Every finding on record at Sulphur Springs Health and Rehabilitation

Based on interview and record review, the facility failed to ensure the residents had the right to exercise their rights and to be treated with respect and dignity for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to honor the request by Resident #1's to change his Medical Power of Attorney on 06/04/26 after his care plan meeting. This failure could place residents at risk of not having their preferred responsible party represent them in medical or care decisions. Findings included: Record review of Resident #1's face sheet, dated 06/23/26 indicated an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included, dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), stroke and high blood pressure. Record review of Resident #1's quarterly MDS assessment, dated 03/10/26, indicated Resident #1 is usually understood at times and was sometimes understood by others. Resident #1 had a BIMS score of 09 which indicated his cognition was moderately impaired. The MDS indicated Resident #1 required assistance with his ADLs. Record review of Resident #1's comprehensive care plan, dated 09/19/25, indicated, Resident #1 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to diagnosis of dementia. The interventions included staff to monitor/document/report to the physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of Resident #1's Medical Power of Attorney dated 05/27/26 had Family Member A and Family Member B listed on his Medical Power of Attorney. Family Member A being the primary. During an interview on 06/22/26 at 11:50 a.m., Family Member C said they had a care plan meeting on a date unknown with Resident #1. Family Member C said Resident #1 indicated he wanted Family Member A and Family Member C to be his Medical [NAME] of Attorney with Family Member A being the primary. Family member C said the facility had not updated or given the family members a copy of his new medical power of attorney. During an attempted interview on 06/23/26 at 11:30 a.m., Resident #1 was in his bed but unable to answer any questions when asked about his Power of Attorney related to his decline in condition and cognition. During an interview on 06/24/26 at 9:55 a.m., Family Member D said they had a care plan meeting on an unknown date with Resident #1. Family Member D said Resident #1 indicated he wanted Family Member A and Family Member C to be his Medical [NAME] of Attorneys with Family Member A being the primary. During an interview on 06/24/26 at 2:42 p.m., the DON said they had a care plan meeting on 06/04/26 for Resident #1. She said Family Member C, Family Member D, the Administrator, and herself were in attendance when Resident #1 said he wanted Family Member A and Family Member C to be his Medical [NAME] of Attorney with Family Member A being the primary. The DON said Resident #1 answered promptly and without hesitation when asked who he wanted to be his Medical Power of Attorney. She said she did not feel the resident was coerced with his answers. The DON said the Social Worker was the person responsible for ensuring the Medical Power of Attorney papers were completed according to the resident wishes. She said she was not aware the paperwork had not been completed. She said failure to complete the paperwork was against the residents' wishes. During an interview on 06/24/26 at 6:42 p.m., the Social Worker said she was responsible for helping residents and families with the Power of Attorney paperwork. She said she did not attend the care plan meeting for Resident #1 on 06/04/26 because she was on vacation. She said she was not aware she needed to complete a new Medical Power of Attorney for Resident #1. She said not filing out the medical power of attorney could be against the residents' rights and wishes. During an interview on 06/24/26 at 7:12 p.m., the Administrator said the Social Worker was responsible for the power of attorney paperwork. She said the facility had a care plan meeting for Resident #1 on 06/04/26. She said Family Member C, Family Member D, the DON, and herself were in attendance when Resident #1 said he wanted Family Member A and Family Member C to be his Medical [NAME] of Attorneys with Family Member A being the primary. She said she thought she and the Social Worker had discussed Resident #1's wishes for his power of attorney. She said failure to have paperwork completed and in his medical records was not honoring his wishes. During an interview on 06/24/26 at 7:50 p.m., the Administrator said they did not have a policy on Power of Attorney. Review of the facility's policy Resident Rights, revised on 02/20/21, indicated: Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Residents Rights: #1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. B. In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law.

Based on interviews and record reviews, it was determined that the facility failed to ensure residents have the right to receive visitors of his or her choice and at the time of his or her choosing for 1 (Resident #2) of 10 Residents reviewed for resident rights. The facility did not allow Resident #2 to visit or talk with her Family Members E and G when they called and or came to the facility when Resident #2 wanted to have visitors and calls. This failure could place residents at risk of isolation, decreased emotional wellbeing, and diminished quality of life. Findings included: Review of Resident #2's face sheet dated 06/23/26 reflected that Resident #2 was a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), depression( sadness), and anxiety (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Review of Resident #2's admission MDS dated [DATE] reflected she needed setup assistance with her ADL's and had severe cognitive impairment for daily decision making. Review of Resident #2's care plan revised on 06/11/26 reflected that Resident #2 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to her diagnosis of dementia with behaviors. Interventions included for staff to reduce any distractions, turn off television or radio, close doors etc., ensure the residents understand, use consistent, simple, direct sentences. Repeat information as needed. Explain all procedures with terms and gestures the resident can understand. Stop and return if the resident becomes agitated. Review of Resident #2's progress notes dated 05/29/26 through 06/23/26 did not include any information regarding visitation limitations or visitors/visitation. Review of Resident #2's psychological services progress note dated 06/11/26 completed by Licensed Professional Counselor (LPC), revealed Resident #2 reported feeling happy because it was her birthday and Family Member F was going to visit. Record review of Resident #2's progress notes dated 06/21/26 documented by LVN C revealed Resident #2's Family Member F wanted to talk to Resident #2 and LVN C told Family Member F she could not let her talk to Resident #2 without Family Member E's approval. During a phone interview on 06/22/26 at 11:24 a.m., Family Member F said the facility would not allow her to visit Resident #2 on unknown dates. She said she was not given a reason she could not visit Resident #2. She said she called the facility to talk with Resident #2 on yesterday (06/21/26) and was denied. She said she felt it was against Resident #2's wishes. During a phone interview on 06/22/26 at 11:45 a.m., Family Member G said the facility would not allow her to visit Resident #2 on an unknown date. She said she was not given a reason why she could not visit. She said she was at the facility when CNA A told her she could not visit Resident #2 without giving a reason why. Family Member G said she asked to speak with management, but no one came so she left the facility. During an interview on 06/23/26 at 12:46 p.m., LVN E said she was Resident #2's nurse. She said to her knowledge family members could visit at any time. She said she was not aware of any restrictions of family calls or visits for Residents #2. LVN E said Resident #2 had a lot of behaviors at the beginning of the month but had improved some with medication adjustments. She said Resident #2 had behaviors such as yelling, throwing things, kicking, or wondering throughout the secure unit and banging on doors, whether she had visitors or not. During a phone interview on 06/23/26 at 2:31 p.m., Family Member E said she did not want Resident #2 to have visits from Family Member G because she would stay too long during visits and tells Resident #2 things such as telling her she does not have to be here. She said Family Member E could visit but on a set schedule. She said she felt Family Members F and G's visits caused Resident #2 to act out and have behavior issues. Family Member E said she had Medical Power of Attorney over Resident #2. She said she had not heard Resident #2 say she did not want to see Family Member F or G. She said she and Resident #2's family members have had confrontations most of her life. She said they were going to have a meeting with the Ombudsman on 06/25/26 at 3:00 pm to talk about visitation for Resident #2. During an interview on 06/23/26 at 4:29 p.m., LVN C said Family Member F called on 06/21/26 and wanted to talk with Resident #2. LVN C said she told Family Member F that she could not talk to Resident #2. LVN C said she called Family Member E to clarify about Resident #2 talking on the phone and Family Member E said she does not want Family Member F to talk to Resident #2. LVN C said she did not hear Resident #2 say she does not want to talk to Family Members F. She said Resident #2 had dementia and she followed Family Member E's wishes because she had Power of Attorney. She said she felt she was doing what was best for Resident #2. During an interview on 06/24/26 at 1:20 p.m., Resident #2 said she wanted to see or talk to her family members and named them. Family Members F and G were included. During a phone interview on 06/24/26 at 2:40 p.m., the Ombudsman said she had been at the facility on 06/19/26 and visited with Resident#2 who said she wanted Family Members F and G to visit her. She said they had a family meeting scheduled for 06/25/26 at 3:00 pm. She said she felt Resident #2 could make her decisions on her visitors. During a phone interview on 06/24/26 at 4:04 p.m., CNA D said Family Member E said she did not want Resident #2 to have visits or phone calls from Family Members F and G unless she approved it. She said Family Member E said they upset Resident #2 and after they visit Resident #2 has behaviors. CNA D said Family Member G came to the facility, and she told Family Member G that she could not see Resident#2 because that was what Family Member E requested. She said she thought the nurses and the Administrator were aware. During an interview on 06/24/26 at 5:00 p.m., the facility's Medical Doctor said he was not aware of any family members not being able to see Resident #2. He said he had taken care of Resident #2 at her previous facility and now at this facility. He said she had dementia with behavior and would have outburst and behaviors at times, sometimes more than less. He said it was part of her diagnosis. During a phone interview on 06/24/26 at 5:00 p.m., LVN B said she worked a variety of shifts as needed. She said Family Member E called on the phone and said she did not want Resident #2 to talk on the phone or have visits from Family Members F or G. She said Family Member E did not say why she did not want Family Members F or G to talk or visit Resident #2 and she said she did not ask. During an interview on 06/24/26 at 6:33 p.m., CMA D said he worked with Resident #2 on his assigned shifts 2pm-10pm. He said Resident #2 had behavior issues most nights such as kicking doors, cursing, or wandering throughout the unit whether she had visitors or not. During an interview on 06/24/26 at 6:42 p.m., the Social Worker said she had never told any family members they could not visit or call any residents. She said there was a concern from Family Member E about visits and things being said when Family Member E and G came to visit, but she was not sure of all the details. She said she became aware on Monday (06/21/26) that Family Member F called the facility to talk with Resident #2 over the weekend but was not sure which date (06/19/26 or 06/20/26) and was denied. She said she had already talked with the Ombudsman Friday (06/19/26) in which Family Member F had already reached out to as well. The Social Worker said they scheduled a care plan for Thursday, 06/25/26 to discuss any issues or concerns. She said failure to allow visits or phone calls could place the residents at risk of isolation, social wellbeing, or increased depression. During an interview on 06/24/26 at 7:12 p.m., the DON said all residents have rights. She said Resident #2 was able to talk and could make decisions for herself. She said she was not aware of any family members who could not see Resident #2. She said all staff were responsible for ensuring resident rights were being honored. She said failure to allow Resident #2 to have visitors was against her choice and could cause isolation. During an interview on 06/24/26 at 7:24 p.m., the Administrator said all staff were responsible for ensuring resident rights were maintained. She said she was not aware Resident #2's family members were not being allowed to visit or talk with her. She said she was only aware of Family Member H who could not visit related to threats toward the administrator and law enforcement ordered a No Trespassing. She said even if Resident #2 had dementia she had rights. She said if a family member had Power of Attorney, it only became effective if the resident was unable to make decisions for themselves. She said failure to have visitors could cause depression and isolation. Review of the facility's policy Resident Rights, revised on 02/20/21, indicated: Residents Rights: #5. Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: d. The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner, which does not impose on the rights of another resident.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety requirements. The facility failed to ensure there was not dust on the air vent above the preparation area.The facility failed to ensure there was no dust and bugs inside the light fixture above the stove. The facility failed to ensure floors did not have a sticky substance.The facility failed to ensure the skillet did not have a carbon buildup around the edge.The facility failed to ensure the baking sheet did not have a carbon buildup around the edge.The facility failed to ensure there was no trash laying on the ground, spilled out of trash bag, in the outdoor garbage dumpster.The facility failed to ensure there was a trash can liner for the hand hygiene trash can. These failures could place residents at risk of foodborne illness, and food contamination.Findings included:During initial tour on 3/23/2026 at 9:40 a.m., the following were identified: the kitchen air vent above the preparation area was dusty, the light fixture above the preparation area was filled with brown dirt and bugs, the floors were sticky, the skillet used to cook a grilled cheese had brown buildup around the entire edge of the pan approximately half an inch, baking sheets had brown residue on the top and bottom, there was trash laying outside of the garbage receptacle on the ground, and there was no trash can liner in the hand hygiene trash can. During an observation on 3/24/2026 at 10:30 AM revealed the kitchen air vent above the preparation area was dusty, the light fixture above the preparation area was filled with brown dirt and bugs, the floors were sticky, the skillet used to cook a grilled cheese had brown buildup around the entire edge of the pan approximately half an inch, baking sheets had brown residue on the top and bottom, and there was no trash can liner in the hand hygiene trash can. German interview on 3/25/2026 at 10:18 AM the Dietary Manager revealed it was the Maintenance Director for cleaning light fixture and the air vent and reported it had not been done in two months although the kitchen was one of his daily rounds. The Dietary Manager stated the last time the event and the light was cleaned was when they had to replace the light bulbs. The Dietary Manager stated she was aware of the dirty light and vent. The Dietary Manager stated there was a risk of dirt and dust getting in the food. The Dietary Manager stated they clean the floors by mopping daily multiple times a day but have been unable to get them clean. The Dietary manager stated after survey or observation of particles built up on the skillet she determined it needed to be thrown away and she cleaned the baking pans. The dietary Manager stated the residents were at risk of foodborne illness and cross contamination due to the dirty equipment, kitchen floor, vent, light, trash on the ground outside, and no trash can liner. The Dietary Manager stated the staff cleaned the hand hygiene trash can but could not provide documentation. During an interview on 3/25/2026 at 11:04 a.m., the Maintenance Director revealed he was responsible for cleaning the lights and the air vent which he had done two months ago when he replaced the light bulbs. The Maintenance Director stated daily stand-up was when he was notified of issues to be addressed and he was unaware of there being any problems at this time. During an interview on 3/25/2026 at 2:21 p.m., [NAME] T revealed the air vents and lights did not get cleaned very often and she was unaware of the last time it was cleaned. [NAME] T stated it was the maintenance director's responsibility for cleaning the light fixture and the air vent. [NAME] T stated the floor was sticky from spilled tea a few weeks ago. [NAME] T stated they routinely cleaned the floors by mopping them but had not been able to get the residue off the ground. [NAME] T stated the pans and skillet did not get used often and were cleaned in the dishwasher, but both the sheet pans and skillet were that way for as long as she could remember. [NAME] T stated it was a shared responsibility between all hand maintenance to maintain the cleanliness of the kitchen to prevent cross contamination and foodborne illnesses. [NAME] T Stated it was a shared responsibility between all kitchen staff and nursing to take trash to the dumpster and she was unaware of why there was trash on the ground outside of the garbage can. [NAME] T stated she did not no one there was not a trash can liner in the hand hygiene trash can and she stated the dietary manager stated they clean the hand hygiene trash can each day. [NAME] tea stated maintenance does daily rounds and believed he was aware of air vent and light being dirty. During a interview on 3/25/2026 at 2:32 p.m., the Registered Dietitian was called and left a voicemail with no return phone call. During an interview on 3/25/2026 at 2:33 p.m., Dietary Aid S revealed she and the cook were responsible for cleaning the kitchen daily after meal services to prevent cross contamination and foodborne illnesses. Dietary Aide S stated they kept a log of when each item in the kitchen was cleaned instead of the air vent and the light fixture above the preparation area had been dirty for months. Dietary aid S stated she took trash out after she was done serving each meal there were two trash cans in the kitchen and between her and the cook they both took one bag out each. The Dietary Aide S stated when she took trash out there was no trash on the ground outside. The dietary Aid S stated she was unaware why there was no trash can liner in the hand hygiene trash can. Dietary aid stated maintenance comes in daily but has not cleaned the vent and light. Dietary aid stated she did not know she needed to report to the maintenance. During an interview on 3/25/2026 at 6:39 p.m., the DON stated she expected the kitchen to be cleaned and the dietary staff were responsible for cleaning and maintaining the area to prevent cross contamination and food borne illness. The maintenance director was responsible for making sure the vent was cleaned, the lights were cleaned and the kitchen was in good repair. The DON stated the Maintenance Director is in daily morning standup which he can be notified at that time of any needs. During an interview on 3/25/2026 at 6:43 p.m., the Administrator revealed it was the Maintenance Directors responsibility for ensuring the air vent and the light fixtures were cleaned routinely. The administrator stated dietary management was responsible for ensuring the kitchen was cleaned daily and after each meal service to prevent cross contamination. Record review of the daily schedule, dated week of 3/22/2026, revealed who was responsible for each equipment area daily which was signed off for all listed areas which indicated the kitchen areas and equipment were cleaned. Record review of the Food safety and Sanitation Plan, revision date 10/24/2022, revealed it is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HACCP) Plan is an example of such a program. Record review of https://www.fda.gov/media/164194/download?attachment accessed on 3/31/2026 indicated:Chapter 4. Equipment, Utensils, and Linens Multiuse 4-101.11Characteristics. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed have an effective pest control program to eradicate the cockroaches in the facility. This facility failure could place residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns.Findings included:During an observation on 3/23/26 at 10:40 a.m. revealed 2 alive water bugs in the secure dining area crawling on the floor. During an observation on 3/23/26 at 11:09 a.m. revealed dead water bugs in the light fixture in the kitchen and on the ground of the dry storage room. During an observation on 3/24/26 at 10:05 a.m. revealed dead water bugs and dark brown particles in the light fixtures in the kitchen above the food preparation area. During an observation on 3/25/26 at 2:30 p.m., revealed large brown bugs in the hall were by the front entrance. During an interview on 3/25/26 at 4:45 p.m., revealed the Maintenance Director was responsible for cleaning the bugs out of the light fixture. During an interview on 3/25/26 at 6:50 p.m. revealed the Maintenance Director had contacted pest control due to the increased amount of alive bugs crawling noted by the staff and in resident rooms. The Maintenance Director reported he had documents from the previous visit from pest control to address the bug issue. The Maintenance Director stated he was responsible for ensuring the pest control program. The Maintenance Director stated the pest control company was coming monthly but not completing their required duties when the facility noticed an increase in alive bugs but could not recall an exact date, he contacted the pest control company supervisor who came to the facility and performed a full inspection and revealed the problem with water bugs. The Pest Control company increased their visits to every 2 weeks due to the increase in bugs. During an interview on 3/25/26 at 5:45 p.m. it was revealed the DON was aware of pest control coming every 2 weeks but did not report any issues with bugs. The DON stated that resident rooms were being treated buy was unaware of which residents. During an interview on 3/25/26 at 6:55 p.m. it was revealed the administrator had a binder of all documented visits by pest control. The Administrator stated the Maintenance Director was responsible for communicating and ensuring the pest control was taking place. The Administrator stated it was important to keep bugs out of the residents home to prevent illness. Record reviews of the only pest control service inspection report provided by the facility, dated 3/23/2026, reflected the device inspection summary listed 0 of 1 insect light trap and 0 of 1 rodent bait stations were inspected. No other pest control logs were provided. Record review of the Pest Control policy, dated 1/1/20, reflected it was the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observation, interview and record review the facility failed to each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents, and 1 of 1 meal reviewed for palatability, attractiveness, and appetizing foods. The dietary staff failed to provide food that was palatable and at an appetizing temperature for residents. This failure could place residents at risk of a decreased food intake, hunger, and unwanted weight loss.Findings included: During an observation on 3/24/2026 at 11:50 PM revealed the last temperature was checked of the lunch meal on the warming table with warming plates to prepare to serve the assisted dining area first, main dining, north hall, west hall, and then South hall. The time betray line service began at 12:07 p.m. the test tray was made at 12:11 p.m. During an observation on 3/24/2026 at 12:20 p.m., the tray cart with the test tray left the kitchen preparation area. The tray cart was reviewed by nurses and left the dining room and went directly to the hall. The trays were passed starting from the dining room, the north hall ending when the test tray arrived in the work room at 12:42 p.m. During a confidential group interview at an undisclosed date at an undisclosed time revealed 11 of 11 residents said the food trays served on the halls were cold. During a test tray interview with the Dietary Manager and State Surveyors on 3/24/2026 at 12:45 p.m., the Dietary Manager stated the following regarding the regular food diet for lunch served on 3/24/2026: the turkey stew was good and warm; mixed vegetables were cold, roll was good but room temperature, and lemon pudding was room temperature not cold but flavor was good. Overall, the Dietary Manager stated the food was good but cold. The State Surveyors tasted each item on the test tray and the turkey stew was warm and had good flavor, the mixed vegetables were cold, the roll was good but room temperature, and the lemon pudding was good. Observation of the tray revealed unappealing food and hair on the plate. During an interview on 3/25/26 at 10:00 a.m. Dietary Aid S was unavailable to be interviewed, stated she would call back at a later time. During an interview on 3/25/26 at 10:10 a.m. [NAME] T was unavailable to be interviewed, stated she would call back at a later time. During an interview on 3/25/26 at 10:18 a.m. revealed the Dietary Manager was responsible for ensuring food was palatable and hot served to the residents to prevent weight loss. The Dietary manager unsure why there was hair on the plate. The Dietary Manager stated she requires all staff to wear hair nets in the kitchen. During an interview on 3/25/2026 at 2:21 p.m. [NAME] T revealed, on a phone call, she was responsible for ensuring the food tasted good and was hot when the resident got their tray. [NAME] T stated residents were at risk of weight loss and low quality of life. [NAME] T stated they do their best in the kitchen to prepare the tray and get them out as fast as possible. During a interview on 3/25/2026 at 2:32 p.m., the Registered Dietitian was called and left a voicemail with no return phone call. During an interview on 3/25/2026 at 2:33 p.m., Dietary Aid S stated her and the [NAME] were responsible for preparing and serving hot and good food to the residents. Dietary Aid S stated the resident had the right to good food to prevent weight loss. During an interview on 3/25/26 at 5:36 p.m. revealed the DON expected the dietary manager to ensure the food was delivered to the residents hot so the residents would eat and not lose weight. During an interview on 3/25/26 at 6:39 p.m. revealed the Administrator stated the dietary manager and the kitchen staff prepared the food in a timely manner so the residents received their food hot and food was good tasting. The administrator stated the residents were at-risk of clinical decline if they did not eat the food that was prepared. Record review of a Resident Council Meeting Form, dated 3/24/2026, indicated the group council voiced their food being cold. Record review of the food temperature log, dated 3/24/2026 , indicated the Regular meat's temperature at the time of serving was 188 degrees Fahrenheit, the cooked vegetables were 187, rolls was room temperature degrees, and the lemon pudding was 40 degrees Fahrenheit. Mechanical soft Turkey Stew was 186 degrees Fahrenheit the mechanical soft carrots was 174 degrees Fahrenheit the mechanical soft rolls were room temperature. Puree Turkey Stew was 185 degrees Fahrenheit. Carrots were 167 degrees Fahrenheit. Rolls were 135 degrees Fahrenheit and all residents were served the same dessert of lemon pudding which was 40 degrees Fahrenheit. Record review of Menus and Nutritional Adequacy policy, dated 7/22/2022, revealed pre-planned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average residents nutritional needs.

Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Resident #45, Resident #37, Resident #19) reviewed for pressure ulcers. The facility failed to change Resident #45, Resident #37, Resident #19's wound dressings according to the physician's orders. This failure could place residents at risk of not receiving wound care services appropriately, could contribute to a decline in a wound, infection and a decline in physical, mental and psychosocial well-being.Findings included:Record review of face sheet dated 3/25/26 revealed Resident #45 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of lymphedema (swelling in the legs fluid build up), obesity (excess body weight), and pressure ulcer stage 4. Record review of care plan dated 3/25/26 revealed Resident #45 was care planned for stage 4 pressure ulcer to the right lateral ankle. Interventions were listed as provide wound care per physician orders. Record review of Quarterly MDS dated [DATE] revealed Resident #45 was admitted to the facility with the stage 4 pressure ulcer. Resident #45 had a BIMS score of 15 indicating no cognitive impairment. Record review of order summary dated 3/25/26 revealed Resident #45 had an order for daily wound care to the right lateral ankle stage 4. Ordered to clean, dry, apply xeroform, and covered with rolled gauze active with a start date of 3/9/26. Record review of treatment administration record dated 3/25/26 revealed Resident #45 did not receive ordered wound care on 3/22/26. Record review of wound care evaluation and summary management dated 2/9/26 revealed Resident #45 had a stage 4 to the right lateral ankle with measurements of 1.2x1.0x0.1cm. No further documentation was provided. Record review of face sheet date 3/25/26 revealed Resident #37 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cellulitis, pressure ulcer to the right heel, pressure ulcer to the left heel and pressure ulcer to the back. Record review of care plan revision date 3/17/26 revealed Resident #37 was care planned for a stage 4 pressure ulcer to the left lateral ankle and left lateral foot with intervention to provide wound care per physician orders. Record review of comprehensive MDS dated [DATE] revealed Resident #37 had 4 stage 4 pressure ulcers which were present on admission. Record review of order summary dated 3/25/26 revealed Resident #37's wound care orders for his left lateral ankle, left lateral foot, left upper back, and right heel. Orders for wound care daily for left upper back include clean, dry, apply calcium alginate and cover with gauze dressing with a start date of 2/13/26. Record review of administration record dated 3/25/26 revealed Resident #37's wound care to left upper back was not completed on 3/22/26 and 3/8/26. Record review of wound care evaluation and summary management dated 3/16/26 and 3/23/26 revealed Resident #37 had wounds to his left lateral foot; left lateral ankle; left heel; right heel; back; left upper back. Measurements listed for left lateral foot 1.4x7.3.0.1cm, measurements for left lateral ankle stage 4 1.3x0.9x0.2cm, measurements for left heel stage 3 1.5x1.7x0.1cm, measurements for right heel stage 3 0.7x0.5x0.1cm, and measurements for upper back unstageable 1.7x2.1.0.1cm. Record review of face sheet date 3/25/26 revealed Resident #19 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of osteomyelitis right ankle and foot and cellulitis of right lower limb. Record review of care plan revision date of 2/24/26 revealed Resident #19 was care planned for pressure ulcer and wound with interventions to provide wound care per physician orders. Record review comprehensive MDS dated [DATE] revealed Resident #19 was not coded for any pressure ulcers. Resident #19 had a surgical wound. Resident #19 BIMS score was 6 indicating severe cognitive impairment. Record review of order summary dated 3/24/26 revealed Resident #19 had orders for daily wound care to the right and left heel. Order indicated to clean, dry, apply hydrogel and cover with a border dressing started on 3/5/26. Record review of administration record dated 3/25/26 revealed Resident #19 did not receive wound care on 3/22/26 to the left and right heel. Record review of wound care evaluation and summary management dated 3/16/26 revealed Resident #19 was seen by the wound care provider for his stage 3 pressure ulcer to the left heel and unstable pressure to the right heel. Measurements of the left heel are 2.1x2.1x0.1cm and right heel 4.4x4.1x0.1cm. An observation and interview on 3/23/26 at 11:26 a.m. revealed Resident #45 without a dressing on his left lateral ankle. Resident #45 stated that the wound care nurse took the bandage off this morning to be seen by the provider and it had been left off for his bed bath. Resident #45 stated had received his bed bath and was waiting for it to be put back on. Resident #45 stated he had been given his bath before 8:00 a.m. on the day shift. An observation on 3/23/26 at 2:30 p.m. revealed Resident #45 without dressing to his left lateral ankle situated up on heel protectors with foot rest at the end of the bed. Swelling noted to the ankle. Resident had been in the same position, on his back, since 11:26 a.m. An observation on 3/23/26 at 4:45 p.m. revealed Resident #45 without dressing to his left lateral ankle with increased swelling, yellow drainage seeping from tops of shins on to sheet and blood to the center of the wound coming off on to the heel protectors. Resident #45 was still lying on his back. An observation and interview on 3/23/26 at 11:24 a.m. revealed Resident #37's wound dressing dated 3/20/26 to the left lateral ankle and left lateral foot. An observation on 3/23/26 at 2:33 p.m. revealed Resident #37 with shoes on both feet in the bed without heel protectors. An observation and interview on 3/23/26 at 11:52 a.m. revealed Resident #19's wound dressing dated 3/20/26 to both heels. An observation on 3/23/26 at 2:36 p.m. revealed Resident #19 with shoes on both feet in the bed without heel protectors. An interview on 3/23/26 at 4:55 p.m. revealed the ADON was responsible for wound care for the day shift however she had not completed Resident #45, Resident #37, Resident #19 wound care and it had not been done since 3/20/26. The dressings should have been changed daily. Daily changes helped with ensuring the wound improved, and if they were not changed daily as ordered, there could be a decline in the wound healing, increased risk of infection, or multiple things. During an interview on 3/25/26 at 5:36 p.m. revealed the DON was made aware the wound care had not been completed 3/25/26 after surveyor intervention. DON stated she expected wound care for pressure ulcers to be completed according to physician orders. DON stated that every Monday the ADON and the wound care physician round in the morning to observe all wounds in the building. DON reported that after she was made aware of the incomplete wound care a verbal in-service with all nursing staff was completed, a progress note was documented, and the responsible party was notified. During an interview on 3/25/26 at 6:39 p.m. the Administrator was made aware that wound care was not complete. Administrator stated that she expected wound care to be done according to physician orders and reported to the DON if it is incomplete by the treatment nurse or charge nurse. Administrator stated that the Resident was at risk for clinical decline. Record review of the Skin Prevention and Management Guidelines, revised 4/13/23, revealed the facility is committed to the promotion of healing of existing pressure injuries. Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. Compliance with interventions will be documented in the monthly wound note summary charting. Pressure ulcer healing is documented using descriptive characteristics of the wound (i.e., depth, width, presence of granulation tissue, exudate).

