Every finding on record at Sundance Inn Health Center

Based on interviews and record reviews, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 86 residents (Resident #1) reviewed for opioid medication administration. Upon Resident #1's admission on [DATE], the facility failed to monitor Resident #1 for adverse effects associated with prescribed opioid medication, including oversedation, lethargy, respiratory depression and/or shortness of breath, resulting in Resident #1 becoming lethargic and difficultto arouse. This failure could place residents at risk for opioid adverse reactions which could include overdose.The findings included: A record review of Resident #1's admission record, dated 8/20/2026, revealed Resident #1 was an [AGE] year-old male admitted on [DATE] with diagnoses which included rib fractures, hemiplegia and hemiparesis (paralysis on one side of the body, and left side hemiparesis means weakness or partial loss of strength on one side of the body). A record review of Resident #1's physicians orders dated 8/19/2026 revealed on 8/13/2026 the physician prescribed for Resident #1 to receive hydrocodone - acetaminophen 7.5mg / 325mg (a narcotic / opioid drug) every 6 hours for pain. Further review revealed no orders for monitoring adverse reactions for narcotic / opioid medication administration. A record review of Resident #1's care plan dated 8/20/2026 revealed nursing focus and interventions dated 8/13/2026 for Pain Management. The care plan failed to include monitoring for adverse reactions for the narcotic opioid medications administered. During an interview on 8/18/2026 at 1:00 PM Resident #1's Representative stated Resident #1 was over sedated during his 4 days stay at the facility and became lethargic and sleepy and could not receive physical therapy. Resident #1's Representative stated Resident #1 was over sedated because the nurses were administering his pain drug every 6 hours for 4 days when on the morning of the fourth day he was so out of it he could not wake up to eat or participate in physical therapy. During an interview on 8/19/2026 at 4:00 PM LVN A stated she was the charge nurse on 8/13/2026 who admitted Resident #1 to the facility. LVN A stated she received an order from the physician to administer Resident #1's hydrocodone / acetaminophen 7.5mg / 325mg, 1 pill every 6 hrs. to control Resident #1's pain related to his broken ribs. LVN A stated she had not secured an order for monitoring for adverse reactions of opioid narcotic drug administration. LVN A stated nurses were not monitoring adverse reactions of sedation directly but were assessing for resident #1's overall well being by skilled nursing assessments every shift which included vital signs. During an interview on 8/20/2026 at 2:00 PM the DON and the ADON stated Resident #1 was admitted for rehabilitative care after hospitalization for broken ribs he received after a fall at home. The DON and the ADON stated Resident #1 was prescribed an opioid drug to control his pain, however the admitting nurse failed to secure an order for monitoring adverse reactions for the opioid drug. The DON and the ADON stated the Medical Director had put in place standing orders for residents who received narcotics / opioids to be monitored for adverse reactions, which could include sleepiness, lethargy, or shortness of breath, but the nurse did not add those orders to Resident #1's orders. The DON and the ADON stated the potential risk for residents who received opioids without monitoring for adverse reactions could be residents may not receive the intended effects of their prescribed medications. During an interview on 8/21/2026 at 10:30 AM The Medical Director stated that his expectation was for each resident who was prescribed an opioid to be monitored for adverse reactions related to the opioid administration. The Medical Diirector stated potential adverse reactions could include shortness of breath, over sedation, respiratory depression, any of which could rise to the level of the resident needing interventions which could range anywhere from cessation of the drug to emergency medical services. A record review of the American Nurse Journal article titled Preventing complications in patients receiving opioids dated 12/11/2023,https://www.myamericannurse.com/preventing-complications-in-patients-receiving-opioids/accessed 8/20/2026, revealed, Do you know what opioid-naive means? What about opioid-tolerant? If you don't know the definitions of these terms, you need to learn them-because a patient's history of opioid use (or lack thereof) has important implications for nursing care. (See the box below.) This article defines these terms, describes the dangers of oversedation (especially in opioid-naive patients), and tells how to assess patients receiving opioids. Identifying high-risk patients . age older than 60 (the risk is 2.8 times greater from ages 61 to 70, 5.4 times greater from ages 71 to 80, and 8.7 greater times after age [AGE]), postoperative status (particularly after upper abdominal or thoracic surgery) . Checking the arousal level, Your patient's arousal level may give a false sense of security. Respiratory depression may occur even with a reasonably normal arousal level. After arousal, patients on opioids may appear to be breathing at a normal rate and able to respond appropriately to questions-yet may be over sedated. So, if the patient appears to be sleeping or resting comfortably, be sure to check arousability. (But don't check it from the hallway by peeking into the patient's room. This isn't an acceptable standard of care. Go into the room and perform the assessment.) . A record review of an education online medical research platform https://www.ovid.com/jnls/nursing/abstract/10.1097/01.nurse.0000268748.58433.6a~10-tips-on-safe-opioid-administration?redirectionsource=fulltextviewTitled 10 TIPS ON SAFE OPIOID ADMINISTRATION accessed 8/20/2026 revealed, Errors with opioids lead to serious adverse events, including allergic reactions, failure to control pain, over sedation, respiratory depression, seizures, and death. nurses are key to error prevention. Adopting these practices helps you fulfill your essential role: . establish guidelines for appropriate patient monitoring, including frequently assessing respiration quality (not just rate) and looking for specific signs of over sedation. A record review of the facility's policy dated December 2025 titled Pain Management revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Pain management and treatment: . factors influencing the choice of treatments include: . potential benefits, risks and adverse consequences of medications .

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (1) of five (5) residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's fracture (a broken bone), diagnosed 06/27/2026, was added to his diagnosis list. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #1's admission Record, dated 07/16/2026, revealed an [AGE] year-old male. He was admitted to the facility on [DATE]. MD B was listed as Resident #1's primary physician and NP C was listed as one (1) of two (2) of Resident #1's Nurse Practitioners. Record review of Resident #1's Medical Diagnosis tab, undated and accessed 07/16/2026 at 12:18 p.m., revealed diagnoses including orthostatic hypotension (low blood pressure when standing up from sitting or lying down), other reduced mobility, and repeated falls. A fracture diagnosis was not noted on the list. Record review of Resident #1's admission MDS Assessment, dated 06/20/2026, revealed Resident #1 had a BIMS score of 00, indicating he was severely cognitively impaired. He required partial/moderate assistance when transitioning from sitting to standing, getting on and off a toilet, and when walking. He used a wheelchair or scooter. He had a fall in the last month prior to his admission but had not had a fall since his admission. Record review of Resident #1's Order Summary Report, dated 07/16/2026, revealed the following order summary with order status, order date, start date, and end date if noted:- monitor left ribs for pain r/t fracture every shift monitor for bruising and deformities, notified [sic] PCP if changes, noted as active, order and start date of 06/29/2026, and no end date. Record review of Resident #1's Care Plan, undated accessed 07/16/2026 at 12:51 p.m., revealed the following focuses:- The resident is at risk for falls .actual fall 6/27/26 with rib fracture ., date initiated 06/15/2026 and date revised 07/16/2026.- [Resident #1] has a # 9 [sic] rib fracture and hx of Fx [sic] r/t previous Fall outside of facility., date initiated and revised 06/30/2026. Record review of Resident #1's Progress Notes, revealed:- dated effective 06/27/2026 at 06:17 p.m. by LPN A, Resident returned to facility, closed fracture of Rib [sic] of left side .- dated effective 06/29/2026 at 11:59 p.m. with signed date noted 06/30/2026 at 05:56 p.m. by NP C, under HPI Relating to this Visit, .Patient was sent to ER via EMS from [Facility name] on 06/27/2026 after a witnessed fall from his chair .Following the fall, he sustained a left ninth rib fracture with minimal displacement . Under Diagnoses, .Fracture of one rib, left side, subsequent encounter for fracture with routine healing . Record review of Resident #1's document titled Fracture/Major Injury, dated 06/29/2026 at 10:43 a.m., revealed the date and time of incident, 06/27/2026 at 01:05 a.m. with Major Injury of b. Fracture(s), Fracture Type noted as b. Traumatic, and Injury location noted as left 9th rib fracture with deformity. Record review of Resident #1's Hospital Clinical document, dated printed 06/27/2026 at 09:55 a.m. included:- a document titled After Visit Summary, revealed under Problem List as of 6/27/2026, Closed fracture of rib of left side, dated 6/27/2026 - Present. - a document titled H&P - H&P Note (continued), revealed under CT [a medical imaging technique that creates a detailed image of the body] Chest Wo Contrast, result date noted as 06/27/2026, Impression: Recent appearing posterior [pertaining to the back of the body or a part] left 9th rib fracture deformity with minimal displacement ., noted as signed by a physician on 06/27/2026 at 03:01 a.m. Record review of Resident #1's Misc tab, undated accessed 07/16/2026 at 05:43 p.m., revealed Resident #1's Hospital Clinical document was uploaded on 06/27/2026 at 09:50 a.m. Attempted observation and interview on 07/16/2026 at 11:01 a.m. of Resident #1. Resident #1 was in a therapy session and unavailable for interview. Attempted telephone interview on 07/16/2026 at 04:13 p.m. with NP C. NP C was not accepting calls that that time. Attempted telephone interview on 07/16/2026 at 04:16 p.m. with MD B. A request for return call with contact information was left with an office staff member; however, a reply was not received. The office staff member stated she would also leave a message with NP C, who worked with MD B. Attempted telephone interviews on 07/16/2026 at 04:33 p.m. and 06:28 p.m. with LPN A. A request for return call with contact information was left for each attempt; however, a return call was not received. During an interview on 07/16/2026 at 04:56 p.m., the Senior DON stated she was not sure on the procedure for the facility, but it was typically the responsibility of the nursing staff to enter the resident's diagnoses into their record. She stated she did not know why Resident #1's fracture was not on the diagnosis list, but it was care-planned. She stated she did not believe the lack of the diagnosis would have delayed Resident #1's care because all staff received training and were notified of Resident #1's fall, so they were all aware of his fracture. She stated she would have to ask the DON, but it was usually the nurse managers that were responsible for entering a diagnosis for an acute change. During an interview on 07/16/2026 at 05:33 p.m., the DON stated for an acute change, the nursing staff were responsible for entering in a resident's new diagnosis. He stated, because everything else was in place, including Resident #1's doctor having been aware of Resident #1's fracture and documented in the doctor's notes, the fracture was care-planned, and there was an order in place for monitoring Resident #1 for pain and discomfort, there was not an impact in Resident #1's care from the diagnosis having not been entered. The DON stated he would have considered Resident #1's fracture as an acute change for him. During an interview on 07/16/2026 at 06:04 p.m., the ED stated she did not believe the diagnosis having not been entered into Resident #1's diagnosis list would have impacted his care because everyone was aware that he had the fracture. She stated there was NP documentation of the fracture and an order for monitoring the area (of Resident #1's body). She stated she also believed the fracture was care-planned. Attempted telephone interview on 07/16/2026 at 06:16 p.m. with Resident #1's family member. Resident #1's family member did not answer and did not return call. Record review of policy titled Change of Condition Policy, dated implemented 10/01/2025, revealed Procedure: When a change in condition occurs, the Licensed Nurse will:1. Evaluate the signs and symptoms the Resident is experiencing and collect pertinent information to report to the Physician on the Resident's status. C. Review Resident history and diagnosis, if indicated.

