes and continue upwards using a spiral technique with a 50% overlap. 2. Mold wrap to the contours of the leg. Finish wrapping 1 - 2 inches below the knee. Smooth out wrinkles as needed. 3. Secure by covering with a secondary dressing such as a self-adherent wrap, elastic bandage, or gauze roll During an interview on 9/26/29 at 3:35 p.m. the ADON said she took the position on Tuesday 9/24/19. The ADON said she had nothing to do with wound care. The ADON said she did not work 9/23/19. She said she did work on 9/22/19 as a Charge Nurse and she saw Resident #1 up in the Geri chair with a lap blanket over her legs, so she did not see her leg. The ADON said she asked Resident #1 about pain and Resident #1 said she did not have any. The ADON said she knew how to put on the Unnaboot dressing because she received training from the WCC when she was the Treatment Nurse (2018); she added the WCC stressed not to wrap the dressing too tight because like wet leather it will shrink. During an interview on 9/26/19 at 3:45 p.m. the pADON said she did not know anything about a follow up referral to the dermatologist. She said technically, there should have a been a telephone order so the management could go over the order in the morning meeting to make sure it was followed through with. She said the WCC would always send orders back if they wanted a follow up appointment. She said the Treatment Nurse was responsible for putting the appointments in the appointment book. She said, we never saw the piece of paper, if there were changes in the order there would be a telephone order. She said after RN B left the aides would get the paper with the orders and give it to the

Based on interviews, observations and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 (Resident #1) of 5 residents whose care was reviewed for quality of care. The facility failed to ensure Licensed Vocational Nurse (LVN) A applied Resident #1's Unnaboot dressing (a specialized gauze wrapping impregnated with zinc or [MEDICATION NAME] that compresses when it dries) from toes to knee as directed by the box instructions between 9/19/19 through 9/23/19. The facility failed to ensure nurses provided dressing changes for Resident #1 when her wound drainage seeped through the dressing. The nurses reinforced the incorrect dressing causing it to constrict further. The facility failed to ensure nurses monitored Resident #1's extremity and identify changes to her left lower extremity (LLE) including swelling and pain. On 9/23/19 Resident #1 was admitted to the hospital with [REDACTED]. The physician recommended amputation of the lower leg. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/27/2019. While the IJ was removed on 09/30/2019, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing [MEDICAL CONDITION] (infection of the blood), severe pain, dismemberment or death. Findings Included: FACILITY CLINICAL RECORDS Record review of Resident #1's Resident Face Sheet dated 1/9/17 documented she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] documented, in part: She scored a 2 of 15 on her mental status exam indicating severe cognitive impairment. She showed signs of [MEDICAL CONDITION] that included inattention and disorganized thinking that fluctuated. Her depression screening indicated she had no indicators of depression. She showed no indicators of [MEDICAL CONDITION]. She had no behaviors documented. Her Activities of Daily Living (ADL) status indicated: she needed total assistance of one person for bed mobility, locomotion, dressing, toilet use, personal hygiene, and showering. Resident #1 needed total assistance of two staff for transfers. She needed supervision for eating. She had no range of motion impairments identified and used a wheelchair. She had active [DIAGNOSES REDACTED]. The MDS documented she received no scheduled or as needed pain medications. Her pain interview indicated she experienced no pain. There were no other health conditions or problems conditions identified. She was not identified as life expectancy of less than six months. She was at risk for developing pressure ulcers but had none at the time of the assessment. She did [MEDICAL CONDITION] the second or third degree. Identified treatments included a pressure reducing device for the bed, application of non-surgical dressings, and application of appointments or medications. Review of Resident #1's Care Plan Summary reviewed 6/5/19 documented she needed extensive assistance of two staff for all ADLs. She had wounds to the left lower extremity and was at risk for pressure ulcers. Review of the Nursing Assistant Care Plan dated 8/1/19 documented that her skin was not intact, and she had lower extremity impairment. Review of the Care Plan updated on 9/2/19 documented she had healing left lateral extremity (LLE) burns. The identified goal was the area will heal without complications. Identified approaches included perform treatments per order, if no improvement for two weeks report to medical doctor. Review of Physician Telephone Orders documented: 6/11/19 Wound Care (WCC) to evaluate and treat on healing third-[MEDICAL CONDITION] left lower extremity. 