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Residents #20, and #5) and 2 of 2 staff reviewed for infection control.1. The facility failed to ensure CNA B thoroughly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #20. 2. The facility did not ensure EBP were put in place for Resident #5. 3. CNA Q failed to perform hand hygiene between resident to resident contact when passing meal trays. 4. CNA R failed to perform hand hygiene between resident to resident contact when passing meal trays. These failures could place residents at risk for cross contamination and the spread of infection. Findings include: 1. During an observation on 03/23/26 at 3:16 p.m., revealed CNA B provided incontinent care to Resident #20. CNA B performed hand hygiene and put on gloves. CNA B pulled Resident #20's foreskin and cleaned the pubic area, without cleaning both crease areas between his legs. CNA B then turned Resident #20 on his left side and proceeded to wipe Resident #20's buttocks without performing hand hygiene or applying new gloves. CNA B grabbed a clean brief, applied the resident's brief, touched his bed remote, adjusted his clothes, lowered his bed, pulled up his covers without performing hand hygiene or applying new gloves. CNA B gathered the trash, disposed of it and performed hand hygiene. During an interview on 03/23/25 at 3:25 p.m., CNA B stated she should have changed gloves and performed hand hygiene after she cleaned the crease areas, turned Resident #20 to his left side and after cleaning Resident #20's buttocks. CNA B stated she was nervous the state surveyor was present. CNA B stated this failure could potentially lead to cross contamination and put Resident #20 at risk for UTI. 2. Record review of Resident #5's face sheet, dated 03/25/26, reflected Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included end stage renal disease (kidneys cease functioning on a permanent basis). Record review of Resident #5's quarterly MDS assessment, dated 03/05/26, reflected Resident #5 usually made himself understood and usually understood others. Resident #5 BIMS score of 10, which reflected his cognition was moderately impaired. Resident #5 received dialysis treatment. Record review of Resident #5's comprehensive care plan, revised 03/24/26, reflected Resident #5 received dialysis related to renal failure and was at risk for the potential complications of dialysis. The care plan interventions included: monitor for possible complications such as shortness of breath peripheral edema (swelling in the legs, ankles and feet), chest pain, elevated blood pressure, dry itchy skin, nausea/vomiting or bleeding at access site. Record review of Resident #5's order summary report, dated 03/25/26, reflected an active physician's order to remove dialysis dressing from the left upper arm in the evening for prophylaxis (any medication treatment, medication, or measures taken to prevent disease of health issues before they occur) with start date of 06/10/25. The physician order summary report did not address EBP. During an interview on 03/23/26 at 11:27 a.m., Resident #5 stated staff did not wear PPE when proving care. During an interview on 03/25/26 at 10:12 a.m., CNA D stated PPE was not required when proving care to Resident #5. CNA D stated it was important to ensure infection control practices were followed to prevent the spread of infection. During a telephone interview on 03/25/26 at 10:17 a.m., RN C stated she accessed Resident #5's shunt by touching to feel the thrill (reflect good blood flow) and bruit (whooshing or blowing sound heard through a stethoscope that signaled turbulent blood flow in an artery). RN C stated PPE was not required when providing care to Resident #5. RN C stated it was important to ensure infection control practices were followed to prevent the spread of infection. During an interview on 03/25/26 at 11:41 a.m., the ADON stated she was the Infection Control Preventionist for the facility. The ADON stated she expected CNA B to change gloves after she cleaned the crease areas, performed hand hygiene, and reapply new gloves before turning Resident #20 to his left side. The ADON stated CNA B should have reapplied new gloves and perform hand hygiene after cleaning Resident #20's buttocks and touching his bed remote and rearranging Resident #20 in the bed. The ADON stated she monitored incontinent care by random spot checks, skill checks and in services. The ADON stated she never had issues with CNA B performing care. The ADON stated staff were not required to wear PPE when providing care to Resident #5 because his dialysis access was under the skin. The ADON stated the nurses did not do anything with access except removed the dressing the afternoon of dialysis. The ADON stated it was important to ensure infection control practices were followed to prevent the spread of infection. During an interview on 03/25/26 at 12:45 p.m., the ADON stated she reviewed the EBP policy on what was required for EBP and Resident #5 should be on EBP. The ADON stated she was told by the previous DON the area had to be opened for a resident to be on EBP. During an interview on 03/25/26 at 5:20 p.m., the DON stated she expected the groin to be cleaned, and gloves changed with hand hygiene performed with each glove change and touching other items and other areas of the resident's body. The DON stated she just learned today (03/25/26) by the ADON that Resident #20 was required to be on EBP. The DON stated initially when EBP rolled out she was told by the previous regional nurse consultant that dialysis residents with shunts did not require EBP. The DON stated ultimately the ADON was responsible for monitoring and overseeing infection control, but she also monitored by monthly hand hygiene check offs and random spot checks. The DON stated it was important to ensure infection control practices were followed to prevent the spread of infection and UTI. During an interview on 03/25/26 at 6:00 p.m., the Administrator stated she expected the entire peri area to be cleaned by resident requirement. The Administrator stated gloves should be changed, and hand hygiene performed before touching a clean brief, and any of Resident #20's items. The Administrator stated she was unaware Resident #5 required PPE when providing care for him. The Administrator stated the DON, or designee, was responsible for monitoring and overseeing infection control. The DON stated it was important to ensure infection control practices were followed to prevent the spread of infection, UTI and skin breakdown. 3. During an observation on 3/24/2026 at 12:30 p.m. revealed CNA Q served meal trays to 4 residences on the North Hall without performing hand hygiene. During an interview on 3/24/2026 at 12:33 p.m., CNA Q stated she had forgotten to use sanitizer before and after delivering food trays. CNA Q stated she had cross contaminated the trays. 4. During an observation on 3/24/2026 at 12:30 p.m. revealed CNA R served meal trays to 4 residences on the North Hall without performing hand hygiene. During interview on 3/24/2026 at 12:35 p.m., CNA R stated she knew she had to perform hand hygiene in between passing the trays but forgot and was reminded by the other CNA R who had hand sanitizer. CNA R stated hand hygiene was to prevent cross contamination. During an interview on 3/25/2026 at 5:36 p.m., the DON revealed she expected the CNA's to perform hand hygiene in between passing each resident there tray to prevent cross contamination. During an interview on 3/25/2026 at 6:43 PM, the Administrator stated she expected the DON to ensure the CNAs were using hand sanitizer in between each tray pass to prevent cross contamination. The administrator stated the DON was responsible for the quarterly in services for all nursing staff for hand hygiene. Record review of the facility's Hand Hygiene policy, dated 11/12/2017, reflected staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is to be performed with either antimicrobial soap and water or alcohol-based hand rub between resident contacts. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/20/24, reflected . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism.2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Record review of the perineal competency checkoff reflected CNA B had been checked off by LVN E for perineal care on 02/09/26.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 24 residents (Resident #15, Resident #10, and Resident #4) reviewed for care plans. The facility failed to ensure Resident #15's care plan included her medication Eliquis (an anticoagulant) and interventions. The facility failed to ensure Resident #4's care plan included her medication Eliquis (an anticoagulant) and interventions. The facility failed to follow Resident #10's care plan for palm protectors. These failures could place residents at risk of not having their needs met. Findings included: 1.Record review of Resident #15's face sheet dated 03/25/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included chronic obstructive pulmonary disease (chronic disease of the lungs that causes difficulty breathing), ventricular tachycardia (life threatening heart arrhythmia defined by a fast heart rate more than 100 beats per minute), diabetes mellitus (chronic metabolic disorder characterized by high blood sugars), major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in things), and high blood pressure. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated she was understood by others, and she was able to make herself understood. The MDS also indicated she had a BIMS score of 13 which indicated she was cognitively intact. The MDS also indicated she required maximal assistance from staff for bed mobility, transfers, toileting, and bathing and she required setup assistance from staff for eating. The MDS also indicated Resident #15 was taking an anticoagulant medication. Record review of Resident #15's comprehensive care plan revised 01/15/26 did not indicate Resident #15 was receiving Eliquis (anticoagulant medication-blood thinner). Record review of Resident #15's order summary report dated as of 03/25/26, indicated she had an order for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for chronic atrial fibrillation with a start date of 02/08/25 and no end date. The order summary report did not indicate Resident #15 was being monitored for any side effects regarding his anticoagulant medication. Record review of Resident #15's medication administration record for the month of March 2026, indicated Resident #15 had received Eliquis 5mg one tablet two times daily since 02/08/25. The medication administration record did not indicate Resident #15 was being monitored for any side effects regarding his anticoagulant medication. 2. Record review of a face sheet dated 3/25/2026 indicated Resident #4 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with a diagnoses of unspecified atrial fibrillation (irregular, often rapid heart rate), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), parkinsonism (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements), history of transient ischemic attach (temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #4's physician orders dated 3/25/2026 indicated Resident #4 was ordered Eliquis Oral Tablet 5 milligrams by mouth two times a day related to heart failure on 8/05/2025 and started on 8/05/2025. Eliquis is a prescription blood thinner used to reduce stroke risk in atrial fibrillation (AFib), Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was sometimes understood and usually understands. Resident #4's BIMS score was three which indicated severe cognitive impairment. The MDS quarterly assessment indicated Resident #4 was taking an anticoagulant. Record review of the comprehensive care plan dated 3/25/2026 indicated no focus, goals, or interventions for Anticoagulant use or monitoring. During an interview on 03/25/26 at 6:07 PM the DON said the medication should have been included on Resident #15 and Resident #4's care plan. The DON said the MDS Nurse was responsible for ensuring the anticoagulant medications were included in the care plan. The DON said the failure placed risks for Resident #15 and Resident #4 not being monitored for bleeding and their blood clotting correctly. During an interview on 03/25/26 at 6:15 PM the MDS Nurse said she was responsible for ensuring the anticoagulant was on Resident #15 and Resident #4's care plan. The MDS Nurse said she wanted to look on her computer and when she went into her computer, the MDS Nurse said the anticoagulant was not included in the care plan, but she was unsure of why not. The MDS Nurse said the failure placed a risk for the staff not knowing the residents were at risk for bleeding. During an interview on 03/25/26 at 6:52 PM the Administrator said she expected the Eliquis to be in the care plan for Resident #15 and Resident #4 to ensure the staff were aware of the medication and interventions. The Administrator said the DON or designee were responsible for ensuring the medication was included in the care plan. The Administrator said the failure placed a risk for the residents having a negative clinical effect for bleeding. 3.) Record review of a Resident #10's face sheet, dated 03/26/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included dementia (loss memory), right hand contractors, muscle weakness, and depressive disorder (persistently depressed mood). Record review of Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 sometimes made herself understood and rarely understood others. Resident #10 had difficulty with recall, and her BIMs score was 02, which indicated severe cognitive impairment. The MDS indicated Resident #10 required extensive assistance with bed mobility, dressing, personal hygiene, and bathing. Record review of Resident #10's physician order dated 11/17/25, indicated: right palm protecter to be worn during waking hours as tolerated. Record review of the comprehensive care plan, revised date of 02/20/26, revealed Resident #10 had an alteration in her musculoskeletal status related to a contracture to the right hand. The intervention was for staff to apply the palm protector to her right hand related to her contracture and notify the charge nurse if she refused to wear the device. During an observation on 03/24/26 at 9:38 a.m., Resident #10 was lying in bed without anything in her right hand. During an observation and interview on 03/24/26 at 4:14 p.m., Resident #10 was lying in her bed without anything in her right hand. CNA B was in the room and said she was not aware of a palm protector for Resident #10. She looked in Resident #10's drawers and throughout the room but did not locate a palm protector. She said she was aware Resident #10 had a contracture to her right hand, but she usually applied a washcloth to her hand. During an observation and interview on 03/25/26 at 11:09 a.m., RN C said she was Resident #10's charge nurse. RN C looked at Resident #10's right hand and saw she did not have on her palm protector. RN C reviewed Resident #10's orders and said she was supposed to wear a palm protector, but she was unaware she had an order for the palm protector or where the palm protector was located. During an interview on 03/25/26 at 11:24 a.m., the Rehab Director said Resident #10 should have a palm protector in her right hand. He looked and saw Resident #10 did not have a palm protector in her right hand. He went and got a new palm protector and placed it in Resident #10's right hand. Resident #10 allowed the palm protector and thanked him for doing it. During an interview on 03/25/26 at 6:36 p.m., the DON said she was aware Resident #10 had orders and was care planned for a palm protector to her right hand. She said she was not aware why staff said they did not know she wore them because when she saw her out of bed in the dining room, she had them on. She said the CNAs were supposed to place the palm protector and the nurses were supposed to ensure the palm protector was on Resident #10's right hand. She said if Resident #10 did not have her palm protector on her right-hand it could make the contracture worse. During an interview on 03/25/26 at 7:00 p.m., the Administrator said she expected Resident #10 to have on her right palm protector if she was care planned and had an order for it. She said the CNAs were supposed to place the palm protector and the DON or designee was supposed to ensure the palm protector was on. She said failure to wear or have on the palm protector could cause her contractures to worsen. Record review of the facility's policy titled, Care Plans and CAAs (Care Area Assessments), dated 05/06/2021, indicated, Purpose: The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set in order to effectively address the Care Area Assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Care Plan Updates: The IDT will review the care plans annually, quarterly, and as needed to ensure all goals and approaches are appropriate. Acute Care Plans: As acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member. Record review of the facility's policy titled, Following Physician Orders, dated 09/28/2021, indicated, Policy: The policy provide guidance on receiving and following physician orders. Policy Explanation and Compliance Guidelines:3. C. Carry out and implement physician orders.

Based on observation, 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 grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #10) reviewed for ADL care.The facility failed to ensure Resident #10's fingernails were free from a brown material substance.This failure could place residents at risk of not receiving care/services, and decreased quality of life impacting their loss of dignity. Findings included:Record review of a Resident #10's face sheet, dated 03/26/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included dementia (loss memory), muscle weakness, and depressive disorder (persistently depressed mood).Record review of Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 sometimes made herself understood and rarely understood others. Resident #10 had difficulty with recall, and her BIMs score was 02, which indicated severe cognitive impairment. The MDS indicated Resident #10 required extensive assistance with personal hygiene and bathing. Resident #10 was always incontinent of bowel and bladder. Record review of the comprehensive care plan, dated 10/10/23, revealed Resident #10 had an activities of daily living self-care performance deficit and was at risk for not having her needs met in a timely manner related to her immobility, and cognitive loss. The interventions were for staff to provide showers, shave, oral care, hair care, and nail care per schedule and when needed.During an observation and interview on 03/24/26 at 9:38 a.m., Resident #10 was lying in bed. She had jagged fingernails, some type of brown substance underneath her third, fourth and fifth fingernails and scattered across her entire hand. Resident #10 was unable to say how long her hand or fingernails had been dirty or the last time her nails had been trimmed.During an observation and interview on 03/24/26 at 4:14 p.m., Resident #10 was lying in her bed. Resident #10 was noted with jagged fingernails and brown like substance scattered on her right hand and under her third, fourth and fifth fingernails. CNA B was in the room and said the brown substance looked like fecal material. CNA B said Resident #10 often placed her hands in her brief. She said Resident #10 had a partial bed bath yesterday (03/23/26). She said she did not have a complete bed bath because Resident #10 became resistant and she stopped. CNA B said she did not attempt to complete the bed bath later during her 2pm-10pm shift. CNA B said she would trim and clean Resident #10's right hand and fingernails.During an observation on 03/24/26 at 4:35 p.m., Resident #10 was in her bed, and her right hand and fingernails were trimmed and cleaned. During an interview on 03/25/26 at 4:10 p.m., LVN H said nurses and CNAs were responsible for nailcare. LVN H said the brown material underneath Resident #10's fingernails could be fecal material. LVN H said she expected Resident #10's nails to be trimmed and clean on Sundays as their routine cleaning day as well as during her bath days of Monday, Wednesday, and Friday and as needed. She said jagged and dirty nails could lead to injury and/or infection control issues.During an interview on 03/25/26 at 6:36 p.m., the DON said nail care was a part of Sunday cleaning schedule. She said the CNAs were supposed to clean/trim all residents' nails on Sunday and the nurses were supposed to ensure nail care was done. She said she did random spot checks of the residents' nails. She said if Resident #10 had a brown like substance under her nails or jagged nails it could place her at risk for injury and/or infection.During an interview on 03/25/26 at 7:00 p.m., the Administrator said she expected fingernails to be clean and free from brown matter. She said the CNAs were responsible for cleaning the nails and the DON or designee were the overseers. She said jagged and dirty nails could lead to infection issues. Record review of the facilities policy titled, Activities of Daily Living Care Guidelines' dated 1/23/2016, indicated, Anticipated Outcome: Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 2 of 6 residents (Resident #15 and Resident #4) reviewed for pharmacy services. 1. The facility failed to monitor Resident #15 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner). 2. The facility failed to monitor Resident #4 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner).These failures could place residents at risk of swelling, bruising, and bleeding. Findings include: 1.Record review of Resident #15's face sheet dated 03/25/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included chronic obstructive pulmonary disease (chronic disease of the lungs that causes difficulty breathing), ventricular tachycardia (life threatening heart arrhythmia defined by a fast heart rate more than 100 beats per minute), diabetes mellitus (chronic metabolic disorder characterized by high blood sugars), major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in things), and high blood pressure. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated she was understood by others, and she was able to make herself understood. The MDS also indicated she had a BIMS score of 13 which indicated she was cognitively intact. The MDS also indicated she required maximal assistance from staff for bed mobility, transfers, toileting, and bathing and she required setup assistance from staff for eating. The MDS also indicated Resident #15 was taking an anticoagulant medication. Record review of Resident #15's comprehensive care plan revised 01/15/26 did not indicate Resident #15 was receiving Eliquis (anticoagulant medication-blood thinner).Record review of Resident #15's order summary report dated as of 03/25/26, indicated she had an order for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for chronic atrial fibrillation with a start date of 02/08/25 and no end date. The order summary report did not indicate Resident #15 was being monitored for any side effects regarding his anticoagulant medication.Record review of Resident #15's medication administration record for the month of March 2026, indicated Resident #15 had received Eliquis 5mg one tablet two times daily since 02/08/25. The medication administration record did not indicate Resident #15 was being monitored for any side effects regarding his anticoagulant medication. 2. Record review of a face sheet dated 3/25/2026 indicated Resident #4 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with a diagnoses of unspecified atrial fibrillation (irregular, often rapid heart rate), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), parkinsonism (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves causes unintended or uncontrollable movements), history of transient ischemic attach (temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #4's physician orders dated 3/25/2026 indicated Resident #4 was ordered Eliquis Oral Tablet 5 milligrams by mouth two times a day related to heart failure on 8/05/2025 and started on 8/05/2025. Eliquis is a prescription blood thinner used to reduce stroke risk in atrial fibrillation (AFib), Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was sometimes understood and usually understands. Resident #4's BIMS score was three which indicated severe cognitive impairment. The MDS quarterly assessment indicated Resident #4 was taking an anticoagulant. Record review of the comprehensive care plan dated 3/25/2026 indicated no focus, goals, or interventions for Anticoagulant use or monitoring.During an interview on 03/25/26 at 5:31 PM the ADON said she expected monitoring for anticoagulants to be in the medication administration record. The ADON said any nurse could place the order in for monitoring. The ADON said the failure placed a risk for Resident #15 and Resident #4 to bleed out . During an interview on 03/25/26 at 6:07 PM the DON said the medication Eliquis should have been on Resident #15's and Resident #4's medication administration record for monitoring. The DON said she was responsible for ensuring the monitoring was in place. The DON said she expected the charge nurses to recognize and know what medications should need monitoring, but the DON was completing an audit to ensure all the monitoring was in place. The DON said the failure placed a risk for Resident #15 and Resident #4 having a fall or bruise, having a bleed, and adverse effects with her diagnosis of atrial fibrillation (heart rhythm disorder characterized by rapid heartbeats), and staff would not know if Resident #15 or Resident #4's blood was clotting correctly. During an interview on 03/25/26 at 6:52 PM the Administrator said she expected the anticoagulant monitoring to be in place for the nurses to check each shift for Resident #15 and Resident #4. The Administrator said the orders should have been input by the DON or designee. The Administrator said the failure placed a risk for Resident #15 and Resident #4 having a negative clinical effect of bleeding. Record review of the facility policy, reviewed 2/15/20, Physician Monitoring Orders did not indicate any monitoring for anticoagulant.

Based on observation, interview, and record review the facility failed provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 7 resident (Residents #5 and #15) reviewed for pharmacy services. 1.The facility did not ensure LVN A administered Resident #5's Sevelamer Carbonate (a medication used to manage high blood phosphorus levels in adults with chronic kidney disease) 800 mg on [DATE]. 2. The facility failed to ensure Resident #15's Novolog insulin vial (medication used to administer to residents with high blood sugars) on the west nurse medication cart was not expired prior to placing the open date of [DATE] on the bottle. These failures could place residents at risk for weak bones, joint pain, severe itching, and fractures.Findings include: 1.Record review of Resident #5's face sheet, dated [DATE], reflected Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included end stage renal disease (kidneys cease functioning on a permanent basis). Record review of Resident #5's quarterly MDS assessment, dated [DATE], reflected Resident #5 usually made himself understood and usually understood others. Resident #5 BIMS score of 10, which reflected his cognition was moderately impaired. Resident #5 received dialysis treatment. Record review of Resident #5's order summary report, dated [DATE], reflected an active physician's order for Sevelamer Carbonate 800 mg: 4 tablets by mouth with meals for vitamin deficiency with a start date [DATE]. Record review of Resident #5's comprehensive care plan, revised [DATE], reflected Resident #5 received dialysis related to renal failure and was at risk for the potential complications of dialysis. The care plan interventions included: monitor for possible complications such as shortness of breath peripheral edema (swelling in the legs, ankles and feet), chest pain, elevated blood pressure, dry itchy skin, nausea/vomiting or bleeding at access site. During an observation and interview on [DATE] at 12:19 p.m., revealed Resident #5 was served a chef salad for his lunch meal. Resident #5 ate his salad and left the dining room at 1:15 p.m. without being given (4) Sevelamer Carbonate with his meal. Resident #5 stated he received medication with his meals but not today with his lunch meal ([DATE]). Resident #5 did not have any adverse reaction to not being administered the medication. During a telephone interview on [DATE] at 4:25 p.m., LVN A stated she was responsible for administering Resident #5's Sevelamer Carbonate with his lunch meal. LVN A stated she was aware the medication must be given with meals, but she had a family emergency. LVN A stated she did not leave Resident #5's medication or let her charge nurse know he had medications to be given with meals. LVN A stated she did not know why it was important to give the medication with meals. During an interview on [DATE] at 5:00 p.m., the DON stated her expectations were for the medication to be given with Resident #5's meals. The DON stated she was not made aware of the nurse leaving until after the state surveyor intervention. The DON stated LVN A should have notified the charge nurse that the medication needed to be administered with Resident #5's lunch meal. The DON stated she monitored medication administration by random spot checks and reviewing the medication administration record that reflected if the medication was given or administered late. The DON stated if there was a problem, she would in-service the nurse or MA immediately. The DON stated this was the first time for as she knew Resident #5's medication not been given with meals. The DON stated it was important Resident #5's medication was given with meals to prevent malnutrition and weight loss. During an interview on [DATE] at 6:00 p.m., the Administrator stated LVN A was responsible for administering Resident #5's medication timely. The Administrator stated she was not aware the medication was not given with his meals but expected LVN A to go to the charge nurse or the DON to inform of issue and to ensure timely delivery of medication. The Administrator stated the DON, or designee, was responsible for monitoring medication administration. The Administrator stated it was important Resident #5's medication was administered timely to ensure there was no adverse effect of the resident care. An attempted telephone interview on [DATE] at 6:42 p.m., with the Medical Director, was unsuccessful. 2. Record review of Resident #15's face sheet dated [DATE] indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included chronic obstructive pulmonary disease (chronic disease of the lungs that causes difficulty breathing), ventricular tachycardia (life threatening heart arrhythmia defined by a fast heart rate more than 100 beats per minute), diabetes mellitus (chronic metabolic disorder characterized by high blood sugars), major depressive disorder (a serious mental health condition characterized by persistent low mood and loss of interest in things), and high blood pressure. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated she was understood by others, and she was able to make herself understood. The MDS also indicated she had a BIMS score of 13 which indicated she was cognitively intact. The MDS also indicated she required maximal assistance from staff for bed mobility, transfers, toileting, and bathing and she required setup assistance from staff for eating. The MDS also indicated Resident #15 was taking an anticoagulant medication. During an observation and interview on [DATE] at 11:17 AM of the west nursing cart revealed Resident #15's Novolog insulin vial had an expiration date of [DATE] and an open date of [DATE]. RN P said she did not notice the bottle expiration date. RN P said she only verified the open date. RN P said the nurse who placed the NovoLog insulin on the cart with the open date was responsible for ensuring the insulin was not out of date. RN P said the failure placed Resident #15 at risk for the insulin not being effective. During an interview on [DATE] at 7:07 PM, the DON said she expected the charge nurses to check insulin to ensure it was removed when it was expired. The DON said RN P failed to look at the actual expiration date on the bottle. The DON said RN P only looked at the opened date on the bottle, but she expected the charge nurses to complete both checks for expirations. The DON said the failure placed a risk for Resident #15's blood sugar not being regulated. During an interview on [DATE] at 6:56 PM, the Administrator said her expectation was for no medications to be given expired. The Administrator said the DON and designee were responsible for ensuring the insulin was removed from the medication cart. The Administrator said the failure placed a risk for negative clinical effects and medications may not work effectively. Record review of the facility's policy titled, Medication-Treatment Administration and Documentation Guidelines, revised [DATE], reflected To provide a process for accurate, timely administration and documentation of medication and treatments.4. Administer the medication according to the physician order. Record review of the facility's policy, dated [DATE], Medication Storage indicated: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 8. Medication Carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible for 1 of 24 residents (Resident #51) reviewed for accidents and hazards. The facility failed to ensure CNA N locked the mechanical lift when transferring Resident #51 from his wheelchair to his bed. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.Findings included: Record review of Resident #51's face sheet dated 03/25/26 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a group of conditions that affect blood vessels and blood flow in the brain), history of traumatic brain injury (disruption in normal brain function caused by a blow or bump to the head), cognitive communication deficit (when someone has trouble with one or more cognitive processes involved in communication), and glaucoma (a group of diseases that damage the optic nerve often due to high fluid pressure). Record review of Resident #51's annual MDS assessment dated [DATE] indicated he usually understood others and usually made himself understood. The MDS also indicated Resident #51 had a BIMS score of 6 which meant he had severe cognitive impairment. The MDS indicated he was dependent upon staff for transfers, bed mobility, and bathing, and required moderate staff assistance with eating. Record review of Resident #51's comprehensive care plan revised 12/10/19 indicated he had ADL self-care performance deficit and required a total of two staff assistance for transfers. During an observation and interview on 03/24/26 at 10:17 AM CNA N and CNA O transferred Resident #51 from his wheelchair to his bed using a mechanical lift. CNA N failed to lock the wheels of the mechanical lift prior to lifting Resident #51 from his wheelchair and prior to lowering Resident #51 to his bed. CNA N said she did not realize she did that, but she did see the mechanical lift move when she began to lift Resident #51 from his wheelchair. CNA N said the failure placed Resident #51 at risk for falling. During an interview on 03/25/26 at 7:20 PM the DON said she expected the CNAs to ensure the mechanical lift was used correctly. The DON said the CNAs should have locked the mechanical lift prior to lifting Resident #51 from his wheelchair and prior to lowering Resident #51 to the bed. The DON said CNA N just started at the facility and she had her checkoff sheet with her and the DON was not sure if CNA N had been checked off on the mechanical lift use. The DON said the failure placed a risk of injury to Resident #51. During an interview on 03/25/26 at 7:22 PM the Administrator said she expected the CNAs to use the mechanical lift correctly and the DON or designee were responsible for ensuring the CNAs were completing mechanical lift transfers safely. The Administrator said the failure placed a risk for Resident #51 to have injury. During an interview on 03/25/26 at 7:27 PM CNA N said she had her skills checklist at home but she did not recall being checked off on using the mechanical lift.During an interview on 03/25/26 at 6:00 PM the Administrator said the facility did not have a mechanical lift policy.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #43) reviewed for quality of care. The facility did not ensure that LVN A followed physician orders for wound care on Resident #43's right second toe on 03/21/26 and 03/22/26. This failure could place residents at risk for a decline in wounds, infection, pain and a decline in functional abilities. Findings include: Record review of Resident #43's face sheet, dated 0325/26, reflected Resident #43 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included hypotension (low blood pressure). Record review of Resident #43's quarterly MDS assessment, dated 02/06/26, reflected Resident #43 usually made himself understood and usually understood others. Resident #43 BIMS score of 8, which reflected his cognition was moderately impaired. Resident #43 had an application of nonsurgical dressing and ointment/medications to feet. Record review of Resident #43's comprehensive care plan, revised on 03/18/26, reflected Resident #43 had a non-pressure wound of the right second toe and was at risk for infection, pain, and a decline in functional abilities. The care plan interventions included provide wound care per physician's order, keep dressing clean, dry, and intact. Record review of Resident #43's order summary, dated 03/25/26, reflected Resident #43 had an order with a start date 02/19/26 to cleanse the right second toe with normal saline (solution of sodium chloride in water) or wound cleanser, dry with gauze, apply xerofoam gauze (wound dressing) and cover with a boarder dressing once daily and as needed for wound healing. Record review of Resident #43's TAR, dated 03/01/26-03/31/26, reflected Resident #43's wound care to his right second toe was to cleanse with normal saline (solution of sodium chloride in water) or wound cleanser, dry with gauze, apply xerofoam gauze (wound dressing) and cover with a boarder dressing once daily and as needed for wound healing. The TAR was not signed off by LVN A as completed on 03/21/26 and 03/22/26. During an interview and observation on 03/23/26 at 10:52 a.m., Resident #43 stated he had a wound to his right foot. The ADON showed the state surveyor the dressing to Resident #43 right foot. The dressing was dated 03/20/26. The ADON stated the wound should be changed daily. During a telephone interview on 03/24/26 at 4:25 p.m., LVN A stated she was the nurse for Resident #43 on 03/21/26 and 03/22/26 and was responsible for wound care. LVN A stated normally the facility has someone come in and do wound care, but she did not show up. LVN A stated she could not remember why wound care was not performed on 03/21/26 and 03/22/26 was chaotic and she forgot. LVN A stated it was important wound was done daily to prevent an infection. During an interview on 03/25/26 at 5:00 p.m., the DON stated she expected wound care orders to be followed including the weekends. The DON stated she was not aware wound care was not done until state surveyor intervention. The DON stated the ADON makes rounds on Monday to ensure the wound care was performed over the weekend. The DON stated this past weekend there was not someone here that was dedicated to doing wound care and the nurses got overwhelmed and did not perform wound care. The DON stated usually there is someone that came in and did the wound care but if not, the nurses were responsible. The DON stated it was important wound care was done to promote healing. During an interview on 03/25/26 at 6:00 p.m., the Administrator stated she expected all wound care treatment to be done as ordered. The Administrator stated the DON or designee were responsible for monitoring wound care. The Administrator stated it was important for wound care to be performed per the physician's order to ensure the continuation of care and prevent worsening of the wound. An attempted telephone interview on 03/25/26 at 6:42 p.m., with the Medical Director, was unsuccessful. Record review of the facility's policy titled, Skin Prevention and Management Guidelines, revised 04/13/23, reflected did not address following physician orders related to wound care.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents for 2 of 24 residents (Resident #6 and Resident #5) reviewed for laboratory services. 1. The facility failed to obtain Resident #6's CMP (lab test that provides an overall picture of your body's chemical balance and metabolism, and can help diagnose, screen for, or monitor health conditions or medication side effects), CBC (used to monitor and diagnose medical conditions, check the health of the immune system, and detect disorders including infections, anemia, and blood cancer), and HgA1c (lab test that provides a measurement of the average of the blood sugars in the last 2-3 months to manage diabetes) as ordered on 11/18/25 and every 3 months.2. The facility failed to obtain Resident #5's Magnesium lab (measures the amount of magnesium in the blood which can affect the heart, muscle, and nerve function) as ordered on 11/15/24 and every 12 months. These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.Findings include:1. Record review of Resident #6's face sheet, dated 03/25/26, indicated a [AGE] year-old male who re-admitted to the facility on [DATE]. Resident #6 had diagnoses which included diabetes mellitus (a disease in which the body loses the ability to produce insulin and causes elevated blood sugars), bipolar disorder (chronic mental health condition characterized by intense mood swings from lows to highs, chronic respiratory failure (long-term condition in which the lungs cannot adequately exchange oxygen and carbon dioxide), and dementia (decline in mental ability that is severe enough to interfere with daily life). Record review of Resident #6's quarterly MDS assessment, dated 02/18/26, indicated he was usually understood by others and sometimes understood others. Resident #6 had a BIMs score of 10, which indicated he had moderate cognitive impairment. Record review of the Order Summary Report, dated as of 03/25/26, indicated Resident #6 had an order for a CMP, CBC, HgA1c in AM, then every 3 months. Diagnosis was diabetes with a date of 11/18/25.Record review of Resident #6's EMR on 03/25/26 indicated the CMP, CBC, and HgA1c labs were never drawn after being ordered on 11/18/25. Record review of Resident #6's care plan did not address obtaining labs.During an interview on 03/25/26 at 5:48 PM, the Resident #51's NP said she inputted the order, and she said she expected the lab to be drawn and followed up on, but she could not recall why it was not, because she had been off for a few months. The Resident #51's NP said a risk of not checking the resident's HgA1c was they wouldn't catch when Resident #51 needed his insulin titrated (the process of adjusting a medication dose to reach a target effect safely). During an interview on 03/25/26 at 6:05 PM, the DON said she expected the labs to be drawn when the physician ordered the labs. The DON said the failure placed a risk for issues with not knowing if his medications were effective or not and could have caused further problems like kidney failure. 2. Record review of Resident #5's face sheet, dated 03/25/26, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included end stage renal disease (permanent irreversible kidney failure where the kidneys can no longer filter waste), cirrhosis of the liver (late stage irreversible scarring of the liver caused by long-term liver disease and conditions such as alcoholism or hepatitis), heart disease, diabetes mellitus (a disease in which the body loses the ability to produce insulin and causes elevated blood sugars), and senile degeneration of the brain (progressive age related cognitive decline caused by brain cell death commonly from Alzheimer's). Record review of Resident #5's quarterly MDS assessment, dated 03/05/26, indicated he was usually understood by others and he usually understood others. Resident #5 had a BIMs score of 10, which indicated he had moderate cognitive impairment. Record review of Resident #5's comprehensive care plan, revised on 02/16/26, indicated he had a diagnosis which included diabetes and was at risk for unstable blood sugars and dependent on dialysis with an intervention to obtain, monitor, and report labs to the physician as ordered. Record review of Resident #5's order summary report, dated 03/25/26, indicated Resident #5 had an order for CBC, BMP magnesium, vitamin D level now and every 12 months. DX: ESRD with a date of 11/15/24. During an interview on 03/25/26 at 2:40 PM, the DON said she expected labs to be drawn as ordered but she called the lab, and she did not know why it was missing. The DON said she was responsible for ensuring the labs were drawn. The DON said the failure placed a risk for issues with not knowing if his medications were effective or not.During an interview on 03/25/26 at 6:54 PM, the Administrator said she expected all labs to be completed as ordered and in a timely manner. The Administrator said the failure placed a risk for staff not knowing what was going on with the residents and had negative effects. Record review of the facility's policy, revised 1/30/26, lab tracking system indicated Process: The lab results are automatically uploaded into the electronic health record. As Lab orders are received, the nurse receiving the order completes the lab requisition and places the requisition slip in lab. The nurse manager will review the facility's Lab results daily and retroactive for seven (7) days to include any test that may take longer to complete.A 24-hour chart check is completed routinely to verify new orders for lab tests are transcribed on the laboratory tracking tool.