Based on interviews and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and the facility failed to provide the notice of transfer or discharge required at least 30 days before the resident is transferred or discharged or provide notice as soon as practicable before transfer for 3 of 3 residents (Residents #1, #2, and #3) reviewed for Discharge Rights.The facility failed to give the representative of Resident #1 written documentation at least 30 days prior to discharge which informed them of the facility-initiated decision to discharge the resident and the right to appeal.The facility failed to give the representative of Resident #2 written documentation at least 30 days prior to discharge which informed them of the facility-initiated decision to discharge the resident and the right to appeal.The facility failed to give the representative of Resident #3 written documentation prior to discharge which informed them of the facility-initiated decision to discharge the resident and the right to appeal.This failure could affect residents who are discharged from the facility and could place them at risk of having their discharge rights violated. Findings included: Record review of Resident #1's admission Record dated 04/29/26 documented an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-ST elevation (NSTEMI) myocardial infarction (type of heart attack), unspecified protein-calorie malnutrition (condition where patient suffers from deficient protein and caloric intake), acute respiratory failure with hypoxia (critical condition where the lungs cannot adequately oxygenate the blood), benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate) and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a stage of memory impairment that requires more assistance with daily activities but are not yet in fully dependent stage).Record review of Resident #1's discharge MDS dated [DATE] indicated a BIMS score of 8 which reflected moderate cognitive impairment. Record review of Resident #1's SLUMS Examination dated 03/19/26 revealed a score of 8 out of 30 indicating the presence of dementia. Record review of Resident #1's Care Plan included focuses of The resident is resistive to care (taking medications/injections), ADL assistance with a date initiated of 03/10/26; and The resident expresses a wish to be discharged to [FACILITY] for elopement risk and wandering to ensure resident has a safe environment with a date initiated of 03/30/26. During an interview with FM A on 04/29/26 at 8:55 am, the concern was expressed that Resident #1 had been in another LTC facility for rehabilitation and a catheter was placed due to urinary issues. Resident #1 pulled out his catheter so it was not replaced but the family was afraid that he still had urinary issues such as an infection which might be causing his restlessness and wandering. FM A also expressed concern about his medications and wanted the facility to have the doctor review and possibly change Resident #1's medications to assist with his anxiety. FM A also stated that she received a call from the facility that Resident #1 had tried going to the exit doors although he had never wandered before. FM A told the facility social worker that she was leaving the country to go on vacation for a few weeks and was told that he would be fine until she returned. After FM A left for her vacation, she received a call from the facility saying Resident #1 would be moved to another facility with a secure unit. No notice was given for this move. FM A stated they got the local Ombudsman involved and she told the facility not to move him. Resident #1 was sent to another facility in another city in spite of the objection of the Responsible Parties, FM A and FM B. During a telephone interview with the Ombudsman on 04/29/26 at 9:29 am, she stated that at the end of March she was notified that the facility was working with Resident #1 who was starting to wander. The Ombudsman stated she received calls from both of Resident #1's Responsible Parties who told her they did not want him to move until FM A was back in town. The Ombudsman stated she emailed the facility and told them they needed to provide a notice and not to move him. The facility then gave a handwritten notice to the family and Ombudsman the day before he was moved which did not provide a 30 day notice or give a reason for immediate discharge. The Ombudsman sent the notice to the State Office to appeal the decision. The facility told the Ombudsman they had spoken with FM B, the other Responsible Party, who lived out of town, and she at first told them to go ahead and send him but then sent an email early in the morning of the move and asked the facility not to move him until the family had time to consider all the options. The Ombudsman also stated the facility had taken a couple of other wandering residents and then wanted to discharge them. The Ombudsman stated she did receive a list of residents discharged each month. During a phone interview with FM B on 04/30/26 at 3:00 pm, FM B shared her concerns about the way Resident #1's discharge was handled. Since she lives in another city several hours away from the local area, she did not have the opportunity to visit other area facilities that could care for Resident #1. FM B also was concerned about the fact that Resident #1 was going to be driven halfway to the receiving facility by way of the facility's van and then transferred to the receiving facility's van and taken to the receiving facility. FM B felt this just added confusion to Resident #1 since he did not know anyone and did not understand where he was going. FM B said she tried to stop the discharge but it was already done by the time she talked with the ADM. After the discharge appeal was made, the ADM offered to bring him back to the facility and said she would do one to one care until there was a resolution. FM B stated she had asked about one to one care until FM A could return from out of town but was told the facility did not provide this service. FM B said she finally decided to just leave him at the new facility until she and FM A could determine if they should move him closer to one of them or leave him at the new facility. 2. Record review of Resident #2's admission Record dated 04/29/26 documented a [AGE] year-old female initially admitted to the facility 09/01/2019 with the most recent admission of 12/20/2025. The diagnoses included major depressive disorder (common mental health condition characterized by persistent, severe sadness, low energy and a loss of interest in activities), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things), cognitive communication deficit (a communication impairment resulting from underlying cognitive issues such as memory, attention, or executive function deficits), and peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels outside the heart and brain, commonly affecting legs and feet) and vascular dementia, senile degeneration of the brain (decline in thinking skills caused by conditions that block or reduce blood flow to the brain). Record review of Resident #2's Discharge MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #2's Care Plan with last revision date of 02/16/26, did not address any issues of wandering but did have a focus of Resident #2 has impaired cognition related to a diagnosis of vascular dementia, senile degeneration of the brain.) Interventions included Cue, reorient and supervise as needed, and Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. During a phone interview on 04/30/26 at 10:38 am with Resident #2's Responsible Party, FM C, FM C stated that the resident's issues started with her roommate. Resident #2 was upset about her roommate having a male resident visit in the room frequently. Resident #2 was moved to another room which was near the double doors that led to the lobby entrance of the facility which allowed her to be closer to the exit. On New Year's Eve Resident #2 went outside thinking she could see fireworks. The door locked behind her so she had to knock on the door and ring the doorbell to get back inside. The facility then considered this an elopement. FM C also stated that she had placed a camera in Resident #2's room so she could monitor how often staff came in to check on her. FM C reported that one time no one checked on her for 14 hours. FM C stated she had called in a complaint about this. FM C stated the facility told her that resident #2 needed to be in a secured unit due to her confusion and wandering. FM C stated that since Resident #2 knew why she wanted to go outside to watch fireworks, this was not wandering since she had a reason. The facility still insisted on her discharge so she was discharged to a facility in another town on 02/12/26 without any type of 30 Day or Prior Notice. FM C stated she was not impressed with the service at the new facility and moved Resident #2 to a local facility with a secure unit about a week later. 3. Record review of Resident #3's admission Record dated 04/29/26 documented an [AGE] year-old male admitted to the facility 04/16/26. The diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by systemic illness, organ failure, or chemical imbalances rather than a direct brain injury), altered mental status, unspecified (a sudden or gradual change in a person's baseline cognitive function, consciousness, or behavior), and dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (indicates significant cognitive decline and functional impairment without psychiatric complications). Record review of Resident #3's Discharge MDS dated [DATE] documented a BIMS score of 7 indicating severe cognitive impairment. Record review of the medical record indicated there was no Discharge Notice provided to Resident #3 or the Responsible Party. The facility had just documented they had talked with the Responsible Party who agreed to move Resident #3.Record review of Resident #3's Care Plan dated 04/16/26 had a Focus of Resident at risk for elopement with a Goal of Resident will not leave facility unattended through the review date. Interventions included Assess patient for elopement risk on admission, readmission, quarterly and with any significant changes, Distract resident from wandering by offering pleasant diversions.During an interview with the SW on 04/30/26 at 12:21 pm, all three of the above residents were discussed along with the reasons for discharge. The SW was asked about the discharge process and whether or not notices were given. The SW stated she met with families and if there was a concern about wandering, a care plan meeting was held to determine if the facility could meet the needs of the resident. If there was a behavioral issue, the nursing department was involved but, according to the SW, the facility cannot do one to one care except for a short time. The SW stated We are not a locked facility. We can provide med management through our contracted psychiatric provider. Regarding Resident #2, the SW stated that she had bad dementia and was pleasantly confused. Resident #2 didn't like her roommate but once she was moved she became more confused since she had depended on her roommate to remind her about what she was supposed to do and where to go. Resident #2 then began wandering more so we talked with her Responsible Party about this. The SW was asked if they gave a discharge notice to the resident and family and she said only the ADM or BOM were the ones to issue such a notice. The SW stated she was not sure about the discharge process. Regarding Resident #3, the SW stated that he was wandering from the day he came in. Resident #3 was also more combative and refusing care. We contacted the family and then provided clinicals to a local facility that had a secure unit. The SW stated she was not sure why Resident #3 had been accepted at this facility in the first place. Regarding Resident #1, the SW stated she was in contact with FM A. The SW stated When he started having behaviors, I told her that this environment wasn't good for him. I suggested a caregiver but she was out of town and couldn't do this. She also wanted him to have Haldol but we don't give that medication here. The SW stated they had a care plan meeting to discuss the concerns. Resident #1 was also put on psych services on 3/31/26 but his needs still could not be met. The SW stated she told FM A they could send him to a sister facility in another city that had a secure unit. FM A said to go ahead and send him and FM B changed her mind on the day he was to be transferred.During an interview with the ADM on 04/30/26 at 1:03 pm, she was asked about the admission, transfer and discharge process. The ADM stated the admissions team consisting of the ADM, ADONs, DON and BOM makes the decision about admitting. The ADM stated they don't always know about whether or not the resident wanders until they arrive. When it becomes evident they cannot meet the resident's needs they talk with the family about alternate placement. The ADM said they ask the family about what they want to do next. The ADM stated that if the family doesn't agree with the discharge plan then we give them a notice. The ADM stated If we see they are not going to be safe, then we talk with the family about the fact that we don't have a secured facility. The ADM stated that since all of the families of Resident #1, Resident #2 and Resident #3 were involved in the decision making process and where the resident was going to go, we didn't feel we needed to give them a written notice. The ADM stated they did give a notice to Resident #1, after a call from the Ombudsman, but acknowledged it was not given 30 days prior to discharge. No notices were given to the Residents or Responsible Parties for Residents #2 or #3. Record review of the Facility Transfer and Discharge Policy documented:The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:The specific reason and basis for transfer or discharge.The effective date of transfer or discharge.The specific location. to which the resident is to be transferred or discharged .An explanation of the right to appeal the transfer or discharge to the State.The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.Information on how to obtain an appeal form.Information on obtaining assistance in completing and submitting the appeal hearing request.The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge if effected because:The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident.d. A resident has not resided in the facility for 30 days.e. In these exceptional cases, the notice must be provided to the resident, resident's representative, if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge. 5. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 1 resident (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication consent form was completed on the most recent consent for antipsychotic or neuroleptic medication treatment for Seroquel (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder) and available in the resident's medical record. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.The findings include: 1. Record review of Resident #1's admission record revealed a female admitted on [DATE] with diagnoses that included metabolic encephalopathy, acute respiratory failure with hypoxia, bipolar disorder, and insomnia. Record review of Resident #1's discharge MDS, dated [DATE], revealed the resident's BIMS score was 13 (fully intact cognition). Record review of Resident #1's care plan, initiated 3/8/26, revealed the resident used psychotropic medications with interventions to administer psychotropic medications as ordered by the physician, monitor for side effects, and effectiveness every shift. Record review of Resident #1's order summary, dated 4/17/26, revealed an order for Seroquel 100 mg tablet, give 1 by mouth two times a day related to bipolar disorder, with a start dated of 3/8/26, and no end date. Record review of a document titled Psychoactive Medication Consent, dated 3/8/26, revealed Resident #1 consented to receive Seroquel 100 mg tablet by mouth two times a day. The document was digitally signed by LVN A and contained Resident #1's initials written at the bottom of the document. During an interview on 4/17/26 at 2:00 p.m. LVN A did not respond to attempts to interview. During an interview on 4/17/25 at 2:46 p.m. the SW stated nursing staff handled medication consents for the residents. During an interview on 4/17/26 at 3:10 p.m. the DON stated the charge nurses usually would complete medication consent for residents on admission. The DON stated she was unfamiliar with a 3713 form for consent of psychotropic medications. She stated the facility would not normally accept residents who were taking antipsychotic medications and were not aware of the required 3713 consent forms that were needed for resident #1's Seroquel. During an observation, interview, and record review on 4/17/26 at 4:45 p.m. the DON provided a different copy of Resident #1's Medication consent, dated 3/8/26. The form was version from September 2021-E and titled Consent for Antipsychotic or Neuroleptic Medication Treatment. The form revealed the resident was admitted with bipolar disorder. The form did not list the diagnostic criteria and assessment findings exhibited by Resident #1. The form stated Seroquel 100 mg twice a day per admission orders- home regime for the dosage and frequency. The form listed side effects of the medications. The form listed the need for the proposed treatment because the patient admitted to the facility with home regime treatment from the hospital, no changes made, managed by PCP, and treatment in place to treat bipolar disorder. The form had the provider's name typed out, the last name of the provider was crossed out, and a different last name was written in. Section II of the document contained Resident #1's initials and a date of 3/8/26. There was no printed name of Resident #1 in section II. The bottom of the form stated, the original copy of this form must be included the resident's clinical record, as required by. Record review of facility policy titled Maintenance of Electronic Clinical Records, implemented 10/1/2025, revealed .a complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized.electronic clinical records will contain at least, but are not limited to. pre-admission screening assessments and results with required signatures as required by state and federal regulations.each staff responsible for an attestation (electronic signature) has an individualized identifier.the date and time is recorded from the computer's internal clock at the time of entry.