7/17/19 Treatment left lower leg: cleanse with normal saline and 4 x 4, pat dry with 4 x 4, wrap with Unnaboot and Coban every other day. (There was no Telephone Order for 8/23/19 indicating new wound care orders). Review of the printed (existing) Wound Treatment Flowsheets (TAR) for (MONTH) 2019 documented: Order - treatment to LLE: cleanse with normal saline and 4 x 4, pat dry with 4 x 4, apply on Unnaboot and Coban; every other day and as needed. The TAR documented the order was discontinued on 8/19/19 Review of the hand written (new) Wound TAR for (MONTH) 2019 documented: Order beginning 8/19/19 for LLE- cleanse with normal saline and 4 x 4, pat dry with 4 x 4, apply all the Unnaboot and Coban toes to knee; once a week and as needed if draining. The order was initialed as completed by the treatment nurse on 8/19/19 and 8/22/19. The Wound Care Clinic (WCC) did the wound care on 8/27/19. Review of the (MONTH) 2019 TAR documented: Order treat wounds at LLE: cleanse with normal saline and 4 x 4, pat dry with 4 x 4's, apply Unnaboot and Coban. The frequency had handwritten changed to every week and as needed. Treatments were shown to be completed on 9/4/19 (by LVN A), 9/9/19, 9/16/19 and 9/19/19 (by LVN A). The WCC completed the wound care on 9/23/19. Review of the Nurses Notes documented: 7/16/19 at 3:24 p.m.: resident returned from wound care appointment. No distress noted. Denies pain. 8/27/19 at 5:00 p.m.: resident returned from doctor appointment with no new orders. No distress noted. Denies pain. Able to voice needs. Eat meals in dining room. (There was no indication if the doctor's appointment was the WCC or another doctor.) 8/28/19 at 6:20 a.m. and 9:30 a.m. showed no indication new wound care orders had been made. 9/15/19 at 8:00 p.m. documented client has a wound care consult at the hospital to be set up. (There were no other notes written between 9/15/19 and 9/23/19.) 9/23/19 at 5:00 p.m. documented: received report that resident went to wound care. Notified at this time resident was admitted to hospital from wound care. 9/23/19 untimed note: called family and notified Doctor of self report. Review of the 24-hour Nurse to Nurse shift report dated 8/27/19 documented no mention of Resident #1 going to the WCC or any new wound care orders. WOUND CARE CLINIC (WCC) Review of Resident #1's WCC records dated 8/6/19 documented: History of Present Illness: changing Unnaboot every other day. Looks like she has more skin. Physician order [REDACTED]. Keep dressing dry and intact. Apply Unnaboot, wrap with Kerlix gauze and secure with Coban, slit cut at top of Unnaboot due to tightness, remove and reapply every other day. Notes: wound care instructions to follow dermatologist, lower leg improved. Orders sent with nurse to facility. Review of Resident #1's WCC records dated 8/19/19 documented: History of Present Illness: wound looks clean and smaller. Physician order [REDACTED]. Order sent with nurse to facility. Discharge Instruction Details: Apply complete Unnaboot from toes to knee, wrap with Coban 4 x 5 from toes to knee. Change every other day due to drainage or once a week if tolerated well. Facility Caregiver given a copy Review of Resident #1's WCC records dated 8/27/19 documented: History of Present Illness: Unnaboot was tight and difficult to remove. The dressing was stuck to wounds. Wounds look about the same. Dermatologist is still overseeing the Unnaboots. Physician order [REDACTED]. Wound care order applied [MEDICATION NAME] to entire leg, wrap lightly with Kerlix and lightly with Coban or #5 netting every day. Other: No Unnaboot unless otherwise ordered by dermatologist. So tight I could not remove easily and did not want to tear her skin, [MEDICAL CONDITION] noted above wrap. Wound unchanged. (The orders did not document if the orders were sent home with the caregiver or sent to the facility.) Review of the fax report confirmation sheet dated (MONTH) 29, 2019 at 11:50 a.m. sent by the WCC documented the results were busy and the fax could not have gone through to the facility. (The WCC did not send the wound care orders back with the care giver but tried to fax the facility). Review of Resident #1's WCC records dated 9/23/19 documented: Physician order [REDACTED]. Rapid response called and patient taken to ER in [MEDICAL CONDITION] called. Called facility to report to DON (Director Of Nurses). Assessment Notes: constricture and bruising below knee where Unnaboot was too tight. [MEDICAL CONDITION] foot, Unnaboot stopped at ankle. Review of a note provided to the WCC (writer unknown) on 9/23/19 documented: I took over treatments last week. The most current orders I found and have from y'all are Unnaboot every week. I realized the resident has not been to your wound care center since 8/27/19. It seems her wound stays really moist and the nurses during the day have to reinforce due to drainage. If orders changed and not sent back to facility with resident, please fax to facility. Observation on 9/26/19 at 10:50 a.m. the Wound Care Center (WCC) showed surveyors the wound care pictures on their camera on 9/23/19. Picture #1 showed Resident #1's knee; the knee was swollen and there was a clear straight indention where the compression bandage started; the calf appeared approximately 1/3rd the size of the knee. Picture #2 showed the entire leg: there were clear lines where the bandage had compressed from the knee to the ankle; there was visible black bruising on the top of the bandage at the knee, the knee and foot were swollen with the ankle/calf visibly compressed. Picture #3 showed an angle view of Resident #1's foot/ankle: the compression line was very clear, Resident #1's foot was swollen from ankle to toes. During an interview on 9/26/19 at 10:17 a.m. WCC RN [NAME] said she was the nurse manager over the WCC and was working 9/23/19. She said she was aware of Resident #1 and her care. WCC RN [NAME] said on 8/27/19 the WCC said they would not see Resident #1 until she followed up with the dermatologist and the vascular specialist. She said the WCC thought the wound care orders were detrimental and wanted it re-assessed. WCC RN [NAME] said the WCC did not see Resident #1 between 8/27/19 and 9/23/19. WCC RN [NAME] said the last time they saw Resident #1 on 8/27/19 they asked that asked the facility not to place the Unnaboot again because the leg was bleeding. WCC RN [NAME] said, I did remove it 8/28/19 and it was very tight. She said at that time the WCC recommended Resident #1 needed [MEDICATION NAME] and Kerlix until she was seen by the dermatologist. WCC RN [NAME] confirmed she worked 9/23/19. She said she went into the room and saw the Unnaboot dressing started at the ankle and went to the knee. She said Resident #1's foot was swollen three times what it normally was. She said, the calf was 21.5 centimeters in diameter (slightly larger than a 12-ounce soda can) and was bright red and bleeding. Her foot was huge and there was an indention and bruising from the wrapping. WCC RN [NAME] said whoever came with Resident #1 on 9/23/19 lay a hand-written note on the desk for her saying they were reinforcing the dressing and not changing it. She said when the WCC was taking off the dressing the staff were just cutting and cutting - there was layer of layer of wrapping. WCC RN [NAME] said they took pictures of it but had not uploaded it into her medical record yet. WCC RN [NAME] said she was trying to take the dressing off when Resident #1 slumped over. She said another nurse took off the dressing and Resident #1 started bleeding when they cut the dressing off. RN [NAME] said Resident #1's blood pressure was 95/56; her pulse was 118; and her respirations were 20. She said the doctor had to hold Resident #1 to get a pulse ox reading and it was. WCC RN [NAME] said Resident #1 was hypotensive and hypoxic. She said she made the decision to send Resident #1 to the emergency room via the hospital's special response team. WCC RN [NAME] said the hospitalization was easily avoidable. She said I don't care they're not a specialist - a nurse would know not to wrap that way. The foot ankle being wrapped could have been avoided. You can look it up. The way the wrap was placed it could have been avoided. During an interview on 9/26/19 at 10:17 a.m. the WCC Doctor said Resident #1's leg had been bad since the start. He said once the dermatologist took over the wound care orders the WCC just kept an eye on things because they did not want to get orders mixed up. He said, when they got the resident (on 9/23/19) it was wrapped in multiple layers of gauze that caused the dressing to constrict further. The WCC MD said once the boot dressing was designed to tighten as it dried and squeeze out fluid once it was applied (he squeezed his hands together). He said his recommendation was to amputate the leg. He said the clinic could not rub the scissors across her skin to cut off the bandage because the skin