Based on interviews and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers,. for 1 of 6 (Resident #1) residents reviewed for psychoactive medications. The facility did not ensure written consent was obtained from the legal authorized representative on HHSC Form 3713 to administer Abilify 10 mg also known as Aripiprazole (atypical antipsychotic medication used to treat schizophrenia, bipolar I disorder, depression, autism-related irritability, and Tourette's syndrome) for Resident #1.This failure could place residents at risk for receiving unnecessary antipsychotic medications without informed consent.Findings included:Record review of Resident #1's face sheet, dated 03/25/26 indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Bipolar (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), depression (sadness), and anxiety (a feeling of fear, dread, and uneasiness).Record review of Resident #1's quarterly MDS assessment, dated 03/05/26, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 14, which indicated she was cognitively intact. The MDS indicated Resident #1 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and supervision for eating. Resident #1 received antianxiety medication during the 7-day look-back period. Record review of the comprehensive care plan, dated 11/14/24 indicated Resident #1 used psychotropic medications related to bipolar disorder. The intervention of the care plan indicated staff would give medication as ordered and would monitor/document for side effects and effectiveness.Record review of Resident #1's physician's orders, dated 10/30/25, indicated the resident had an order for Abilify 10 mg, give one tablet by mouth every day for bipolar and depression disorder.Record review for Resident #1's medication administration record, dated 03/01/26 through 03/25/26, indicated she received Abilify 10 mg as ordered over the last 25 days.Record review for Resident #1's consent for use of psychotropic medication, Abilify 10 mg every day was not documented in her chart.During an interview on 03/25/26 at 12:16 p.m., Resident #1 said she was not aware of her meds, but knew she took a lot of them. She said she trusted what the nurses gave her.During an interview on 03/25/26 at 5:15 p.m., LVN H said she was the nurse for Resident #1. She said consent should be obtained for all psychotropic medication before being given to allow the resident/responsible party an opportunity to decline or accept and to be aware of all possible side effects from the medications. LVN H said Resident #1 was given Abilify for bipolar and depression. LVN H said she was not aware that if the medication strength changed, she needed to obtain a new psychotropic medications consent.During an interview on 03/25/26 at 6:36 p.m., the DON said consent should be signed before administering any psychoactive medication. The DON said one reason consent was obtained was to inform the residents/families about the risks and benefits before receiving medication. The DON said the charge nurse who received the order was responsible for obtaining consent, and she was the overseer. She said she missed Resident #10's Abilify order change in October 2025 and therefore HHSC Form 3713 was not updated to the correct medication dosage. The DON said failure to obtain the correct consent could cause the resident/ family not to have all the information about the medication or a choice about the resident's care. During an interview on 03/25/26 at 7:00 p.m., the Administrator said she expected the nurses to ensure the consent form was completed. She said she expected the DON or designee to ensure the HHSC Form 3713 was filled out correctly for psychotropic medications. The Administrator said consents should be done to inform residents/families of risks and/or benefits of medication or a choice to decline it. Record review of the facility's policy titled Psychotropic Medication Policy review date of 01/12/25, indicated It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary Psychotropic drugs.Procedure: 3. Informed consent for Psychotropic medication prior to administration.21. Consents will be obtained as per state guidelines.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 1 of 24 (Resident #11) reviewed for abuse. The facility did not implement their policy on reporting abuse to the Abuse Coordinator when Resident #11 stated the word rape while been provided a shower by CNA L. This deficient practice could place residents at risk of unreported abuse, neglect, and a decreased quality of life. Findings included: Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22, reflected. 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with state law.VII Reporting/Response . A. (2.) Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or result in serious bodily injury.Record review of Resident #11's face sheet, dated 03/25/26, reflected Resident #11 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions).Record review of Resident #11's quarterly MDS assessment, dated 03/06/26, reflected Resident #11 rarely/never made herself understood and rarely/never understood others. The assessment did not address Resident #11's BIMS score but reflected she had long term and short-term memory problems.Record review of Resident #11's comprehensive care plan, revised on 08/04/25, reflected Resident #11 had a history of trauma that may have a negative effect: sexual abuse. The care plan interventions included: identify resident's triggers that have the potential to re-traumatize which may include male hugging or providing care, identify items that lessen the effects of trauma and provide her comfort, and monitor for signs and symptoms of depression, anxiety, sleep disturbances and substance abuse issues. Record review of the PIR, dated 03/24/26, reflected an allegation of abuse incident on Resident #11. The PIR reflected the date of the incident was unknown but occurred during a shower that was given by CNA L when Resident #11 stated the word rape. The PIR reflected no staff witnessed the incident. The incident was reported to the state agency on 03/24/26 at 2:23 p.m.During an attempted interview on 03/23/26 at 2:06 p.m., with Resident #11, indicated she was non-interview able due to cognitive loss. During a telephone interview on 03/24/26 at 9:41 p.m., Resident #11's family members stated Resident #11 had a history of sexual abuse prior to being admitted to the facility. Resident #11's family member stated she told the facility she did not want a male hugging or providing care to Resident #11. During an interview on 03/24/26 at 2:45 p.m., the Administrator stated she had called in a reportable incident of an allegation of abuse regarding Resident #11 The Administrator stated she was notified by LVN H last night (03/23/26) that an allegation of possible abuse was reported on Resident #11. LVN H stated she did not remember the conversation with the nurse until 3/24/26 when CNA B asked for a follow-up and that was when she called LVN H to reiterate the allegation from the night before. The Administrator stated that was when she reported the incident earlier today (03/24/26). The Administrator stated this was the first time she had ever heard Resident #11 said the word rape. The Administrator stated she expected staff to notify her directly and immediately of any allegation of abuse being mentioned. During an interview on 03/24/26 at 4:38 p.m., CNA B stated she and CNA K were getting ready to give Resident #11 a shower and CNA K made a comment to LVN H and her about Resident #11 screaming and hollering the word rape two weeks ago when she gave her a shower. CNA B stated 03/23/26 was the first time she heard a staff member stating Resident #11 stated the word rape during a shower. CNA B stated she gave Resident #11 a shower on 03/23/26 and did not have any issues. CNA B stated Resident #11 had a history of sexual abuse from a previous facility and had never made any accusations towards her when she provided her with a shower. CNA B stated she regularly provided a calming environment using music during Resident #11's routine showers because of her previous history and her becoming tense when you start wiping the perineal area. CNA B stated she had only had to assist CNA L once with Resident #11's shower which had been a long time ago and she never stated the word rape. CNA B stated CNA L's voice was a little heavier and her body frame was masculine. During an interview on 03/24/26 at 4:50 p.m., LVN H stated she heard CNA K discussing with CNA G and CNA B about Resident #11 stating the word rape when they provide her a shower. LVN H stated she asked the aides how long this had been going on and CNA K stated she was not able to give an exact date when she heard her saying it. LVN H stated CNA K stated when they cleaned her private area that was when she hollered out rape. LVN H stated she went and reported the incident to the DON, and she instructed her to contact the Administrator. LVN H stated she called the Administrator between 8:30 p.m.-9:00 p.m. on 03/23/26 and told her what was going on and informed her she confronted the aides about not reporting the allegation before 03/23/26. LVN H stated the Administrator stated she would take care of it and will have the Social Worker speak to the aides tomorrow. LVN H stated she went and monitored CNA B and CNA K while providing Resident #11 a shower on 03/23/26 and Resident #11 never showed any aggressive behavior or fear towards the aides. LVN H stated she was told when Resident #11 was first admitted she had a history of sexual abuse but did not have a history of false accusations. During an interview on 03/24/26 at 5:20 p.m., CNA K stated she could not recall the exact date when the incident occurred, but she was doing her charting at the nursing station when CNA L came up the hall flustered, stating she needed help because Resident #11 was stating something that made her feel uncomfortable. CNA K stated she asked if she could come and be a second witness and assist her with showering Resident #11. CNA K stated she went in to clean the shower room because Resident #11 was the last resident that needed a shower. CNA K stated CNA L continued to provide a shower to Resident #11 and she heard Resident #11 state the word rape under her breath and that was when she asked Resident #11 if she was ok. CNA K stated Resident #11 looked at her and stated ok which was her normal response. CNA K stated CNA L placed a gown on her and walked Resident #11 to her room. CNA K stated CNA L told her after she took her to her room, she was going to report the allegation to her nurse LVN M. CNA K stated she did not report the incident because CNA L stated she was going to. CNA K stated she was her regular shower aide and had never heard Resident #11 make an allegation of sexual abuse. CNA K stated that anytime you tried and pulled her pants down or clean between her private area Resident #11 became tensed. CNA K stated CNA L normally did not work the North Hall but due to a call-in she had to that night. CNA K stated she had heard about Resident #11 being touched inappropriately but at a different facility. CNA K stated it was her first time hearing Resident #11 make an allegation of abuse. During a telephone interview om 03/25/26 at 5:39 p.m., CNA L stated she was put on the North Hall with CNA B when the incident with her and Resident #11 occurred. CNA L stated the incident occurred between 03/02/26-03/06/26, unable to give the exact date. CNA L stated she grabbed supplies and started performing showers. CNA L stated she was told by CNA B Resident #11 normally gets her showers between 8:00 p.m.-8:30 p.m. CNA L stated she took Resident #11 in the shower room, and she noticed that Resident #11 started to grab her shirt and pants like she was holding on for dear life. CNA L stated she explained to her it was time for a shower and that was when she started to ease up while she undressed her. CNA L stated she got Resident #11 to sit down in the shower chair and had the water warm enough for her. CNA L stated she put some soap on the washcloth and washed her back, hair, under her arms, chest, stomach, legs and feet. CNA L stated she told Resident #11 she was about to wash in between her private area and once she started washing under her belly fold, she stated, rape. CNA L stated she stopped immediately, rinsed her off, and got a towel to dry her off the best she could. CNA L stated she took Resident #11 back to her room and asked CNA G, CNA K and CNA B if Resident #11 had ever made a statement about rape when you washed her private area. CNA L stated they all stated yes she had stated that before. CNA L stated she told them she had stated the word while providing her with a shower and from now on if she had to give her a shower, she would like someone to assist her. CNA L stated she had never asked CNA K to come in and assist with providing care to Resident #11. CNA L stated she had provided a shower a couple of months back prior to the incident and did not have any problems, that was why it caught her by surprise when she stated it. CNA L stated she did not report the incident to LVN M or the Administrator because it slipped my mind, I was busy. CNA L stated this failure put Resident #11 at risk for abuse. During an interview on 03/25/26 at 9:16 a.m., CNA G stated she did not know anything about Resident #11 stating the word rape until 03/23/26 when she heard CNA B tell LVN H about Resident #11 stating the word rape when CNA L gave her a shower. CNA G stated she used to provide Resident #11 her showers when she worked the North Hall, and she never stated the word rape. CNA G stated Resident #11 would tense up her thighs when providing incontinent care or putting water on her private area, CNA G stated you had to inform her you were not going to hurt her and she would loosen up. CNA G stated Resident #11 had a history of being messed with at another facility. CNA G stated she did not report the incident because CNA B had already reported the incident to LVN H. An attempted telephone interview on 03/25/26 at 9:54 a.m. with LVN M, was unsuccessful, voicemail left. During an interview on 03/25/26 at 5:00 p.m., the DON stated prior to the incident that occurred on 03/23/26, she had no knowledge of sexual abuse allegations related to Resident #11 when provided a shower. The DON stated she was not aware that Resident #11 had a history of sexual abuse until Monday (03/23/26). The DON stated LVN H came to her on 03/23/26 and stated she was letting her know that CNA B had informed her she was told by CNA L that Resident #11 had made those allegations two weeks ago. The DON stated LVN H asked what she needed to do and she advised her to notify the Administrator immediately. The DON stated she was not aware Resident #11 became uncomfortable when providing care to the private areas. The DON stated she monitored abuse by speaking to the residents that were cognitive and able to voice any concerns and those that were not she watched their body language and paid attention to how they reacted to staff. The DON stated she has not seen any issues with abuse. The DON stated Resident #11's showers had been changed to 6a-2p instead of 2p-10p for closer monitoring. The DON stated CNA L was tall, masculine like, and wore her hair up most of the time. The DON stated it was very possible that it could have been a trigger for Resident #11.During an interview on 03/25/26 at 6:00 p.m., the Administrator stated she was the Abuse Coordinator for the facility. The Administrator stated she monitored abuse by constant education provided to staff/cognitive residents, QOL rounds every morning, and open conversation with residents/staff to ensure comfortability to report concerns to her. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to prevent other incidents of abuse.

Based on interview and record review, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, to the administrator of the facility and to other officials including to the State Survey Agency for 1 of 24 (Resident #11) residents reviewed for abuse and neglect. The Abuse Coordinator failed to identify and report an allegation of abuse to HHSC within 2 hours when LVN H informed him on 03/23/26 that Resident #11 stated the word rape and appeared scared while been provided a shower by CNA L. This failure to report could place the residents at risk for abuse and emotional distress. Findings included:Record review of Resident #11's face sheet, dated 03/25/26, reflected Resident #11 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions).Record review of Resident #11's quarterly MDS assessment, dated 03/06/26, reflected Resident #11 rarely/never made herself understood and rarely/never understood others. The assessment did not address Resident #11's BIMS score but reflected she had long term and short-term memory problems.Record review of Resident #11's comprehensive care plan, revised on 08/04/25, reflected Resident #11 had a history of trauma that may have a negative effect: sexual abuse. The care plan interventions included: identify resident's triggers that have the potential to re-traumatize which may include male hugging or providing care, identify items that lessen the effects of trauma and provide her comfort, and monitor for signs and symptoms of depression, anxiety, sleep disturbances and substance abuse issues. Record review of the PIR, dated 03/24/26, reflected an allegation of abuse incident on Resident #11. The PIR reflected the date of the incident was unknown but occurred during a shower that was given by CNA L when Resident #11 stated the word rape. The PIR reflected no staff witnessed the incident. The incident was reported to the state agency on 03/24/26 at 2:23 p.m.During an attempted interview on 03/23/26 at 2:06 p.m., with Resident #11, indicated she was non-interview able due to cognitive loss. During a telephone interview on 03/24/26 at 9:41 p.m., Resident #11's family members stated Resident #11 had a history of sexual abuse prior to being admitted to the facility. Resident #11's family member stated she told the facility she did not want a male hugging or providing care to Resident #11. During an interview on 03/24/26 at 2:45 p.m., the Administrator stated she had called in a reportable incident of an allegation of abuse regarding Resident #11 The Administrator stated she was notified by LVN H last night (03/23/26) that an allegation of possible abuse was reported on Resident #11. LVN H stated she did not remember the conversation with the nurse until 3/24/26 when CNA B asked for a follow-up and that was when she called LVN H to reiterate the allegation from the night before. The Administrator stated that was when she reported the incident earlier today (03/24/26). The Administrator stated this was the first time she had ever heard Resident #11 said the word rape. The Administrator stated she expected staff to notify her directly and immediately of any allegation of abuse being mentioned. During an interview on 03/24/26 at 4:38 p.m., CNA B stated she and CNA K were getting ready to give Resident #11 a shower and CNA K made a comment to LVN H and her about Resident #11 screaming and hollering the word rape two weeks ago when she gave her a shower. CNA B stated 03/23/26 was the first time she heard a staff member stating Resident #11 stated the word rape during a shower. CNA B stated she gave Resident #11 a shower on 03/23/26 and did not have any issues. CNA B stated Resident #11 had a history of sexual abuse from a previous facility and had never made any accusations towards her when she provided her with a shower. CNA B stated she regularly provided a calming environment using music during Resident #11's routine showers because of her previous history and her becoming tense when you start wiping the perineal area. CNA B stated she had only had to assist CNA L once with Resident #11's shower which had been a long time ago and she never stated the word rape. CNA B stated CNA L's voice was a little heavier and her body frame was masculine. During an interview on 03/24/26 at 4:50 p.m., LVN H stated she heard CNA K discussing with CNA G and CNA B about Resident #11 stating the word rape when they provide her a shower. LVN H stated she asked the aides how long this had been going on and CNA K stated she was not able to give an exact date when she heard her saying it. LVN H stated CNA K stated when they cleaned her private area that was when she hollered out rape. LVN H stated she went and reported the incident to the DON, and she instructed her to contact the Administrator. LVN H stated she called the Administrator between 8:30 p.m.-9:00 p.m. on 03/23/26 and told her what was going on and informed her she confronted the aides about not reporting the allegation before 03/23/26. LVN H stated the Administrator stated she would take care of it and will have the Social Worker speak to the aides tomorrow. LVN H stated she went and monitored CNA B and CNA K while providing Resident #11 a shower on 03/23/26 and Resident #11 never showed any aggressive behavior or fear towards the aides. LVN H stated she was told when Resident #11 was first admitted she had a history of sexual abuse but did not have a history of false accusations. During an interview on 03/24/26 at 5:20 p.m., CNA K stated she could not recall the exact date when the incident occurred, but she was doing her charting at the nursing station when CNA L came up the hall flustered, stating she needed help because Resident #11 was stating something that made her feel uncomfortable. CNA K stated she asked if she could come and be a second witness and assist her with showering Resident #11. CNA K stated she went in to clean the shower room because Resident #11 was the last resident that needed a shower. CNA K stated CNA L continued to provide a shower to Resident #11 and she heard Resident #11 state the word rape under her breath and that was when she asked Resident #11 if she was ok. CNA K stated Resident #11 looked at her and stated ok which was her normal response. CNA K stated CNA L placed a gown on her and walked Resident #11 to her room. CNA K stated CNA L told her after she took her to her room, she was going to report the allegation to her nurse LVN M. CNA K stated she did not report the incident because CNA L stated she was going to. CNA K stated she was her regular shower aide and had never heard Resident #11 make an allegation of sexual abuse. CNA K stated that anytime you tried and pulled her pants down or clean between her private area Resident #11 became tensed. CNA K stated CNA L normally did not work the North Hall but due to a call-in she had to that night. CNA K stated she had heard about Resident #11 being touched inappropriately but at a different facility. CNA K stated it was her first time hearing Resident #11 make an allegation of abuse. During an interview on 03/25/26 at 9:27 a.m., the Social Worker stated on 03/24/26 midafternoon was the first time she was made aware of any abuse allegations related to Resident #11. The Social Worker stated she was asked by the Administrator to performed safe surveys on North Hall with cognitive females. The Social Worker stated she spoke with psych services to come in and evaluate Resident #11. The Social Worker stated she had not spoken to the CNAs that were involved in the incident. During a telephone interview om 03/25/26 at 5:39 p.m., CNA L stated she was put on the North Hall with CNA B when the incident with her and Resident #11 occurred. CNA L stated the incident occurred between 03/02/26-03/06/26, unable to give the exact date. CNA L stated she grabbed supplies and started performing showers. CNA L stated she was told by CNA B Resident #11 normally gets her showers between 8:00 p.m.-8:30 p.m. CNA L stated she took Resident #11 in the shower room, and she noticed that Resident #11 started to grab her shirt and pants like she was holding on for dear life. CNA L stated she explained to her it was time for a shower and that was when she started to ease up while she undressed her. CNA L stated she got Resident #11 to sit down in the shower chair and had the water warm enough for her. CNA L stated she put some soap on the washcloth and washed her back, hair, under her arms, chest, stomach, legs and feet. CNA L stated she told Resident #11 she was about to wash in between her private area and once she started washing under her belly fold, she stated, rape. CNA L stated she stopped immediately, rinsed her off, and got a towel to dry her off the best she could. CNA L stated she took Resident #11 back to her room and asked CNA G, CNA K and CNA B if Resident #11 had ever made a statement about rape when you washed her private area. CNA L stated they all stated yes she had stated that before. CNA L stated she told them she had stated the word while providing her with a shower and from now on if she had to give her a shower, she would like someone to assist her. CNA L stated she had never asked CNA K to come in and assist with providing care to Resident #11. CNA L stated she had provided a shower a couple of months back prior to the incident and did not have any problems, that was why it caught her by surprise when she stated it. CNA L stated she did not report the incident to LVN M or the Administrator because it slipped my mind, I was busy. CNA L stated this failure put Resident #11 at risk for abuse. During an interview on 03/25/26 at 9:16 a.m., CNA G stated she did not know anything about Resident #11 stating the word rape until 03/23/26 when she heard CNA B tell LVN H about Resident #11 stating the word rape when CNA L gave her a shower. CNA G stated she used to provide Resident #11 her showers when she worked the North Hall, and she never stated the word rape. CNA G stated Resident #11 would tense up her thighs when providing incontinent care or putting water on her private area, CNA G stated you had to inform her you were not going to hurt her and she would loosen up. CNA G stated Resident #11 had a history of being messed with at another facility. CNA G stated she did not report the incident because CNA B had already reported the incident to LVN H. An attempted telephone interview on 03/25/26 at 9:54 a.m. with LVN M, was unsuccessful, voicemail left. During an interview on 03/25/26 at 5:00 p.m., the DON stated prior to the incident that occurred on 03/23/26, she had no knowledge of sexual abuse allegations related to Resident #11 when provided a shower. The DON stated she was not aware that Resident #11 had a history of sexual abuse until Monday (03/23/26). The DON stated LVN H came to her on 03/23/26 and stated she was letting her know that CNA B had informed her she was told by CNA L that Resident #11 had made those allegations two weeks ago. The DON stated LVN H asked what she needed to do and she advised her to notify the Administrator immediately. The DON stated she was not aware Resident #11 became uncomfortable when providing care to the private areas. The DON stated she monitored abuse by speaking to the residents that were cognitive and able to voice any concerns and those that were not she watched their body language and paid attention to how they reacted to staff. The DON stated she has not seen any issues with abuse. The DON stated Resident #11's showers had been changed to 6a-2p instead of 2p-10p for closer monitoring. The DON stated CNA L was tall, masculine like, and wore her hair up most of the time. The DON stated it was very possible that it could have been a trigger for Resident #11.During an interview on 03/25/26 at 6:00 p.m., the Administrator stated she was the Abuse Coordinator for the facility. The Administrator stated she monitored abuse by constant education provided to staff/cognitive residents, QOL rounds every morning, and open conversation with residents/staff to ensure comfortability to report concerns to her. The Administrator stated she was the only one in the facility who could report abuse allegations to HHSC. The Administrator stated it was important to report an allegation of abuse and neglect for safety and protection of the residents and try to prevent other incidents of abuse.Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22, reflected.: 2(a). Immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or result in serious bodily injury.

Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 1 of 2 residents (Resident #13) reviewed for services provided to meet professional standards. The facility did not ensure Resident #13's hospice POC reflected her medication regimen. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings include: Record review of Resident #13's face sheet, dated 03/25/26, reflected Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included CAD (occurred when plaque buildup in the arteries, restricting blood flow and oxygen to the heart muscle). Record review of Resident #13's quarterly MDS assessment, dated 03/05/26, reflected Resident #13 sometimes made herself understood and rarely/never understood others. Resident #13 BIMS score of 3, which reflected his cognition was severely impaired. Resident #13 had a life expectancy of less than 6 months and received hospice services. Record review of Resident #13's comprehensive care plan, revised on 07/30/25, reflected Resident #13 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included: monitor for s/sx of increased pain, discomfort, give medications, treatments as ordered and monitor for relief. Record review of the order summary report, dated 02/27/26, reflected Resident #13 had an order to admit to hospice with an order date 06/19/25. Record review of Resident #13's hospice binder and EMR, accessed on 03/24/26 at 9:30 a.m. reflected the hospice administration record and the facility's physician orders did not match. The following orders were noted on the hospice medication record: Bisacodyl 10mg rectally twice a day as needed for constipation; Levsin 0.125 mg 1-2 tablets by mouth or sublingual every 4 hours as needed for secretions. The facility order summary report reflected: Bisacodyl 10mg rectally every 24 hours as needed for constipation; Levsin (generic name Hyoscyamine Sulfate) 1 tablet by mouth as needed for increased secretion. During a telephone interview on 03/25/26 at 2:59 p.m., the Hospice RN Case Manager stated Resident #13 was admitted to hospice on 06/19/25 for CAD. The Hospice RN Case Manager stated she should be reviewing the facility medication list monthly to ensure the medication list was correct and updated. The Hospice RN Case Manager stated she could not remember the last time the medications were reviewed. The Hospice RN Case Manager stated it was important to ensure the medication list was updated in the hospice binder so Resident #13 would receive the correct medication. During a telephone interview on 03/25/26 at 3:07 p.m., RN C stated she coordinated with hospice weekly. RN C stated she was unaware the medication list was not updated. RN C stated she did not review the medication list in the binder because everything she should document regarding those medications would be in PCC. RN C stated it was important to ensure that recent hospice documentation was in the facility to keep communication between the facility and hospice for continuation of care. During an interview on 03/25/26 at 5:00 p.m., the DON stated she was not made aware of the medication difference until today (03/25/26). The DON stated MA F was responsible for reviewing the medication orders monthly to ensure compliance. The DON stated the Administrator was responsible for monitoring and overseeing hospice. The DON stated it was important to ensure recent hospice documentation was in the facility to keep communication between the facility and hospice for continuation of care. During an interview on 03/25/26 at 5:48 p.m., MA F stated she was responsible for uploading the hospice documents. MA F stated she had never been told to reconcile the medications orders from the hospice compared to the facility orders to ensure accuracy. During an interview on 03/25/26 at 6:00 p.m., the Administrator stated she expected the medication lists from the hospice and facility to match. The Administrator stated the DON/designee was responsible for ensuring the information was updated. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuation of care. Record review of the facility's policy titled Coordination of Hospice Services, dated 04/21/21, reflected, . When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being.2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs.7. The facility will monitor for medications. to ensure they are provided by hospice and indicated in the plan of care for palliation and management of the terminal illness.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items in the refrigerator and freezer. 2) The facility failed to clean deep fryer weekly. 3) The Facility failed to label and date all food items in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Record Review of daily cleaning scheduled dated on the week of [DATE] did not indicated that the fryer had been cleaned by a cook on [DATE] (Monday), [DATE] (Tuesday). [DATE] (Wednesday), [DATE] (Thursday), [DATE] (Friday), [DATE] (Saturday) and on [DATE] (Sunday). Record Review of in-services on labeling and dating was last completed by staff on [DATE] and [DATE]. Record Review of in-services on the cleaning schedule was last completed by staff on [DATE]. Record Review of in-services on cleaning the deep fryer was last completed by staff on [DATE]. During observation in the kitchen on [DATE] at 9:37 a.m. the following was observed with the Dietary Manager: - The fryer was not cleaned; the fryer cooking oil was black in color and had brownish black food crumps floating on top of the cooking oil. - The fryer cover had food crumps and grease build up on the fryer cover. During observation in the kitchen refrigerator on [DATE] at 9:45 am the following was observed with the Dietary Manager: - (1) cut up tomato prepped on [DATE] had no expiration date. - (1) 6-ounce container of pineapples with a prep date of [DATE] had no expiration date. - (1) Quart of white gravy had an expiration date of [DATE] and no preparation date. (expired) - (11) cups of orange juice had a preparation date of [DATE] and no expiration date - (40) cups of teas were not labeled, had no preparation date and no expiration date - (20) cup of water was not labeled, had no preparation date and no expiration date - (1) plate of salad had a preparation date of [DATE] and no expiration date During observation in the kitchen freezer on [DATE] at 9:52 a.m., the following was observed with the Dietary Manager: - (1) zip lock bag of French fries had an open date of [DATE] and no expiration date - (1) zip lock bag of French fries had an open date of [DATE] and no expiration date - (1) bag of frozen diced chicken had an expiration date of [DATE] an no open date. (expired) During an interview with the Dietary Manager on [DATE] at 9:37 a.m., The Dietary Manager stated staff were cleaning the fryer but had not been signing off that they had been cleaning the fryer. The Dietary Manager stated the fryer was to be cleaned once a week. The Dietary Manager stated she worked Monday thru Friday and sometimes on the weekend. The Dietary Manager stated she ensured staff were cleaning because she watched what her staff did and how her staff cleaned. The Dietary Manager stated the fryer was used every day. The Dietary Manager stated the fryer was last cleaned on Monday [DATE]. The Dietary Manager stated staff were to put their initials on the daily cleaning schedule indicating what was cleaned and by whom it was cleaned by. The Dietary Manager stated she did not know why staff did not initial on [DATE] indicating the fryer had been cleaned but it was okay because it was going to fall on her indicating that she should have checked to make sure staff initialed the cleaning schedule for each day. The Dietary Manager stated the foods prepared in the kitchen should be labeled, have a preparation date and an expiration date. The Dietary Manager stated once food was prepared that it was good for 7 days. The Dietary Manager stated in-services on labeling and dating had been completed a few months ago. The Dietary Manager stated it was important to ensure staff were labeling and dating food items and cleaning the fryer to keep the residents from getting sick, to prevent sending out spoiled food to the residents and to prevent the residents from getting salmonella. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manger stated she was responsible for ensuring staff were labeling and dating food items and responsible for ensuring staff were cleaning the fryer weekly. During an interview on [DATE] at 11:12 a.m., Confidential Complainant stated the kitchen was filthy. Confidential Complainant stated the grease was changed once a month in the kitchen. Confidential Complainant stated the fryer was used every day. During a phone interview on [DATE] at 9:23 a.m., the Administrator stated she had been employed since [DATE] of 2024. The Administrator stated she over saw the Dietary Manager. The Administrator stated she tried to do walk thru biweekly. The Administrator stated her last walk thru was on [DATE] (Thursday). The Administrator stated all food items in the refrigerator were to be labeled, dated with receive date, open date and expiration date. The Administrator stated recently staff had completed in-services on labeling and dating all food items. The Administrator stated staff had not completed in-services on cleaning the deep fryer recently. The Administrator stated she was not aware of the expired food items not being discarded and the deep fryer was not getting cleaned weekly. The Administrator stated she did expect the Dietary Manager to report to her all issues found in the kitchen. The Administrator stated it was important to ensure staff was labeling, dating and resealing refrigerator and frozen food items and cleaning the fryer weekly to ensure cleanliness, to provide the highest quality of food and to ensure safety for the residents. Record Review of the kitchen policy titled, Equipment cleaning Procedures dated on [DATE] indicated, Cleaning Frequency: (daily) Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily. (Weekly) If the fryer is used frequently (five or more times a week), clean weekly. If fryer is used less often than that, clean monthly. If grease is strained after each use, it extends the life of the grease. Record review of the kitchen policy titled Frozen and Refrigerated Foods Storage with review dated on [DATE], indicated, (7) Refrigerate cooked foods in shallow containers to speed the cooling process. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by'' date. Refrigerated products that are opened must be labeled with an opened on date. The ''use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. For all foods that have a manufacturer use by, sell by or expirations dates this date will be used. Examples of foods that typically have manufacturer, use by, sell by or expirations dates are cottage cheese, milk, sour cream, pre-pared refrigerated salads etc. Foods prepared in the building and properly cooled will be dated as to the date prepared and ''use by'' date which will be 7 days from the date prepared; (11) All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #14) reviewed for accidents and supervision. 1. The facility failed to ensure 2-person assistance was used while providing Resident #14 a bed bath on 06/09/2024. This resulted in Resident #14 falling out of bed and fracturing her right distal tibia (right lower end of the leg). 2. The facility failed to ensure staff knew where to find resident information on the required level of assistance each resident needed. An Immediate Jeopardy (IJ) situation was identified on 12/11/2024 at 4:25 PM. While the IJ was removed on 12/12/2024 at 3:59 PM, the facility remained out of compliance at a scope of isolated with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk for falls, injuries and hospitalization s. Findings include: Record review of Resident #14's face sheet, dated 12/12/2024, indicated Resident #14 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and rheumatoid arthritis (chronic disease that causes inflammation of the joints and pain and can also affect other body systems). Record review of Resident #14's quarterly MDS assessment dated [DATE], indicated Resident #14 was dependent on staff for toileting hygiene, showering/bathing self, and personal hygiene. Record review of Resident #14's Quarterly MDS Assessment, dated 10/25/2024, indicated Resident #14 usually understood others and was usually able to make herself understood. Resident #14 had a BIMS score of 8, which indicated her cognition was moderately impaired. Resident #14 was dependent on staff for toileting hygiene, showering/bathing self, and personal hygiene. Resident #14 required substantial to maximum assistance with rolling left and right. T Resident #14 was always incontinent. Record review of Resident #14's care plan, revised 11/06/2024, indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner related to weakness, immobility, poor balance, and forgetfulness. Resident #14 indicated she required for bed mobility maximum assistance of 2 staff, transfers total assistance of 2 staff using a lift, toileting maximum assistance of 2 staff, and bathing total assistance of 1. 2 staff for transfers in and out of the shower. Record review of Resident #14's progress note, dated 06/09/2024 at 11:48 AM, indicated, Called to resident room by aide resident sitting in floor beside bed. Aid [sic] was giving resident a bed bath and asked resident roll onto her left side. Resident rolled to [sic] fast and to [sic] far and slid out of bed aid [sic] was able to partially catch resident before her whole body hit the floor resident did not hit her head full assessment done no deformity or shortening noted Resident assisted back into bed resident has bruise to right ankle resident can move foot with no pain. MD, RP and Admin notified signed by LVN Z. Record review of Resident #14's progress note dated 06/09/24 at 9:25 PM and signed by LVN Z, indicated . received x-ray results resident has FX (fracture) of distal tibia called [telehealth] got order to send to ER. Record review of Resident #14's progress note dated 06/10/24 at 2:32 AM and signed by LVN FF, indicated . Resident returned from ER at approx. (approximately) 0030 (12:30 AM) hrs (hours) via ambulance. Splint to RLE (right lower extremity) to immobilize r/t (related to) fx to distal tibia . Record review of Resident #14's progress note dated 06/11/24 at 11:57 AM signed by RN B, indicated . Res (resident) back from ortho (orthopedic) apt. (appointment) with new cast to r/t lower leg circulation cont. (continues) . Record review of Resident #14's radiology (medical imaging) Patient Report for the right ankle, dated 06/09/2024, indicated, .Findings: there is a fracture of the distal tibia (fracture of the lower leg). Record review of Resident #14's Post Fall Evaluation, with an effective date of 06/09/2024, signed 07/18/2024 by the previous DON, indicated position at the time of the fall lying in bed, activity at the time of the fall was a bed bath, range of motion was limited per the resident's norm, the resident had no falls in the past 6 months, immediate intervention implemented to prevent further falls was education. The root cause or causes of the fall was bed positioning during bed bath. Intervention/system change was assist rails. Record review of an undated witness statement signed by CNA A indicated, On Sunday June 9, 2024 I, [CNA A], was working west hall when [Resident #14] got on her call light needing to be changed when I [CNA A] went to change [Resident #14] I notice [sic] she had BM all up and down her from head to toe. I told her would she like a shower to get all the BM off her she said no I [CNA A] than told [Resident #14] she needed and [sic] bed bath to remove all the BM. [Resident #14] wasn't happy but turned to the side saying she don't want anything done to her I [CNA A] told [Resident #14] I can't not [sic] leave her in that condition I [CNA A] turned my back to get everything I needed to clean [Resident #14] up when I notice [sic] she had throwed [sic] her legs off the side of the bed and started to go down on her knees I [CNA A] ran over to the other side to help her to the floor when ask [sic] [Resident #14] why did she throw her legs off the bed she look [sic] at me and cut [sic] her eyes. During an observation on 12/11/2024 at 12:41 PM, revealed Resident #14 had assist bars on both sides of the bed. During an interview on 12/09/2024 at 11:49 AM, Resident #14 said a CNA was changing her and the CNA let me fall. Resident #14 said the CNA was talking on her phone and the CNA turned her back to her. Resident #14 said she told the CNA I'm going to fall and she fell . Resident #14 said she broke her ankle, and this happened about 3-4 months ago and they got rid of her the same day she was a black girl. Resident #14 said she did not know the CNAs name. During an attempted phone interview on 12/11/24 at 12:14 PM, LVN Z did not answer the phone. During an attempted phone interview on 12/11/2024 at 12:17 PM, the previous DON did not answer the phone. During an interview on 12/11/2024 at 12:58 PM, CNA C said she worked on 06/09/2024, but was not the CNA who provided care to Resident #14. CNA C said she remembered the CNA who cared for Resident #14 the day of the fall, but she could not remember her name. CNA C said Resident #14 required 2-person assistance for bed baths and mobility. During an interview on 12/11/2024 at 1:59 PM, CNA E said Resident #14 required 2-person assistance for her bed baths and repositioning. CNA E said whenever it was hard to turn the residents, she would use 2 people to provide care. CNA E said she did not have her log in to the electronic system. CNA E said sometimes when they reported at the end of the shift the other CNAs reported to her the level of assistance the residents required with their ADLs. During an interview on 12/11/2024 at 2:01 PM, CNA F said Resident #14 required 2-person assistance for her bed baths. CNA F said Resident #14 required one person on one side and one person on the other because she was totally dependent for mobility. CNA F said if she did not know the level of assistance a resident required, she would ask the nurse. CNA F said she relied on the nurse to tell her. CNA F said the level of assistance required by a resident for ADLs should be in the computer. CNA F attempted to demonstrate where to locate the information but was unable to find it. During an interview on 12/11/2024 at 2:04 PM, RN B said she had been a nurse at the facility for [AGE] years, and Resident #14 had always required 2-person assistance with all her ADLs for safety because of the air bed she had. RN B said most of the time the CNAs could ask the nurses and they could tell them the type of assistance the residents required. RN B said the information might be in the computer where the CNAs documented that they used to have a binder with the level of assistance required for the residents ADLS at the nurses' station, but it was no longer there. RN B said she was not working on 06/09/2024 when Resident #14 fell . During an interview on 12/11/2024 at 2:08 PM, CNA C said she remembered it was CNA A who provided care to Resident #14 on 06/09/2024. CNA C said if she was not familiar with a resident, she would ask the nurse what type of assistance they required for their ADLs. CNA C said there used to be a book at the nurses' station with the information, but it was no longer there. CNA C said she did not know where in the electronic system she could find the information regarding the level of assistance a resident required with their ADLs. During an interview on 12/11/2024 at 2:13 PM, CNA G said she was PRN, and Resident #14 required 2-person total assistance for changing her. CNA G said she usually asked the other CNAs the level of assistance required by the residents. CNA G said she did not know if there was anywhere they could look, and they did not have time to look in the electronic system when they started their shift. CNA G said it was important to know the level of assistance a resident required for their ADLs so they knew what the residents needed, and they could properly care for them. During an interview on 12/11/2024 at 2:23 PM, the ADON said Resident #14 required 2-person assistance for her ADLs. The ADON said the staff could look in the Kardex (electronic system they chart on) for the information regarding how much assistance the residents required for their ADLs. The ADON said the CNAs should be aware they could find the information in the Kardex. The ADON said if the CNAs did not know where to find this information it was a safety issue. During an interview on 12/11/2024 at 2:26 PM, the DON said Resident #14 required 2-person assistance for ADLS which included bed mobility and bathing. The DON said the MDS Coordinator was responsible for ensuring the care plans were updated. The DON said she thought where the care plan indicated bathing total assistance of 1. 2 staff for transfers in and out of the shower it was saying 1-to-2-person assistance, but she had only known for Resident #14 to require 2-person assistance. The DON said the care plan should indicate 2-person assistance. The DON said she did not know what happened on 06/09/2024. The DON said the MDS Coordinator should have revised Resident #14's care plan after the fall. The DON said the CNAs should be checking the Kardex for the level of assistance required, and they should have access to it. The DON said in the past she verbally provided the CNAs education regarding using the Kardex, but she had not done an official in-service. The DON said it was important for the staff to know the level of assistance a resident required for the resident's safety and to prevent injuries to themselves or to the residents. During an interview on 12/11/2024 at 3:24 PM, the Administrator said when Resident #14 had the fall on 06/09/2024, she had only been at the facility for four days, and she did not remember much about the incident. The Administrator said she remembered the CNA, the bed bath, and she thought Resident #14 was too close to the edge of the bed. The Administrator said she only remembered the CNA was in the room and was trying to change the bed and Resident #14 rolled off the bed. The Administrator said the CNA did not work there anymore, and she could not recall the CNAs name. During an attempted phone interview on 12/11/2024 at 3:40 PM, CNA A did not answer the phone. During an attempted phone interview on 12/12/2024 at 10:08 AM, CNA A did not answer the phone. Record review of the facility's Fall Management System, reviewed 02/19/2021, indicated It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs . The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. 4. Documentation in the nurse's notes and/or care plan will reflect interventions attempted . An Administrative nurse will ensure that the resident's plan of care is revised to reflect each fall and interventions that were implemented . interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable This was determined to be an Immediate Jeopardy (IJ) was identified on 12/11/2024 at 4:25 PM. The Administrator and the Corporate Nurse were notified. The Administrator was provided with the IJ template on 12/11/2024 at 4:39 PM. The following Plan of Removal submitted by the facility was accepted on 12/12/2024 at 1:41 PM: Issue Cited: Failure to use 2 staff transfer assistance while providing Resident #14 a bed bath. The Facility failed to ensure staff knew where to find resident information on the required assistance needed. 1. Immediate Action Taken: A. On 6/9/2024 Resident #14 was assessed by charge nurse, notification to physician and X-rays obtained after the fall. Resident #14 was monitored every shift. B. On 6/10/2024 the Nurse Assistance was suspended pending investigation where she was subsequently terminated due to failure to report back to work. C. On 6/10/2024 the DON/Designee completed an investigation into an incident involving Resident #14. D. On 6/10/2024 the DON provided in-service education to all staff on Abuse and neglect. This education was completed on 6/10/2024. E. On 6/14/2024 the DON/Designee in-service education with license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's. This was completed on 6/15/2024. All clinical staff are provided with training and access upon hire. F. On 12/11/2024 DON/Therapy assessed all residents to determine the type and number of staff assistance required for ADL's and validated that all Kardex have been updated. This was completed on 12/11/2024. F. On 12/11/2024 the DON/Designee provided in-service education with all license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's. This was completed on 12/12/2024 at 6:30 am, and no licensed nurse or Nurse Aide will be allowed to work until this education has been provided. 2. Identification of Residents Affected or Likely to be Affected: On 6/14/2024 the DON/Designee reviewed all residents requiring 2 persons bed mobility and bathing to verify that care plan and C.N.A. Kardex reflected the type of care residents require. 3. Actions to Prevent Occurrence/Recurrence: A. DON/Designee will review 24-hour nurse report daily in the morning meeting to validate that the care plan and Kardex has been reviewed/revised for any resident that has a change in bed mobility or bed bath. B. The DON/Designee will review all Incident/Accidents daily in the morning meeting to validate those residents with falls that involved bed mobility or falls during bed baths, had the appropriate number of staff needed during the transfer. C. The Regional Nurse Consultant will provide oversight into this process weekly x 4 weeks. D. The facility will continue to provide training to all license nurse and Nurse Aides upon hire and as need on documentation procedures for the Kardex system on PCC to identify type and amount of care a resident requires. On 12/11/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 12/12/24 Monitoring of the POR included the following: During an interview on 12/12/2024 at 1:50 p.m., the DON and the Corporate Nurse said the In-service on ADL care was verbal and there was not any handouts or policy to review. The DON said she in-serviced on positioning a resident in bed during care, and in-serviced verbally on Finding the information on the amount of assistance each resident for bathing, and bed mobility required on the Kardex. The DON said the staff not only verbalized understanding but also demonstrated understanding of the use of the Kardex. The DON and Corporate nurse said the post incident/fall protocol policy was not an actual policy but an assessment in the computerized system required completion after a fall. During an interview on 12/12/2024 at 2:46 PM, the DON said she would review the 24-hour report daily in the morning meetings and verify that all the necessary assessments and updates were completed for any incidents that occurred the day before. During an interview on 12/12/2024 at 2:20 PM, the Medical Director said he had been contacted regarding the immediate jeopardy and plan of removal. During interviews conducted on 12/12/2024 between 2:29 PM and 3:57 PM, MA N, LVN O, CNA P, the ADON, CNA F, LVN K, CNA H, CNA Q, LVN R, CNA E, CNA G, the Treatment Nurse, MA D, MA S, CNA T, CNA U, CNA V, LVN W, MA X, and CNA Y were able to verbalize they were provided in-service education on the use of the Kardex and where to find the type and amount of care residents required for all ADL's. Record review of Resident #14's progress notes indicated on 06/09/2024 she was assessed by the charge nurse; the physician was notified and an x-ray obtained. Resident #14's progress notes indicated she was monitored every shift from 6/9/2024-6/11/2024. Record review of a facility document titled, Associate Discplinary [sic] Memorandum, indicated CNA A was suspended pending investigation beginning on 06/10/24. After the investigation was completed, discharge was effective 06/13/24. The document indicated, During f/u (follow up) call for investigation employee quit on the spot w/ (with) no notice via phone-hung up on the Admin/DON signed by the Administrator and the previous DON on 06/13/2024. Record review completed of Resident #14's Witnessed Fall Incident Report, dated 06/09/2024 indicated, Nursing Description: called to residents room by aid [sic] resident sitting in the floor beside bed; Resident Description: I rolled out; Witnessed: Yes . Injuries observed at time of incident bruise right ankle (outer) .Other info rolled out of bed while getting bed bath . Record review of an In-Service Program Attendance Record with the topic Abuse and Neglect, dated 06/10/2024, indicated 23 staff signatures. Record review of an In-Service Program Attendance Record, dated 06/14/2024, with the topic Incontinent Care: Rotating and changing residents in a timely manner, completing showers as scheduled and upon request, know your residents and check for Kardex changes, and taking your time and letting the resident know what is happening with their care indicated 14 staff signatures. Record review of the CNA job description indicated Essential job Duties and Responsibilities: Assists residents with activities of daily living including bathing, dressing, grooming, toileting, changing of bed linens, and positioning in and out of bed, chair, etc. Assists with resident recreation programs. Prepares residents for meals and snacks, assists residents in eating where needed and records food intake. Reads and follows daily care plans; performs assigned restorative and rehabilitative procedures; reports changes in resident condition to nurse in charge; documents care provision on resident record/flowsheets as required and reports accidents and incidents; and provides nursing functions as directed by supervisor. Record review completed of the Kardex and care plans for 60 residents to verify they included the type and number of staff assistance required for ADLs and the Kardex and care plans matched. The Administrator was notified the Immediate Jeopardy was removed on 12/12/2024 at 3:59 PM. The facility remained out of compliance at a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, and record review, the facility failed to ensure an effective infection control program to help prevent the development and transmission of communicable diseases and infections was maintained for the facility. The facility did not check the temperatures or screen Residents #1, #2, #3, #4, #5, and #6 for COVID-19 symptoms daily. The facility did not check temperatures or screen residents who were not on skilled services for COVID-19. An Immediate Jeopardy (IJ) situation was identified on 4/15/20. The IJ was removed on 4/16/20. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope identified as a pattern, due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal. This failure could place residents at risk for late detection of COVID-19 virus, the spread of the COVID-19 virus throughout the facility, serious illness, and death. Findings included: 1. The clinical record from 3/15/20- 4/15/20 indicated Resident #1 had no assessment for COVID-19 symptoms. The clinical record for Resident #1 indicated he had his temperature checked daily on the following dates: *4/6/20-97.0 degrees F (Fahrenheit); *4/5/20-97.0 degrees F: *4/4/20-97.2 degrees F; *3/18/20-97.7degrees F; and *3/17/20-97.5 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #1. The clinical record from 3/15/20- 4/15/20 indicated Resident #2 had no assessment for COVID-19 symptoms. The clinical record for Resident #2 indicated she had her temperature checked daily on the following dates: *4/6/20-97.8 degrees F (Fahrenheit); *4/5/20-98.0 degrees F: *4/4/20-98.0 degrees F; *3/18/20-98.3 degrees F; and *3/17/20- 97.4 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #2. The clinical record from 3/15/20- 4/15/20 indicated Resident #3 had no assessment for COVID-19 symptoms. The clinical record for Resident #3 indicated she had her temperature checked daily on the following dates: *4/6/20-97.6 degrees F (Fahrenheit); *4/5/20-97.1 degrees F: *3/18/20-97.8 degrees F; and *3/17/20- 96.9 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #3. The clinical record from 3/15/20- 4/15/20 indicated Resident #4 had no assessment for COVID-19 symptoms. The clinical record for Resident #4 indicated he had his temperature checked daily on the following dates: *4/6/20-97.0 degrees F (Fahrenheit); *4/5/20-98.2 degrees F: *3/18/20-98.6 degrees F; and *3/17/20- 97.7 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #4. The clinical record from 3/15/20- 4/15/20 indicated Resident #5 had no assessment for COVID-19 symptoms. The clinical record For Resident #5 indicated she had her temperature checked daily on the following dates: *4/6/20-97.6 degrees F (Fahrenheit); *4/5/20-97.1 degrees F: *3/18/20-96.8 degrees F; and *3/17/20- 97.8 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #5. The clinical record from 3/15/20- 4/15/20 indicated Resident #6 had no assessment for COVID-19 symptoms. The clinical record For Resident #6 indicated she had her temperature checked daily on the following dates: *4/6/20-98.0 degrees F (Fahrenheit); *4/5/20-97.9 degrees F: *4/4/20-97.0 degrees F; *3/18/20-97.9 degrees F; and *3/17/20- 97.6 degrees F. There were no other dates between 3/15/20 and 4/15/20 documenting temperatures for Resident #6. The COVID 19 Monitoring Tool, dated 4/6/20 indicated all residents were screened for COVID-19 signs and symptoms, including temperature checks on 4/6/20 on the 6am-2pm shift. The facility was unable to provide COVID-19 assessment documentation past this date. During an interview on 4/15/20 at 1:25 p.m., CNA E said the nurses took the residents' vital signs. She said she was not sure if CMAs took resident temperatures. During an interview on 4/15/20 at 1:30 p.m., LVN A said residents were not being screened daily for COVID-19 signs and symptoms. LVN A said temperatures of all residents were not being taken daily. LVN A said some residents had a daily temperature check and a respiratory assessment if they were receiving skilled nursing services or in a period of follow up related to illness/new medication. LVN A said until approximately a week ago, all residents' temperatures and respiratory status were being screened daily. She said she was not sure why residents were no longer being assessed daily for fever and COVID-19 signs and symptoms. LVN A said nurses were responsible for obtaining the residents' vital signs. During an interview on 4/15/20 at 1:35 p.m., RN B said she assessed the residents she was assigned for signs and symptoms of COVID-19 daily but had not been documenting her assessments. She said temperatures of all the residents were not obtained daily. RN B said approximately a week ago all residents were assessed for COVID-19 signs and symptoms with temperature checks daily. She said currently, resident temperatures were not checked daily unless the resident was on skilled nursing services, a follow-up, or a new admission. RN B said new admissions received a daily COVID-19 assessment, including temperature check, for three days. She said she was not sure why they were no longer assessing residents for COVID-19 signs and symptoms with daily temperature checks. RN B said 5 of 67 residents were receiving skilled nursing services. During an interview on 4/15/20 at 2:00 p.m., CMA G said nurses took the vital signs of the residents. CMA G said she did not take residents' temperatures. During an interview on 4/15/20 at 2:05 p.m., ADON D said she had been employed at the facility since 3/30/20 but started as an ADON on 4/15/20. She said the facility assessed for COVID-19 signs and symptoms, including temperature checks on all the residents until approximately a week ago. ADON D said she believed the cessation of the daily COVID-19 screenings occurred due to a lack of communication. During an interview on 4/15/20 at 2:08 p.m., ADON C said she started her new position as ADON on 4/13/20. She said she was not aware how often assessments for COVID-19, including temperature checks were performed. She said she believed it was a daily assessment until recently. ADON C said she did not know why the daily COVID-19 screenings ceased. During an interview on 4/15/20 at 2:10 p.m., the DON said she started her position on 4/13/20 but worked at the facility prior to becoming the DON. She said residents were assessed daily for COVID-19 signs and symptoms, including temperature checks until about a week ago. The DON said she was not sure why the daily COVID-19 assessments stopped. She said she believed there was a breakdown in communication which caused the cessation of daily COVID-19 assessments/temperature checks. The DON said 10 residents continued to receive daily temperature checks and respiratory assessments because they were on follow-up or received skilled nursing services. During an interview on 4/15/20 at 2:12 p.m., the administrator said the nurses should perform daily assessments for COVID-19 signs and symptoms, including temperature checks for all residents. The CMS guidance titled COVID-19 Long-Term Care Facility Guidance, dated 4/2/20 stated . (3) Long-term care facilities should immediately implement symptom screening for all .In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day. The CDC publication titled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes accessed on 4/15/20 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html, stated, .Things Facilities should do now . Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (temperature of 100.0 degrees Fahrenheit) and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, muscle aches). If positive for fever or symptoms, implement Transmission-Based Precautions . The facility policy, revised on 3/16/20, titled Infection Control Guidelines COVID-19 stated .all residents will have a COVID-19 evaluation completed daily which includes temperature, cough, sore throat, vomiting, diarrhea, headache, shortness of breath. If there is a COVID-a9 event the Infection Control Monitoring will increase to every shift or as indicated . The administrator and DON were notified on 4/15/20 at 4:40 p.m., an immediate jeopardy situation had been identified due to the above failures. The IJ template was provided to the administrator. The facility's Plan of Removal was accepted on 4/15/20 at 7:00 p.m. and stated: Immediate action(s) taken for the resident(s) found to have been affected include: *On 4/15/20 the DON and designees began screening all 67 resident that currently reside in the facility. *Today 4/15/2020 the administrator/designee started in service education to all license nurses regarding daily monitoring of all resident for COVID-19 symptoms using the Infection Control monitoring tool. This education will start today 4/15/2020 and be completed today 4/15/2020 and any licensed nurse will not be allowed to work until this education has been completed. *The medical director was notified of immediate jeopardy *Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4-16-2020 1. Identification of other residents having the potential to be affected was accomplished by *All residents were assessed today 4/15/2020 by DON/licensed Designee taking temperature, assessing for sore throat, cough and shortness of breath. Any resident with any temperature, sore throat, cough or shortness of breath will have physician notification. No resident found with any COVID-19 Symptoms 2. Actions to Prevent Occurrence/Recurrence *The following actions were taken to ensure occurrence or reoccurrence of process/system failure that could lead to serious adverse outcome and when those actions were completed. *In service education will continue daily to all licensed nurses until all have received this education *Notebooks will be set up for each nurse with the Infection Control Monitoring Form where nurses will assess residents daily and documented in PCC. *DON/Designee will review the Infection Control Monitoring book for each assessment and documentation daily. *This system will be reviewed in QAPI meeting to include the medical director and will be conducted on 4/16/2020 to discuss sustaining compliance. The investigator confirmed the plan of removal had been implemented sufficiently to remove the immediate threat by: The facilities COVID-19 screening books (one for North/West halls and one for South/East Halls) were reviewed. The COVID-19 screening tool indicated all residents had temperature checks and were asked about/assessed for the following signs and symptoms; sore throat; shortness of breath; cough; vomiting; diarrhea; and headache. The COVID-19 screening tool was completed for 4/15/20 and 4/16/20 on all residents in the facility. The facility in-service sign in sheet over the COVID-19 monitoring tool dated 4/16/20 indicated 4 nurses on the 6am-2pm shift received instruction over daily COVID-19 assessment including temperature checks and documenting on the COVID-19 monitoring tool in the COVID-19 screening books. The facility in-service sign in sheet over the COVID-19 monitoring tool dated 4/15/20 indicated 2 nurses on the 10pm-6am shift received instruction over daily COVID-19 assessment including temperature checks and documenting on the COVID-19 monitoring tool in the COVID-19 screening books. The facility in-service sign in sheet over the COVID-19 monitoring tool dated 4/15/20 indicated 5 nurses on received instruction over daily COVID-19 assessment including temperature checks and documenting on the COVID-19 monitoring tool in the COVID-19 screening books. The facility in-service sign in sheet over the COVID-19 monitoring tool dated 4/15/20 indicated 4 nurses received instruction over daily COVID-19 assessment including temperature checks and documenting on the COVID-19 monitoring tool in the COVID-19 screening books. Out of the facilities 22 floor nurses 15 had completed the in-service over the COVID-19 daily screening requirements. Nine nurses were interviewed and indicated they received the in-service before the start of their shifts (2 staff nurses on the 6am-2pm shift, 2 staff nurses on the 2-10pm shift,1 nurse on the 10pm-6am shift, 2 ADONs, the treatment nurse and the DON). They said they were to assess all residents daily for fever, cough, sore throat, shortness of breath vomiting, diarrhea and headache. They said they were to document the findings on the COVID-19 monitoring tool. Two CNAs and 1 CMA were interviewed. They said if a resident were experiencing possible COVID-19 signs and symptoms such as; cough; sore throat; shortness of breath; vomiting; diarrhea; and headache, they would report it to a nurse. Six residents were interviewed and indicated staff had asked them if they were experiencing any signs and symptoms of COVID-19 and checked their temperature on 4/15/20, as well as 4/16/20. During an interview on 4/16/20 at 2:30 p.m., the DON said no nurse would be allowed to start their shift until they were in-serviced over the COVID-19 monitoring requirements and documentation. During an interview on 4/16/20 at 2:30 p.m., the administrator said no nurse would be allowed to start their shift until they were in-serviced over the COVID-19 monitoring requirements and documentation. The facility held a QAPI meeting on 4/16/20 at 9:15 a.m. to address further implementation of corrective actions. The administrator was notified the Immediate Jeopardy was lifted on 4/16/20 at 4:15 p.m., however the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope identified as a pattern, due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure the environment remained free of accident hazards for 1 (Resident #1) of 6 residents reviewed for accidents and adequate supervision was provided for 1 of 6 residents reviewed for elopement. (Resident # 2) The facility did not keep the floor free from water. Resident #1 slipped in a puddle of water and fractured her right wrist. The facility did not prevent Resident #2 from eloping from the facility. The Resident was found walking along a busy highway. This failure could place residents at risk of injury or death. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, and was admitted [DATE] with [DIAGNOSES REDACTED]. A fall assessment dated (MONTH) 2019 indicated Resident #1 was a low risk for falls. A care plan dated 7/18/19 and updated on 9/23/19 indicated Resident #1 was at risk for falls due to poor safety awareness and interventions included to educate the resident about safety reminders and what to do if a fall occurred. The interventions included to ensure the resident was wearing appropriate footwear when ambulating and to perform a fall risk assessment quarterly to identify risk factors. The interventions were updated on 9/23/19 to include a referral to therapy for pain control, orthopedic appointment on 9/30/19, observe floors for spills/clutter and to administer pain medications as ordered. The most recent MDS dated [DATE] indicated Resident #1 was understood and understood others and her cognition was intact. The MDS indicated she was independent with all ADLs and required supervision for bathing. The assessment indicated she was independently ambulatory without an assistive device and she had no falls since her last quarterly assessment. The MDS indicated Resident #1 had no presence of pain during the 5 day lookback period. An incident report dated 9/23/19 at 3:15 p.m., indicated Resident #1 was walking from the dining room and her left foot hit a puddle of water and she slid to the floor. The incident report indicated she had pain in her right wrist and left knee. The report indicated the physician was notified and the resident was treated in the facility. A communication note dated 9/23/19 indicated a fax was sent to the physician at 3:25 p.m. and indicated Resident #1 fell and complained of pain in her right wrist and left knee. The communication note was returned to the facility at 6:38 p.m., with a response from the physician to obtain an x-ray of left knee and right wrist. A mobile radiology report dated 9/23/19 at 8:07 p.m., indicated Resident #1 had a mildly displaced acute triquetral (a small bone in the wrist) [MEDICAL CONDITION] wrist. A physician order [REDACTED].#1 was to see her medical doctor on 9/24/19, apply ice to her right wrist as needed and administer Tylenol 3 (pain medication with [MEDICATION NAME]) as needed every 4 hours for pain. A MAR indicated [REDACTED] A provider investigation report dated 9/24/19 at 6:29 p.m. indicated Resident #1 fell on [DATE] at 3:15 p.m. The report indicated the next resident council meeting would include instruction to the residents to allow staff to refill their drinks and the staff would be re-trained on safety precautions. A physician order [REDACTED]. The in-service report for the most recent 3 months received on 10/2/19 indicated staff had not completed training on safety or fall precautions after Resident #1's fall on 9/23/19. Staff on line training for fall precautions was scheduled on 10/2/19 after surveyor entrance. During an observation and interview on 10/2/19 at 9:04 a.m., Resident #1 had a cast on her right hand from her finger tips to mid arm. She said the cast was placed at her orthopedic appointment on 9/30/19. Resident #1 said on 9/23/19 at approximately 3:15 p.m., she slipped in a puddle of water while walking from the dining room. She said she always looked down on the floor when walking in the hallway because she had seen water on the floor in the past. Resident #1 said the puddle of water was in front of the nursing station where the nurse's cart was parked. She said the water was shadowed by the cart and she did not see the puddle. Resident #1 said there were no staff or residents present when she fell . Resident #1 said she immediately complained of pain in her left knee and right wrist. She said when she returned to her room, she complained of increasing pain in her right wrist and left knee and requested an x-ray because she knew something was broken. Resident #1 said LVN A told her she would call the physician. Resident #1 said it was after her evening meal on 9/23/19 when the mobile x-ray arrived. The resident said she was told the first available appointment with the orthopedic specialist was on 9/30/19. Resident #1 said her sister brought her a wrist brace on 9/24/19 and it helped to alleviate her pain. During an interview on 10/3/19 at 11:04 a.m., LVN A said on 9/23/19 at approximately 3:15 p.m., she came out of the medication room and saw Resident #1 on the floor. She said the resident was complaining of pain in her right wrist and left knee. LVN A said there was water on the floor and the resident's bottom and the back of her shirt was soaked with water. LVN A said she did not know how the water got on the floor and she did not see the water prior to going in the medication room. LVN A said she received an order for [REDACTED]. LVN A said she had not received any new training or instructions on fall precautions since Resident #1's fall. During an interview on 10/2/19 at 10:04 a.m., CNA J said Resident #1 did not have any cognitive deficits and was able to make her needs known. CNA J said she dried water on the floors in the halls frequently but did not know where the water came from. CNA J said she was not present when Resident #1 fell , and she had not received any training or instructions on fall precautions and prevention or safety measures since the resident fell . During an interview on 10/2/19 at 10:53 a.m., CNA C said she was not present when Resident #1 fell . She said she had not received any training or instructions on fall precautions or prevention since Resident #1's fall. She said she occasionally saw water in the floor but was not sure where the water came from. CNA C said when it rained the ceiling leaked and the staff placed buckets under the leak to prevent water on the floor. During an interview on 10/2/19 at 11:18 a.m., CNA D said she was not sure how Resident #1 fell and broke her wrist. She said she had not received any instructions or training on fall precautions or prevention since Resident #1's fall. During an interview on 10/2/19 at 12:43 p.m., CNA H said Resident #1 told her she slipped in a puddle of water and fell . She said the resident was upset about it and said she was sore after it happened. CNA H said she had not received any instruction on fall precautions or prevention since Resident #1's fall. During an interview on 10/2/19 at 1:49 p.m., CNA G said Resident #1 slipped in a puddle of water and fell . She said she did not witness the fall and she had not received any instruction on fall precautions or prevention since the incident. CNA G said the resident told her she usually watched for water on the floor and did not see the puddle until she slipped. During an interview on 10/3/19 at 1:37 p.m., the DON said an in-service on safety hazards should have been completed immediately after Resident #1's fall. She said the water in the floor may have been from residents getting their own ice. During an interview on 10/3/19 at 1:51 p.m., the administrator said she was not aware of Resident #1's fracture until 9/24/19. The administrator said the staff training for fall precautions/prevention had not been scheduled until 10/2/19 and the resident council had not met for (MONTH) 2019 to date. She said the roof leaked in the past and they were in the process of getting it fixed. She said the water in the floor may have been from melted ice. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An elopement/wandering assessment tool dated 1/11/19 indicated Resident #2 was scored as a low risk for elopement. An elopement/assessment tool dated 7/21/19 (day of elopement) indicated Resident #2 was a moderate risk for elopement. Nursing notes dated 7/21/19 for Resident #2 did not include an entry of the resident's elopement or his condition upon return to the facility. A nursing note dated 7/22/19 at 9:30 p.m., indicated Resident #2 had a wander guard bracelet placed on him by the administrator due to wandering. The note indicated Resident #2's brother was notified of the device placement. A care plan titled unsafe wandering/exit seeking dated 7/23/19 indicated Resident #2 was at risk for leaving unsupervised as evidenced by wanting to go to the store. The interventions included to monitor the resident for tailgating when visitors were in the building, use audible monitoring system to alert staff of exit seeking behaviors and to check the audible alarm system every shift and as needed. A witness statement dated 7/23/19 provided by the dietary supervisor (now former employee) indicated Resident #2 ate lunch in the dining room at approximately 12:35 p.m., to 1:00 p.m. 7/21/19. The statement indicated she received a phone call from a dietary aide at approximately 1:15 p.m. who said Resident #2 was walking alongside the highway down from the facility. The statement indicated the dietary supervisor left immediately and brought the resident back to the facility in her personal car. Her statement said she asked the resident where he was going, and he said he was walking to the store. A nursing note dated 7/24/19 at 8:22 a.m., indicated a late entry for 7/21/19. The note indicated Resident #2 was found wandering outside the facility walking towards the hospital. The note indicated the resident was picked up by staff in a private car and brought back to the facility and there were no signs or symptoms of distress or injury. The nursing note entry was initialed by LVN [NAME] An incident report dated 7/24/19 indicated Resident #2 eloped outside the facility and was found wandering down the road on 7/21/19 at 1:00 p.m. The report indicated Resident #2's responsible party was notified on 7/22/19 at 9:30 p.m., and his physician was notified on 7/24/19 at 8:18 a.m. A witness statement dated 7/24/19 provided by LVN A indicated she was alerted on 7/21/19 Resident #2 was walking down the street and was going to be picked up and brought back to the facility by the dietary supervisor. The statement indicated the ADON instructed LVN A to notify the administrator and complete an elopement sheet. During an interview on 10/3/19 at 11:04 a.m., LVN A said she was working on 7/21/19 when Resident #2 eloped from the facility. LVN A said at approximately 1:20 p.m., the ADON told her Resident #2 was walking down the side of the highway. She said the ADON told her he was not to leave the facility without signing himself out. She said another staff member brought the resident back in her personal car. LVN A said she could not remember if she assessed Resident #2 when he returned. LVN A said she could not remember if Resident #2 was placed on 1:1 supervision after his return to the facility. She said she did not consider him a wandering/elopement risk at the time of his return. She said she was not sure if Resident #1 had a wander guard placed on his ankle on 7/21/19. LVN A said Resident #2 had not left the faciity on his own before 7/21/19 and sat outside on the porch daily with other residents prior to this incident. LVN A said since Resident #2's elopement staff were not to give the exit door code to residents and Resident #2 was not to go outside unsupervised. An observation on 10/3/19 at 8:10 a.m., at the described location (in front of the hospital) of where Resident #2 was found indicated he was approximately 250 yards from the facility on a busy two lane farm to market highway with a speed limit of 50 MPH. An elopement/assessment tool dated 7/24/19 indicated Resident #2 was a high risk for elopement. The most recent MDS dated [DATE] indicated Resident #2 was usually understood, usually understood others with severely impaired cognition. The MDS indicated Resident #1 had wandering behavior 1 to 3 days during the 7-day look-back period. The MDS indicated Resident #2 was independent with all ADL's, required supervision when bathing and was always continent of bowel and bladder. The MDS indicated Resident #2 was not steady, but able to stabilize without staff assistance when walking. A care plan dated 8/1/19 indicated Resident #2 was at risk for wandering as evidenced by being ambulatory with a [DIAGNOSES REDACTED]. The care plan indicated he had impaired cognition and impaired vision and was at risk for falls, injury and decline in functional ability. The interventions included to ensure his glasses were labeled and within reach, announce yourself as you enter an area to interact and ensure the call light was within reach. During an observation and interview on 10/3/19 at 12:50 p.m., Resident #2 was ambulating in the hall and a wander guard bracelet was on his right ankle. He said he could leave the facility anytime he wanted, and he was not worried about getting hit by a car because he knew better than to walk in front of a moving vehicle. The resident was confused as to why he was in the facility and said he could go home anytime he wanted. During an interview on 10/3/19 at 1:27 p.m., the ADON said on 7/21/19 she was working as an aide on the floor and was told by kitchen staff Resident #2 was walking towards the main highway down from the facility. She said the dietary supervisor went to pick him up and return him to the facility. The ADON said she told LVN A who was the charge nurse to complete the elopement form and notify the administrator. The ADON said she did not follow up on the instructions given to LVN [NAME] She said she was not aware if he Resident #2 was placed on 1:1 supervision after his return to the facility. The ADON said Resident #2 had no history of exit seeking and had not left the facility prior to this incident. During an interview on 10/2/19 at 10:04 a.m., CNA J said she was not present when Resident #2 eloped. She said he now had a wander guard on his ankle and was not allowed to have the exit door code. CNA J said Resident #2 was confused and would not be safe leaving the facility without assistance because he had no safety awareness. During an interview on 10/2/19 at 10:53 a.m., CNA C said did not know if Resident #2 wore a wander guard, but she knew not to give him the exit door code. During an interview on 10/2/19 at 11:18 a.m., CNA D said Resident #2 wore a wander guard on his ankle and was not to be provided with the code to the exit door. During an interview on 10/2/19 at 12:43 p.m., CNA H said she did not work at the facility in (MONTH) 2019 when Resident #2 eloped. She said the residents were not to have the exit code and Resident #2 wore a wander guard because he was at risk for leaving the facility. During an interview on 10/2/19 at 1:49 p.m., CNA G said Resident #2 was at risk for elopement and wore a wander guard. During an interview on 10/3/19 at 1:37 p.m., the DON said after Resident #2's elopement on 7/21/19 staff were informed not to give the exit door code to residents. She said when Resident #2 went outside he was supervised by staff and had a wander guard in place to alert staff if he were to follow someone out the door. An in-service dated 9/24/19 indicated staff were instructed Resident #2 required supervision when exiting the facility and to not give the resident the door code. During an interview on 10/3/19 at 10:50 a.m., the administrator said Resident #2 left the faciity on [DATE]. She said kitchen staff reported to the dietary supervisor he was walking down the highway towards the main highway. She said the dietary supervisor reported to the ADON and left in her personal car to bring Resident #2 back to the facility. The administrator said after a call with corporate on 7/22/19 to discuss the elopement it was decided Resident #2 was safe to leave the facility. The administrator said later (1 to 2 days), it was determined he was not safe to leave the facility and a wander guard was placed on him and the code on the exit door was changed. The administrator said she told corporate during the call on 7/22/19 that she did not consider Resident #2 to be safe. She said corporate called her back and told her to go ahead with a wander guard, change the code and complete the in-services. She said staff were in-serviced on 9/24/19 to supervise Resident #2 when he goes outside and to not give him the door code. She said Resident #2 had not attempted to exit the facility again. During an interview on 10/3/19 at 1:51 p.m., the administrator said Resident #2 simply did not check himself out before he left the facility to go to the store on 7/21/19. The administrator said Resident #2 was not aware of safety precautions and he was unsafe to walk to the store without supervision. The administrator said staff were in-serviced on 7/24/19 to not give the door coed to residents and Resident #2 must be supervised when outside the building. A Missing Patient Guideline dated 9/14/13 indicated . actions when patient is located . examine patient and record findings in the chart .notify family, police, admitting physician and state licensing agency . place the patient on 1:1 observation to prevent further wandering, and the care plan can be reviewed/ revised . Once the patient is located .monitor behavior, plan general and specific interventions to prevent future incidents, communicate interventions to staff .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent injury for 1 of 3 residents reviewed for accidents. (Resident #1) The facility did not provide adequate supervision for Resident #1 while providing care. CNA A was dressing Resident #1 after providing incontinent care, and the resident rolled off the bed onto the floor, resulting in fractures to his right shoulder and knee, and abrasion to his head. This failure could place 8 residents requiring assistance for toileting and 24 residents who were dependent for dressing at risk for injury, hospitalization , pain and decreased quality of life. Findings included: Consolidated physician's orders [REDACTED].# 1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood. The MDS indicated he required extensive assistance of 2 staff for bed mobility, dressing, toileting and hygiene. The MDS indicated he was 5 feet tall and weighed 241 pounds. A care plan dated 4/2/18 indicated Resident #1 had cognitive impairment related to his [DIAGNOSES REDACTED]. The care plan indicated he required total assistance with dressing and hygiene. A nursing note dated 5/31/18 at 11:45 a.m. indicated Resident #1 was rolled over during incontinent care and rolled out of bed onto the floor. A superficial abrasion was noted to his forehead and he complained of severe shoulder and arm pain. An ambulance was called for transfer to the emergency room . A nursing note dated 6/1/18 at 8:00 p.m. indicated Resident #1 returned to the facility with his right arm in a sling and his right leg in an immobilizer. An incident/accident report dated 5/31/18 at 11:45 a.m. indicated CNA rolled Resident #1 out of bed and on to the floor while she was providing patient care. The incident/accident report indicated Resident #1 had an abrasion to his mid forehead and complained of severe pain to his right shoulder and arm. The incident report contained a witness statement from CNA A that indicated she was providing care and rolled Resident #1 away from her and he rolled out of the bed onto the floor. An Interdisciplinary post-fall assessment dated [DATE] indicated CNA A was providing care and rolled the resident away from her, causing the resident to roll off the bed. Hospital emergency department provider notes dated 5/31/18 indicated Resident #1 presented to the ER after a fall from his bed. The resident was found to have a distal femur fracture and humeral head fracture. He was placed in a knee immobilizer and arm sling and referred to the orthopedic. A shoulder x-ray report dated 5/31/18 indicated Resident #1 had a right humerus fracture that was not significantly displaced or angulated. A right knee x-ray report dated 5/31/18 indicated Resident #1 had a displaced femoral fracture. During an observation on 6/20/18 at 9:00 a.m., Resident #1 was lying in bed in his room. He had a sling on his right arm and his leg was in an immobilizer. He was in a bariatric bed. Resident #1 was unable to be interviewed. During an interview on 6/20/18 at 9:23 a.m., Resident #1's wife said she received a call from the hospital on [DATE] asking permission to treat her husband. She said the hospital told her Resident #1 had fallen out of bed while an aide was cleaning him up and he had broken his arm and knee. She said she later got a call from the DON and was told CNA A was getting him up and he reached across the bed to grab some orange juice and he fell . Resident #1's wife said Resident #1 was a very large man and he was in a small bed. She said one person should not have been providing care alone. She said Resident #1 had dementia and would answer simple questions. She said he could not carry on a conversation. She said the facility now had him in a big bed. During an interview on 6/20/18 at 10:36 a.m., CNA A said she had just finished providing incontinent care to Resident #1 and was getting him dressed. She said she was providing care to Resident #1 by herself. CNA A said she normally provided incontinent care and dressed Resident #1 by herself. CNA A said she rolled Resident #1 away from her to pull up his sweatpants. She said she was standing by the wall on his right side. She said she rolled him on his left side. She said he reached for a glass of orange juice and fell out of bed. CNA A said she went to the door and yelled for help. CNA A said they used the mechanical lift and assisted Resident #1 into his wheelchair. CNA A said Resident #1 did not assist in care. She said he did not help by rolling himself on his side at all. She said he could put his arms through his shirt and that was all. During an interview on 6/20/18 at 11:24 a.m., CNA B said Resident #1 could not make his needs known. She said they got him out of bed daily using the mechanical lift. CNA B said some of the aides could provide his care without assistance, but she always got help. She said Resident #1 was a big man and too heavy to provide care for without assistance. She said Resident #1 did not help roll himself to his side at all. She said they must do everything for him. She said she felt it was unsafe to provide care to Resident #1 with only 1 person. During an interview on 6/20/18 at 11:51 a.m., CNA C said Resident #1 was a 2 person assist and required a Hoyer lift for transfers before the fall. She said it was possible one person could provide care for him by themselves if he was in the center of the bed. CNA C said she did not think it was safe to provide care to Resident #1 with only one person. She said Resident #1 would not help roll at all. She said Resident #1 required 2 persons for assistance for all care except eating now, with no exceptions. During an interview on 6/20/18 at 12:01 p.m., Nurse Aide D said Resident #1 was totally dependent on staff for ADLs. She said he had always been a 2 person assist for incontinent care and dressing. She said he was not able to assist with care. During an interview on 6/20/18 at 12:05 p.m., Nurse Aide E said Resident #1 was totally dependent on staff for ADLs. She said Resident #1 required 2 people to provide care. She said he had required 2 staff for assistance before his fall as well. She said Resident #1 was too large to provide care safely with only 1 person. During an interview on 6/20/18 at 12:10 p.m., CNA F said Resident #1 had always been a 2 person assist for turning, dressing and changing. She said he was too large to do by herself. CNA F said Resident #1 could not make his needs known and he did not assist at all with care. During an interview on 6/20/18 at 12:22 p.m., RN G said Resident #1 could not make his needs known. She said Resident #1 was a 2 person assist for incontinent care and dressing even before the fall. She said Resident #1 was not safe to provide care with only 1 person. During an interview on 6/20/18 at 12:38 p.m., LVN H said Resident #1 required total care and was bed and wheelchair bound. LVN E said Resident #1 would answer simple questions. She said it was not safe to provide care with just one person for Resident #1. During an interview on 6/20/18 at 12:46 p.m., LVN J said she worked the day Resident #1 fell from his bed. She said Resident #1 was lying on his back in the floor when she went into his room. She said the bed was in the highest position. She said she assessed him and the only visible injury she saw was a superficial scrape to his forehead. She said they used the mechanical lift and put him in his high back wheelchair that reclined. She said Resident #1 complained of pain to his shoulder and arm. She said he could not raise his arm and was supporting it with his other arm. She said she notified the physician and sent Resident #1 to the hospital for evaluation. LVN J said CNA A had told her she was rolling Resident #1 away from her and he reached for a glass of orange juice and just rolled off the bed. LVN J said Resident #1 was a 2 person assist. She said she did not know why CNA A was doing incontinent care or attempting to roll him by herself. She said Resident #1 was a large man and it was not safe to provide care for him with only one person. During an interview on 6/20/18 at 12:59 p.m., Restorative aide K said one person could possibly provide care to Resident #1 if he was in the center of the bed. However, it would take 3 people to pull Resident #1 into the center of the bed. Restorative aide K said Resident #1 needed 2 people to provide care safely. He said Resident #1 would not assist with care and could not make his needs known. During an interview on 6/20/18 at 1:08 p.m., the DON said she was not working when the incident happened. She said Resident #1 sustained a fracture to his right shoulder and right femur. She said CNA A was dressing Resident #1 and rolled him away from her. She said he reached for a glass on the bed side table and rolled onto the floor. She said a risk event call was made to corporate. She said staff were in-serviced immediately. She said according to Resident #1's care plan he was a total assist for dressing. She said total assist did not necessarily mean 2 people were assisting. She said staff were interviewed and said they had always safely provided care with just one person. She said she was not sure why the MDS said Resident #1 required extensive assist of 2 persons and the care plan indicated he was a total assist. During an interview on 6/20/18 at 1:40 p.m., The MDS nurse said she was responsible for the MDS and the care plans. She said she got her information from the care tracker to input into the MDS. She said total assistance could mean one person or two. She said it would depend on the resident. She said she was not sure why Resident #1's care plan was not specific to the number of staff required to provide assistance with his dressing. She said she guessed it was just an oversight. During an interview on 6/20/18 at 2:00 p.m., the administrator said CNA A was providing care to Resident #1. She said she had changed his brief and was attempting to pull up his pants. She said CNA A rolled Resident #1 onto his side and he reached for a glass of orange juice and rolled off the bed. She said the charge nurse had assessed him and sent him to the hospital for further evaluation. She said she suspended CNA A immediately. She said she talked to other staff and 50% of the staff said they would have provided the care the same way. The administrator said she believed they had followed the protocol. She said they felt CNA A did not cause the fall. They felt reaching for the glass of orange juice caused Resident #1 to fall. She said CNA A was allowed to return to work. Staff were in-serviced on fall prevention. She said an audit was done on the larger residents and other residents received the larger bariatric beds as well to prevent this from happening again. The CMS 672 dated 6/20/18 indicated 8 residents required assistance for toileting and 24 residents were dependent for dressing.