Based on observation, interview, and record review, the facility failed to immediately inform or consult the physician and the resident's representative when there was a need to alter treatment for one (Resident #8) of three residents reviewed for physician notifications.1. The facility failed to ensure MA X and nursing staff alerted the physician that Resident #8 missed 7 doses of ear drop medication on 08/22/25 at 9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM and 08/23/25 at 9:00 AM, 12:00 PM, 5:00 PM.2. The facility failed to ensure LVN G notified the physician that Resident #8 had missed 2 doses of ear drop medication on 08/28/25 at 9:00 AM and 12:00 PM.This failure placed residents at risk of a delay in treatment, and a worsening of their condition.Findings included:Record review of Resident #8's Quarterly MDS assessment, dated 06/30/25, revealed Resident #8 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #8 had moderate cognition impairment with a BIMS score of 8. Resident #8 required supervision or touching assistance by staff for personal hygiene and partial assistance for shower/bathing. Resident #8 had adequate hearing reflecting no difficulty in normal conversation, social interaction or listening to the television. Active diagnoses included Renal Insufficiency (when both kidneys no longer work on their own), Non-Alzheimer's Dementia (memory loss), Hypertension (high blood pressure), Depression (mood disorder that causes persistent feeling of sadness and loss of interest), anxiety disorder (excessive worry or fear).Review of Resident #8's care plan, undated, revealed Resident #8 had a self-care performance deficit and required assistance with ADLs. Goal: Resident #8 will maintain current level of function. Intervention: Hygiene/Grooming required set-up to supervision/touching assistance. Bathing required supervision/touching to partial/moderate assistance. Record review of Resident #8's physician orders revealed:1. May have podiatry, dental, audiology, and ophthalmology consult as needed. No directions specified for order. Active 5/14/2025 2. Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Active 8/22/2025 09:00 Record review of Resident #8's progress notes written by LVN H revealed: 8/27/2025 08:24Orders - Administration NoteNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days8/23/2025 13:51Orders - Administration Note Written by Medication AideNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 DaysEar drops pending delivery from central supply.8/23/2025 13:50Orders - Administration Note Written by Medication AideNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 DaysEar drop on order pending delivery from central supply.8/22/2025 20:41Orders - Administration Note written by RN KNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days.8/22/2025 16:07 Orders - Administration Note written by RN KNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days.8/21/2025 21:58 Nursing- General Note written by LVN LNote Text: Received return call from [name of doctor] regarding left ear pain with some hearing loss. New orders received to include Cortisporin Otic Suspension 4 drops to the left ear four times daily for 7 days.8/21/2025 18:51Nursing- General Note written by LVN LNote Text: Resident reported left ear pain with difficulty hearing. Contacted [name of doctor] through Perfect Serve, awaiting physician response.Record review of Resident #8's medication administration record revealed a physician's order Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Start date 08/22/2025 0900 (9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM)On 08/22/25 Resident #8 received treatment at 9:00 AM, 12:00 PMOn 08/22/25 Resident #8 did not receive treatment at 5:00 PM, 9:00 PMOn 08/23/25 Resident #8 did not receive treatment at 9:00 PM, 12:00 PMOn 08/23/25 Resident #8 received treatment at 5:00 PM, 9:00 PMOn 08/24/25, 08/25/25, 08/26/25, 08/27/25 Resident #8 received treatment at 9:00 AM, 12:00 PM, 5:00 PM, 9:00 PMOn 08/28/25 the medication administration record indicated Resident #8 received treatment at 9:00 AM, 12:00 PMInterview and observation on 08/26/25 at 11:08 AM revealed Resident #8 in bed with something white sticking out her left ear, according to Resident #8 she had an earache for about a week. Resident #8 stated staff were applying drops 4 times a day, however Resident #8 felt that the treatment was not working. Resident #8 stated she had not finished the treatment so far and would report to the staff if she did not see an improvement after the treatment. Interview on 08/28/25 2:30 PM with MA X revealed Resident #8 had not been receiving ear drops due to central supply not delivering them yet. MA X stated she was not sure of what had been going on, but they were checking off on the MAR that it had been administered due to it popping up on the Medication administration; (staff did not clearly express why she would indicate as completed instead of on hold however, Resident #8 had not received drops. All ear drops had been placed on HOLD. MA X stated she reported to the ADON (on unknown date) the medication had not delivered . Attempted interview on 08/28/25 at 2:48 PM with LVN H was unsuccessful.Attempted interview on 08/28/25 at 2:52 PM with LVN I was unsuccessful. Attempted interview on 08/28/25 at 2:56 PM with ADON A was unsuccessful.Interview and observation on 08/28/25 at 3:10 PM with LVN G and the DON revealed LVN G confirmed she did not administer Resident #8 with ear drop medication and that she checked it as administered by mistake. LVN G stated she was not able to find the medication and needed to return to the medication administration record and make the correction. LVN G went to the medication cart and was able to locate the medication, while looking for the medication the DON stated Resident #8 had been administered the ear drop medication as ordered by the physician. LVN G had expressed to the DON that she could not find the ear drop medication earlier but had indicated she administered it on the medication administration record. The DON advised that the physician be notified. LVN G further explained the medication administration record indicated 4 additional missed dosed due to the medication being placed on hold due to not being delivered. The DON reiterated to LVN G to contact the physician to report all missed doses. According to the DON nursing staff was responsible for administering Resident #8's medication treatment for her earache according to the physician orders. The DON stated she was not able to explain why there were missed doses because the medication entered the facility on 08/22/25. Interview on 08/28/25 at 4:00 PM with LVN G stated she contacted the physician to notify him of the missed doses and was told to provide Resident with a dose at 3:30 PM and provided a new order to extend the dates of treatment to end on 08/30/25 at 5:00 PM. According to LVN G she was responsible for communicating with the physician on any missed doses to ensure Resident #8 completed treatment as ordered. LVN G stated not doing so placed Resident #8 at risk for continued ear infections. Record review of Resident #8's revised physician order revealed: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Active 8/23/2025 5:00 PM End 08/30/25Interview on 08/28/25 at 4:25 PM with the DON revealed she expected nurses to follow physician orders, and if there was a time when orders could not be followed or there was a delay with administering treatment it was the responsibility of nurses to call the physician and rectify the order and document results. The DON stated she was not aware Resident #8 had missed treatments, and stated she was not able to identify the reason for the missed doses but believed the medication had been in the building therefore there was no reason or documentation for those missed doses. The DON stated with today's missed treatment the LVN G should have fixed the medication administration record to reflect the dose was not given. The DON stated all staff should document accurately, not doing so placed residents at risk of delayed infections and allowing symptoms to become worse. Interview on 08/28/25 at 4:40 PM with the Physician revealed he expected the nursing staff to call him with any missed doses of mediation treatment. The Physician stated he was not sure if Resident #8 in fact had an ear infection however the mediation was provided as a prevention, he further stated Resident #8 would be ok with just a three-day dose however he extended the treatment to end on 08/30/25 at 5:00 PM. The Physician stated he did not see any risk to resident at this time. Review of the facility's Physician Orders policy revised February 2010 reflected: Responsibility of the Licensed Nurse staff for orders to be carried out as stated by the physician.

Based on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #8) of 3 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #8's missed doses of ear drops was documented accurately and completely on 08/22/25 and 08/23/25. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication or a delay in services.Findings included: Record review of Resident #8's Quarterly MDS assessment, dated 06/30/25, revealed Resident #8 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #8 had moderate cognition impairment with a BIMS score of 8. Resident #8 required supervision or touching assistance by staff for personal hygiene and partial assistance for shower/bathing. Resident #8 had adequate hearing reflecting no difficulty in normal conversation, social interaction or listening to the television. Active diagnosis included Renal Insufficiency (when both kidneys no longer work on their own), Non-Alzheimer's Dementia (memory loss), Hypertension (high blood pressure), Depression (mood disorder that causes persistent feeling of sadness and loss of interest), anxiety disorder (excessive worry or fear).Review of Resident #8's care plan, undated, revealed Resident #8 had a self-care performance deficit and required assistance with ADLs. Goal: Resident #8 will maintain current level of function. Intervention: Hygiene/Grooming required set-up to supervision/touching assistance. Bathing required supervision/touching to partial/moderate assistance. Record review of Resident #8's physician orders revealed:1. May have podiatry, dental, audiology, and ophthalmology consult as needed. No directions specified for order. Active 5/14/2025 2. Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium - used to treat outer ear infections caused by bacteria) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Active 8/22/2025 09:00 Record review of Resident #8's progress notes written by LVN H revealed:8/27/2025 08:24Orders - Administration NoteNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days8/23/2025 13:51Orders - Administration Note Written by Medication AideNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 DaysEar drops pending delivery from central supply.8/23/2025 13:50Orders - Administration Note Written by Medication AideNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 DaysEar drop on order pending delivery from central supply.8/22/2025 20:41Orders - Administration Note written by RN KNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days.8/22/2025 16:07Orders - Administration Note written by RN KNote Text: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/MLInstill 4 drop in left ear four times a day for Left Ear Pain for 7 Days.8/21/2025 21:58Nursing- General Note written by LVN LNote Text: Received return call from Dr. [NAME] regarding left ear pain with some hearing loss. New orders received to include Cortisporin Otic Suspension 4 drops to the left ear four times daily for 7 days.8/21/2025 18:51Nursing- General Note written by LVN LNote Text: Resident reported left ear pain with difficulty hearing. Contacted Dr. [NAME] through Perfect Serve, awaiting physician response.Record review of Resident #8's medication administration record revealed a physician's order Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Start date 08/22/2025 0900 (9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM)On 08/22/25 Resident #8 received treatment at 9:00 AM, 12:00 PMOn 08/22/25 Resident #8 did not receive treatment at 5:00 PM, 9:00 PMOn 08/23/25 Resident #8 did not receive treatment at 9:00 PM, 12:00 PMOn 08/23/25 Resident #8 received treatment at 5:00 PM, 9:00 PMOn 08/24/25, 08/25/25, 08/26/25, 08/27/25 Resident #8 received treatment at 9:00 AM, 12:00 PM, 5:00 PM, 9:00 PMOn 08/28/25 the medication administration record indicated Resident #8 received treatment at 9:00 AM, 12:00 PMInterview and observation on 08/26/25 at 11:08 AM revealed Resident #8 in bed with something white sticking out her left ear, according to Resident #8 she had an earache for about a week. Resident #8 stated staff were applying drops 4 times a day, however Resident #8 felt that the treatment was not working. Resident #8 stated she had not finished the treatment so far and would report to the staff if she did not see an improvement after the treatment. Interview on 08/28/25 2:30 PM with MA X revealed Resident #8 had not been receiving ear drops due to central supply not delivering them yet. MA X stated she was not sure of what had been going on, but they were checking off on the MAR that it had been administered due to it popping up on the Medication administration; (staff did not clearly express why she would indicate as completed instead of on hold however, Resident #8 had not received drops. All ear drops had been placed on HOLD. MA X stated she reported to the ADON (on unknown date) the medication had not delivered. Attempted interview on 08/28/25 at 2:48 PM with LVN H was unsuccessful.Attempted interview on 08/28/25 at 2:52 PM with LVN I was unsuccessful. Attempted interview on 08/28/25 at 2:56 PM with LVN J was unsuccessful. Interview on 08/28/25 at 3:10 PM with LVN G and the DON revealed LVN G confirmed she did not administer Resident #8 with ear drop medication and that she checked it as administered by mistake. LVN G stated she was not able to find the medication and needed to return to the medication administration record to make the correction. LVN G went to the medication cart and was able to locate the medication, while looking for the medication the DON stated Resident #8 had been administered the ear drop medication as ordered by the physician. LVN G had expressed to the DON that she could not find the ear drop medication earlier but had indicated she administered it on the medication administration record. The DON advised that the physician be notified. LVN G further explained the medication administration record indicated 4 additional missed dosed due to the medication being placed on hold. The DON reiterated to LVN G to contact the physician to report all missed doses. According to the DON nursing staff was responsible for administering Resident #8's medication treatment for her earache according to the physician orders. The DON stated she was not able to explain why there were missed doses because the medication entered the facility on 08/22/25. Interview on 08/28/25 at 4:00 PM with LVN G revealed she contacted the Physician to notify him of the missed doses at 9:00 AM and 12:00 PM on 08/28/25 and missed doses on 08/22/25 and 08/23/25. LVN G stated she was told to provide Resident with a dose at 3:30 PM on 08/28/25 and she was provided a new order to extend the dates of treatment until 08/30/25 at 5:00 PM. According to LVN G she and the administering nurses and medication aide was responsible for accurately documenting any missed doses. LVN G stated the ear infection medication for Resident #8 was received by LVN J on 08/23/25 during the 2:00 PM - 10:00 PM shift. LVN G stated the order should have been entered to start administration on 08/24/25 instead of 08/22/25 so that she could complete the full order. LVN G stated not doing so placed Resident #8 at risk for continued ear infections.Record review of Resident #8's revised physician order revealed: Cortisporin-TC Otic Suspension 3.3-3-10-0.5 MG/ML (Neomycin-Colistin-HC-Thonzonium) Instill 4 drop in left ear four times a day for Left Ear Pain for 7 Days. Active 8/23/2025 5:00 PM End 08/30/25Interview on 08/28/25 at 4:25 PM with the DON revealed she expected nurses to follow physician orders, and if there was a time when orders could not be followed or there was a delay with administering treatment it was the responsibility of nurses to call the physician, rectify the order and accurately document results. The DON stated with today's missed treatment the LVN G should have fixed the medication administration record to reflect the dose was not given. The DON stated all staff should document accurately, not doing so placed residents at risk of delayed infections and allowing symptoms to become worst. Review of the facility's Documentation of Medication Administration on eMAR/eTAR policy revised February 2010 reflected: Responsibility of the Licensed Nurse, Certified Nurse Assistant and Certified Medication Aide to provide proper documentation of medication administration and treatments in the medical record. Medications must be administered within the required time, within one hour the time in the eMAR/eTAR. Only the RN, LVN, or MA that removes the medication from the package may administer and document the medications, When removing a medication from the package, the RN, LVN or MA will electronically sign the eMAR/eTAR then administer the medication or the RN, LVN or MA will remove the medication from the package, administer the medication then initial the eMAR/eTAR. If the patient refuses or the mediation is not given due to other situations note in the eMAR/eTAR.

Based on observation, interview, and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 08/27/25) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal on 08/27/25 by providing the pureed trays with lemon pudding for dessert and the regular trays with a cherry cream cheese swirl brownie for dessert. This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life.Findings included:Record review of the facility's menu, dated 08/27/25, reflected for Wednesday (08/27/25) the following: Lunch-Open Face [NAME] Sandwich, Breaded Corn Nuggets, Marinated Vegetable Salad, Cherry Cream Cheese Swirl Brownie. Observation on 08/27/25 at 10:35 AM revealed that the [NAME] pureed rye bread, the [NAME] sandwich ingredients (pastrami, sour kraut, cheese, and thousand island dressing), creamed corn, and the vegetables. No cherry cream cheese brownie was pureed or served to residents who should have received pureed meals. Interview on 08/27/25 at 2:15 PM with the [NAME] revealed that puree meals should be the same as the regular meals. The [NAME] stated she was unaware of the desserts served because she only cooks the main courses. The [NAME] said that no one brought her a cherry cream cheese swirl brownie to puree. The [NAME] revealed both the regular diets and puree diets should be the same so that everyone gets the same flavors and nutrition. The [NAME] also stated that it was also important that staff received the same meals so that no one feels left out or different. The [NAME] said that different meals would create confusion both for the residents, because they would not understand why they could not eat the same as everyone else, as well as in the kitchen staff when preparing meals. The [NAME] revealed that it was important for residents who received puree meals to have the same variety as residents who received regular meals because it would increase their meal intakes. The [NAME] stated that if she knew something was not being served according to the menu, she would report it to the dietary manager. The [NAME] said that she was in-serviced recently on following the facility menu but did not recall the date. Interview on 08/27/25 at 2:22 PM with the Dietician revealed that all residents should receive the same items on the menu so that all residents receive a variety of flavor and tastes. The Dietician stated it was important for residents to receive the correct proteins and calories per the menu items for nutrition purposes. The Dietician also revealed if residents received different meals or menu items such as the lemon pudding instead of the cherry cream cheese brownie, then they could get upset because they would not understand why their food is different. The Dietician stated that it was the Dietary Manager's responsibility to ensure that the menus were followed and notify her if any substitutions were necessary. Interview on 08/27/25 at 2:39 PM with the Dietary Manager revealed that the pureed dessert was not the same as the regular dessert. The Dietary Manager stated that the facility policy was that all residents should have the same meals. The Dietary Manager acknowledged that the pureed dessert was lemon pudding, and the regular tray had a cherry cream cheese brownie as the dessert. The Dietary Manager stated she did not notice that the desserts were not the same on the puree tray and the regular tray that day. The Dietary Manager said it was her responsibility to ensure that the meals served were the same as on the menu. The Dietary Manager revealed it was important for puree meals to have the same items as the regular meals so that residents received the necessary calories and nutrients for their bodies. The Dietary Manager stated all substitutions should have been posted and approved by the dietician. The Dietary Manager said she in-serviced the dietary staff in June 2025 on following dietary menus. Record review of the facility's Puree Diet policy, revised, 03/2013, reflected: Policy: It is the policy of the facility to serve a puree diet that is nutritionally adequate and textually appropriate to the Patients. Procedures: 1. The Chef/Cooks must follow the Puree Diet as written on the Menu Guide Report (therapeutic diet spreadsheets). 2. The Regular Diet is followed as closely as possible to provide adequate nutrition.