would peel back like hide. HOSPITAL Review of Resident #1's emergency room (ER) Physician Notes dated 9/23/19 documented: Muscular-skeletal - the patient's left lower extremity looks awful. From the knee down the patient has open maceration with exposed underlying tissue. Their circumference of the leg is much smaller than the right and looks like it has been wrapped heavily in a compressive bandage for a long time. The patient has 4+ [MEDICAL CONDITION] of the foot. Medical Decision Making - the patient has an awful looking lower left leg. I wonder if she needs amputation. Emergency Department Disposition - she was admitted to the hospital. Review of the hospital's Consultation Note dated 9/23/19 at 5:11 p.m. documented: History of present illness: [AGE] year-old female presented with a complaint of weakness. ER Doctor evaluated her and noted her left lower extremity from the knee to the ankle is macerated circumferentially and does not appear to be healing well. It appears this may be the source of [MEDICAL CONDITION]. ER Doctor called consultant to consider above the knee amputation. Consulting physician explained indications would be if there's any osteo[DIAGNOSES REDACTED], if this was the source [MEDICAL CONDITION] and the chronic/non-healing, and if the patient's lifestyle is limited by the non-healing large wound to the left lower extremity. Muscular-skeletal: left lower extremity shows from the knee to the ankle to be much smaller and caliber than the contralateral (other side). Her left foot is markedly swollen likely due to limited venous and lymphatic drainage. There are islands of fresh skin mixed with open granulation tissue on the left lower leg circumferentially. Review of the Hospital History and Physical dated 9/23/19 at 7:49 PM documented: History of present illness - today patient was at the wound care clinic, she collapsed, a rapid response was called, and she was brought to the emergency room . In the emergency room she was found to be essentially not very communicative except for severe pain. According to the son she does not like to talk to anybody usually. In the emergency room it was found that she has significant alterations and infection of the left lower extremity from the knee all the way down. There is extensive areas of simple bleeding and bruising from the left lower extremity. Seems to be very tender upon touch. Patients son stated that since (YEAR) her left lower extremity has been managed by the wound care at the nursing home, she has improved gradually and there were areas of healing to the extent that was only a small ulcer left. And later on, it would get worse again and flare up an infection would involve the left lower extremity. This is an ongoing issue with this patient for the past three years. Physical exam- examination of the left lower extremity does reveal alterations, areas of bleeding. There are areas of intermittent healing ulcers, as well as areas of normal looking skin. The left ankle is definitely swollen. Assessment and plan -[MEDICAL CONDITION] most probably due to left lower extremity infection and ulceration. Possibly significant vascular compromise in the left lower extremity. Patient is being managed currently with antibiotics as well as IV fluids. Review of the Hospital Discharge Documentation dated 9/26/19 documented: Primary Discharge Diagnosis -[MEDICAL CONDITION], left lower extremity [MEDICAL CONDITION]. Hospital course - patient was admitted through the emergency room , she was essentially not very cooperative and not wanting to talk too much. She was found to have left lower extremity [MEDICAL CONDITION] from the knee all the way down to the ankle. She had ankle [MEDICAL CONDITION] as well. But overall her condition is not very good. Case was discussed with the patient's son. Doctor did ask him about his preference of surgery versus hospice. He stated that hospice has been considered in the past. Upon further evaluation and considerations, it seems that above the knee amputation will not add much quality of life to the patient's life except will probably cause more pain related to surgery. She is already in some degree of pain because of the [MEDICAL CONDITION] of the left lower extremity. It was elected to discharge the patient back to the nursing home with hospice service. Right lower extremity without significant [MEDICAL CONDITION] and/or ulceration. Left lower extremity is definitely with significant [MEDICAL CONDITION] as well as some degree of alterations were areas of normal skin. Condition on Discharge - guarded and she was to return back to the nursing home with a hospice service consult. During an interview on 9/26/19 at 9:52 a.m. hospital LVN C said Resident #1 looked awful. She said the WCC had pictures in the chart of her leg. Hospital LVN C said Resident #1 had a large amount of drainage from her leg. Hospital LVN C said the doctor wanted to amputate Resident #1's leg but the hospital was unable to reach the family and the hospital was concerned she would not make it through the surgery. Hospital LVN C said Resident #1's admitting [DIAGNOSES REDACTED].