Based on observation, interview and record review, the facility failed to provide appropriate services for the attainment of the highest practicable mental and psychosocial well-being, for 1 of 9 residents reviewed for psychosocial difficulties (Resident #1). The facility did not notify Resident #1's physician of a psych services recommendation for an antidepressant. The resident reported [MEDICAL CONDITION] with a plan to overdose. The facility did not complete an accurate assessment of Resident #1's mood and psychosocial state and did not provide activities to improve and maintain Resident #1's maximum mental and psychosocial functioning. The facility did not develop a care plan to address Resident #1's depression and suicidal ideation and did not educate staff regarding residents with suicidal tendencies. This failure could place the 18 residents with symptoms of depression at risk of not having their mental or psychosocial needs addressed and having a decreased quality of life. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 usually understood others and was sometimes understood. The MDS indicated Resident #1 required extensive assistance of two persons with transfers and toileting. Resident #1 was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 enjoyed listening to music, being around animals, and doing things with groups of people. The MDS section for Mood was not completed. A previous MDS dated [DATE] for Resident #1 indicated the section for Mood was not completed. The most recent care plan dated 10/18/16 indicated Resident #1 had impaired cognitive function related to memory loss, impaired decision making, and head injury. The care plan indicated Resident #1 was dependent on all staff for activities, cognitive stimulation and social interaction related to his immobility and cognitive deficits. The care plan indicated Resident #1 had a communication problem related to his head injury. There was no care plan for depression or psychosocial well-being available. There was no care plan or treatment plan for depression or suicidal ideation. During observations on 2/20/17 at: 9:26 a.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared to be asleep. 10:10 a.m. - Resident #1 was lying in bed, the room was dimly lit, his were eyes closed, and he appeared to be asleep. 10:46 a.m. - Resident #1 was semi erect in bed, the room was dimly lit, and he was easily awakened. 12:02 p.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared to be asleep. 2:19 p.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared asleep. 3:42 p.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared asleep. During observations on 2/21/17 at: 9:00 a.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared asleep. 11:22 a.m. - Resident #1 was lying in bed, the room was dimly lit, his eyes were closed, and he appeared asleep. 12:15 p.m. - Resident #1 was lying in bed, the room was dimly lit. He was easily awakened. 2:31 p.m. - Resident #1 was lying in bed, the room was dimly lit, eyes were closed, and he appeared asleep. During an observation and interview on 2/20/17 at 10:46 a.m., Resident #1 was sitting semi erect in the bed. The lighting in the room was dim. Resident #1's eyes were closed but he was easily aroused. When asked how he was doing, Resident #1 said hurt. When asked where he hurt, he said, stomach. Resident #1 was asked if he felt sad or depressed and he said yes. Resident #1 was asked if he had thoughts of hurting himself and he said yes. When asked how often he had these thoughts, he said every single day. When Resident #1 was asked if he had a plan to hurt himself, and if he could share the plan, he said pills. During an observation and interview on 2/21/17 at 12:15 p.m., Resident #1 was lying in bed with his eyes closed. The room was dimly lit and he appeared to be sleeping, but was easily awakened. Resident #1 said he was still feeling depressed. He said he still had thoughts of wanting to harm himself every single day. When he was asked about a plan Resident #1 closed his eyes and did not respond. He appeared to drift back to sleep. The Behavioral Health Progress Notes dated 2/7/17 indicated Resident #1 was very depressed, isolated, withdrawn, and wanted to kill himself by overdose. It was noted Resident #1 had [MEDICAL CONDITION] since December 2016. It was recommended by the psychologist to add an antidepressant, increase his antipsychotic medications, and place him on one to one supervision. During a telephone interview on 2/21/17 at 12:18 p.m., the Behavioral Health Nurse Practitioner said she tried to see Resident #1 weekly. She said he was often too drowsy and she was unable to assess him. She said she got a good assessment about every 2 to 3 weeks. She said Resident #1 was very depressed and expressed [MEDICAL CONDITION] with a plan to overdose. She said she recommended an antidepressant on 02/07/17 for Resident #1 but it had not been added. An email from the Behavioral Health Nurse Practitioner to the SW dated 2/7/17 indicated Resident #1 was, very depressed. Had a suicidal plan of overdose. Said staff and other people hit him. Paranoid and psychotic. Can we add antidepressant, like [MEDICATION NAME] 50 mg AM? Also can we put him on one to one? Social service notes dated 2/7/17 indicated Resident #1 confirmed with the SW his depression and suicidal ideation. The note indicated he reported having depression since his accident and had been having thoughts of self-harm since that time. The note indicated Resident #1 was told medication adjustments would be looked at to see if it would help and Resident #1 agreed. During a phone interview on 2/21/17 at 11:50 a.m., the Psych Services LVN said she was the interpreter for the Behavioral Health Nurse Practitioner on telehealth (provides mental healthcare remotely by means of telecommunications technology). She said she takes the computer into the resident's room and the Behavioral Health Nurse Practitioner assesses the patient on line. The Psych Services LVN said she helped facilitate this process. She said she and the Behavioral Health Nurse Practitioner saw Resident #1 weekly because they were concerned about his mental well-being. She said he expressed [MEDICAL CONDITION] since December of 2016. She said in February he expressed [MEDICAL CONDITION] by overdose. The Psych Services LVN said Resident #1 was always very sedated in the mornings. She said on 2/7/17 Resident #1 reported he wanted to kill himself by overdosing. She said the Behavioral Health Nurse Practitioner made recommendations, but they were not carried out. The psych services LVN said she was concerned for Resident #1's quality of life because he was only [AGE] years old, in a nursing home, unable to eat, and in bed all day. She said she never saw Resident #1 with an iPod or headphones. During an interview on 2/22/17 at 10:13 a.m., the SW said she received a hand written note from the Psych Services LVN when they saw residents and received an email from the Behavioral Health Nurse Practitioner about recommendations. The SW said she printed out the recommendation and put it in the NP's book. She said she did not know how Resident #1's recommendation for an antidepressant got missed. She said she did not know why Resident #1 did not have a care plan for depression or self-harm. The SW said she was responsible for completing the Mood portion of the MDS. She said she didn't completely fill out the section because Resident #1 was difficult to assess. Behavioral Health visit summaries on: 2/21/17 - pleasant affect. Feeling more depressed 2/14/17 - resident sleeping 2/7/17 - depression continues; continued [MEDICAL CONDITION] 1/10/17 - sick 12/30/16 - feeling sad and depressed A physician progress notes [REDACTED]. Patient reported he was treated roughly. There is no evidence of physical abuse. He reports he is sorry and appears content. He is medically cleared. During an interview on 2/20/17 at 9:28 a.m., CNA C said Resident #1 rarely got up. She said he stayed in his room in the bed the majority of the time. She said he occasionally sat in the Geri chair. CNA C said Resident #1 usually only answered yes or no questions. She said Resident #1 frequently used profanity when staff were providing care. CNA C said Resident #1 used the headphones to listen to music, but not in the last couple of months. She said he had been spending more time in his room. CNA C said she was aware Resident #1 had made statements about hurting himself. She said she had not been in-serviced on caring for residents at risk for self-harm. During an interview on 2/20/17 at 11:18 a.m., LVN A said Resident #1 stayed in his room a lot. She said he did not participate in activities. She said he did the music memory program but she did not know how often he listened to the music. LVN A said she was aware of Resident #1's suicidal statements but said he had a peg tube so he couldn't overdose on pills. LVN A said Resident #1 was seen by psych services and he was placed on one to one supervision for a couple of days after he made the suicidal comments. She said he was cleared by the medical doctor. She said Resident #1 had not made statements to her about wanting to hurt himself. She said she had not specifically asked him questions about wanting to harm himself because he was followed by psych services. LVN A said she was unaware of a recommendation by psych services to start Resident #1 on an antidepressant. She said Resident #1 was not currently taking medication for depression. During an interview on 2/20/17 at 11:46 a.m., the DON said Resident #1 made suicidal statements on 2/7/17. She said he was placed on one to one supervision for 2 days until the medical doctor cleared him. She said Resident #1 was seen by psych services once a week. She said she was not aware of the recommendation for an antidepressant to be added for Resident #1. The DON said staff had been in serviced on abuse and neglect after Resident #1 made the suicidal statements but no in-service was provided specifically for residents at risk for self-harm. During an interview on 2/20/17 at 2:57 p.m., the social worker (SW) said Resident #1 had suffered head trauma. She said he was tube fed and did not receive any food or drink by mouth. She said Resident #1 was seldom happy. She said he did not enjoy socializing with the older residents and did not participate in activities. The SW said he liked to watch TV and listen to music. The SW said he was unable to carry on reliable conversations and often used profanity. The SW said Resident #1 was depressed and was seen by psych services. She said she did not know if the recommendation for the antidepressant had been added. She said Resident #1 was put on one to one supervision after making suicidal statements. She said he was unlikely to harm himself because he couldn't get his hands on medications. The SW said Resident #1 was cleared by the medical doctor and was being encouraged to come out of his room more. She said the staff had talked about having another swallow study performed to see if he could receive pleasure feedings. During an interview on 2/20/17 at 3:15 p.m., the activity director (AD) said Resident #1 received in-room activities. She said she saw the resident every morning. She said Resident #1 participated in the music memory program. She said he had an iPod that was made specifically for him. She said he enjoyed the music. The AD said the iPod and headphones were at the nurses' station and available for any of the staff to give to the resident. She said she did not document daily or weekly in room activities. She said she started out documenting each time the residents signed the iPod out but it got to be too much. The AD said Resident #1 had never made self-harming statements to her. She said she had not received education specifically geared to residents at risk for self-harm. During an interview on 2/20/17 at 3:48 p.m., CNA D said Resident #1 stayed in his room most of the time. She said he had occasional outbursts and cursed at the staff. She said she had not seen Resident #1 using an iPod or headphones. CNA D said Resident #1 had never made self-harming comments to her. She said she had not received training for residents at risk for self-harm. During an interview on 2/21/17 at 10:22 a.m. the AD said Resident #1's in room activities consisted of socializing, watching television in his room, music memory, and sensory stimulation such as scented hand lotions. She said she only had quarterly documentation. She did not document Resident #1's daily or weekly activities. She said Resident #1 had been sleeping a lot lately. During an interview on 2/21/17 at 10:53 a.m., LVN E said the charge nurse was responsible for making sure orders were carried out. LVN E was unaware of the recommendation for an antidepressant to be added for Resident #1. She said the charge nurse should have taken care of it. She said she was unsure how the recommendation got missed. LVN E said Resident #1 stayed in his room most of the time. She said he did not participate in activities. She said she believed he was on the music memory program but was not sure how often he participated. LVN E said she was not aware Resident #1 did not have a care plan for depression or self-harm. She said he should have been care planned for depression. During an interview on 2/21/17 at 11:12 a.m., the ADON said Resident #1 reported wanting to harm himself on 2/7/17. She said he was placed on one to one supervision until 2/9/17. The ADON said the medical doctor cleared him on 2/9/17. She said one to one supervision means that a staff member is with the resident at all times. The ADON was unaware of the recommendation for an antidepressant to be added for Resident #1. She said whoever received the order should have taken care of it. During an interview on 2/21/17 at 2:00 p.m., Resident #1's guardian said the facility did not notify her of Resident #1's suicidal statements. She said she was not surprised he made those statements because Resident #1 was very depressed and had no quality of life. She said she was unable to visit often but when she did, he was always in his room. She said the facility used to take him to the front by the nursing station but that had stopped. She said Resident #1 loved music but she never saw him with an iPod or headphones on. She said he was doing rehab, but the facility told her it would be better if they stopped the rehab because Resident #1 started to think he was doing better and was falling more often. Resident #1's guardian said she did not believe he was being abused in the facility, but she believed they could do more for him. During an interview on 2/22/17 at 11:30 a.m., the primary physician said he was not made aware of Resident #1's recommendation for an antidepressant until yesterday. He said he was a family physician and would follow the recommendations of psych services. He said he believed Resident #1 needed to go to a behavioral health facility. The physician said he believed the recommendation was misplaced due to human error, but the antidepressant would be added for Resident #1. During an interview on 2/22/17 at 1:55 p.m., the NP said she was made aware of Resident #1's recommendation for an antidepressant yesterday. She said the facility called to inform her and she requested the recommendation and all notes be faxed to her office. She said they normally follow the recommendations of psych services. She said she never told facility staff the medication was not needed. During an interview on 2/22/17 at 9:00 a.m., the DON said the MDS nurse was responsible for care plans. She said care plans were updated every time they had a reportable event. She said Resident #1 should have been care planned for depression and the care plan should have been updated when he made the suicidal statements. During an interview on 2/22/17 at 9:21 a.m., the corporate nurse said she did not know why Resident #1 did not have a care plan for depression. She said she would expect depression to be care planned if there was a diagnosis. During an interview on 2/22/17 at 9:36 a.m., the MDS nurse said Resident #1 was not care planned for depression because he didn't trigger on the MDS. She said she was responsible for doing initial care plans and nursing was responsible for acute care plans. The MDS nurse said she completes the MDS from what she reads and what she sees. She said she knew that Resident #1 cursed frequently and was sometimes sexually inappropriate. She said she did not know he was depressed. The MDS nurse said the SW was responsible for completing the mood section of the MDS. A social service evaluation dated 10/10/16 indicated Resident #1 stayed in his room most of the time and did not attend activities. Social service notes dated 2/7/17 indicated Resident #1 confirmed with the SW his depression and suicidal ideation. The note indicated he reported having depression since his accident and had been having thoughts of self-harm since that time. The note indicated Resident #1 was told medication adjustments would be looked at to see if it would help and Resident #1 agreed. The undated investigation synopsis indicated the allegation of abuse or neglect was unfounded. The resident was seen by psych services, placed on one to one supervision, and head to toe assessment was completed. Nursing notes, MDS, MAR, psych notes, SW notes, and care plan were reviewed. A psychosocial policy dated 4/13/14 indicated .the facility would optimize the quality of life and function of patients that have psychosocial needs that require person centered approaches to meet their psychosocial needs .consider if the environment is supportive and promotes comfort; activities are relevant , cognitively appropriate and focus on patient individualized needs, staff is consistent, and evaluations are completed on new or worsening behaviors .Implement individualized person centered care plans to address psychosocial expressions of distress, monitor and follow up the care plan, adjust interventions as needed . The CMS 672 dated 2/20/17 indicated 18 residents had documented signs and symptoms of depression.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment, to prevent development and worsening of pressure injuries for 1 of 5 residents reviewed for pressure injuries. (Resident #11) The facility did not implement new offloading interventions after Resident #11's facility acquired Stage 2 pressure injury declined to a Stage 4. This failure could place 4 residents with pressure injuries at risk for developing new pressure injuries and a decline in existing pressure injuries. Findings included: Consolidated physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. There was an order for [REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 usually made her needs known and usually understood others. The MDS indicated Resident #11 required extensive assistance with all ADLs. The MDS indicated Resident #11 was at risk of developing pressure injuries, but did not have a pressure injury during the 7 day look back period for this assessment. A care plan with a start date of 1/2/17 for a pressure injury on Resident #11's right ankle was updated weekly (last update 2/14/17). Interventions included: Topical treatment per physician, assess pressure injury weekly, inform physician of change in status, give antibiotic for infected injury, obtain labs, assess nutrition, encourage fluids, protect injury from sheer, pressure or trauma, turn and reposition every two hours, keep clean and dry, suspend heels with pillows, orthotic foot device (Prevalon padded boots intended for pressure relief). An undated entry said, Resident #11 occasionally had [MEDICAL CONDITION] .kept her foot on the wheelchair, attempted to get out of her wheelchair and frequently took her Prevalon boot off. A sonograph (doppler) exam on 12/27/16 indicated no restriction to blood flow in Resident #11's right extremity. A Braden risk scale assessment (for predicting pressure injury) dated 2/9/17 indicated Resident #11 was at a high risk for developing pressure injuries. The weekly pressure injury records for Resident #11's right outer ankle indicated: *1/2/17- Stage 2 measuring 0.6 cm x 0.4 cm x 0.1 cm with serous (clear) drainage. The wound bed was pink with a normal surrounding skin/wound edges. *1/10/17- Stage 3 measuring 0.5 cm x 0.4 cm x 0.1 cm with serous drainage. The wound bed had slough (grey/yellow) with normal surrounding skin/wound edges. *1/31/17-unstageable measuring 0.8 cm x 0.8 cm x 0.1 cm with serous drainage. The wound bed had slough/black brown eschar and the surrounding skin was normal. *2/14/17- (per the wound care physician) Stage 4 measuring 0.7 cm x 0.5 cm x 0.1 cm with serous drainage. The wound bed was brown and the surrounding skin was normal During an observation and interview on 2/20/17 at 7:55 p.m., Resident #11 was lying in bed on a scooped pressure redistribution mattress. Resident #11's family said they were concerned Resident #11's right ankle wound was not improving and was worsening. During an observation and interview on 2/21/17 at 9:25 a.m., CNA F and the treatment nurse transferred Resident #11 to her bed. The treatment nurse removed the dressing to Resident #11's outer right ankle that had an approximate dime size area of clear/bloody drainage. The wound bed was covered with 95% yellow slough, the periwound bed was discolored and white in appearance and the skin surrounding the wound was red in appearance. The treatment nurse measured Resident #11's pressure injury. The opened area was 1.3 cm by 1.2 cm; the circumference of the wound was 3.5 cm by 2.8 cm (this included the white discolored periwound and the unblanchable skin,) red in color surrounding the periwound. She cleaned Resident #11's pressure injury with normal saline, applied Santyl ointment in the wound bed, applied [MEDICATION NAME] foam dressing (padded foam dressing), and reapplied her Prevalon boots. The treatment nurse said when Resident #11 was in bed her right outer ankle would often be lying on the mattress. Resident #11's wound declined in condition, became larger from the previous skin assessment and maceration and discoloration indicated further deterioration. During observations on 2/21/17: *At 2:00 p.m. - Resident #11 was awake in bed, A Prevalon boot was in the bed, but not on her foot. Her right outer foot /ankle was flat on the mattress surface. *At 5:00 p.m. - Resident #11 was sitting in her wheelchair near the nursing station. The Prevalon boot was not on, and her foot was on the wheelchair pedal which was metal and there was no pillows or padding. RN H replaced her Prevalon boot. During an interview on 2/22/17 at 8:10 a.m., LVN G said Resident #11 had not been on a low air loss mattress, but she did not think it would help her as she spent most of the day in her wheelchair. She wore a Prevalon boot that she often removed. During an interview on 2/22/17 at 10:05 a.m., the hospice nurse said Resident #11 was seen two times a week by a nurse. She said Resident #11 received the scoop mattress at the beginning of February. She said the resident had not been on a low air loss mattress nor had anyone at the facility contacted her about a low air loss mattress. During an interview on 2/22/17 at 1:30 p.m., the DON and treatment nurse said they had not tried a low air loss mattress for Resident #11. They said she tried to sit up at times and they thought she would fall with a low air loss mattress. The treatment nurse said offloading her feet on pillows did not work as she would move her feet off the pillows, like she did with the Prevalon boots. The only intervention initiated was Prevalon boots and pillows. During an interview on 2/23/17 at 12:30 p.m., the wound care physician said Resident #11 was usually up in her wheelchair when he provided wound care. He said a low air loss mattress would be beneficial for Resident #11 as would turning her on her left side for pressure relief to her right ankle. He said he would make recommendations for positioning and a low air loss mattress. The wound care physician evaluation for Resident #11 included on: *1/30/17- An unstageable pressure injury- 100% necrotic tissue (black/brown dead tissue). Measured 0.8 cm by 0.8 cm by 0.1 cm. Recommendations included: Santyl (removed necrotic tissue), foam dressing, calcium alginate. Zinc 220 mg daily for 14 days, float heels in bed and off-load wound. *2/6/17- A Stage 4 pressure injury-0.8 cm by 0.7 cm by 0.1 cm, necrotic tissue 100%. Treatment remained the same and added multivitamin daily. *2/13/17- A Stage 4 pressure injury - 0.7 cm by 0.5 cm by 0.1 cm, necrotic tissue 100%. Treatment remained the same, added Vitamin C 500 mg twice daily. *2/20/17-A Stage 4 pressure injury- 1.2 cm by 1.5 cm by 0.1 cm , periwound maceration (wet moist, skin white in color); necrotic tissue 100%. Wound progress- worsened. The skin management policy updated 2/1/14 said the purpose was to describe steps to identify residents at risk for developing pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries. The evaluation section said if the pressure ulcer failed to show evidence of progress towards healing within 2-4 weeks, the resident's overall clinical condition should be reviewed, and re-evaluate the treatment plan . On 2/23/17 at 4:00 p.m. web page: http://www.npuap.org/ was accessed and said; Stage 4 pressure injury: full thickness skin and tissue loss- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable pressure injury: obscured full-thickness skin and tissue loss-Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The CMS 672 dated 2/20/17 indicated 4 residents had pressure injuries.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for management of blood sugar. (Resident #1) LVN A did not consult with the physician when Resident #1's blood sugar level continued to be high following administration of 5 units of insulin, resulting in Resident #1 becoming unresponsive and requiring hospitalization . This failure could place 20 residents with a [DIAGNOSES REDACTED]. Findings included: A physician order [REDACTED].#1, was [AGE] years old and admitted on [DATE]. Resident #1 had an order for [REDACTED].#1's blood sugar was over 400, 5 units were to be given and the physician was to be notified. The MDS assessment dated [DATE] indicated Resident #1 was usually able to understand others and was able to make herself understood. Her cognition was moderately impaired. She did not exhibit altered levels of consciousness. She was totally dependent on staff for transfers, locomotion, personal hygiene, and required extensive assistance with bed mobility, dressing, eating, and toileting. She was not steady when moving from a seated to standing position and required staff assistance for stabilization. The most recent MDS assessment dated [DATE] indicated Resident #1 was sometimes able to understand others and sometimes make herself understood. Her cognition was severely impaired. She exhibited a short-term and long-term memory problem. She exhibited altered level of consciousness and no longer moved from a seated to a standing position. A care plan initiated 7/8/13 indicated Resident #1 had the [DIAGNOSES REDACTED]. The interventions included for Resident #1's insulin to be given as ordered by the doctor, monitor/document for side effects and effectiveness, and to monitor blood sugars as ordered by the doctor. A nursing note dated 8/8/15 at 11:15 p.m. indicated Resident #1 was moaning and LVN A assessed her. Resident #1's blood sugar was taken and read: HI. The resident's skin was warm and dry. The physician on call was notified and ordered insulin per sliding scale, repeat blood sugar check in two hours, and continue with the sliding scale insulin. It was noted 5 units of insulin was given as ordered. LVN A noted she would continue to monitor the resident's condition. A nursing note dated 8/9/15 at 1:30 a.m. indicated Resident #1's blood sugar was tested again and read: HI. 5 units of insulin were given per sliding scale, Resident #1's skin was dry and warm and her respirations were even and unlabored. LVN A noted she would continue to monitor the resident's condition. A nursing note dated 8/9/15 at 4:45 a.m. indicated Resident #1 was unresponsive to verbal and tactile stimuli. Her blood sugar was taken and read: HI. The physician on call was notified, and an order was received to send Resident #1 to the emergency room (ER) for evaluation. An insulin administration record dated August 2015 indicated Resident #1's blood sugar read HI (above 500) on 8/8/15 at 11:10 p.m. and 5 units of insulin were given. Her blood sugar read HI on 8/9/15 at 1:30 a.m. and 5 units of insulin was given. There was no documentation on the insulin administration record to indicate 5 units were administered at 4:45 a.m. During a telephone interview on 10/2/15 at 4:07 p.m., LVN A said she checked Resident #1's blood sugar at 11:15 p.m. and it registered HI. She said she called the physician, he told her to give Resident #1 insulin per sliding scale, and to check it again in two hours. She said she did not call the physician back when she checked Resident #1's blood sugar two hours and 15 minutes later and it again registered as HI because he did not tell her to call him back. She said she meant to check Resident #1's blood sugar again two hours later but must have gotten busy and was not able to take it again until 4:45 a.m. (3 hours and 15 minutes later) when Resident #1 was found to be unresponsive. LVN A said she would probably not have done anything differently. During a telephone interview on 10/2/15 at 10:58 a.m., the on call physician the night of 8/8/15 and morning of 8/9/15, said he did not recall the incident with Resident #1 but would have expected another call if Resident #1's blood sugar level did not improve after she was initially given insulin per sliding scale. The physician said the second time her blood sugar read HI; he would have ordered to send her to the ER. A discharge summary dated 8/13/15 indicated Resident #1 admitted to the hospital on [DATE] and discharged back to the nursing facility on 8/13/15. The report indicated Resident #1 was brought into the ER after being found unresponsive in her bed. Resident #1 was intubated due to total unresponsiveness and was found to have a blood sugar just under 1,000 with severe diabetic ketoacidosis. Resident #1 had a central line placed, was admitted to the intensive care unit (ICU) with a white blood count of 27,000, and mechanical ventilation. During an interview on 10/2/15 at 6:10 p.m., the DON said she had not trained staff on blood sugars and staff were expected to implement standard blood sugar protocol to call the physician if the resident's blood sugar was over 400. She said she just trained staff on their new policy implemented 9/22/15 on notification of the physician of significant changes. The policy on notification of changes dated 7/13/15 indicated the facility would immediately inform the resident, consult with the resident's physician, and notify the residents legal representative or appropriate family members of a significant change in the physical, mental, or psychosocial status of the resident. A list dated 10/1/15 provided by the DON indicated there were 20 residents with a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to consult with the physician with a clinical complication that required a change of treatment for 1 of 6 residents reviewed for unstable blood sugars. (Resident #1). LVN A did not consult with the physician when Resident #1's blood sugar level continued to be high following administration of 5 units of insulin, resulting in Resident #1 becoming unresponsive and requiring hospitalization . This failure could place 20 residents with a [DIAGNOSES REDACTED]. Findings included: A physician order [REDACTED].#1, was [AGE] years old and admitted on [DATE]. Resident #1 had an order for [REDACTED].#1's blood sugar was over 400, 5 units were to be given and the physician was to be notified. The MDS assessment dated [DATE] indicated Resident #1 was usually able to understand others and was able to make herself understood. Her cognition was moderately impaired. She did not exhibit altered levels of consciousness. She was totally dependent on staff for transfers, locomotion, personal hygiene, and required extensive assistance with bed mobility, dressing, eating, and toileting. She was not steady when moving from a seated to standing position and required staff assistance for stabilization. The most recent MDS assessment dated [DATE] indicated Resident #1 was sometimes able to understand others and sometimes make herself understood. Her cognition was severely impaired. She exhibited a short-term and long-term memory problem. She exhibited altered level of consciousness and no longer moved from a seated to a standing position. A care plan initiated 7/8/13 indicated Resident #1 had the [DIAGNOSES REDACTED]. The interventions included for Resident #1's insulin to be given as ordered by the doctor, monitor/document for side effects and effectiveness, and to monitor blood sugars as ordered by the doctor. A nursing note dated 8/8/15 at 11:15 p.m. indicated Resident #1 was moaning and LVN A assessed her. Resident #1's blood sugar was taken and read: HI. The resident's skin was warm and dry. The physician on call was notified and ordered insulin per sliding scale, repeat blood sugar check in two hours, and continue with the sliding scale insulin. It was noted 5 units of insulin was given as ordered. LVN A noted she would continue to monitor the resident's condition. A nursing note dated 8/9/15 at 1:30 a.m. indicated Resident #1's blood sugar was tested again and read: HI. 5 units of insulin were given per sliding scale, Resident #1's skin was dry and warm and her respirations were even and unlabored. LVN A noted she would continue to monitor the resident's condition. A nursing note dated 8/9/15 at 4:45 a.m. indicated Resident #1 was unresponsive to verbal and tactile stimuli. Her blood sugar was taken and read: HI. The physician on call was notified, and an order was received to send Resident #1 to the emergency room (ER) for evaluation. An insulin administration record dated August 2015 indicated Resident #1's blood sugar read HI (above 500) on 8/8/15 at 11:10 p.m. and 5 units of insulin were given. Her blood sugar read HI on 8/9/15 at 1:30 a.m. and 5 units of insulin was given. There was no documentation on the insulin administration record to indicate 5 units were administered at 4:45 a.m. During a telephone interview on 10/2/15 at 4:07 p.m., LVN A said she checked Resident #1's blood sugar at 11:15 p.m. and it registered HI. She said she called the physician, he told her to give Resident #1 insulin per sliding scale, and to check it again in two hours. She said she did not call the physician back when she checked Resident #1's blood sugar two hours and 15 minutes later and it again registered as HI because he did not tell her to call him back. She said she meant to check Resident #1's blood sugar again two hours later but must have gotten busy and was not able to take it again until 4:45 a.m. (3 hours and 15 minutes later) when Resident #1 was found to be unresponsive. LVN A said she would probably not have done anything differently. During a telephone interview on 10/2/15 at 10:58 a.m., the on call physician the night of 8/8/15 and morning of 8/9/15, said he did not recall the incident with Resident #1 but would have expected another call if Resident #1's blood sugar level did not improve after she was initially given insulin per sliding scale. The physician said the second time her blood sugar read HI; he would have ordered to send her to the ER. A discharge summary dated 8/13/15 indicated Resident #1 admitted to the hospital on [DATE] and discharged back to the nursing facility on 8/13/15. The report indicated Resident #1 was brought into the ER after being found unresponsive in her bed. Resident #1 was intubated due to total unresponsiveness and was found to have a blood sugar just under 1,000 with severe diabetic ketoacidosis. Resident #1 had a central line placed, was admitted to the intensive care unit (ICU) with a white blood count of 27,000, and mechanical ventilation. During an interview on 10/2/15 at 6:10 p.m., the DON said she had not trained staff on blood sugars and staff were expected to implement standard blood sugar protocol to call the physician if the resident's blood sugar was over 400. She said she just trained staff on their new policy implemented 9/22/15 on notification of the physician of significant changes. The policy on notification of changes dated 7/13/15 indicated the facility would immediately inform the resident, consult with the resident's physician, and notify the residents legal representative or appropriate family members of a significant change in the physical, mental, or psychosocial status of the resident. A list dated 10/1/15 provided by the DON indicated there were 20 residents with a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide an environment to humanize and promote dignity for 1 of 13 residents reviewed for quality of life. (Resident #10) Resident #10 was verbally, mentally, and sexually abused by her roommate (Resident #11). Resident #10 stopped eating, sleeping and taking her medications. The facility did not intervene and remove Resident #11 from her room until 4/16/14. (5 days after the initial allegations of abuse were made). This failure could place the census of 80 at risk of depression and decline in health. Findings included: Physician orders [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #10 indicated she had clear speech, was understood and understands others. She was totally dependent for transfers, did not walk and required extensive assistance for other ADLs. Social service evaluation dated 02/11/14 indicated for Resident #10 was alert and oriented. The evaluation noted she got along well with her roommate. There were no SW notes dated from 04/11/14 to present. A plan of care dated 04/14/14 indicated Resident #10's moods were not easily altered by staff intervention. The approach included listening when resident was upset and try to resolve the issue and discuss with social worker for interventions. Nursing notes for Resident #10 indicated the following: -04/12/14 at 3:00 p.m., resident was alert and oriented. -04/13/14 at 3:00 p.m., Resident #10 was informed roommate (Resident #11) was a long term placement ...resident became tearful ...upset due to earlier incident with roommate trying to climb into bed with her. -04/13/14 at 4:30 p.m., Resident #10 refusing all care ... ' stated to nurse she is just ready to die, not going to live in this world around all of this hell. ' -04/14/14 at 12:30 p.m., awake, alert, agitated, yelling at roommate, refused meds, stated 'I'm not taking any more meds, or eating or drinking anything.' ...continue to monitor. -04/14/14 at 11:30 a.m., tears falling, stated she was being mistreated. During an interview on 04/23/14 at 2:35 p.m., LVN R said she worked on 4/11/14. She said Resident #11 was yelling screaming profanities and said she would 'knock hell out of me '. LVN R said Resident #11 was moved to the room with Resident #10 an hour later. LVN R said Resident #11 was getting into Resident #10's belongings and threatening to throw items. She said the next night (4/12/14) Resident #10 started refusing care including medications. LVN R said she saw Resident #11 naked exhibiting sexual behaviors and taunting Resident #10 to join in. She said Resident #10 was crying and was embarrassed. LVN R said she did not report or document the incident. Physician order [REDACTED].#11 was [AGE] years old and admitted to the secure unit with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #11 had clear speech, usually understands, understood others, and required limited assistance of one staff for all ADLs. She was ambulatory with supervision, occasionally incontinent of bladder but was always continent of bowel. Resident #11's care plan indicated she had the potential to demonstrate verbally abusive behaviors and was resistive to care related to her dementia diagnosis. Nursing notes for Resident #11 indicated she was moved to Resident #10's room from the secure unit on 04/11/14 at 3:30 p.m. and moved out of the room on 04/16/14 at 9:45 a.m. During an interview on 04/21/14 at 12:05 p.m., Resident #10 said she had a new roommate (Resident #11) about two weeks ago, who was mentally ill. She said Resident #11 tried to choke her and got into bed with her. Resident #10 said she called the Ombudsman who got involved and got Resident #11 moved out of her room. She said she reported the abuse to facility staff, but they would not listen or do anything. During an interview on 04/22/14 at 9:15 a.m., the Ombudsman said Resident #10 complained of her roommate (Resident #11) yelling out and other behaviors. Ombudsman said she reported Resident #10's complaints to the administrator and of her plan to return to the facility that night. Ombudsman said she returned that night to verify these complaints and found them to be true. She said Resident #s: 10 and 11 were not a good match as roommates and had reported this to the administrator the next morning. During an interview on 04/22/14 at 10:55 a.m., the SW said she was aware Resident #1's roommate (Resident #11) crawled into bed with her. SW said she had not been involved with Resident #10's complaints about her roommate. During an interview on 04/21/14 at 7:20 a.m., Resident #10 said the SW had not helped her with her complaints. During an interview on 04/22/14 at 12:20 p.m., the administrator said she was unaware of Resident #11's behaviors until the Ombudsman informed her. The administrator said Resident #10 had called the Ombudsman. The administrator said they did not intervene until Resident #'s 10 and 11 were not separated until after the Ombudsman made a night visit and informed her they were not compatible. She said then the residents were separated. During an interview on 04/22/14 at 11:00 a.m., the DON said Resident #11 was moved into room with Resident #10 for one night. (when) Resident #11 was delusional and got into bed with Resident #10. DON was suspended and not available for further interview. During an interview on 04/23/14 at 10:25 a.m., the SW said she had not followed-up with Resident #10 since roommate was moved. During an interview on 04/23/14 at 10:55 a.m., ADON P said the administrator and DON usually decided roommate changes. ADON P said she was aware Resident #10 was upset and in tears over behaviors of roommate (Resident #11). Resident #10 told her Resident #11's yelling kept her awake at night. ADON P said the complaints were not documented. During an interview on 04/23/14 at 1:53 p.m., LVN X said she worked the night shift on Resident #10's hall and was aware of the difficulty Resident # 10 was having with her roommate Resident #11. She was with roommate and said they argued back and forth all night long. LVN X said Resident #10 usually slept through the night prior to Resident #11 moving into the room. She said Resident #11 yelled a lot at night. LVN X said Resident #10 complained Resident #11 kept her awake. She said she did not report Resident #10's complaints or document them. There was no complaint report written. During an interview on 04/23/14 at 2:25 p.m., CNA Y said she worked the evening shift on Resident #10's hall. CNA Y said Resident #10 was very unhappy when her roommate (Resident #11) got in bed with her. She said Resident #10 refused to go to bed, refused care and wanted to move to another room. CNA Y said she heard Resident #11 say she was going to slap Resident #10. She said Resident #10 was a 'sitting target in bed' because she could not transfer herself. CNA Y said she reported this to the nurse. During an interview on 04/23/14 at 4:00 p.m., the corporate nurse consultant said an aggressive verbally abusive resident should have been put on 1 on 1 monitoring. The resident roster dated 04/21/14 indicated the census was 80.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit mistreatment, neglect, abuse or misappropriation of resident property for 2 of 13 residents reviewed for abuse. (Resident #7and #10) Resident #10 was verbally, mentally, and sexually abused by her roommate (Resident #11). Resident #10 complained to staff on 4/11-4/14 and to the ombudsman on 4/15/14. The facility did not address the abuse until 4/16/14 when Resident #11 was removed from the room. (5 days after the initial allegations of abuse were made). Resident #7 was admitted to the facility for a sleep study appointment to obtain a bi-pap machine. The facility canceled the original appointment and their delay in obtaining a new appointment caused mental stress and a financial burden. This failure contributed to Resident #10's refusal of care and wanting to die and could place the census of 80 residents at risk of failure to receive needed services. Findings included: An undated Admissions Agreement indicated " ...the resident has a right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion ... " The admission agreement section Seclusion indicated " ...involuntary seclusion was not permitted in this facility ... " The section on Resident Rights indicated " ...the resident has a right to be free from abuse and be free from any physical or chemical restraints imposed for the purpose of discipline or convenience ... " The Abuse Prohibition Policy and Procedure revised July 2012 indicated the following: *Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion...The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services will be notified in accordance with federal and state law; *information would be provided to inform residents, staff and agencies whom they could report concerns, incidents and grievances without fear of retribution; *the administrator or designee would be responsible to provide feedback regarding concerns; *identify residents whose personal histories render them at risk for abusing other residents; *the facility would be proactive in identifying events and occurances that may contribute to abuse or neglect; *review incident reports and complete an investigation report to determine if such things contributed to abuse; *the facility must have evidence all violations, including allegations were throughly investigated; *if alleged violation was verified, the appropriate corrective and disciplinary action would be taken; *the administrator or designee would be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance; *incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies; *all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately; *the charge nurse or supervisor must immediately contact the administrator or the DON of the incident; *the nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24 hour report; *the administrator or designee would analyze occurances to determine what changes, if any, would be needed to policies and procedures to prevent further occurances; *involuntary seclusion - separation of a resident from others or from his room against the resident's will or the will of the resident's legal representative; *mental/psychosocial abuse - mistreatment within the definition of abuse not resulting in physical harm, including, but not limited to humiliation, harassment, threats of punishment, deprivation or intimidation; *sexual abuse - any touching or exposure of the anus, breast, or any part of the genitals of a resident; *verbal abuse- the use of any oral, written, or gestured language which includes disparging or derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend or disability; *allegation - a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident property; *mistreatment- any degrading body language or verbal communication; and *neglect- failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental/anguish/illness or physical injury, or harm or death to the resident. 1. Physician orders [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #10 indicated she had clear speech, was understood and understands others. She was totally dependent for transfers, did not walk and required extensive assistance for other ADLs. Social service evaluation dated 02/11/14 indicated for Resident #10 was alert and oriented. The evaluation noted she got along well with her roommate. There were no SW notes dated from 04/11/14 to present. A plan of care dated 04/14/14 indicated Resident #10's moods were not easily altered by staff intervention. The approach included listening when resident was upset and try to resolve the issue and discuss with social worker for interventions. Nursing notes for Resident #10 indicated the following: -04/12/14 at 3:00 p.m., resident was alert and oriented. -04/13/14 at 3:00 p.m., Resident #10 was informed roommate (Resident #11) was a long term placement ...resident became tearful ...upset due to earlier incident with roommate trying to climb into bed with her. -04/13/14 at 4:30 p.m., Resident #10 refusing all care ... "stated to nurse she is just ready to die, not going to live in this world around all of this hell." -04/14/14 at 12:30 p.m., awake, alert, agitated, yelling at roommate, refused meds, stated 'I'm not taking any more meds, or eating or drinking anything.' ...continue to monitor. -04/14/14 at 11:30 a.m., tears falling, stated she was being mistreated. During an interview on 04/23/14 at 2:35 p.m., LVN R said she worked on 4/11/14. She said Resident #11 was yelling screaming profanities and said she would " knock hell out of me. " LVN R said Resident #11 was moved to the room with Resident #10 an hour later. LVN R said Resident #11 was getting into Resident #10's belongings and threatening to throw items. She said the next night (4/12/14) Resident #10 started refusing care including medications. LVN R said she saw Resident #11 naked exhibiting sexual behaviors and taunting Resident #10 to join in. She said Resident #10 was crying and was embarrassed. LVN R said she did not report or document the incident. Physician order [REDACTED].#11 was [AGE] years old and admitted to the secure unit with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #11 had clear speech, usually understands, understood others, and required limited assistance of one staff for all ADLs. She was ambulatory with supervision, occasionally incontinent of bladder but was always continent of bowel. Resident #11's care plan indicated she had the potential to demonstrate verbally abusive behaviors and was resistive to care related to her dementia diagnosis. Nursing notes for Resident #11 indicated she was moved from the secure unit to Resident #10's room on 04/11/14 at 3:30 p.m. and moved out of Resident #10's room on 04/16/14 at 9:45 a.m. During an interview on 04/21/14 at 12:05 p.m., Resident #10 said she had a new roommate (Resident #11) about two weeks ago, who was mentally ill. She said Resident #11 tried to choke her and got into bed with her. Resident #10 said she called the Ombudsman who got involved and got Resident #11 moved out of her room. She said she reported the abuse to facility staff, but they would not listen or do anything. During an interview on 04/22/14 at 9:15 a.m., the Ombudsman said Resident #10 complained of her roommate (Resident #11) yelling out and other behaviors. (date of complaint) Ombudsman said she reported Resident #10 ' s complaints to the administrator and of her plan to return to the facility that night. Ombudsman said she returned that night to verify these complaints and found them to be true. She said Residents #10 and #11 were not a good match as roommates and had reported this to the administrator the next morning. During an interview on 04/22/14 at 10:55 a.m., the SW said she was aware Resident #10's roommate (Resident #11) crawled into bed with her. The SW said she had not been involved with Resident #10's complaints about her roommate. During an interview on 04/22/14 at 11:00 a.m., the DON said Resident #11 was moved from the secure unit into the room with Resident #10 on the afternoon of 4/11/14. The DON said Resident #11 was delusional and got into bed with Resident #10. During an interview on 04/22/14 at 12:20 p.m., the administrator said she was unaware of Resident #11's behaviors until the Ombudsman informed her. The administrator said Resident #10 called the Ombudsman. The administrator said they did not intervene and move Resident #11 out of the room with Resident #10 until after the Ombudsman made a night visit and informed her they were not compatible. She said after the Ombudsman reported to her that she witnessed Resident #11's inappropriate behavior toward Resident #10, the residents were separated. During an interview on 04/21/14 at 7:20 a.m., Resident #10 said the SW had not helped her with her complaints. During an interview on 04/23/14 at 10:25 a.m., the SW said she had not followed-up with Resident #10 since the roommate was moved out of Resident #10 ' s room. During an interview on 04/23/14 at 10:55 a.m., ADON P said the administrator and DON usually decided roommate changes. ADON P said she was aware Resident #10 was upset and in tears over behaviors of Resident #11. Resident #10 told her Resident #11's yelling kept her awake at night. ADON P said the complaints were not documented. During an interview on 04/23/14 at 1:53 p.m., LVN X said she worked the night shift on Resident #10's hall and was aware of the difficulty Resident # 10 was having Resident #11. She said they argued back and forth all night long. LVN X said Resident #10 usually slept through the night prior to Resident #11 moving into the room. She said Resident #11 yelled a lot at night. LVN X said Resident #10 complained Resident #11 kept her awake. She said she did not report Resident #10 ' s complaints or document them. During an interview on 04/23/14 at 2:25 p.m., CNA Y said she worked the evening shift on Resident #10's hall. CNA Y said Resident #10 was very unhappy when her Resident #11 got in bed with her. She said Resident #10 refused to go to bed, refused care and wanted to move to another room. CNA Y said she heard Resident #11 say she was going to slap Resident #10. She said Resident #10 was a " sitting target in bed " because she could not transfer herself. CNA Y said she reported this to the nurse. During an interview on 04/23/14 at 4:00 p.m., the corporate nurse consultant said an aggressive verbally abusive resident should have been put on 1 on 1 monitoring. During an interview on 04/23/14 at 4:30 p.m., Resident #10 said she was having a bad day because a corporate nurse told her the administrator and DON had not done anything wrong and she (resident) would need to meet with them and work out their differences. Resident #10 was crying during this conversation. 2. Physician orders [REDACTED].#7 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. admission orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #7 understands, is understood, has minimal recall problems, requires supervision of activities of daily living, continent of bowel and bladder, received use of a [MEDICAL CONDITION] machine for assistance in breathing, and continuous oxygen therapy. The comprehensive care plan dated 4/1/14 indicated a focus on oxygen therapy with monitoring for respiratory distress and use of oxygen therapy. During an interview on 4/21/14 at 10:30 a.m., Resident #7 said he was mentally stressed worrying over a bill incurred at the facility. He said his physician only wanted him admitted long enough to have testing in order to return home with a breathing machine. Resident # 7 said he had an appointment for a sleep test on 3/27/14 that was cancelled by the facility. He said he was told that there was an emergency that afternoon and the facility cancelled his appointment. Resident #7 said his appointment was reset by the facility for April 23, 2014. He said since he has had to reside in the facility longer awaiting his appointment he had a bill of $1153.00. During an interview on 4/22/14 at 11:00 the BOM said Resident #7 as of April 1, 2014 owed the facility $1153.00 his applied income. She said she had discussed with him the billing. The BOM denied setting up payment arrangements. She said Resident #7's 21st day in the facility was 4/1/14 as a Medicare and Medicaid resident therefore would be charged his applied income. During an interview on 4/23/14 at 9:30 a.m., CNA HH said he was driving the van on 3/27/14 and he received a call to change his driving plans deleting Resident #7's schedule and adding a new Resident pick up at a hospital in Tyler, Texas. CNA HH said he does not cancel or schedule appointments. During an interview on 4/23/14 at 9:45 a.m., Medical Records GG said she and the ADONs participate in the scheduling. She said she did not cancel Resident # 7's sleep study appointment. Medical Records GG said she documented the trip to Tyler for another Resident on the March 2014 calendar and has Resident # 7 scheduled again for his sleep study on 4/23/14 at 7:00 p.m. During an interview on 4/23/14 at 9:55 a.m., ADON P (acting DON) said she was aware Resident # 7 admitted to await testing for a [MEDICAL CONDITION] machine to go home. She said missed his appointment because the van had to pick up a new resident coming from a Tyler hospital. She said when the hospital calls that the resident has discharge we have to pick them up. ADON P said administration and corporate makes the decision to cancel appointments to have admissions. ADON P said she understood how incurring a large bill for a missed appointment would be stressful. During an interview on 4/23/14 at 7:00 p.m., the SW said she had not assisted Resident #7 in obtaining an earlier appointment or assisted with his financial burden prior to the survey. The CMS 672 dated 4/21/14 indicated a census of 80 residents.