Based on observation, interview, and record review, the facility failed to ensure a resident received foot care that was consistent with professional standards of practice and treatment to prevent complications from conditions such as diabetes and assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation for 1 (Resident #7) of 10 residents reviewed for foot care. The facility failed to provide Resident #7 assistance with foot care leaving his toenails to be about an inch long on both feet. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included:Record review of Resident #7's Quarterly MDS assessment, dated 06/30/25, revealed Resident #7 was a [AGE] year-old male admitted on [DATE]. Resident #7 had cognition intact with a BIMS score of 11. Resident #7 was dependent on staff for shower/baths. Active diagnoses included Diabetes Mellitus (high blood sugar), Non-Alzheimer's Dementia (memory loss), Hypertension (high blood pressure), Depression (mood disorder that causes persistent feeling of sadness and loss of interest).Review of Resident #7's care plan, undated, revealed Resident #7 had a diagnosis of chronic venous insufficiency and is at an increased risk for pain, skin breakdown, heart attack, stroke, and blood clots. Goal: Resident #7 will remain free of complications related to chronic venous insufficiency. Interventions included: elevate legs when sleeping. If resident had thick nails, corns, calluses, refer to podiatrist. Resident #7 had a diagnosis of Diabetes Mellitus II and was at risk for frequent infections, skin breakdown, decline/changes in vision, renal failure, and acute changes in cognition due to abnormal glucose levels. Goal: The resident will have no complications related to diabetes. Interventions: Refer to podiatrist to monitor/document foot care needs and to cut long nails as needed.Record review of podiatry request for service dated 06/23/25 for Resident #7 revealed a verbal consent with the Social Worker. Record review of Resident #7's podiatry request for services/consultation dated 06/24/25 revealed to have the podiatrist examine the resident for the following reasons: Thickened, dystrophic, and/or painful nails with increased risk of infection. Observation on 08/26/25 at 12:05 PM of Resident #7 revealed the resident was in bed covered by a sheet, Resident #7's toenails were uncovered. His toenails were at least an inch long. Resident #7 stated he had been in the facility over a year and had not been seen by the podiatrist at any time during his stay. Resident #7 stated he had spoken with the Social Worker about having his toenails trimmed, and he was supposedly placed on the list to be seen, however when podiatry was last in the building, they did not visit him. Resident #7 stated podiatry was last in the building a couple of weeks ago. Resident #7 stated he felt he was not seen by podiatry due to him being overweight. He stated this made him feel uncomfortable and sad, and he did not know what to do about getting his nails cut. Resident #7 expressed that he had not talked to anyone about how he felt when he was not seen by the podiatrist on 08/19/25. Interview on 08/27/25 at 9:59 AM with LVN F revealed she worked with Resident #7 for some time now. LVN F stated she was aware of the condition of his toenails and described them as really long with possible fungal symptoms so she requested a referral for podiatry. LVN F stated she notified ADON, DON, and the Social Worker during morning stand up meeting about two weeks ago. LVN F stated the Social Worker provided the referral and LVN F stated she presented them to the ADON for physician signatures. LVN F stated she last saw podiatry in the building about two weeks ago, however, was not aware that his toenails were still long. According to LVN F, Resident #7 was a diabetic, so it was her responsibility to provide nail care. LVN F stated she had never tried to trim his toenails; persons diagnosed with diabetes were referred to the Social Worker to be seen by podiatry. Interview on 08/27/25 at 10:30 AM with the Social Worker revealed she spoke with Resident #7 on Saturday 08/23/25, and saw his toenails, and described them as long and needed to be trimmed. The Social Worker stated Resident #7 was placed on the list for the first time to be seen by podiatry on 08/19/25. The Social Worker stated Resident #7 was not seen and stated perhaps he would be seen on the next podiatry visit to the facility in mid-October 2025. According to the Social Worker she contacted the podiatry service provider to inquire why Resident #7 was missed and she found out the provider will only see 30 residents per visit. The Social Worker stated nurses were responsible for trimming resident nails and toenails, not ensuring residents received proper nail care placed them at risk of infections. Interview on 08/28/25 at 10:30 AM with ADON A stated resident's with a diagnosis of diabetes were referred to the podiatrist to have their toenails cut and trimmed. The DON stated the podiatrist came to the facility every so often but if a resident had a need for immediate care, we would inform the Social Worker to call out to be seen immediately. The DON stated he had not seen Resident #7's toenails and it had not been reported to him that they needed to be cut and trimmed. The DON stated the nurses should report to him so that he could complete an assessment and notify the Social Worker. Observation and interview on 08/28/2025 at 11:14 AM with ADON A and Resident #7 of Resident #7's feet revealed ADON A stating he was seeing Resident #7's feet for the first time in a long while. Resident #7 shared he felt like he was missed by the podiatrist because he was fat, and that it made him feel uncomfortable. The ADON, stopped to express to Resident #7 that his weight was not a factor, and apologized to Resident #7 for being missed by the podiatry provider. ADON A stated Resident #7 toenails appeared to have not been cut or trimmed in a long time by looking at the length and appeared to have jagged edges. ADON A stated the appearance of his feet and toes was not ok and he needed to speak with the Social Worker to have someone come out to cut resident toenails. According to ADON A not having routine toenail care placed Resident #7 at risk for infection, bacteria, unwanted skin conditions and could create a dignity issue. The ADON stated he would work with the Social Worker to get Resident #7 an expedited appointment to have his nails cut and trimmed. Review of the facility's Diabetes Mellitus Patient - Nursing Care of Adult policy revised February 2024 reflected: Responsibility of the Licensed Nurse and Certified Nurse Assistant to provide foot care by gently bathe feet as necessary to keep clean, keep feet dry, especially between toes, encourage use of non-constricting, well-fitting shoes, slippers and hose, keep feet warm without using external sources of heat, with physicians orders only, licensed nurse may trim toenails straight across and with caution, consult podiatrist regarding care of corns, calluses, thick and indurated toenails.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 1 (Resident #12) of 8 residents reviewed for care plans. The facility failed to include Resident #12's PTSD (Post Traumatic Stress Disorder) in his care plan. This failure could place the residents at risk of not receiving services to meet their needs. Findings included: Record review of Resident #12's admission MDS, dated [DATE], reflected the resident was admitted to the facility on [DATE] with diagnoses which included stroke, Diabetes, and (PTSD). Resident #12 had a BIMS score of 14, indicating he was cognitively intact. Record review of Resident #12's care plan, dated 8/8/25 reflected he had no intervention for his PTSD. In an interview on 8/27/25 at 10:42 AM the DON stated the MDS nurse was responsible for ensuring the care plans were comprehensive and up-to-date. In an interview on 8/27/25 at 10:47 AM the MDS Nurse stated she was primarily responsible for care plans being completed, but the DON and ADONs could also add to the care plans as needed. She stated after she completes the MDS assessment, she then transfers that info to the care plan. She stated the risk of not having a comprehensive care plan could be the resident not receiving the services they need. She said she should have added Resident #12's PTSD to his care plan. In an interview on 8/28/25 at 9:35 AM the Social Worker stated she would be the one responsible for notifying psychiatric services of a consult for Resident #12. She stated she had ordered the consult on 8/22/25 but did not recall who had notified her of the need. She did not know why the consult had not been ordered when the resident's MDS had been completed on 8/14/25. She stated the consult was pending insurance approval. In an interview on 8/28/25 at 9:50 AM ADON- B stated she had not been aware of Resident #12's PTSD diagnosis. She stated the resident had been visited by the local fire department's Mobile Integrated Health resources staff while in the facility. She stated they had followed the resident when he lived independently and had followed up with him in the facility after he was admitted . In an interview on 8/28/25 at 9:55 AM the Nurse Practitioner stated she had been unaware Resident #12 had a PTSD diagnosis. She stated she had been aware of his anxiety and had prescribed medications for that. She stated his anxiety was related to his dialysis. She stated she had not ordered a psych consult. She stated there were no risks to his PTSD not being addressed since he was being treated with anxiety medications and was not exhibiting any symptoms. In an interview on 8/28/25 at 10:34 AM the Paramedic with the local fire department stated she works with community members who overuse the 911 system, connecting them with services in the community with the goal of keeping them out of the 911 system. She stated she had worked with Resident #12 for about a year arranging for dialysis and doctor's appointment transportation. She stated she continued to check on Resident #12 after he was admitted to the facility just to see how he was doing. She stated she did not provide any psych services for Resident #12. Record review of the facility's policy Care Plans-Comprehensive, dated September 2010. An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative develops and maintains a comprehensive care plan for each resident. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans.

Based on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #92) reviewed for discharge summary.The facility failed to complete a discharge summary for Resident #92.This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included:Record review of Resident #92's Discharge MDS Assessment, dated 06/28/25, reflected Resident #92 was a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #92 had diagnoses which included Chronic obstructive pulmonary disease with acute exacerbation (ongoing lunch condition caused by damage to the lungs with sudden worsening in airway function and respiratory symptoms), acute respiratory failure with hypoxia (occurs when there is not enough oxygen in the blood), Diabetes Mellitus (group of diseases that affect how the body uses blood sugar), anxiety disorder (a type of mental health condition), and unspecified atrial fabulation (a type of irregular heartbeat where the upper chambers of the heart beat irregularly and rapidly, but the specific cause or underlying condition is unknown) insomnia (sleep disorder), unspecified Record review of Resident #92's physician order, dated 06/26/25, reflected Discharge Home with home health on 06/29/25 with current medications, PT, OT, ST, Nurse to Eval and Treat as Indicated, DME-None. Record Review of Resident 92's Nursing Progress Note by LVN E on 06/28/25 at 22:16 reflected Resident #92 was sent to the Emergency Room.Record review of Resident #`92's care plan, revised date 06/18/25, reflected: Focus-The resident wished to (Specify return/be discharged to (Specify home, another facility)Goal-The resident will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date.Interventions-Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. Evaluate the resident's motivation to return to the community. Make arrangements with the required community resources to support independence post-discharge. Record review of Resident #92's clinical record reflected no discharge summary. Interview on 08/27/25 at 3:57 PM with LVN D revealed that a discharge summary should be completed by the social worker. LVN D stated that the nurse would follow up with the hospital to determine if a resident would be returning from the hospital. LVN D said if the resident would not be returning to the facility, the nurse would notify the ADON and document it in the clinical record. LVN D then stated the social worker was responsible for the discharge summary. LVN D said that with no discharge summary the resident would continue returning to the ER for treatment and would have no follow up services at home. Interview on 08/27/25 at 4:10 PM with ADON B revealed every discharged resident should have a discharge summary. ADON B said that Resident #92 did not have a discharge summary. ADON B stated that if there was no discharge summary, there would be no means for the resident to have follow-up services such as medications and durable medical equipment. ADON B said that primary nurse's responsibility was to ensure that the resident had a discharge note. ADON B then revealed that the discharge summary was completed by social services, and the nurse completed and locked it. Interview on 08/27/25 at 4:29 PM with the Social Worker revealed that Resident # 92 did not have a discharge summary. The Social Worker stated that Resident #92 exited the facility, and the responsible party refused to sign paperwork that she was taking Resident #92 out of the building. The Social Worker said that she did not know how to complete a discharge summary when a resident left the facility and refused to sign any paperwork. The Social Worker revealed that the DON should direct the charge nurse to open the discharge summary and direct how it should be followed. The Social Worker stated she was unclear about the policy and procedure after that or who was responsible for the discharge summary. The Social Worker would not answer how not having a discharge summary would affect the resident.Interview on 08/27/25 at 4:49 PM with the DON revealed that Resident #92 did not have a discharge summary. The DON sated that normally medical records should open the discharge summary. The DON said that each discipline then would enter their information. The DON revealed that the normal procedure did not occur because the resident left the facility without signing any documentation on a Saturday and the nursing department expected Resident #92 to return to the facility. The DON stated that the discharge summary was important because it provided residents with medications, equipment, etcetera. The DON said that it was her responsibility to ensure discharge summaries are completed. Interview on 08/27/25 at 5:44 PM with the Administrator revealed he expected the nursing department to complete the discharge summary for residents. The Administrator stated the discharge summary should be started immediately after discharge. The Administrator said that the discharge summary was important so that the resident could continue care services after exiting the facility. The Administrator revealed that he was not familiar with the specific procedure of the discharge summary. Record review of the facility's Discharge Summary and Plan, dated 11/2016, reflected the following: .The Discharge summary will include a recapitulation of the Patient's/Resident's stay at his facility and a final summary of the Patient's/Resident/s status at the time of the discharge in accordance with the established regulations governing release of resident information and as permitted by the resident.