#1 had [MEDICAL CONDITION] literally from knee to ankle. Observation and interview on 9/26/19 at 9:55 a.m. hospital LVN C said she could not find a pulse in Resident #1's left foot because it was too swollen. Hospital Registered Nurse (RN) D said she could not find a pedal pulse either. Resident #1 had 3+ [MEDICAL CONDITION] to the left foot (indentation where skin was depressed by finger for up to 30 seconds). Resident #1 was in bed dressed in a hospital gown; she either ignored or was not aware of other people in the room with her unless that person was touching her left leg. Resident #1 was in a hospital gown, her leg was uncovered, resting on a paper pad. Resident #1's left leg had open shallow wounds with serosanguineous (clear) fluid weeping from it from her knee to her ankle. The wounds were shallow with a dark red base. Some yellow tissue with irregular margins. The wounds on the back of Resident #1's leg had sanguineous (red) drainage in an approximately quarter sized area. Hospital RN D picked up Resident #1's leg to show drainage; the pad showed drainage from the ankle the length of the pad to the knee. Hospital RN D said she changed the paper pad approximately three minutes prior and the pad already had enough drainage on it that it stuck to leg. Hospital RN D placed a cloth pad that would not stick to wounds underneath the leg During an interview on 9/25/19 at 10:54 a.m. the Administrator said there was no formal Treatment Nurse but they had some as-needed nurses coming in to do treatments. The Administrator said the facility received a call from the WCC that LVN A put the Unnaboot on wrong on 9/23/19 and the hospital said it was too tight. The Administrator said the WCC manager at the hospital said the resident's dressing was put on very tight and she was being admitted to the hospital. Administrator said she went to the hospital. She said Resident #1's leg was not infected but acknowledged it was very bloody. Surveyor requested all WCC orders. During an interview on 9/25/19 at 2:10 p.m. the Administrator said she called WCC for copies of orders for the Unnaboot. The Administrator said the WCC wanted the Unnaboot discontinued on 8/27/19 and the order was communicated on 8/27/19 discharge notes. The Administrator said the facility never got the change in orders. The Administrator said the previous Treatment nurse was instructed to get a follow up appointment with the dermatologist to get the Unnaboot discontinued and did not follow through. The Administrator acknowledged Resident #1 was receiving the wrong wound care because the order did not get communicated to the facility and they were unaware of it. The Administrator said usually when a resident went to the WCC they returned with a report that documented order changes. During an interview on 9/25/19 at 3:34 p.m. the previous Treatment Nurse (RN B) confirmed she was the last Treatment Nurse. She said she took over as Treatment Nurse in (MONTH) 2019 and her last day was 8/22/19. RN B said she remembered Resident #1. She said Resident #1 had an un-healing wound on her left calf that had been there 2 -3 years. RN B said the orders were an Unnaboot dressing toes to knee. RN B said the WCC told her to use the entire boot and do it loosely because it constricts. During an interview on 9/26/19 at 2:15 p.m. RN F said she only worked at the facility for a week on the 2 p.m. - 10 p.m. shift. She confirmed she worked with Resident #1. She said it looked like Resident #1 had a wound infection so the facility sent her to the WCC. She said the hospital then called to say they were admitting her. RN F acknowledged she saw Resident #1's dressing. She said the wrap started at the ankle and extended to right below her knee. RN F said she was pretty sure the dressing was dated 9/19/19. RN F said on Sunday night (9/22/19 the night before Resident #1 was admitted to the hospital) she wanted to change the dressing because it was seeping through but was told not to touch it and the wound care nurse would take care of it. RN F said she reinforced the dressing on the medial area with 4 X 4 dressings where it was draining and wrapped with Kerlix. She said she elevated the leg and Resident #1 said she was not in any pain. RN F described Resident #1's foot as slightly