Based on observation, interview and record review, the facility failed to implement their policies and procedures to prohibit mistreatment, neglect, abuse or misappropriation of resident property for 2 of 13 residents reviewed for abuse. (Resident #7and #10) Resident #10 was verbally, mentally, and sexually abused by her roommate (Resident #11). Resident #10 complained to staff on 4/11-4/14 and to the ombudsman on 4/15/14. The facility did not address the abuse until 4/16/14 when Resident #11 was removed from the room. (5 days after the initial allegations of abuse were made). Resident #7 was admitted to the facility for a sleep study appointment to obtain a bi-pap machine. The facility canceled the original appointment and their delay in obtaining a new appointment caused mental stress and a financial burden. This failure contributed to Resident #10's refusal of care and wanting to die and could place the census of 80 residents at risk of failure to receive needed services. Findings included: 1. Physician orders [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #10 indicated she had clear speech, was understood and understands others. She was totally dependent for transfers, did not walk and required extensive assistance for other ADLs. Social service evaluation dated 02/11/14 indicated for Resident #10 was alert and oriented. The evaluation noted she got along well with her roommate. There were no SW notes dated from 04/11/14 to present. A plan of care dated 04/14/14 indicated Resident #10's moods were not easily altered by staff intervention. The approach included listening when resident was upset and try to resolve the issue and discuss with social worker for interventions. Nursing notes for Resident #10 indicated the following: -04/12/14 at 3:00 p.m., resident was alert and oriented. -04/13/14 at 3:00 p.m., Resident #10 was informed roommate (Resident #11) was a long term placement ...resident became tearful ...upset due to earlier incident with roommate trying to climb into bed with her. -04/13/14 at 4:30 p.m., Resident #10 refusing all care ... "stated to nurse she is just ready to die, not going to live in this world around all of this hell." -04/14/14 at 12:30 p.m., awake, alert, agitated, yelling at roommate, refused meds, stated 'I'm not taking any more meds, or eating or drinking anything.' ...continue to monitor. -04/14/14 at 11:30 a.m., tears falling, stated she was being mistreated. During an interview on 04/23/14 at 2:35 p.m., LVN R said she worked on 4/11/14. She said Resident #11 was yelling screaming profanities and said she would " knock hell out of me. " LVN R said Resident #11 was moved to the room with Resident #10 an hour later. LVN R said Resident #11 was getting into Resident #10's belongings and threatening to throw items. She said the next night (4/12/14) Resident #10 started refusing care including medications. LVN R said she saw Resident #11 naked exhibiting sexual behaviors and taunting Resident #10 to join in. She said Resident #10 was crying and was embarrassed. LVN R said she did not report or document the incident. A Physician order [REDACTED].#11 was [AGE] years old and admitted to the secure unit with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #11 had clear speech, usually understands, understood others, and required limited assistance of one staff for all ADLs. She was ambulatory with supervision, occasionally incontinent of bladder but was always continent of bowel. Resident #11's care plan indicated she had the potential to demonstrate verbally abusive behaviors and was resistive to care related to her dementia diagnosis. Nursing notes for Resident #11 indicated she was moved from the secure unit to Resident #10's room on 04/11/14 at 3:30 p.m. and moved out of Resident #10's room on 04/16/14 at 9:45 a.m. During an interview on 04/21/14 at 12:05 p.m., Resident #10 said she had a new roommate (Resident #11) about two weeks ago, who was mentally ill. She said Resident #11 tried to choke her and got into bed with her. Resident #10 said she called the Ombudsman who got involved and got Resident #11 moved out of her room. She said she reported the abuse to facility staff, but they would not listen or do anything. During an interview on 04/22/14 at 9:15 a.m., the Ombudsman said Resident #10 complained of her roommate (Resident #11) yelling out and other behaviors. (date of complaint) Ombudsman said she reported Resident #10 ' s complaints to the administrator and of her plan to return to the facility that night. Ombudsman said she returned that night to verify these complaints and found them to be true. She said Residents #10 and #11 were not a good match as roommates and had reported this to the administrator the next morning. During an interview on 04/22/14 at 10:55 a.m., the SW said she was aware Resident #10's roommate (Resident #11) crawled into bed with her. The SW said she had not been involved with Resident #10's complaints about her roommate. During an interview on 04/21/14 at 7:20 a.m., Resident #10 said the SW had not helped her with her complaints. During an interview on 04/22/14 at 11:00 a.m., the DON said Resident #11 was moved from the secure unit into the room with Resident #10 on the afternoon of 4/11/14. The DON said Resident #11 was delusional and got into bed with Resident #10. During an interview on 04/22/14 at 12:20 p.m., the administrator said she was unaware of Resident #11's behaviors until the Ombudsman informed her. The administrator said Resident #10 called the Ombudsman. The administrator said they did not intervene and move Resident #11 out of the room with Resident #10 until after the Ombudsman made a night visit and informed her they were not compatible. She said after the Ombudsman reported to her that she witnessed Resident #11's inappropriate behavior toward Resident #10, the residents were separated. During an interview on 04/23/14 at 10:25 a.m., the SW said she had not followed-up with Resident #10 since the roommate was moved out of Resident #10 ' s room. During an interview on 04/23/14 at 10:55 a.m., ADON P said the administrator and DON usually decided roommate changes. ADON P said she was aware Resident #10 was upset and in tears over behaviors of Resident #11. Resident #10 told her Resident #11's yelling kept her awake at night. ADON P said the complaints were not documented. During an interview on 04/23/14 at 1:53 p.m., LVN X said she worked the night shift on Resident #10's hall and was aware of the difficulty Resident # 10 was having Resident #11. She said they argued back and forth all night long. LVN X said Resident #10 usually slept through the night prior to Resident #11 moving into the room. She said Resident #11 yelled a lot at night. LVN X said Resident #10 complained Resident #11 kept her awake. She said she did not report Resident #10 ' s complaints or document them. During an interview on 04/23/14 at 2:25 p.m., CNA Y said she worked the evening shift on Resident #10's hall. CNA Y said Resident #10 was very unhappy when her Resident #11 got in bed with her. She said Resident #10 refused to go to bed, refused care and wanted to move to another room. CNA Y said she heard Resident #11 say she was going to slap Resident #10. She said Resident #10 was a " sitting target in bed " because she could not transfer herself. CNA Y said she reported this to the nurse. During an interview on 04/23/14 at 4:00 p.m., the corporate nurse consultant said an aggressive verbally abusive resident should have been put on 1 on 1 monitoring. During an interview on 04/23/14 at 4:30 p.m., Resident #10 said she was having a bad day because a corporate nurse told her the administrator and DON had not done anything wrong and she (resident) would need to meet with them and work out their differences. Resident #10 was crying during this conversation. 2. Physician orders [REDACTED].#7 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. admission orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #7 understands, is understood, has minimal recall problems, requires supervision of activities of daily living, continent of bowel and bladder, received use of a [MEDICAL CONDITION] machine for assistance in breathing, and continuous oxygen therapy. The comprehensive care plan dated 4/1/14 indicated a focus on oxygen therapy with monitoring for respiratory distress and use of oxygen therapy. During an interview on 4/21/14 at 10:30 a.m., Resident #7 said he was mentally stressed worrying over a bill incurred at the facility. He said his physician only wanted him admitted long enough to have testing in order to return home with a breathing machine. Resident # 7 said he had an appointment for a sleep test on 3/27/14 that was cancelled by the facility. He said he was told that there was an emergency that afternoon and the facility cancelled his appointment. Resident #7 said his appointment was reset by the facility for April 23, 2014. He said since he has had to reside in the facility longer awaiting his appointment he had a bill of $1153.00. During an interview on 4/22/14 at 11:00 the BOM said Resident #7 as of April 1, 2014 owes the facility $1153.00 his applied income. She said she had discussed with him the billing. The BOM denied setting up payment arrangements. She said Resident #7 as of April 1, 2014 was on his 21st day in the facility in which he as a Medicare and Medicaid resident therefore would be charged his applied income. During an interview on 4/23/14 at 9:30 a.m., CNA HH said he was driving the van on 3/27/14 and he received a call to change his driving plans deleting Resident #7 ' s schedule and adding a new Resident pick up at a hospital in Tyler, Texas. CNA HH said he does not cancel or schedule appointments. During an interview on 4/23/14 at 9:45 a.m., Medical Records GG said she and the ADONs participate in the scheduling. She said she did not cancel Resident # 7 ' s sleep study appointment. Medical Records GG said she documented the trip to Tyler for another Resident on the March 2014 calendar and has Resident # 7 scheduled again for his sleep study on 4/23/14 at 7:00 p.m. During an interview on 4/23/14 at 9:55 a.m., ADON P (acting DON) said she was aware Resident # 7 admitted to await testing for a [MEDICAL CONDITION] machine to go home. She said missed his appointment because the van had to pick up a new resident coming from a Tyler hospital. She said when the hospital calls that the resident has discharge we have to pick them up. ADON P said administration and corporate makes the decision to cancel appointments to have admissions. ADON P said she understood how incurring a large bill for a missed appointment would be stressful. During an interview on 4/23/14 at 7:00 p.m., the SW said she had not assisted Resident #7 in obtaining an earlier appointment or assisted with his financial burden prior to the survey. An undated Admissions Agreement indicated " ...the resident has a right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion ... " The admission agreement section Seclusion indicated " ...involuntary seclusion was not permitted in this facility ... " The section on Resident Rights indicated " ...the resident has a right to be free from abuse and be free from any physical or chemical restraints imposed for the purpose of discipline or convenience ... " The Abuse Prohibition Policy and Procedure revised July 2012 indicated the following: *Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion...The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services will be notified in accordance with federal and state law; *information would be provided to inform residents, staff and agencies whom they could report concerns, incidents and grievances without fear of retribution; *the administrator or designee would be responsible to provide feedback regarding concerns; *identify residents whose personal histories render them at risk for abusing other residents; *the facility would be proactive in identifying events and occurances that may contribute to abuse or neglect; *review incident reports and complete an investigation report to determine if such things contributed to abuse; *the facility must have evidence all violations, including allegations were throughly investigated; *if alleged violation was verified, the appropriate corrective and disciplinary action would be taken; *the administrator or designee would be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance; *incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies; *all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately; *the charge nurse or supervisor must immediately contact the administrator or the DON of the incident; *the nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24 hour report; *the administrator or designee would analyze occurances to determine what changes, if any, would be needed to policies and procedures to prevent further occurances; *involuntary seclusion - separation of a resident from others or from his room against the resident's will or the will of the resident's legal representative; *mental/psychosocial abuse - mistreatment within the definition of abuse not resulting in physical harm, including, but not limited to humiliation, harassment, threats of punishment, deprivation or intimidation; *sexual abuse - any touching or exposure of the anus, breast, or any part of the genitals of a resident; *verbal abuse- the use of any oral, written, or gestured language which includes disparging or derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend or disability; *allegation - a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident property; *mistreatment- any degrading body language or verbal communication; and *neglect- failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental/anguish/illness or physical injury, or harm or death to the resident. The CMS 672 dated 4/21/14 indicated a census of 80 residents.