Base of observations, record reviews and interviews the facility failed to develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for emotional and physical abuse.The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record review of Resident #1's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #1's Entry MDS was the only MDS complete. Record review of Resident #1's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/28/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an interview on 07/30/2025 at 09:08 a.m., Resident #1's family member stated Resident #1 called him on 07/28/2025 around 04:00 p.m. regarding a CNA (CNA A) making threatening statements and throwing a wheelchair at her (Resident #1). He stated he was not present to witness the incident, but Resident #1's roommate, Resident #2 and Resident #2's family were present in the room. He stated he stayed in Resident #1 and Resident #2's room overnight (07/28/2025 to 07/29/2025) following the incident and until both residents were discharged to another facility, due to feeling unsafe. He stated ADON G did not seem to care and only offered to change the CNA assigned to Resident #1 and Resident #2. He stated the facility staff did not immediately the police following the report of CNA A making threatening statements or throwing the wheelchair at Resident #1 until after he told ADON G he reported the incident to the police. During an observation and interview with Resident #1, at NF C, on 07/30/2025 at 02:00 p.m., revealed Resident #1 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #1 stated an incident occurred on 07/28/2025 at 02:51 p.m. Resident #1 observed to verify the time of the incident by reviewing her text messages to a family member. Resident #1 stated the incident occurred after she had turned on her call light due to needing assistance to go to the restroom. She stated CNA A came into her room, took the wheelchair that was in the room and removed it from the room. She stated the facility staff seemed to be trying to locate a missing wheelchair for another resident and that was why CNA A took the wheelchair out of the room. She stated she told CNA A that she needed to go to the restroom and CNA A replied by pushing a walker at her. Resident #1 stated the only reason the walker didn't hit her was because she lifted her leg out of the way. Resident #1 was observed to indicate her leg with no visible injury. Resident #1 stated after CNA A returned and assisted her to the restroom on the day of incident, 07/28/2025, she overheard CNA A say under her breath, I'm getting ready to shoot people and later stated I'm fixing to start busting people. Resident #1 stated she would have normally taken CNA A's statements as expressions of annoyance or frustration but because CNA A had been visibly getting more and more heated prior to those statements, she took the statements as threats and didn't know what people CNA A was referring to, the other staff or the residents. Resident #1 stated after the incident her family could not leave due to her and her roommate's concerns for safety. Resident #1 stated she and her roommate transferred to a different nursing facility due to concerns for quality of care and safety. Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture (break) of right patella (kneecap), and type 2 diabetes mellitus (DM2; a condition that develops with the way the body regulates and uses sugar as fuel). Record review of Resident #2's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #2's Entry MDS was the only MDS complete. Record review of Resident #2's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/23/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an observation and interview with Resident #2, at NF C, on 07/30/2025 at 04:40 p.m., revealed Resident #2 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #2 was observed to be Resident #1's roommate at NF C. Resident #2 stated she was Resident #1's roommate at NF B and transferred with Resident #1 following the incident that occurred on 07/28/2025. Resident #2 stated she had several quality-of-care concerns with staff prior to the incident. Resident #2 stated she had not had previous concerns regarding CNA A; however, after the incident on 07/28/2025 CNA A was mad at her. Resident #2 stated she was unable to hear or witness the alleged statements or the walker having been thrown due to the positioning and location of her bed in NF B. Resident #2 stated CNA A had told her prior to the incident on 07/28/2025 that she (CNA A) had a bad temper. During an interview on 07/31/2025 at 11:01 a.m., Resident #2's family member stated she was present in Resident #1 and Resident #2's room at the time of the incident on 07/28/2025. She stated she was unable to hear CNA A's alleged threatening statements during the incident. She stated she did observe CNA A storm out of Resident #1 and Resident #2's room while facility staff were trying to locate a missing wheelchair and then later re-entered the room and threw a walker toward Resident #1. She stated Resident #1 would have been hit if Resident #1 wasn't paying attention and was able to lean back and out of the way. During an interview on 07/31/2025 at 03:06 p.m., ADON G stated she was notified of a grievance by the LSW regarding Resident #1 around 05:15 p.m. on 07/28/2025. She stated the allegation was regarding CNA A. ADON G stated Resident #1's family member approached her around 06:00 p.m. on 07/28/2025 and asked her what she was doing and the plan of action regarding the allegation. ADON G stated Resident #1's family member stated he would have hog tied her [CNA A] down. She stated he asked her if she had called the police and if she had not, he would. ADON G stated calling the police was part of the procedure for reporting an abuse allegation but had not done it yet. ADON G stated the threatening statements, I'm going to start shooting everybody, was not part of the initial grievance she had received, and she was first told about the threatening statement by Resident #1's family member around 06:15 p.m. ADON G stated she was not told by Resident #1 or her family member regarding a walker having been thrown. ADON G stated following the allegations and grievance, a skin assessment was completed, the CNA was reassigned, interviewed, and sent home; and the police, the DON, and the ED were notified. ADON G stated Resident #1's skin assessment did not reveal any new skin issues. ADON G stated CNA A told her during her interview on 07/28/2025 that she was overwhelmed, that she was trying to take Resident #1 to the restroom and the roommate's [Resident #2] family grabbed her. ADON G stated CNA A was crying during the interview. During an interview on 07/31/2025 at 04:19 p.m., the LSW stated she had received a grievance from Resident #2 and her family prior to the incident on 07/28/2025. The LSW stated the grievance was regarding food temperature and staff not assisting with the call light. The LSW stated the day following the incident, on 07/29/2025 she spoke with Resident #1's family member and Resident #2's family member. She stated Resident #1's family member stated he did not feel safe with Resident #1 staying at NF B because CNA A stated she would go off on someone and he requested Resident #1's clinicals be sent to NF C. She stated Resident #2's family requested for her clinicals be sent to NF C. During an interview on 08/01/2025 at 01:35 p.m., CNA D stated she switched halls with CNA A on 07/28/2025. CNA D stated she was not given a reason for the assignment change. CNA D stated she was present in the room during the police interview with Resident #1, Resident #2, and their family members. CNA D stated the police officer asked Resident #1 if everyone present could stay and Resident #1 replied yes. CNA D stated Resident #1 did not mention the walker being thrown at her to the police, but Resident #2's family member did mention it. She stated she did not recall Resident #2's family member stating the walker was thrown. She recalled Resident #2's family member stating it was shoved. CNA D stated she had not previously provided care to Resident #1 and Resident #2 and was therefore unable to identify if they had any changes in mood or behaviors. CNA D stated she did not observe any noticeable agitation, crying, or fear while providing care for them on 07/28/2025 evening. CNA D stated Resident #1 and Resident #2 appeared calm. CNA D stated Resident #1's family member notified her he was planning on staying the night. During an interview on 08/01/2025 at 04:03 p.m., CNA A stated she was scheduled to work a 02:00 p.m. to 10:00 p.m. shift on 07/28/2025. CNA A stated during her shift the facility staff were trying to locate a missing wheelchair and she was told they needed to verify the wheelchair in Resident #1 and Resident #2's room was not the missing wheelchair. She stated she removed the wheelchair and for an unknown reason, it was taken to therapy. She stated Resident #1 told her she needed to use the bathroom, and she said okay, let me go get your chair back from therapy. She stated, while in the therapy room, Resident #2's family member grabbed her shoulder and said that, if I didn't hurry up, I would be cleaning urine off the floor. CNA A stated when she returned to the room with the wheelchair, Resident #2's family member started to request multiple things for Resident #2. CNA A stated she said under her breath, I can't do this to herself. CNA A stated she then assisted Resident #1 to the restroom, but while waiting outside the restroom door for Resident #1 to finish, Resident #2's family member again started asking for assistance with Resident #2. CNA A stated after assisting Resident #1 back to bed, she asked Resident #1 if she wanted to change into her pajamas prior to dinner and prior to having her shower. CNA A stated Resident #1 stated she was okay with waiting. CNA A stated following this interaction with Resident #1, Resident #2, and Resident #2's family member, she left to assist with passing out meal trays. CNA A stated while passing out meal trays she was approached by CNA D and was told CNA D was relieving her from her hall and wanted a report on the residents' needs. CNA A stated after she gave CNA D report ADON G told her that she needed to go home and needed to write a statement. CNA A stated she did not know what the statement was supposed to be about and was told to write about the wheelchair incident. CNA A stated she was called on 07/30/2025 by the ED and told to come into the facility for an interview. CNA A stated the ED told her that the allegation was that she pushed a wheelchair into Resident #1 and had stated under her breath that she was going to shoot you or shoot your mother. CNA A stated she told the ED that she did state under her breath that she couldn't do this but did not state she would hurt anyone or say anything like that. CNA A stated she did not say anything about shooting anyone or taking anyone out. CNA A stated the only time she moved the wheelchair, or walker was when she moved them to the bed to assist Resident #1 to stand up and go to the restroom. CNA A stated she did not take her hands off either piece of equipment while moving it. During an interview on 08/01/2025 at 05:22 p.m., the DON stated she also interacted with Resident #1 on 07/29/2025 morning. She stated she entered the room and asked if Resident #1 or Resident #2 had any issues. She stated the residents were laughing and only said one issue, referring to the incident on 07/28/2025 evening. She stated the residents did not voice any concerns to her. The DON stated Resident #2 had a scheduled care planning meeting on 07/28/2025. She stated Resident #2 and her family only mentioned concerns about a banana on the breakfast tray. The DON stated she was notified after she had left the NF by the LSW on 07/28/2025 that Resident #1's family member had made an allegation. She stated she replied that the CNA had to be suspended. She stated education was initiated and the police were called. The DON stated a skin assessment was done, and safe surveys and statements were taken. The DON stated the skin assessment and pain assessment was done on 07/28/2025, with no findings identified and Resident #1 stated everything was fine. The DON stated Resident #1 did not require treatment. During an interview on 08/01/2025 at 06:14 p.m., the ED stated he was notified of the incident on 07/28/2025 by the DON. The ED stated the DON initially took the lead in the incident response. He stated the DON directed ADON G to speak with CNA A and send CNA A home. The ED stated the DON directed the LSW to get statements and interview residents that were under CNA A's care. In-services were started and the ADONs were directed to gather staff signatures for the in-services. The ED stated on 07/29/2025, he went to interview Resident #1. He stated he had difficulty interviewing Resident #1 because her family member kept interrupting and interjecting. He stated he primarily understood that Resident #1 was not comfortable, she contacted her family member, and Resident #1's family member came to the facility. The ED stated Resident #1's story was consistent with what her family member stated, but when he tried to speak with her, the family member would finish her sentences, and the ED would have to ask Resident #1 to verify. The ED stated Resident #1 appeared calm during his interview with her, but the family member was anxious for Resident #1 to transfer to another facility. The ED stated the DON submitted the self-report, the police were called, and the physician was notified. During an interview on 08/02/2025 at 10:45 a.m., the ED stated the facility door codes were changed the day CNA A was suspended, 07/28/2025. He stated the facility only had two exit/entry doors and both door codes were changed. He stated the Maint Dir was called and the Maint Dir came to the facility, changed the door codes, and alerted the department heads of the new codes. The ED stated CNA A was notified that she was suspended. He stated she was called and scheduled to be interviewed by him on Wednesday, 07/30/2025. Upon her arrival, she was told to stay in the front lobby until called for interview. She was interviewed on 07/30/2025 and told she was on suspension and to not come back without a notice to return. The ED stated staff were educated to know if someone was not supposed to be in the facility, whether it is a staff member or visitor to alert him and to call the police if they refuse to leave. The ED stated this training was part of their in-service training during orientation. The ED stated staff were aware when a staff member was taken off the schedule. During an interview on 08/02/2025 at 11:36 a.m., ADON G stated she was CNA A's direct supervisor. ADON G stated CNA A was easy to work with and never really gave her push back. ADON G stated CNA A was not a quiet person, her voice carried, and she did not really have a filter. ADON G stated if CNA A had an issue, she was open and honest, sometimes providing personal information. ADON G stated CNA A did not have a history of behaviors or resident complaints, but did have a loud voice. ADON G stated CNA A was acting normally prior to the alleged incident on 07/28/2025, but had stated she was overwhelmed, so ADON G had already messaged the staffing coordinator to see if CNA A could have a different assignment. ADON G stated the alleged incident occurred prior to her attempts to address CNA A's concerns. ADON G stated if CNA A came to the facility while being suspended, she would kindly ask CNA A to go back home and if CNA A refused after two times, ADON G would escalate by notifying her upper supervisor and call 911. ADON G stated CNA A would not be able to come into the facility while suspended because the front desk staff were aware of her suspension and someone at the front desk or nurses' station would recognize her. ADON G stated the entry and exit door codes were changed on 07/28/2025. ADON G stated both ADONs and the business personnel were notified when a staff member was out pending an investigation. She stated the ADONs were responsible for notifying their direct staff when a staff member was out pending an investigation. ADON G stated staff were trained to call the ED immediately and notify the supervisor on premises if someone was at the facility when they were on suspension. ADON G stated the staff are trained upon hire on threat response procedures and they receive a badge buddy which included abuse during orientation. During an interview on 08/02/2025 at 12:32 p.m., CNA F stated she had worked with CNA A several times. CNA F stated she and CNA A had argued several times about how CNA A spoke with residents. CNA F stated she had observed CNA A joking with residents and taking the joking to another level, sometimes being rude to residents. CNA F stated CNA A had a very short fuse and seemed to have toddler-like tantrums. CNA F stated she had not witnessed CNA A be abusive or threatening to residents, only rude. CNA F stated she had reported her concerns to multiple charge nurses from different shifts, but nothing had been done following her reports. CNA F declined to identify who she had reported these concerns to or when. CNA F denied having ever witnessed CNA A be physically abusive to residents or ever heard statements such as I am going to shoot everyone up or anything to that effect. During an observation and interview on 08/02/2025 at 03:35 p.m., the Maint Dir stated he changed the facility entry and exit door locks on Monday night, 07/28/2025 at around 09:00 p.m. He stated he changed the locks on 4 exit doors. The Maint Dir was observed indicating the 4 entry/exit doors and the camera feeds for each door visible in 1 of 2 of the facility nurses' stations. The second facility nurses' station was observed to also have visible camera feeds for all 4 entry/exit doors. The camera feeds were observed to allow staff sitting in the facility nurses' stations to see any person entering and exiting the facility via the entry/exit doors. During an interview on 08/02/2025 at 03:40 p.m., Receptionist I stated she worked as the receptionist on Fridays and Saturdays and occasionally picked up additional shifts. She stated the ED notified her of a staff member being on suspension. She stated she was aware of the facility's procedure for if a staff member on suspension came to the facility. She stated she would immediately let the ED know, not unlock the front entry door, explain to the staff member that they are not supposed to be there, and if they refused to leave or per the ED's instruction, call the police. Record review of Resident #1's Progress Notes, dated 07/30/2025 with effective date range 06/30/2025 to 07/31/2025, reflected: - Skin/Wound Note, effective date 07/28/2025 at 08:08 a.m., by RN K noted as LATE ENTRY, reflected Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home.All other skin intact. - Nursing- General Note, effective date 07/28/2025 at 06:27 p.m., by LPN L reflected Skin check completed with [CNA J] per [ADON G] request. Patient states she had a fall 07/21/2025, the following skin issues noted: Large healing bruise to L posterior [back] arm, RLE, R and L ac areas. 