swollen with no pitting. RN F repeated, I really wanted to change the dressing, but I was told no. It just looked so Nasty. During an interview on 9/26/19 at 2:25 p.m. LVN G said she has worked for the facility before but has only been back 3 weeks. She said when Resident #1's drainage seeps through the dressing the staff reinforced it and wrapped it with gauze. LVN A confirmed she worked the morning of 9/23/19 (the WCC appointment/ hospital admission). She said Resident #1 was up in her Geri chair that morning. LVN G said she did not notice any swelling to Resident #1's foot but there was some bloody drainage. LVN G remembered the dressing being applied above the toes and ended below the knee. She said LVN A placed a handwritten note with Resident #1's demographics to go with her with some questions. During an interview on 9/26/19 at 2:25 p.m. the previous Treatment Nurse (RN B) said the usual process for wound care from the WCC was: the WCC would give the order, the nurse would write a Telephone Order, put it in the clinical record, and then write the order on the TAR. RN B said the dermatologist instructed her to go toe to knees. The previous RN B acknowledged she did not communicate those instructions to anyone She said she never found the dressing applied incorrectly. RN B said in general she did not train staff to do treatments because it was only her and the previous ADON (pADON) who did treatments. She said she did question if the 2 p.m. - 10 p.m. or 10 p.m. - 6 a.m. shift needed to be trained but was told it would be fine. She said two nurses shadowed her on learning how to do treatments on the weekend. RN B said minor dressing changes supplies were left out for the nurses and if there was an emergency they would call her or the pADON to do it. She said saline, gauze and the island dressings were left out for the charge nurses. During an interview on 9/26/19 at 2:46 a.m. the previous Assistant of Nurses (pADON) her last day at the facility was 9/17/19. She said she did not remember when the Treatment Nurse walked out. She said once the treatment nurse left she (the pADON) did treatments on Mondays including measurements and skin assessments. She said then LVN A did treatments Tuesday through Friday while acting as a charge nurse. She said she had finally found a nurse to do treatments on the weekends. She said the residents were getting the treatments as ordered by the physician when she left. The pADON said she remembered Resident #1. She said Resident #1 had the third-[MEDICAL CONDITION]. She said when Resident #1 was admitted both legs were burned but they got the right leg healed up. She said Resident #1 was going to wound care and it was looking better. She said Resident #1 had an appointment to see the vascular specialist but they had to reschedule because family was not present to sign the initial paperwork. The pADON said the Unnaboot dressing was a gauze that was tightly woven and impregnated with [MEDICATION NAME] or zinc. She said it was a wet dressing so it needed Kerlix on top of it. She said it was a normal treatment for [REDACTED]. She said to apply it you started at the tips of the toes and worked up. The pADON added if the dressing was not started at the toe it would cut off circulation and you could not start mid-foot. She said to apply they needed to wrap lightly, not tightly all the way to the knee and repeat with Kerlix and Coban. She said she gave a training on it a long time ago but did not remember when. The pADON said she showed the staff to start at the toes and work and apply it lightly. She said she did not remember when she told them. She said the nurses had access to ABD pad and wrap with Kerlix or Coban. Observation and interview on 9/26/19 at 3:32 p.m. the current Assistant of Nurses (ADON) said Charge Nurses did not have access to the treatment cart (nurses did not have access to the Unnaboot dressing or any other kind of specialized dressing in order to change it if necessary). She said that was going to have to change because the pADON lived close and could go changed the dressing on demand and she would not be able to. She added she did not know if there was even an Unnaboot (dressing) in the Treatment cart. The ADON opened the treatment cart and found an Unnaboot dressing. Observation of the Unnaboot bandage instructions on the outside of the box showed: The bandage provide mild compression. A picture showed the bandage was to be applied from the toes to the knee. The directions read: 1. position the foot at a right angle, so the foot is perpendicular to the leg. Begin wrapping without pressure just above the toes and continue upwards using a spiral technique with a 50% overlap. 