Based on observation, interview and record review the facility failed to ensure the right to be free from physical abuse and involuntary seclusion for 2 of 13 residents reviewed for abuse. (Residents #1 and #10) Resident #10 was verbally, mentally, and sexually abused by her roommate (Resident #11). Resident #10 complained to staff on 4/11-4/14 and to the ombudsman on 4/15/14. The facility did not address the abuse until 4/16/14 when Resident #11 was removed from the room. (5 days after the initial allegations of abuse were made). Resident #1 left the building without notifying staff. Upon return to the facility Resident #1 was immediately placed on the secure unit without assessment or physician order. Resident #1 did not meet facility requirement for placement on the locked unit per their policy. This failure contributed to Resident #10 refusing care and wanting to die and could place the census of 80 at risk of mental and physical trauma. Findings included: 1. Physician orders [REDACTED].#10 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #10 indicated she had clear speech, was understood and understands others. She was totally dependent for transfers, did not walk and required extensive assistance for other ADLs. Social service evaluation dated 02/11/14 indicated for Resident #10 was alert and oriented. The evaluation noted she got along well with her roommate. There were no SW notes dated from 04/11/14 to present. A plan of care dated 04/14/14 indicated Resident #10's moods were not easily altered by staff intervention. The approach included listening when resident was upset and try to resolve the issue and discuss with social worker for interventions. Nursing notes for Resident #10 indicated the following: -04/12/14 at 3:00 p.m., resident was alert and oriented. -04/13/14 at 3:00 p.m., Resident #10 was informed roommate (Resident #11) was a long term placement ...resident became tearful ...upset due to earlier incident with roommate trying to climb into bed with her. -04/13/14 at 4:30 p.m., Resident #10 refusing all care ... "stated to nurse she is just ready to die, not going to live in this world around all of this hell." -04/14/14 at 12:30 p.m., awake, alert, agitated, yelling at roommate, refused meds, stated 'I'm not taking any more meds, or eating or drinking anything.' ...continue to monitor. -04/14/14 at 11:30 a.m., tears falling, stated she was being mistreated. During an interview on 04/23/14 at 2:35 p.m., LVN R said she worked on 4/11/14. She said Resident #11 was yelling screaming profanities and said she would " knock hell out of me. " LVN R said Resident #11 was moved to the room with Resident #10 an hour later. LVN R said Resident #11 was getting into Resident #10's belongings and threatening to throw items. She said the next night (4/12/14) Resident #10 started refusing care including medications. LVN R said she saw Resident #11 naked exhibiting sexual behaviors and taunting Resident #10 to join in. She said Resident #10 was crying and was embarrassed. LVN R said she did not report or document the incident. Physician order [REDACTED].#11 was [AGE] years old and admitted to the secure unit with [DIAGNOSES REDACTED]. An admission elopement assessment dated [DATE] indicated she could not leave the facility on her own. An MDS dated [DATE] indicated Resident #11 had clear speech, usually understands, understood others, and required limited assistance of one staff for all ADLs. She was ambulatory with supervision, occasionally incontinent of bladder but was always continent of bowel. Resident #11's care plan indicated she had the potential to demonstrate verbally abusive behaviors and was resistive to care related to her dementia diagnosis. Nursing notes for Resident #11 indicated she was moved from the secure unit to Resident #10's room on 04/11/14 at 3:30 p.m. and moved out of Resident #10's room on 04/16/14 at 9:45 a.m. During an interview on 04/21/14 at 12:05 p.m., Resident #10 said she had a new roommate (Resident #11) about two weeks ago, who was mentally ill. She said Resident #11 tried to choke her and got into bed with her. Resident #10 said she called the Ombudsman who got involved and got Resident #11 moved out of her room. She said she reported the abuse to facility staff, but they would not listen or do anything. During an interview on 04/22/14 at 9:15 a.m., the Ombudsman said Resident #10 complained of her roommate (Resident #11) yelling out and other behaviors. Ombudsman said she reported Resident #10's complaints to the administrator and of her plan to return to the facility that night. Ombudsman said she returned that night to verify these complaints and found them to be true. She said Residents #10 and #11 were not a good match as roommates and had reported this to the administrator the next morning. During an interview on 04/22/14 at 10:55 a.m., the SW said she was aware Resident #10's roommate (Resident #11) crawled into bed with her. The SW said she had not been involved with Resident #10's complaints about her roommate. During an interview on 04/21/14 at 7:20 a.m., Resident #10 said the SW had not helped her with her complaints. During an interview on 04/22/14 at 11:00 a.m., the DON said Resident #11 was moved from the secure unit into the room with Resident #10 on the afternoon of 4/11/14. The DON said Resident #11 was delusional and got into bed with Resident #10. During an interview on 04/22/14 at 12:20 p.m., the administrator said she was unaware of Resident #11's behaviors until the Ombudsman informed her. The administrator said Resident #10 called the Ombudsman. The administrator said they did not intervene and move Resident #11 out of the room with Resident #10 until after the Ombudsman made a night visit and informed her they were not compatible. She said after the Ombudsman reported to her that she witnessed Resident #11's inappropriate behavior toward Resident #10, the residents were separated. During an interview on 04/23/14 at 10:25 a.m., the SW said she had not followed-up with Resident #10 since the roommate was moved out of Resident #10's room. During an interview on 04/23/14 at 10:55 a.m., ADON P said the administrator and DON usually decided roommate changes. ADON P said she was aware Resident #10 was upset and in tears over behaviors of Resident #11. Resident #10 told her Resident #11's yelling kept her awake at night. ADON P said the complaints were not documented. During an interview on 04/23/14 at 1:53 p.m., LVN X said she worked the night shift on Resident #10's hall and was aware of the difficulty Resident # 10 was having Resident #11. She said they argued back and forth all night long. LVN X said Resident #10 usually slept through the night prior to Resident #11 moving into the room. She said Resident #11 yelled a lot at night. LVN X said Resident #10 complained Resident #11 kept her awake. She said she did not report Resident #10 ' s complaints or document them. During an interview on 04/23/14 at 2:25 p.m., CNA Y said she worked the evening shift on Resident #10's hall. CNA Y said Resident #10 was very unhappy when her Resident #11 got in bed with her. She said Resident #10 refused to go to bed, refused care and wanted to move to another room. CNA Y said she heard Resident #11 say she was going to slap Resident #10. She said Resident #10 was a "sitting target in bed" because she could not transfer herself. CNA Y said she reported this to the nurse. During an interview on 04/23/14 at 4:00 p.m., the corporate nurse consultant said an aggressive verbally abusive resident should have been put on 1 on 1 monitoring. During an interview on 04/23/14 at 4:30 p.m., Resident #10 said she was having a bad day because a corporate nurse told her the administrator and DON had not done anything wrong and she (resident) would need to meet with them and work out their differences. Resident #10 was crying during this conversation. 2. Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An elopement/wandering assessment tool dated 3/20/14 indicated Resident #1 was physically able to leave the building on her own. She had resided in the facility less than 90 days and was able to sign herself out for therapeutic leave. The assessment tool indicated if Resident #1 was not disoriented to place, and was able to sign herself out then she was not deemed an elopement risk. The most recent MDS dated [DATE] indicated Resident #1 made herself understood, understands, had inattention and disorganized thinking with fluctuating behaviors, and no recall problems. Resident #1 required supervision for transfers and walking in the corridor. A physician order [REDACTED].#1 was to be moved to the locked unit for safety because the resident left the facility without notification to staff or charge nurse. The comprehensive care plan dated 4/15/14 did not indicate Resident #1 was at risk for elopement from the facility. The care plan indicated Resident #1 had adjustment issues related to admission. Interventions included " ...to have an opportunity to communicate feelings regarding placement in a nursing home ... " An interdisciplinary care plan dated 4/17/14 indicated Resident #1 had inappropriate/disruptive behaviors including leaving the facility without notification, smoking against facility policy, and was demanding of staff. The objective of the care plan was Resident #1 would follow the facility procedure for 90 days. Approaches included: " ...monitor behavior and try to determine cause, monitor for signs of escalating behavior and set guidelines and be consistent, redirect for more appropriate behaviors, explain what is expected of the resident in a firm, calm voice, monitor for changes in behaviors for worsening conditions, encourage to discuss the cause of disruptive behavior, explain the policies and reasons for compliance, contact medical doctor as needed and for the resident to reside in the secured unit for one night ( 4/17/14) for personal safety..." An incident/accident report dated 4/17/14 at 8:00 p.m., indicated Resident #1 left the facility without informing staff. The report noted staff found Resident #1at the convenience store, with no injuries noted. An investigation follow up dated 4/17/14 indicated Resident #1 was not found in the facility on rounds. The staff located Resident #1 at the convenience store. Staff documented past interventions were attempted with Resident #1 such as explanation of facility procedures. New interventions were to place Resident #1 on the secured unit overnight for own safety. The social worker was to follow up on 4/18/14 with discussion about the policies. A witness statement dated 4/17/14 indicated upon return to the facility, Resident #1 was escorted to the locked unit until the DON arrived. A nursing note dated 4/17/14 at 9:00 p.m., indicated Resident #1 was back at the facility without injuries. Resident #1's cigarettes and matches were taken away, and she was put in the locked unit. A social service progress note dated 4/18/14 indicated the SW informed Resident #1 of the policy and procedure for leaving the facility. The note indicated the SW explained to Resident #1 her continued non-compliance could result in discharge. During an interview on 4/21/14 at 9:26 a.m., Resident #1 said she told staff on the night she left, that she was tired of being there, and was going to leave. She said she got a ride down to the store. Resident #1 said she " feels like the facility staff treated her like a child. " Resident #1 said she was not allowed to smoke while she was in "lock down." During an interview on 4/21/14 at 12:14 p.m., Resident #1 said the DON and LVN R were mean and locked her in the secured unit overnight after she left the facility because she was angry and "just had to get away for a while." She said she was planning to return to the facility on her own. Resident #1 said she knew she was [MEDICAL CONDITION], but did not deserve to be locked away from her possessions in the secured unit with highly confused residents. She said she was scared to sleep in the secured unit and sat on the sofa all night concerned for her safety if she fell asleep. Resident #1 said she would have been fine and obeyed the rules if she had been reminded of the sign out rule. She said staff treated her as a "two year old" instead of an adult. She said she was afraid that she would be retaliated against by the staff if she complained about being locked in the secured unit overnight. During an interview on 4/22/14 at 10:45 a.m., Resident #1 said when she returned to the facility she was thrown in "lock down." She said the staff " chewed her out for two hours. " Resident #1 said she was not being treated properly in the facility. Resident #1 said she left because she just, "needed a break." During an interview on 4/22/14 at 9:03 a.m., the DON said she was notified Resident # 1 had been missing, but was in route to the facility. She said she advised nursing staff to place Resident #1 on the secured unit. She said Resident #1 was in an argument with her roommate earlier, already taken her evening medications, and felt the secured unit was where she needed to be placed. The DON said the facility had no other empty resident rooms. During an interview on 4/22/14 at 9:42 a.m., the SW said she was not aware Resident #1 was placed on the secured unit, until she arrived on 4/18/14. The SW said she explained the policy to Resident #1, and released her from the secured unit at approximately 8:30 a.m. The SW said Resident #1 was very upset about being placed on the secured unit. During an interview on 4/22/14 at 11:10 a.m., RN U said Resident #1 being locked on the secured unit was not an appropriate intervention. She said a more appropriate intervention for Resident #1 would have been 1:1 monitoring. During an interview on 4/22/14 at 12:00 p.m., the administrator said she was notified and agreed that placement on the secured unit was a good intervention for Resident #1. She said Resident #1 was only on the secured unit for 12 hours. The administrator said she had not considered 1:1 monitoring or a wander-guard bracelet. She said the secured unit was used for residents with dementia. During an interview on 4/22/14 at 2:05 p.m., the physician said he was on call the night of 4/17/14. He said he was not notified that Resident #1 had left the facility, nor did he give an order for [REDACTED]. During an interview on 4/22/14 at 2:20 p.m., LVN R said Resident #1 had been crying prior to leaving the facility. She said she was instructed by the DON to place Resident #1 on the secured unit upon arrival back to the facility. She said Resident #1 was not allowed back to her room for her belongings. LVN R said Resident #1 was escorted on the secured unit, provided a bed and offered a gown. She said Resident #1 was not allowed back to her room for her belongings. LVN R said she did not call the physician to obtain an order to place Resident #1 on the secured unit. During an interview on 4/22/14 at 4:05 p.m., Resident #1 said the SW made her sign a form to see a psychiatrist. She said the SW said everyone had to sign the form. Resident #1 said after asking other residents she learned no one else was made to sign the forms. Resident #1 said she had her own psychiatrist and would much rather continue seeing him. During an interview on 4/23/14 at 1:06 p.m., LVN V said she knew involuntary seclusion was a form of abuse, and witnessed involuntary seclusion used with Resident #1. She said she was the charge nurse the morning of 4/18/14 for Resident #1. She said the SW released Resident #1 from the secured unit back to her room, between 8:00 and 9:00 a.m. LVN V said she did not report the abuse. During an interview on 4/23/14 at 1:18 p.m., RN O said she was aware Resident #1 was on the secured unit. She said due to not enough staff, 1:1 monitoring could not be provided for Resident #1. During an interview on 4/23/14 at 2:10 p.m., CNA Y said she was working on 4/17/14, the night Resident #1 left the facility. She said Resident #1 was upset and voiced she was leaving. CNA Y said she reported this to LVN R. CNA Y said Resident #1, upon return to the facility, was escorted to the secured unit. She said she heard Resident #1 saying, "don't put an ankle bracelet on me and don't lock me up." CNA Y said she felt it was abuse to Resident #1, but did not report it. During an interview on 4/23/14 at 3:00 p.m., LVN AA said she was aware Resident #1 was placed on the secured unit on 4/17/14. LVN AA said 1:1 monitoring was not an option due to not enough staffing. During an interview on 4/23/14 at 3:50 p.m., CNA J said she worked on secured unit on 4/17/14 when Resident #1 was placed on the unit. CNA J said Resident #1 said she did not want to be on the locked unit. A missing resident locator form dated 4/17/14 provided 4/24/14 did not indicate Resident #1 signed the form agreeing to be placed in the secured unit. A Missing Patient Guidelines dated 9/2013 indicated when " ...the patient is located, place the patient on 1:1 observation to prevent further wandering, or exit seeking until a full review is completed by a physician and the care plan was reviewed and revised ... " An Admission Criteria for Secured Continuous Care Unit dated 4/11 indicated a secured continuous care unit potential resident will have an admitting primary [DIAGNOSES REDACTED]. An undated Admissions Agreement indicated " ...the resident has a right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion ... " The admission agreement section Seclusion indicated " ...involuntary seclusion was not permitted in this facility ... " The section on Resident Rights indicated " ...the resident has a right to be free from abuse and be free from any physical or chemical restraints imposed for the purpose of discipline or convenience ... " The Abuse Prohibition Policy and Procedure revised July 2012 indicated the following: *Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion...The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services will be notified in accordance with federal and state law; *information would be provided to inform residents, staff and agencies whom they could report concerns, incidents and grievances without fear of retribution; *the administrator or designee would be responsible to provide feedback regarding concerns; *identify residents whose personal histories render them at risk for abusing other residents; *the facility would be proactive in identifying events and occurances that may contribute to abuse or neglect; *review incident reports and complete an investigation report to determine if such things contributed to abuse; *the facility must have evidence all violations, including allegations were throughly investigated; *if alleged violation was verified, the appropriate corrective and disciplinary action would be taken; *the administrator or designee would be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance; *incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies; *all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately; *the charge nurse or supervisor must immediately contact the administrator or the DON of the incident; *the nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24 hour report; *the administrator or designee would analyze occurances to determine what changes, if any, would be needed to policies and procedures to prevent further occurances; *involuntary seclusion - separation of a resident from others or from his room against the resident's will or the will of the resident's legal representative; *mental/psychosocial abuse - mistreatment within the definition of abuse not resulting in physical harm, including, but not limited to humiliation, harassment, threats of punishment, deprivation or intimidation; *sexual abuse - any touching or exposure of the anus, breast, or any part of the genitals of a resident; *verbal abuse- the use of any oral, written, or gestured language which includes disparging or derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend or disability; *allegation - a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident property; *mistreatment- any degrading body language or verbal communication; and *neglect- failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental/anguish/illness or physical injury, or harm or death to the resident. The CMS-672 dated 04/21/14 indicated the census was 80.