1 small scab noted to back of R heel. 1 scab to R hand, middle finger. 3 scratches to L foot. Scars to bil [both sides] chest. 2 scars to bil [both sides] buttocks. Record review of Resident #1's .Skin Check, dated effective 07/28/2025 at 06:30 p.m., reflected a new issue on the right heel. The skin issue was described as scabbing and present on admission with exact date of 07/25/2025. A second new issue was identified on outer left upper arm. The skin issue was described as bruising and present on admission with exact date of 07/25/2025. A third new issue was identified on the right dorsum 3rd digit (middle)- phalanx (back part of the right middle finger). The skin issue was described as on the knuckle, scabbing, and present on admission with exact date of 07/25/2025. A fourth new issue was identified on the left elbow. The skin issue was described as scabbing/scratch and present on admission with exact date of 07/25/2025. A skin issue note revealed Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home. Record review of facility grievances, dated 05/01/2025 to 07/30/2025, reflected: - a grievance reported by Resident #2 family to LSW on 07/28/2025, reflected [Resident #2 family member] stated, [Resident #2] needed assistance with all meals. 7/28/25 Family pushed call light and cna [sic] took over 10 minutes to get oxygen for resident to come to COE meeting. At 4:55 pm resident family stated they want clinicals sent over to [NF C]. - a grievance reported by Resident #1 family to LSW on 07/28/2025, reflected [Resident #1 family member] stated that [CNA A] came into resident room screaming, ‘Im [sic] about to go off on someone.' [Resident #1 family member] stated he did not feel like [Resident #1] was safe at the facility. [Resident #1 family member] stated he wants her clinicals sent to [NF C] for a skilled transfer. Record review of local police department police report, dated as occurred and reported 07/28/2025 at 06:18 p.m., reflected Dispatch advised of a TERRORISTIC THREAT call at the above location [NF B]. Dispatch advised that staff, specifically [CNA A] threatened to shoot up the place & was being removed by staff.When I arrived at the location, I met with the supervisor on duty, later identified as [ADON G]. She advised that in room [Resident #1 and Resident #2 prior room at NF B], a staff member was having a bad day and was frustrated with patients at the facility. She later advised that and occupants of room [Resident #1 and Resident #2 prior room at NF B] were in a verbal dispute. She later heard that the staff told the patient, If y'all don't calm down, I'm going to start shooting. She later advised that the staff was removed from the facility and sent home.[ADON G] stated that she heard this information from the third party and did not believe the statement to be a threat. I then met with family, and specifically the complainant and his [family member, Resident #1]. I spoke with [Resident #1], who advised that she had just started residing in the facility on 07/25/25 and had minimal interaction with [CNA A]. [CNA A] had been verbally aggressive towards her, and at one point, assisted her to the restroom. [CNA A] was upset with [Resident #1] as she was taking a long time, and said that she was going to start shooting. [Resident #1] stated that initially she did not take it seriously but thought about it after a while and it made her feel unsafe. She relayed the information to her [family member], who contacted dispatch. It was later determined that no offense at the time met the elements. [CNA A] was not on scene, and was not able to be questioned. [Resident #1] and [family member] decided to request a transfer to another facility in [neighboring city], after being treated this way by staff and was awaiting approval. At this time, no charges were filed and both parties did not wish to pursue against one another. Observation and record review of ADON G's Badge Buddy on 08/02/2025 at 11:49 a.m., revealed Abuse Coordinator is? Executive Director. All allegations must be reported immediately. Record review of Patient Abuse Investigation Questionnaire forms, dated 07/29/2025 reflected 14 resident forms with 3 incomplete due to Sleeping can't wake up, Couldn't follow questions, and At an appointment. The completed 11 of 14 forms did not reveal concerns or complaints of physical or verbal abuse or misappropriation. Record review of staff in-service training document, dated 07/28/2025, revealed 19 of 19 nursing staff scheduled during 2-10 shift were in-serviced on Abuse and Neglect. Record review of facility policy, Abuse Protocol, dated April 2019 revealed, 1. The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation.by anyone, including staff members, other Patient, consultants, volunteers, staff of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individual 3. our facility will screen potential employees for a history of abuse, neglect or mistreatment of Patients as defined by the applicable legal requirements. This will include attempting to obtain information from previous and/or current employers and checking with the appropriate licensing boards and registries. (See PCMS 15-Personnel). (Screening) 4. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse prevention Coordinator. 5. The Abuse Coordinator will assure the Facility staff is in-serviced on recognizing abuse, abuse prevention, and abuse reporting upon employment, and as necessary to maintain an abuse free environment. Patient and family members are educated on what constitutes patient Abuse, how to recognize Patient Abuse, how to minimize the potential for patients abuse, how to respond to patient Abuse or other inappropriate behavior when it is observed or suspected, and how to appropriately report Patient Abuse. (Training) 6. Our facility will not retaliate against any person who in good faith reports an allegation. Accidents and Incidents must be reported both internally and externally in accordance with the Reportable Incident Protocol (see Protocol 3-C) a. Staff will be made aware of the name and contact phone number for the Abuse Prevention coordinator. b. All persons who report an allegation of Abuse or Neglect will be kept confidential by the Abuse Prevention Coordinator. c. A person who believes he or she has been subjected to retaliation as a result of reporting an allegation, or who believes an allegation has been ignored, may contact the Abuse Prevention Coordinator the DADS office or the Office of the Attorney General. d. The Facility may take disciplinary action, including termination, against any person who engages in retaliation. e. Our Facility will post a notice indicating the Facility's retaliation policy and the person's rights to file a complaint. 7. The following definitions are provided to assist our Facility staff members in recognizing incidents of patient abuse: a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being. Instances of abuse of all patient/Resident, irrespective of any physical or mental condition, cause physical harm, pain, or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. b. Taking or using photographs ore recordings in any manner that would demean or humiliate a Patient. This includes using any type of equipment (e.g. cameras, smart phones and other electronic devices) to take, keep or distribute photographs and recordings on social media. c. Misappropriation of Patient property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of patient's belongings or money without the patients consent. d. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to Patients or their families, or within their hearing distance, to describe Patients regardless of their age, ability to comprehend, or disability. e. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with the Patient. f. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. g. Involuntary seclusion is defined as separation of a patient from other Patients or from his or her room against the patients will, or the will of the patients legal guardian or representative. Note; temporary monitored separation from other Patients will not be considered involuntary seclusion and may be permitted when used as a therapeutic intervention to reduce agitation as determined by the Medical Director, and/or the Director of Nursing, and such actions is consistent with the Patients Care Plan. h. Mental abuse is defines as but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. (identifying) i. Adverse event is an untoward, undesirable, and usually unanticipated event that cause death or serious injury, or the risk thereof. j. Exploitation means taking advantage of a Patients for personal gain through use of manipulation, intimidation, threats, or coercion. k. Mistreatment means inappropriate treatment or exploitation of a patient l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. m. Person centered care means to focus on the patient as the locus of control and support the patient in making their own choices and having control over their daily lives. 8. Any person observing an incident of patient abuse or suspecting patient abuse must immediately report such incidents to the charge nurse. The following information should be reported to the charge nurse: a. The name of the patient involved, B. The date and time that the incident occurred; See. Where the incident took place; D. The names of the person committing the incident, if known; E. The names of any witnesses to the incident; F. The types of abuse that was committed (i.e verbal, physical, sexual, etc.); And G. Other information that may be requested by the charge nurse. 9. The Charge nurse will immediatel

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for emotional and physical abuse. The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record review of Resident #1's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #1's Entry MDS was the only MDS complete. Record review of Resident #1's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/28/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an interview on 07/30/2025 at 09:08 a.m., Resident #1's family member stated Resident #1 called him on 07/28/2025 around 04:00 p.m. regarding a CNA (CNA A) making threatening statements and throwing a wheelchair at her (Resident #1). He stated he was not present to witness the incident, but Resident #1's roommate, Resident #2 and Resident #2's family were present in the room. He stated he stayed in Resident #1 and Resident #2's room overnight (07/28/2025 to 07/29/2025) following the incident and until both residents were discharged to another facility, due to feeling unsafe. He stated ADON G did not seem to care and only offered to change the CNA assigned to Resident #1 and Resident #2. He stated the facility staff did not immediately the police following the report of CNA A making threatening statements or throwing the wheelchair at Resident #1 until after he told ADON G he reported the incident to the police. During an observation and interview with Resident #1, at NF C, on 07/30/2025 at 02:00 p.m., revealed Resident #1 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #1 stated an incident occurred on 07/28/2025 at 02:51 p.m. Resident #1 observed to verify the time of the incident by reviewing her text messages to a family member. Resident #1 stated the incident occurred after she had turned on her call light due to needing assistance to go to the restroom. She stated CNA A came into her room, took the wheelchair that was in the room and removed it from the room. She stated the facility staff seemed to be trying to locate a missing wheelchair for another resident and that was why CNA A took the wheelchair out of the room. She stated she told CNA A that she needed to go to the restroom and CNA A replied by pushing a walker at her. Resident #1 stated the only reason the walker didn't hit her was because she lifted her leg out of the way. Resident #1 was observed to indicate her leg with no visible injury. Resident #1 stated after CNA A returned and assisted her to the restroom on the day of incident, 07/28/2025, she overheard CNA A say under her breath, I'm getting ready to shoot people and later stated I'm fixing to start busting people. Resident #1 stated she would have normally taken CNA A's statements as expressions of annoyance or frustration but because CNA A had been visibly getting more and more heated prior to those statements, she took the statements as threats and didn't know what people CNA A was referring to, the other staff or the residents. Resident #1 stated after the incident her family could not leave due to her and her roommate's concerns for safety. Resident #1 stated she and her roommate transferred to a different nursing facility due to concerns for quality of care and safety. Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture (break) of right patella (kneecap), and type 2 diabetes mellitus (DM2; a condition that develops with the way the body regulates and uses sugar as fuel). Record review of Resident #2's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #2's Entry MDS was the only MDS complete. Record review of Resident #2's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/23/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an observation and interview with Resident #2, at NF C, on 07/30/2025 at 04:40 p.m., revealed Resident #2 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #2 was observed to be Resident #1's roommate at NF C. Resident #2 stated she was Resident #1's roommate at NF B and transferred with Resident #1 following the incident that occurred on 07/28/2025. Resident #2 stated she had several quality-of-care concerns with staff prior to the incident. Resident #2 stated she had not had previous concerns regarding CNA A; however, after the incident on 07/28/2025 CNA A was mad at her. Resident #2 stated she was unable to hear or witness the alleged statements or the walker having been thrown due to the positioning and location of her bed in NF B. Resident #2 stated CNA A had told her prior to the incident on 07/28/2025 that she (CNA A) had a bad temper. During an interview on 07/31/2025 at 11:01 a.m., Resident #2's family member stated she was present in Resident #1 and Resident #2's room at the time of the incident on 07/28/2025. She stated she was unable to hear CNA A's alleged threatening statements during the incident. She stated she did observe CNA A storm out of Resident #1 and Resident #2's room while facility staff were trying to locate a missing wheelchair and then later re-entered the room and threw a walker toward Resident #1. She stated Resident #1 would have been hit if Resident #1 wasn't paying attention and was able to lean back and out of the way. During an interview on 07/31/2025 at 03:06 p.m., ADON G stated she was notified of a grievance by the LSW regarding Resident #1 around 05:15 p.m. on 07/28/2025. She stated the allegation was regarding CNA A. ADON G stated Resident #1's family member approached her around 06:00 p.m. on 07/28/2025 and asked her what she was doing and the plan of action regarding the allegation. ADON G stated Resident #1's family member stated he would have hog tied her [CNA A] down. She stated he asked her if she had called the police and if she had not, he would. ADON G stated calling the police was part of the procedure for reporting an abuse allegation but had not done it yet. ADON G stated the threatening statements, I'm going to start shooting everybody, was not part of the initial