2. Mold wrap to the contours of the leg. Finish wrapping 1 - 2 inches below the knee. Smooth out wrinkles as needed. 3. Secure by covering with a secondary dressing such as a self-adherent wrap, elastic bandage, or gauze roll. During an interview on 9/26/29 at 3:35 p.m. the ADON said she had nothing to do with wound care for six months. The ADON said she knew how to put on the Unnaboot dressing because she received training from the WCC when she was treatment nurse (2018); she added the WCC stressed not to wrap the dressing too tight because like wet leather it will shrink. During an interview on 9/26/19 at 3:45 p.m. the pADON repeated she showed LVN A how to apply the Unnaboot dressing. She repeated she showed LVN A to start at toes and work up but she did not remember when. Interview and 9/27/19 at 5:51 p.m. LVN H said the nurses had access to gauze and ABD pads at the nurse's station. LVN H said there were all sorts of things in the treatment cart and/or the medication room. During an interview on 9/28/19 at 11:40 a.m. Medication Aide (MA) J said she normally worked the 300 hall and knew Resident #1. MA J said Resident #1 got treatments on her leg and she usually would get up in the morning. She said Resident #1 had been at the facility for less than 5 years and had always had a bandage on her leg. MA J said she saw that bandage on 9/23/19. She said the dressing smelled because of the blood dripping from it MA J said she the other aides (unidentified) and were concerned about it. She said the aides would mention it to the nurse and the nurse would tell them they were handling it. MA J shrugged and said, I guess the treatment nurse was handling it. MA J described the bandage as tan and it went from ankle to knee. She said, to me it looked really tight and Resident #1 faded in and out of her normal. MA J said the dressing caused her pain and Resident #1 had scheduled [MEDICATION NAME] for it. MA J said Resident #1 did not complain of pain and she would not scream or moan or anything. She said whenever they did treatments they would instruct MA J to give Resident #1 pain medication. During an interview on 9/28/19 at 11:43 a.m. LVN G said she did not remember the aides ever reporting concerns about Resident #1's dressing not looking right. LVN G said the aides did report drainage and bleeding and when that happened she would tell them to put a towel under her leg or would reinforce it. LVN G said before the nurses had access to drainage sponges, band-aids and gauze that were kept in the medication room. She said the best we could have done is reinforce the dressing. She said she would call LVN A but she was only an as-needed nurse. During an interview on 9/29/19 at 6:45 p.m. LVN A said she worked at the facility for three years. LVN A said she had been doing treatments since 9/3/19 when the Treatment Nurse left. She said Resident #1 had wounds since she came in three years ago. LVN A sad Resident #1 had lots of sanguineous drainage. She said Resident #1's wound care orders were for an Unnaboot to be changed once a week. LVN A denied ever being shown how to apply the Unnaboot dressing. She said she just read the directions on the box and put it on accordingly. LVN A said she asked the pADON how to apply it and was told that the instructions were on the box (start at the toes wind to knees, smooth and do not use any type of pressure) and to wrap it like Kerlix. LVN A acknowledged she put the Unnaboot dressing on Resident #1 on 9/19/19. She said it was not the first time she applied the Unnaboot dressing, that it was maybe her third time doing so. LVN A said they said I did it from just below the knee to the ankle. It should have been from knees to toes. I honestly don't remember if I placed it like that, I must have because they said I did. She said her in-service on applying the Unnaboot was a webinar on-line. LVN A said if you answered the question correctly you got a certificate and turned it in. She said she did not know the Unnaboot constricted. LVN said Honestly, I don't know that day, I really can't tell why I did it like that. I'm upset with myself. I should have known. LVN A acknowledged she should have educated herself better and looked it up on-line for herself. She said she should not have trusted the order and called to check with the doctor. She said she went to the required in-service on 9/29/19. No policy related to general wound care was provided. Review of the Action Plan provided by the facility dated (MONTH) 23, 2019 documented: Problem skin system not 100%, wound care voicing Unnaboot on too tight and dressing not on upon arrival to wound care appointment Goal: ensure skin system is maintained, ensure