Based on interview and record review, the administrator and DON failed to ensure the facility's resources were managed effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 3 of 13 residents reviewed for abuse and neglect. (Resident #'s 1, 7 and 10) The administrator and DON failed to ensure staff were monitored, trained, and supervised for: *implementation of policy and procedure for misappropriation of resident funds. *implementation of policy and procedures for reporting and investigating abuse. *implementation of policy and procedures for secluding residents. *implementation of policy and procedure for residents having pets in the facility. Resident #1 was placed on the locked unit for leaving the building without signing out and was not allowed to have her pet with her in the facility. Resident # 7 was admitted to the facility awaiting an appointment for the provision of a bi-pap machine. The facility's delay of appointment setting caused mental stress and a financial burden to Resident#7. Resident #10 was verbally, mentally, and sexually abused by her roommate (Resident #11) and staff did not intervene. Findings included: During an interview on [DATE] at 7:20 p.m., the administrator said she watched call lights, visited with residents, assisted with meals, observed care, and observed residents by walking the halls in order to ensure all resident needs are being met. The administrator said she monitored staff to ensure they were competent by walking in the halls, and talking with staff at the daily standup meetings. The administrator said she had an open door policy for all complaints. She said it was the policy of the facility not to use seclusion. The administrator said she knew Resident #10 very well and she was grieving over another resident who left the facility. She said everything was too much for Resident #9 to handle. The administrator said the behaviors of Resident #11 may have contributed to Resident #9's problems. The administrator said she knew about Resident #10 and #11 having problems, but nothing was documented. The administrator said she planned on apologizing to Resident #10 and try to solve her problem. The administrator said Resident #1 went to smoke and went up the street to the store and a staff member found her there and brought her back to the facility. The administrator said Resident #1 agreed to stay in the secured unit overnight and was out at 8:00 a.m. the next morning. The administrator said she did not have enough staff to sit one on one with Resident #1. The administrator said if this happened again she would sit one on one with a resident herself. The administrator said she had spoken to the DON about the situation, but had not in-serviced staff on what to do. The DON was suspended and unavailable for interview. 1. During an interview on [DATE] at 12:05 p.m. Resident #10 said she had a new roommate (Resident #11) about two weeks ago that was mentally ill and tried to choke her and got into bed with her. She said staff refused to help her and she had called the Ombudsman who got involved and had the roommate moved. She said she reported this to facility staff but they would not listen or do anything. Nursing notes for Resident #10 indicated the following: -[DATE] at 3:00 p.m. resident was alert and oriented. -[DATE] at 3:00 p.m. resident informed roommate was a long term placement ...resident became tearful ...upset due to earlier incident with roommate trying to climb into bed with her. -[DATE] at 4:30 p.m. resident refusing all care ... ' stated to nurse she is just ready to die, not going to live in this world around all of this hell. ' -[DATE] at 12:30 p.m. awake, alert, agitated, yelling at roommate, refused meds, stated 'I'm not taking any more meds, or eating or drinking anything.' ...continue to monitor. -[DATE] at 11:30 a.m. tears falling, stated she was being mistreated. A plan of care dated [DATE] for Resident #10 indicated resident moods not easily altered by staff intervention with approach to listen when resident was upset and try to resolve the issue and discuss with social worker for interventions. Social service evaluation dated [DATE] for Resident #10 indicated she was alert and oriented and got along well with her roommate. There were no SW notes dated from [DATE] to present. During an interview on [DATE] at 7:20 a.m. Resident #10 said the SW had not helped her with her complaints. During an interview on [DATE] at 9:15 a.m. the Ombudsman said Resident #10 had complained of her roommate (Resident #11) yelling out and other behaviors. Ombudsman said she reported resident complaints to the administrator and informed administrator of her plan to return to the facility that night. Ombudsman said she returned that night to verify these complaints and found them to be true. She said residents were not a good match as roommates and she had reported this to the administrator the next morning. During an interview on [DATE] at 10:55 a.m. the SW said she was aware Resident #10's roommate (Resident #11) crawled into bed with her. SW said she had not been involved with Resident #10's complaints about her roommate. During an interview on [DATE] at 12:20 p.m. the administrator said she was unaware of Resident #11's behaviors until the Ombudsman informed her. The administrator said Resident #10 had called the Ombudsman. The administrator said they did not intervene until after the Ombudsman made a night visit and informed her the residents were not compatible and then the residents were separated. During an interview on [DATE] at 11:00 a.m. the DON said Resident #11 was moved into room with Resident #10 for one night. Resident #11 was delusional and got into bed with Resident #10. DON was suspended and not available for further interview. During an interview on [DATE] at 10:25 a.m. the SW said she had not followed-up with Resident #10 since roommate was moved. During an interview on [DATE] at 10:55 a.m. ADON P said the administrator and DON usually decide on roommate changes. ADON P said she was aware Resident #10 was upset and in tears over behaviors of roommate (Resident #11). Resident #10 had told her Resident #11's yelling kept her awake at night. ADON P said the complaints were not written up. During an interview on [DATE] at 1:53 p.m. LVN X said she worked the night shift on Resident #10's hall and was aware of difficulty with roommate and they argued back and forth all night long. Resident #10 usually slept through the night prior to Resident #11 moving to room. Resident #11 yelled a lot at night. Resident #10 said Resident #11 kept her awake. There was no complaint report written. During an interview on [DATE] at 2:25 p.m. CNA Y said she worked the evening shift on Resident #10 's hall. CNA Y said Resident #10 was very unhappy when her roommate (Resident #11) got in bed with her. Resident #10 refused to go to bed, refused care and wanted to move to another room. CNA Y said she heard Resident #11 say she was going to slap Resident #10. She said Resident #10 was a 'sitting target in bed' because she could not transfer herself. CNA Y said she reported this to the nurse. During an interview on [DATE] at 2:35 p.m. LVN R reviewed nurses notes she wrote for Resident #11 on [DATE] which indicated resident was yelling screaming profanities and told her she would 'knock hell out of me ' Resident #11 was moved to room with Resident #10 an hour later. LVN R said Resident #11 was getting into Resident #10 ' s belongings and threatening to throw items. The next night Resident #10 starting refusing care including medications. LVN R said she saw Resident #11 naked exhibiting sexual behaviors and taunting Resident #10 to join in. She said Resident #10 was crying and was embarrassed. LVN R said she did not write up the incident. Nursing notes for Resident #11 indicated she was moved to Resident #10's room on [DATE] at 3:30 p.m. and moved out of the room on [DATE] at 9:45 a.m. During an interview on [DATE] at 4:00 p.m. the corporate nurse consultant said an aggressive verbally abusive resident should have been put on 1 on 1 monitoring. During an interview on [DATE] at 4:30 p.m. Resident #10 said she was having a bad day because a corporate nurse told her the administrator and DON had not done anything wrong and she (resident) would need to meet with them and work out their differences. Resident #10 was crying during this conversation. 2. During an interview on [DATE] at 12:14 p.m., Resident #1 said she was " homeless." She did not know where her money was and needed CBA (community based assistance) to be released from the facility. Resident #1 said the social worker and the human resources representative would not tell her how much she owed the facility and she could not leave until she paid what she owed. The administrator moved her to a semi-private room after her Medicare days expired ([DATE]) without telling her or giving her a choice of available rooms and/or roommates. She said the DON and LVN R were mean and locked her in the secured unit overnight after she left the facility because she was angry and " just had to get away for a while." She said she planned to return to the facility on her own. Resident #1 said she knew she was [MEDICAL CONDITION], but did not deserve to be locked away from her possessions in the secured unit with highly confused residents. She said she was scared to sleep in the secured unit and sat on the sofa all night concerned for her safety if she fell asleep. Resident #1 said she would have been fine and obeyed the rules if she had been reminded of the sign out rule. She said the staff had treated her as a " two year old " instead of an adult. She said she was afraid that she would be retaliated against by the staff if she complained about being locked in the secured unit overnight. Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood, understands, had inattention and disorganized thinking fluctuating behaviors, no recall problems, and required supervision for transfers and walking in the corridor. A physician order [REDACTED].#1was to be moved to locked unit for safety resident left the facility without notification to staff or charge nurse. The comprehensive care plan dated [DATE] did not indicate Resident #1 was at risk to elope from the facility. The care plan indicated Resident #1 had adjustment issues related to the admission with the interventions to have an opportunity to communicate feelings regarding placement in a nursing home. During an interview on [DATE] at 9:03 a.m., the DON said she was notified that Resident # 1 missing and was in route to the facility. She said she advised the nursing staff to place Resident #1 on the secured unit. She said Resident #1 was in an argument with her room-mate earlier, had already taken her evening medications, and she felt the secured unit was where she needed to be placed. The DON said the facility had no other empty rooms. During an interview on [DATE] at 9:42 a.m., the SW said she was not aware Resident #1 was placed on the secured unit until she arrived on [DATE]. The SW said she explained to Resident #1 the policy and then released her from the unit at about 8:30 a.m. The SW said Resident #1 was very upset about being placed on the secured unit. During an interview on [DATE] at 10:45 a.m., Resident #1 said when she returned to the facility she was thrown in " lock down. " She said the staff chewed her out for two hours. Resident #1 said she was not being treated properly in the facility. Resident #1 said she left because she just , " needed a break. " During an interview on [DATE] at 11:10 a.m., RN U said Resident #1 being locked on the secured unit was not an appropriate intervention. She said a more appropriate intervention for Resident #1 would have been 1:1 monitoring. During an interview on [DATE] at 12:00 p.m., the administrator said she was notified that Resident #1 was being placed on the secured unit. She said she agreed that it was a good intervention and Resident #1 was only there 12 hours. The administrator said she had not considered 1:1 monitoring or a wander-guard bracelet. She said the secured unit was used for residents with dementia. Resident #1 does not have a [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:05 p.m., the physician said he was on call the night of [DATE]. He said he was not notified that Resident #1 had left the facility, nor did he give an order to place Resident #1 on the secured unit. During an interview on [DATE] at 2:20 p.m., LVN R said Resident #1 had been crying prior to leaving the facility. She said she was told by DON to place Resident #1 on the secured unit upon arrival back to the facility. She said Resident #1 was not allowed back to her room for her belongings. She said Resident #1 was escorted on the secured unit, provided a bed and offered a gown. LVN R said she did not call the physician for an order to place Resident #1 on the secured unit. During an interview on [DATE] at 4:05 p.m., Resident #1 said the SW made her sign a form to see a psychiatrist. She said the SW said everyone had to sign the form. Resident #1 said after asking other residents she learned no one else was made to sign the forms. Resident #1 said she had her own psychiatrist and would much rather continue using him. During an interview on [DATE] at 1:06 p.m., LVN V said she knew that involuntary seclusion was a form of abuse, and she had seen involuntary seclusion used with Resident #1. She said she was the charge nurse the morning of [DATE] for Resident #1. She said the SW released Resident #1 between 8:00 and 9:00 a.m. LVN V said she did not report the abuse. During an interview on [DATE] at 1:18 p.m., RN O said she was aware Resident #1 was on the secured unit. She said due to staffing could not do 1:1 interventions. During an interview on [DATE] at 2:10 p.m., CNA Y said she was working the night Resident #1 left the facility. She said Resident #1 was upset and voiced she was leaving. CNA Y said she reported this to LVN R. CNA Y said when she had been alerted of Resident #1 leaving the facility, she told LVN R that she told her the resident said she was leaving. CNA Y said Resident #1, upon return to the facility, was escorted to the unit. She said she heard Resident #1 saying, " don ' t put an ankle bracelet on me and don ' t lock me up. " CNA Y said she felt it was abuse to Resident #1, but did not report. During an interview on [DATE] at 3:00 p.m., LVN AA said she was aware Resident #1 was placed on the unit on [DATE]. LVN AA said 1:1 was not an option due to staffing. She said the staff were not in abundance on the evening shift and the night shift had even less. During an interview on [DATE] at 3:50 p.m., CNA J said she was working on [DATE] on the secured unit when Resident #1 was placed on the unit. CNA J said Resident #1 said she did not want to be on the locked unit. An interdisciplinary care plan dated [DATE] indicated Resident #1 had inappropriate/disruptive behaviors of leaving facility without notification, smoking against facility policy, and was demanding of staff. The objective of the care plan was Resident #1 would follow the procedure of the facility for 90 days. Approaches included: monitor behavior and try to determine cause, monitor for signs of escalating behavior and set guidelines and be consistent , redirect for more appropriate behaviors, explain what is expected of the resident in a firm, calm voice, monitor for changes in behaviors for worsening conditions, encourage to discuss the cause of disruptive behavior, explain the policies and reasons for compliance, contact medical doctor as needed and for the resident to reside in the secured unit for one night ( [DATE]) for personal safety. An elopement/wandering assessment tool dated [DATE] indicated Resident #1 was physically able to leave the building on her own, she had resided in the facility less than 90 days and was able to sign herself out for therapeutic leave. The assessment tool indicated if Resident #1 was not disoriented to place, and was able to sign herself out then she was not deemed an elopement risk. An incident/accident report dated [DATE] at 8:00 p.m., indicated Resident #1 left the facility without notification and was found at the convenience store by staff the resident had no injuries. An investigation follow up dated [DATE] indicated Resident #1 was not found in the facility on rounds. The facility staff located Resident #1 at the convenience store. The past interventions were documented as attempted explanation of facility procedures. New interventions were to place Resident #1 on the secured unit overnight for own safety. The social worker was to follow up on [DATE] with discussion about the policies. A witness statement dated [DATE] indicated that upon return to the facility, Resident #1 was escorted to the locked unit until the DON arrived. A nursing note dated [DATE] at 9:00 p.m. indicated Resident #1 was back at the facility without injuries, her cigarettes and matches were taken away, and she was put in the locked unit. A social service progress note dated [DATE] indicated the SW informed Resident #1 of the policy and procedure for leaving the facility. The note indicated the SW explained that continued non-compliance could result in discharge. During an interview on [DATE] at 9:26 a.m., Resident #1 said she told staff on the night she left, that she was tired of being there, and was going to leave. She said she got a ride down to the store. Resident #1 said she " feels like the facility staff treated her like a child. " Resident #1 said she was not allowed to smoke while she was in "lock down." A Missing Patient Guidelines dated ,[DATE] indicated when the patient is located, place the patient on 1:1 observation to prevent further wandering, or exit seeking until a full review is completed by a physician and the care plan was reviewed and revised. The administrator refused to allow Resident #1 to keep her dog although the facility's pet policy allowed it. During an interview on [DATE] at 12:00 noon, the administrator said Resident #1 was discovered missing from the facility on [DATE] and staff initiated normal elopement protocol. The administrator said she agreed with staff that placing Resident #1 on the secured unit for the night was a good intervention because she did not have enough staff to provide one on one oversight with her. The administrator said she retrieved Resident #1's dogs from the resident's apartment and found homes for them since the length of Resident #1's stay at the facility was uncertain. The administrator said she kept the female dog Resident #1 had asked not to be given away. The administrator said when Resident #1 discharged , she would give her the female dog, but that pets were contraindicated in a nursing facility for safety reasons; because residents with behaviors went in and out of rooms. 3. Physician orders [REDACTED].#7 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. admission orders [REDACTED]. During an interview on [DATE] at 10:30 a.m., Resident #7 said he was mentally stressed worrying over a bill incurred at the facility. He said his physician only wanted him admitted long enough to have testing in order to return home with a breathing machine. Resident # 7 said he had an appointment for a sleep test on [DATE] that was cancelled by the facility. He said he was told that there was an emergency that afternoon and the facility cancelled his appointment. Resident #7 said his appointment was reset by the facility for [DATE]. He said since he has had to reside in the facility longer awaiting his appointment he had a bill of $1153.00. During an interview on [DATE] at 11:00 the BOM said Resident #7 as of [DATE] owes the facility $1153.00 his applied income. She said she had discussed with him the billing. The BOM denied setting up payment arrangements. She said Resident #7 as of [DATE] was on his 21st day in the facility in which he as a Medicare and Medicaid resident therefore would be charged his applied income. During an interview on [DATE] at 9:30 a.m., CNA HH said he was driving the van on [DATE] and he received a call to change his driving plans deleting Resident #7's schedule and adding a new Resident pick up at a hospital in Tyler, Texas. CNA HH said he does not cancel or schedule appointments. During an interview on [DATE] at 9:45 a.m., Medical Records GG said she and the ADONs participate in the scheduling. She said she did not cancel Resident # 7's sleep study appointment. Medical Records GG said she documented the trip to Tyler for another Resident on the [DATE] calendar and has Resident # 7 scheduled again for his sleep study on [DATE] at 7:00 p.m. During an interview on [DATE] at 9:55 a.m., ADON P (acting DON) said she was aware Resident # 7 was admitted to wait for testing for a [MEDICAL CONDITION] machine to go home. She said missed his appointment because the van had to pick up a new resident coming from a Tyler hospital. She said when the hospital calls that the resident has discharge we have to pick them up. ADON P said administration and corporate makes the decision to cancel appointments to have admissions. ADON P said she understood how incurring a large bill for a missed appointment would be stressful. During an interview on [DATE] at 7:00 p.m., the SW said she had not assisted Resident #7 in obtaining an earlier appointment or assisted with his financial burden prior to the survey. The undated Admission agreement indicated the resident has a right to be free from verbal, sexual, physical, or mental abuse, corporal punishment and involuntary seclusion. An Abuse Prohibition Policy and Procedure dated ,[DATE] denoted residents had the right to be free from abuse and neglect. The Abuse policy defines neglect as a deprivation of life's necessities of food, water or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. The undated Admissions Agreement denoted the resident has a right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. The admission agreement section Seclusion indicated involuntary seclusion was not permitted in this facility. The section on Resident Rights indicated the resident has a right to be free from abuse and be free from any physical or chemical restraints imposed for the purpose of discipline or convenience. The Abuse Prohibition Policy and Procedure revised [DATE] indicated the following: *Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion...The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services will be notified in accordance with federal and state law; *information would be provided to inform residents, staff and agencies whom they could report concerns, incidents and grievances without fear of retribution; *the administrator or designee would be responsible to provide feedback regarding concerns; *identify residents whose personal histories render them at risk for abusing other residents; *the facility would be proactive in identifying events and occurances that may contribute to abuse or neglect; *review incident reports and complete an investigation report to determine if such things contributed to abuse; *the facility must have evidence all violations, including allegations were throughly investigated; *if alleged violation was verified, the appropriate corrective and disciplinary action would be taken; *the administrator or designee would be assigned throughout the investigation to follow-up with the person or persons involved with the concern, incident or grievance; *incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies; *all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately; *the charge nurse or supervisor must immediately contact the administrator or the DON of the incident; *the nurse must document all incidents of alleged abuse/neglect on the incident report and on the 24 hour report; *the administrator or designee would analyze occurances to determine what changes, if any, would be needed to policies and procedures to prevent further occurances; *involuntary seclusion - separation of a resident from others or from his room against the resident's will or the will of the resident's legal representative; *mental/psychosocial abuse - mistreatment within the definition of abuse not resulting in physical harm, including, but not limited to humiliation, harassment, threats of punishment, deprivation or intimidation; *sexual abuse - any touching or exposure of the anus, breast, or any part of the genitals of a resident; *verbal abuse- the use of any oral, written, or gestured language which includes disparging or derogatory terms to a resident within the resident's hearing distance, regardless of the resident's age, ability to comprehend or disability; *allegation - a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident property; *mistreatment- any degrading body language or verbal communication; and *neglect- failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental/anguish/illness or physical injury, or harm or death to the resident. The CMS 672 dated [DATE] indicated a census of 80 residents.

Based on interview and record review the facility failed to consult the physician regarding a significant change in condition for 1 of 3 residents reviewed for physician notification. Resident #1 had a history of [REDACTED]. The facility did not consult with the physician and the family when Resident #1's surgical site had copious amounts of thick green colored drainage on 10/19/12. Resident #1 was admitted to the hospital 10/22/12 with an infection that required possible amputation of her left leg. This failure contributed to Resident #1 being admitted to the hospital for an infection at a surgical site and could place 5 residents with wounds at risk of a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 was alert and able to make her needs known. She required assistance of two staff for transfers. Physician orders [REDACTED]. The orders required staff to monitor sutures to both of Resident #1's groin area every shift for signs/symptoms of infection. A care plan dated 10/9/12 indicated the staff would assess Resident #1's incision for redness, [MEDICAL CONDITION], drainage and approximation (tissue surfaces close together) every shift. The care plan interventions included notification of the physician and family of any changes. The nursing notes dated 10/19/12 for Resident #1 indicated the following: *4:10 p.m., Resident #1 had drainage to her left incision site from a surgical procedure. The notes indicated the incision site was cleaned and a dry dressing was applied. The note read, "Called physician's office that performed the surgery (bilateral femoral bypass) unable to contact physician". *5:00 p.m., called the physician's office again without success. *5:20 p.m., attempted the physician again without success. *10:00 p.m., Resident #1's left groin and dressing to area were "very wet" with a large amount of clear drainage from the site. The area was open where the sutures were and yellow slough was visible. The site was about 4.2 x 3 cm with a depth of 1 cm. The note indicated the area was cleaned area with normal saline and calcium alginate (A wound dressing used to manage drainage in partial to full-thickness wounds) and a dry dressing was applied. The note indicated an attempt to call the on call physician was made without success. The note indicated Resident #1 said the area was tender when touched. An untimed nursing notes dated 10/22/12 indicated Resident #1 was admitted to the hospital. A hospital history and physical dated 10/22/12 indicated Resident #1 was a [AGE] year old woman who had limb-threatening ischemia and was status [REDACTED]. She was initially doing well but then developed onset of sersanguinous (composed of serum and blood) drainage from her wound. She presented to the hospital with evidence of an exposed segment of her graft in her left groin with obvious infection. She was taken to the operating room and underwent a resection of the portion of her graft which appeared to be grossly infected. An "Associate Memorandum" form dated 10/24/12 indicated on 10/19/12 RN C was notified of a skin concern for Resident #1. The form indicated RN C failed to assess the area when it was reported to her. The form indicated RN C cared for Resident #1 three days after she first looked at the surgical area and still did not complete an assessment. During an interview on 11/5/12 at 10:35 a.m., the DON said "we neglected Resident #1 all weekend and she will probably lose her leg". She said the staff did not notify the family and said they could not get in contact with a physician. During an interview on 11/5/12 at 1:55 p.m. RN C said the nurse responsible for treatments called her to Resident #1's room [ROOM NUMBER]/19/12 to look at her groin area. RN C said the resident had a small area of her groin with yellowish/white drainage that she considered a moderate amount. She said she told the nurse to contact the physician and assumed she called. RN C said when she returned to work she did not assess the resident because she thought the situation was resolved. During an interview on 11/5/12 at 3:30 p.m. LVN A said when she assessed Resident #1's groin area at 10:00 p.m. on 10/19/12; the bandage was soaked with clear drainage. She said she attempted to notify the physician several times with no response. LVN A said she attempted to contact the surgeon who had performed the surgery however later learned she had the wrong surgeon. LVN A said she wrote an order to cleanse groin area with normal saline, pat dry, apply calcium alginate, cover twice a day and as needed without consulting with a physician. During an interview on 11/5/12 at 2:45 p.m., RN B said she was the weekend supervisor and did not receive any reports of a change in condition regarding Resident #1. RN B said she followed the orders and cleansed the resident's left groin area and applied the dressing. She said the area looked like a small amount of "snot" with no redness or odor. RN B said she was not aware another nurse had written the order and was not aware the physician had not been notified. The undated Condition change of the resident (observing, recording, and reporting) policy indicated the following: Purpose: To observe, record, and report any condition change to the attending physician so proper treatment will be implemented. Procedure: after all resident falls, injuries or condition changes contact the attending physician or designee. If attending physician fails to respond within five minutes, contact again. If still no response, contact the medical director. If no response from the medical director within five minutes, send the resident to the nearest emergency room for evaluation. During an interview on 11/5/12 at 9:00 a.m. the treatment nurse said 5 residents had wounds.

Based on interview and record review the facility failed to provide care and services according to the plan of care to maintain the physical well-being for 1 of 3 residents reviewed for assessment. Resident #1 had a history of [REDACTED].#1's surgical site after large amounts of thick green colored drainage was identified on 10/19/12. Resident # 1 was admitted to the hospital 10/22/12 with an infection and possible amputation of her left leg. This failure contributed to Resident # 1 being admitted to the hospital for an infection at a surgical site and could place 5 residents with wounds at risk of a delay in medical evaluation and treatment. Findings Included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 was alert and able to make her needs known. She required assistance of two staff for transfers. Physician orders [REDACTED]. The orders required staff to monitor sutures to both of Resident #1's groin area every shift for signs/symptoms of infection. A care plan dated 10/9/12 indicated the staff would assess Resident #1's incision for redness, [MEDICAL CONDITION], drainage and approximation every shift. The care plan interventions included notification of the physician and family of any changes. The nursing notes dated 10/19/12 for Resident #1 indicated the following: *4:10 p.m., Resident #1 had drainage to her left incision site from a surgical procedure. The note indicated the incision site was cleaned and a dry dressing was applied. The note read, "Called physician's office that performed the surgery (bilateral femoral bypass) unable to contact physician". The note did not include an assessment of the amount, color or odor of the drainage or the tissue surrounding the wound. *5:00 p.m., called the physician's office again without success. There was no assessment of the wound documented. *5:20 p.m., attempted the physician again without success. There was no assessment of the wound documented. *10:00 p.m., Resident #1's left groin and dressing to area were "very wet" with a large amount of clear drainage from the site. The area was open where the sutures were and yellow slough was visible. The site was about 4.2 x 3 cm with a depth of 1 cm. The note indicated the area was cleaned area with normal saline and calcium alginate (A wound dressing used to manage drainage in partial to full-thickness wounds) and a dry dressing was applied. The note indicated an attempt to the on call physician was made without success. The note indicated Resident #1 said the area was tender when touched. *10:45 p.m., dressing to left groin was clean, dry, and intact. The nursing notes dated 10/20/12 indicated the following: *7:30 a.m., Resident alert, oriented denied any needs. Treatment done sutures intact. The note did not include an assessment of the area. *8:00 p.m., resting quietly, no distress, dressing clean, dry, and intact. The nursing notes dated 10/21/12 indicated the following: *12:05 a.m., dressing clean, dry, and intact. *7:00 a.m., left groin area open with dressing clean, dry, and intact, treatments completed. The nursing notes dated 10/22/12 indicated the following: *12:05 a.m., Resident #1 resting in bed, dressing clean, dry, and intact with no signs/symptoms of distress. *6:30 a.m., Resident # 1 status [REDACTED]. Resident had appointment with physician for follow up status [REDACTED]. *untimed - Resident admitted to hospital. A hospital history and physical dated 10/22/12 indicated Resident #1 was a [AGE] year old woman who had limb-threatening ischemia (insufficient supply of blood) and was status [REDACTED]. She was initially doing well but then developed onset of sersanguinous (composed of serum and blood) drainage from her wound. She presented to the hospital with evidence of an exposed segment of her graft in her left groin with obvious infection. She was taken to the operating room and underwent a resection of the portion of her graft which appeared to be grossly infected. Hospital lab work dated 10/22/12 indicated Resident #1's WBC (white blood cell count) was elevated at 13.5. The reference range was (3.8-10.6). An "Associate Memorandum" form dated 10/24/12 indicated on 10/19/12 RN C was notified of a skin concern for Resident #1. The form indicated RN C failed to assess the area when it was reported to her. The form indicated RN C cared for Resident #1 three days after she first looked at the surgical area and still did not complete an assessment. During an interview on 11/5/12 at 10:35 a.m., the DON said "we neglected Resident #1 all weekend and she will probably lose her leg". She said the staff did not notify the family and said they could not get in contact with a physician. During an interview on 11/5/12 at 1:55 p.m. RN C said the nurse responsible for treatments called her to Resident #1's room [ROOM NUMBER]/19/12 to look at her groin area. RN C said the resident had a small area of her groin with yellowish/white drainage that she considered a moderate amount. She said she told the nurse to contact the physician and assumed she called. RN C said when she returned to work she did not assess the resident because she thought the situation was resolved. During an interview on 11/5/12 at 3:30 p.m. LVN A said when she assessed Resident #1's groin area at 10:00 p.m. on 10/19/12; the bandage was soaked with clear drainage. She said she attempted to notify the physician several times with no response. LVN A said she attempted to contact the surgeon who had performed the surgery however later learned she had the wrong surgeon. LVN A said she wrote an order to cleanse groin area with normal saline, pat dry, apply calcium alginate, cover twice a day and as needed without consulting with a physician. During an interview on 11/5/12 at 2:45 p.m., RN B said she was the weekend supervisor 10/20 and 10/21/12. She said she and did not receive any reports of a change in condition regarding Resident #1. RN B said she followed the orders and cleansed the resident's left groin area and applied the dressing. She said the area looked like a small amount of "snot" with no redness or odor. RN B said she was not aware another nurse had written the order and was not aware the physician had not been notified. The undated Condition change of the resident (observing, recording, and reporting) policy indicated the following: Purpose: To observe, record, and report any condition change to the attending physician so proper treatment will be implemented. Procedure: after all resident falls, injuries or condition changes contact the attending physician or designee. If attending physician fails to respond within five minutes, contact again. If still no response, contact the medical director. If no response from the medical director within five minutes, send the resident to the nearest emergency room for evaluation. During an interview on 11/5/12 at 9:00 a.m. the treatment nurse said 5 residents had wounds.