grievance she had received, and she was first told about the threatening statement by Resident #1's family member around 06:15 p.m. ADON G stated she was not told by Resident #1 or her family member regarding a walker having been thrown. ADON G stated following the allegations and grievance, a skin assessment was completed, the CNA was reassigned, interviewed, and sent home; and the police, the DON, and the ED were notified. ADON G stated Resident #1's skin assessment did not reveal any new skin issues. ADON G stated CNA A told her during her interview on 07/28/2025 that she was overwhelmed, that she was trying to take Resident #1 to the restroom and the roommate's [Resident #2] family grabbed her. ADON G stated CNA A was crying during the interview. During an interview on 07/31/2025 at 04:19 p.m., the LSW stated she had received a grievance from Resident #2 and her family prior to the incident on 07/28/2025. The LSW stated the grievance was regarding food temperature and staff not assisting with the call light. The LSW stated the day following the incident, on 07/29/2025 she spoke with Resident #1's family member and Resident #2's family member. She stated Resident #1's family member stated he did not feel safe with Resident #1 staying at NF B because CNA A stated she would go off on someone and he requested Resident #1's clinicals be sent to NF C. She stated Resident #2's family requested for her clinicals be sent to NF C. During an interview on 08/01/2025 at 01:35 p.m., CNA D stated she switched halls with CNA A on 07/28/2025. CNA D stated she was not given a reason for the assignment change. CNA D stated she was present in the room during the police interview with Resident #1, Resident #2, and their family members. CNA D stated the police officer asked Resident #1 if everyone present could stay and Resident #1 replied yes. CNA D stated Resident #1 did not mention the walker being thrown at her to the police, but Resident #2's family member did mention it. She stated she did not recall Resident #2's family member stating the walker was thrown. She recalled Resident #2's family member stating it was shoved. CNA D stated she had not previously provided care to Resident #1 and Resident #2 and was therefore unable to identify if they had any changes in mood or behaviors. CNA D stated she did not observe any noticeable agitation, crying, or fear while providing care for them on 07/28/2025 evening. CNA D stated Resident #1 and Resident #2 appeared calm. CNA D stated Resident #1's family member notified her he was planning on staying the night. During an interview on 08/01/2025 at 04:03 p.m., CNA A stated she was scheduled to work a 02:00 p.m. to 10:00 p.m. shift on 07/28/2025. CNA A stated during her shift the facility staff were trying to locate a missing wheelchair and she was told they needed to verify the wheelchair in Resident #1 and Resident #2's room was not the missing wheelchair. She stated she removed the wheelchair and for an unknown reason, it was taken to therapy. She stated Resident #1 told her she needed to use the bathroom, and she said okay, let me go get your chair back from therapy. She stated, while in the therapy room, Resident #2's family member grabbed her shoulder and said that, if I didn't hurry up, I would be cleaning urine off the floor. CNA A stated when she returned to the room with the wheelchair, Resident #2's family member started to request multiple things for Resident #2. CNA A stated she said under her breath, I can't do this to herself. CNA A stated she then assisted Resident #1 to the restroom, but while waiting outside the restroom door for Resident #1 to finish, Resident #2's family member again started asking for assistance with Resident #2. CNA A stated after assisting Resident #1 back to bed, she asked Resident #1 if she wanted to change into her pajamas prior to dinner and prior to having her shower. CNA A stated Resident #1 stated she was okay with waiting. CNA A stated following this interaction with Resident #1, Resident #2, and Resident #2's family member, she left to assist with passing out meal trays. CNA A stated while passing out meal trays she was approached by CNA D and was told CNA D was relieving her from her hall and wanted a report on the residents' needs. CNA A stated after she gave CNA D report ADON G told her that she needed to go home and needed to write a statement. CNA A stated she did not know what the statement was supposed to be about and was told to write about the wheelchair incident. CNA A stated she was called on 07/30/2025 by the ED and told to come into the facility for an interview. CNA A stated the ED told her that the allegation was that she pushed a wheelchair into Resident #1 and had stated under her breath that she was going to shoot you or shoot your mother. CNA A stated she told the ED that she did state under her breath that she couldn't do this but did not state she would hurt anyone or say anything like that. CNA A stated she did not say anything about shooting anyone or taking anyone out. CNA A stated the only time she moved the wheelchair, or walker was when she moved them to the bed to assist Resident #1 to stand up and go to the restroom. CNA A stated she did not take her hands off either piece of equipment while moving it. During an interview on 08/01/2025 at 05:22 p.m., the DON stated she also interacted with Resident #1 on 07/29/2025 morning. She stated she entered the room and asked if Resident #1 or Resident #2 had any issues. She stated the residents were laughing and only said one issue, referring to the incident on 07/28/2025 evening. She stated the residents did not voice any concerns to her. The DON stated Resident #2 had a scheduled care planning meeting on 07/28/2025. She stated Resident #2 and her family only mentioned concerns about a banana on the breakfast tray. The DON stated she was notified after she had left the NF by the LSW on 07/28/2025 that Resident #1's family member had made an allegation. She stated she replied that the CNA had to be suspended. She stated education was initiated and the police were called. The DON stated a skin assessment was done, and safe surveys and statements were taken. The DON stated the skin assessment and pain assessment was done on 07/28/2025, with no findings identified and Resident #1 stated everything was fine. The DON stated Resident #1 did not require treatment. During an interview on 08/01/2025 at 06:14 p.m., the ED stated he was notified of the incident on 07/28/2025 by the DON. The ED stated the DON initially took the lead in the incident response. He stated the DON directed ADON G to speak with CNA A and send CNA A home. The ED stated the DON directed the LSW to get statements and interview residents that were under CNA A's care. In-services were started and the ADONs were directed to gather staff signatures for the in-services. The ED stated on 07/29/2025, he went to interview Resident #1. He stated he had difficulty interviewing Resident #1 because her family member kept interrupting and interjecting. He stated he primarily understood that Resident #1 was not comfortable, she contacted her family member, and Resident #1's family member came to the facility. The ED stated Resident #1's story was consistent with what her family member stated, but when he tried to speak with her, the family member would finish her sentences, and the ED would have to ask Resident #1 to verify. The ED stated Resident #1 appeared calm during his interview with her, but the family member was anxious for Resident #1 to transfer to another facility. The ED stated the DON submitted the self-report, the police were called, and the physician was notified. During an interview on 08/02/2025 at 10:45 a.m., the ED stated the facility door codes were changed the day CNA A was suspended, 07/28/2025. He stated the facility only had two exit/entry doors and both door codes were changed. He stated the Maint Dir was called and the Maint Dir came to the facility, changed the door codes, and alerted the department heads of the new codes. The ED stated CNA A was notified that she was suspended. He stated she was called and scheduled to be interviewed by him on Wednesday, 07/30/2025. Upon her arrival, she was told to stay in the front lobby until called for interview. She was interviewed on 07/30/2025 and told she was on suspension and to not come back without a notice to return. The ED stated staff were educated to know if someone was not supposed to be in the facility, whether it is a staff member or visitor to alert him and to call the police if they refuse to leave. The ED stated this training was part of their in-service training during orientation. The ED stated staff were aware when a staff member was taken off the schedule. During an interview on 08/02/2025 at 11:36 a.m., ADON G stated she was CNA A's direct supervisor. ADON G stated CNA A was easy to work with and never really gave her push back. ADON G stated CNA A was not a quiet person, her voice carried, and she did not really have a filter. ADON G stated if CNA A had an issue, she was open and honest, sometimes providing personal information. ADON G stated CNA A did not have a history of behaviors or resident complaints, but did have a loud voice. ADON G stated CNA A was acting normally prior to the alleged incident on 07/28/2025, but had stated she was overwhelmed, so ADON G had already messaged the staffing coordinator to see if CNA A could have a different assignment. ADON G stated the alleged incident occurred prior to her attempts to address CNA A's concerns. ADON G stated if CNA A came to the facility while being suspended, she would kindly ask CNA A to go back home and if CNA A refused after two times, ADON G would escalate by notifying her upper supervisor and call 911. ADON G stated CNA A would not be able to come into the facility while suspended because the front desk staff were aware of her suspension and someone at the front desk or nurses' station would recognize her. ADON G stated the entry and exit door codes were changed on 07/28/2025. ADON G stated both ADONs and the business personnel were notified when a staff member was out pending an investigation. She stated the ADONs were responsible for notifying their direct staff when a staff member was out pending an investigation. ADON G stated staff were trained to call the ED immediately and notify the supervisor on premises if someone was at the facility when they were on suspension. ADON G stated the staff are trained upon hire on threat response procedures and they receive a badge buddy which included abuse during orientation. During an interview on 08/02/2025 at 12:32 p.m., CNA F stated she had worked with CNA A several times. CNA F stated she and CNA A had argued several times about how CNA A spoke with residents. CNA F stated she had observed CNA A joking with residents and taking the joking to another level, sometimes being rude to residents. CNA F stated CNA A had a very short fuse and seemed to have toddler-like tantrums. CNA F stated she had not witnessed CNA A be abusive or threatening to residents, only rude. CNA F stated she had reported her concerns to multiple charge nurses from different shifts, but nothing had been done following her reports. CNA F declined to identify who she had reported these concerns to or when. CNA F denied having ever witnessed CNA A be physically abusive to residents or ever heard statements such as I am going to shoot everyone up or anything to that effect. During an observation and interview on 08/02/2025 at 03:35 p.m., the Maint Dir stated he changed the facility entry and exit door locks on Monday night, 07/28/2025 at around 09:00 p.m. He stated he changed the locks on 4 exit doors. The Maint Dir was observed indicating the 4 entry/exit doors and the camera feeds for each door visible in 1 of 2 of the facility nurses' stations. The second facility nurses' station was observed to also have visible camera feeds for all 4 entry/exit doors. The camera feeds were observed to allow staff sitting in the facility nurses' stations to see any person entering and exiting the facility via the entry/exit doors. During an interview on 08/02/2025 at 03:40 p.m., Receptionist I stated she worked as the receptionist on Fridays and Saturdays and occasionally picked up additional shifts. She stated the ED notified her of a staff member being on suspension. She stated she was aware of the facility's procedure for if a staff member on suspension came to the facility. She stated she would immediately let the ED know, not unlock the front entry door, explain to the staff member that they are not supposed to be there, and if they refused to leave or per the ED's instruction, call the police. Record review of Resident #1's Progress Notes, dated 07/30/2025 with effective date range 06/30/2025 to 07/31/2025, reflected: - Skin/Wound Note, effective date 07/28/2025 at 08:08 a.m., by RN K noted as LATE ENTRY, reflected Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home.All other skin intact. - Nursing- General Note, effective date 07/28/2025 at 06:27 p.m., by LPN L reflected Skin check completed with [CNA J] per [ADON G] request. Patient states she had a fall 07/21/2025, the following skin issues noted: Large healing bruise to L posterior [back] arm, RLE, R and L ac areas. 1 small scab noted to back of R heel. 1 scab to R hand, middle finger. 3 scratches to L foot. Scars to bil [both sides] chest. 2 scars to bil [both sides] buttocks. Record review of Resident #1's .Skin Check, dated effective 07/28/2025 at 06:30 p.m., reflected a new issue on the right heel. The skin issue was described as scabbing and present on admission with exact date of 07/25/2025. A second new issue was identified on outer left upper arm. The skin issue was described as bruising and present on admission with exact date of 07/25/2025. A third new issue was identified on the right dorsum 3rd digit (middle)- phalanx (back part of the right middle finger). The skin issue was described as on the knuckle, scabbing, and present on admission with exact date of 07/25/2025. A fourth new issue was identified on the left elbow. The skin issue was described as scabbing/scratch and present on admission with exact date of 07/25/2025. A skin issue note revealed Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home. Record review of facility grievances, dated 05/01/2025 to 07/30/2025, reflected: - a grievance reported by Resident #2 family to LSW on 07/28/2025, reflected [Resident #2 family member] stated, [Resident #2] needed assistance with all meals. 7/28/25 Family pushed call light and cna [sic] took over 10 minutes to get oxygen for resident to come to COE meeting. At 4:55 pm resident family stated they want clinicals sent over to [NF C]. - a grievance reported by Resident #1 family to LSW on 07/28/2025, reflected [Resident #1 family member] stated that [CNA A] came into resident room screaming, ‘Im [sic] about to go off on someone.' [Resident #1 family member] stated he did not feel like [Resident #1] was safe at the facility. [Resident #1 family member] stated he wants her clinicals sent to [NF C] for a skilled transfer. Record review of local police department police report, dated as occurred and reported 07/28/2025 at 06:18 p.m., reflected Dispatch advised of a TERRORISTIC THREAT call at the above location [NF B]. Dispatch advised that staff, specifically [CNA A] threatened to shoot up the place & was being removed by staff.When I arrived at the location, I met with the supervisor on duty, later identified as [ADON G]. She advised that in room [Resident #1 and Resident #2 prior room at NF B], a staff member was having a bad day and was frustrated with patients at the facility. She later advised that and occupants of room [Resident #1 and Resident #2 prior room at NF B] were in a verbal dispute. She later heard that the staff told the patient, If y'all don't calm down, I'm going to start shooting. She later advised that the staff was removed from the facility and sent home.[ADON G] stated that she heard this information from the third party and did not believe the statement to be a threat. I then met with family, and specifically the complainant and his [family member, Resident #1]. I spoke with [Resident #1], who advised that she had just started residing in the facility on 07/25/25 and had minimal interaction with [CNA A]. [CNA A] had been verbally aggressive towards her, and at one point, assisted her to the restroom. [CNA A] was upset with [Resident #1] as she was taking a long time, and said that she was going to start shooting. [Resident #1] stated that initially she did not take it seriously but thought about it after a while and it made her feel unsafe. She relayed the information to her [family member], who contacted dispatch. It was later determined that no offense at the time met the elements. [CNA A] was not on scene, and was not able to be questioned. [Resident #1] and [family member] decided to request a transfer to another facility in [neighboring city], after being treated this way by staff and was awaiting approval. At this time, no charges were filed and both parties did not wish to pursue against one another. Observation and record review of ADON G's Badge Buddy on 08/02/2025 at 11:49 a.m., revealed Abuse Coordinator is? Executive Director. All allegations must be reported immediately. Record review of Patient Abuse Investigation Questionnaire forms, dated 07/29/2025 reflected 14 resident forms with 3 incomplete due to Sleeping can't wake up, Couldn't follow questions, and At an appointment. The completed 11 of 14 forms did not reveal concerns or complaints of physical or verbal abuse or misappropriation. Record review of staff in-service training document, dated 07/28/2025, revealed 19 of 19 nursing staff scheduled during 2-10 shift were in-serviced on Abuse and Neglect. Record review of facility policy, Abuse Protocol, dated April 2019 revealed, 1. The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation.by anyone, including staff members.10. The Abuse Prevention Coordinator will: . e. Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress.19. The Facility will provide orientation and regular in-services to employees on abuse prevention practices,. The ED was notified of an Immediate Jeopardy (IJ) on 08/02/2025 at 04:53 p.m., due to the above failures and the IJ Template was provided at 04:53 p.m. The facility's Plan of Removal (POR) was accepted on 08/02/2025 at 07:28 p.m. and included: Removal Plan for F-Tag 600 Date/Time of Notification to the Facility: 08/02/2025 at 4:53pm Concern: The facility failed to ensure that each resident had the right to be free from physical and verbal abuse for 1 of 4 (Resident #1) residents reviewed for abuse. Resident #1 stated on 07/28/2025 CNA A pushed her walker at her, but it did not hit her due to Resident #1 lifting her leg. Resident #1 stated CNA A, later in the afternoon on the same day, while CNA A was in the restroom with her, made the statement, I'm getting ready to shoot people. Resident #1 stated she did not know who CNA A was referring to but felt fearful for her safety. Resident #1 stated she was fearful of retaliation. Resident #1 stated her [family member] stayed with her overnight following the incident due to her safety concerns. Immediate Actions Resident #1 is no longer in the community. - The C.N.A was suspended on 07/28/2025. The Police were notified of the concern and came to the facility at the time of the complaint/concern on 07/28/2025 and interviewed the appropriate parties. - On 08/02/2025 safe surveys were initiated on all interview able residents, no pattern or concerns were identified nor noted. - On 08/02/2025 Head-to-toe assessments were initiated on all nonverbal residents with no pattern or evidence of any deviation from all of the residents' normal baseline status. - On 08/02/2025 The Medical Director was notified of the immediate jeopardy; the Medical Director was the residents physician. - The Ombudsmen was notified of the content of the immediate jeopardy via email on 08/02/2025. - On 08/02/2025 The community initiated a new protocol to increase the safety of the community by locking the main entry door and only allowing entrance into the community by the facility staff inside. The receptionist and staff were notified and educated of the new protocol via group messaging and in person. - On 08/02/2025 All other entry/exit doors keypad codes were changed. Systematic Approach On 08/02/2025 An ad hoc QAPI meeting was held, in attendance were the: Medical Director (via TEAMS), Executive Director, DON and the Regional [NAME] President of Operations to review appropriate interventions and to review our present Policy and Procedures on: Abuse Prevention, Workplace Aggression/Violence Policy. Review of the present policies was found to be sufficient and met state and federal requirements. Education - On 8/01/2025 The Abuse Coordinator [ED] was in re-serviced by the Regional [NAME] President of Operations, on the Abuse Prevention Protocol, to include a questionnaire and in service on abuse and neglect. - Beginning on 8/1/25-All staff were re-in serviced by the Administrator /Director of Nursing Services and/or Manager on Abuse Prevention Protocol. - On 08/02/2025 Additional Inservice's with competency were added for all staff: Customer Service, Recognizing Employee/Caregiver Burnout and retaliation. In addition, each staff member began in servicing with competency on the Workplace Aggression/Violence policy. ******Any staff who are not present to complete the in-service by 08/02/2025 will be required to complete the in-services at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee. Monitoring - Resident safe surveys and/or head to toe assessments will be conducted weekly x 4 weeks on all patients, then monthly x 3 months with oversite from the facility DON and Administrator. - Employees will complete Abuse questionnaires / and in-servicing weekly x 4 weeks then monthly x 3 months with oversite and monitoring from the facility DON and Administrator. Quality Assurance In-servicing on Abuse and Neglect and any associated concerns will be included in the facility's monthly QAPI meeting for 3 months to include the Medical Director with oversight from the facility Administrator and DON. On 08/03/2025 at 12:50 p.m., the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy with the following: During an observation on 08/03/2025 at 12:47 p.m., a doorbell was noted at the entrance to the nursing facility and staff assistance was required for entry. During an interview on 08/03/2025 at 12:53 p.m., the DON stated CNA A was suspended but will be terminated. During an interview and record review on 08/03/2025 at 03:31 p.m., the MD stated he came to the NF on the night of 08/02/2025 to review and sign the Emergency QAPI Plan. The MD stated he understood the IJ concern and was aware the resident named in the incident had since moved to another nursing facility. During an interview on 08/03/2025 at 04:10 p.m., Receptionist M stated she worked the weekends. She stated the facility front door was now locked all day and she now had to let each person into the facility as they arrived. She stated the front door was previously unlocked from 08:00 a.m. to 06:00 p.m. She stated visitors would continue to be able to exit the facility. She stated the change to having the door locked was done due to a suspended employee. During a dual interview on 08/03/2025 at 04:00 p.m. with the DON and ED, the ED stated the facility only had

Based on interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #2) whose environment was reviewed for safety hazards. Nursing staff failed to properly discard and remove a syringe used for insulin (a hormone essential for individuals with insulin insufficiency, such as diabetics, to convert food into energy and maintain blood sugar levels) administration from Resident #2's room. This deficient practice could affect residents exposed to syringes and could contribute to avoidable accidents.The findings included: Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture (break) of right patella (kneecap), and type 2 diabetes mellitus (DM2; a condition that develops with the way the body regulates and uses sugar as fuel). Record review of Resident #2's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #2's Entry MDS was the only MDS complete. Record review of Resident #2's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/23/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. Record review of Resident #2's Order Recap Report, dated 07/30/2025 with order date: 07/01/2025- 07/31/2025, reflected an active order Humulin R Infection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 8 unit subcutaneously [under the skin] two times a day for DM2. The order was ordered on 07/22/2025 and started on 07/23/2025. Record review of Resident #2's Medication Administration Record, dated 07/01/2025- 07/30/2025 and printed 07/30/2025, reflected the order Humulin R Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 8 unit subcutaneously [under the skin] two times a day for DM2 was administered by LPN E at 0800 (08:00 a.m.) and 2000 (08:00 p.m.) on 07/26/2025 and 07/27/2025. During an interview with Resident #2, at NF C, on 07/30/2025 at 04:40 p.m., revealed Resident #2 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #2 stated she did not have any problems with her medications while a resident at NF B. During an interview on 07/31/2025 at 11:01 a.m., Resident #2's family member stated Resident #2 did not have any medication administration issues at NF B, but she had found a used syringe for injecting Resident #2's insulin on Resident #2's bedside table. She stated she found a syringe one day while visiting Resident #2 and when she asked Resident #2 and her roommate, they replied that it was not the first time the incident had happened. She stated she picked up the syringe and walked it to the nurses' station and said, isn't this supposed to be in the nurses' station?. The nurse said yes and that she was sorry. She stated she told the charge nurse that she better not see this happen again. She stated she didn't know if the syringe was the one used to inject Resident #2's insulin or if it was someone else's. She stated she discovered the syringe in the afternoon and if it was Resident #2's, the syringe would have been sitting on Resident #2's side table since the morning due to the timing of Resident #2's insulin administrations. During an interview on 08/01/2025 at 05:53 p.m., LPN E stated she worked double shifts on the weekends, Saturday and Sunday from 06:00 a.m. to 10:00 p.m. She stated she worked the prior weekend, 07/26/2025 and 07/27/2025 and Resident #2 was one of her assigned residents. LPN E stated Resident #2's family member approached her on Saturday morning, 07/26/2025 about finding a used syringe in Resident #2's room. LPN E stated she apologized for the incident and reviewed Resident #2's orders to verify Resident #2 was a diabetic patient. LPN E stated Resident #2's family member stated, it better not happen again. LPN E stated she might have left it in the room. She stated she recalled going into Resident #2's room to check her blood sugar, but did not recall Resident #2 requiring insulin that morning. LPN E stated the incident only happened that one time and she did not report it since she just corrected the situation and made sure it would not happen again. LPN E stated she believed it happened because she was trying to figure out what her residents with diabetes needed prior to breakfast and got distracted while taking blood pressures and other vitals. LPN E stated the syringe was locked so a person could not access the needle when she received it from Resident #2's family member. During an interview on 08/01/2025 at 05:22 p.m., the DON stated there were sharp containers in resident rooms and on the medication carts. The DON stated staff needed to dispose of used sharps or syringes in the biohazard containers and if they found one, they were to dispose of it and make sure they notified their supervisor so administrative staff could take additional measures, such as training or education if someone did not follow the policy. The DON stated she had not been notified of an incident regarding an unsecured syringe. During an interview on 08/01/2025 at 06:14 p.m., the ED stated if there were an incident of a syringe or sharp being left unsecured, he would have had a documented conversation with the staff member. He stated the incident would have obviously been an error. He stated he might respond with a verbal disciplinary action but that it would depend on if the situation resulted in harm. The ED stated this type of incident could result in cross contamination or injury due to the medical equipment left behind. He stated he had not been notified of an incident regarding an unsecured syringe. Record review of facility policy, Nursing Policy & Procedures, Infection Control Program- Section 15, SYRINGE, NEEDLE, LANCET AND RAZOR DISPOSAL (ONE-WAY CONTAINERS), date reviewed and revised March 2019, reflected, ResponsibilityLicensed Nurse/CNAPurposeTo prevent contamination and cross-contamination from used syringes, needles, lancets and razors.ProcedureAfter opening or using a syringe, needle, lancet, or razor, do not replace cap.Place, intact, in rigid, puncture-proof container with one-way opening.Replace lid on container securely.

Based on interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility did not provide showers or baths to Resident #1 as scheduled and requested on 07/26/2025. This failure can affect residents by decreasing their quality of life. The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record review of Resident #1's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #1's Entry MDS was the only MDS complete. Record review of Resident #1's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/28/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. Record review of Resident #1's .Functional Abilities, dated effective 07/26/2025, reflected Resident #1 needed some help with self-care and indoor mobility (ambulation). Resident #1's Shower/bathe self ability and Tub/Showr [sic] Transfer ability was noted as Not assessed/no information. Resident #1 was noted to need partial/moderate assistance with upper and lower body dressing and personal hygiene; and supervision or touching assistance with sit to stand mobility. Record review of Resident #1's Task: Bathing, undated and accessed 08/01/2025 with look back period of 14 days, reflected Resident #1 with only 1 documented bath or shower, 07/28/2025 at 10:45 (a.m. or p.m. not noted). Record review of facility Skin Site Identification Form provided upon request for shower sheets, dated 07/26/2025 reflected 26 residents received a shower on Saturday, 07/26/2025. Resident #1 form not found in forms dated 07/26/2025. Record review of facility Skin Site Identification Form, dated 07/28/2025 reflected Resident #1 received a shower on 07/28/2025 at 07:30 p.m. During an interview with Resident #1, at NF C, on 07/30/2025 at 02:50 p.m., revealed Resident #1 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #1 stated she was not provided a shower in the hospital prior to her admission to NF B on 07/25/2025 and had asked multiple CNAs after her admission for a shower. She stated the CNAs would respond by stating it was a different staff member's responsibility. She stated she did not receive a shower until Monday, 07/28/2025, 3 days after her admission. During an interview on 07/31/2025 at 03:06 p.m., ADON G stated she was notified by Resident #1's roommate and Resident #1's roommate family member on Monday, 07/28/2025 that Resident #1 had not received a shower since her admission. ADON G stated Resident #1 was supposed to be showered on Saturday (07/26/2025). She stated she had not completed her daily audit list, which included a review of the shower sheets from the daily list. ADON G stated A and B beds were showered on opposite days and the facility had a shower book with a shower list. She stated the shower list included a list of each shower due for each shift. ADON G stated Resident #1 would probably not have been on the shower list on 07/26/2025 since she was admitted on a Friday, but the expectation was for the CNAs to still check their rooms and provide showers for their residents. ADON G stated the charge nurse would have been accountable for ensuring all their residents received their expected shower. The ADON G stated the charge nurse for weekends worked a double, so the missed shower should have been caught on Saturday, 07/26/2025. During an interview on 08/01/2025 at 03:11 p.m., the Th Dir stated she met with Resident #1 on Friday, 07/25/2025 and Resident #1 was assessed on Saturday, 07/26/2025 for transfers. The Th Dir stated Resident #1 was found to require moderate assistance with bathing, was able to transfer by using a walker, and was not able to walk with the walker during the 07/26/2025 assessment. During an interview on 08/01/2025 at 04:03 p.m., CNA A stated residents were provided showers on Monday, Wednesday, and Fridays or Tuesdays, Thursdays, and Saturdays, depending on if the resident was in A bed or B bed. She stated the time of day of the shower, during the 06:00 a.m. to 02:00 p.m. shift or the 02:00 p.m. to 10:00 p.m. shift, would depend on the resident's room number. CNA A stated if a resident was a new admission, the therapy department would have to evaluate the resident's activity of daily living needs for mobility prior to her providing the resident with a shower. CNA A stated Resident #1 asked about a shower on the night of her admission, Friday 07/25/2025, but she stated she told Resident #1 that therapy would have to first assess her prior to the staff being able to give her a shower. CNA A stated Resident #1 did not receive a shower on Saturday, 07/26/2025 because Resident #1 had not been assessed. CNA A stated some therapy staff were working on Saturday, 07/26/2025, but she did not believe Resident #1 had been assessed. She stated Resident #1's room number would have been on the shower chart for Saturday since the list was by room and bed number, not by resident name. She stated she was not sure if Resident #1's nurse was aware Resident #1 did not have a shower, but the nurse would have told her if Resident #1 was good to go. CNA A stated she believed Resident #1 did not mention she had not had a shower until Saturday night (statement different from prior statement of Friday evening). CNA A stated she did mention to a nurse that Resident #1 had not received a shower (statement different from prior statement) and the nurse stated Resident #1 had not been evaluated yet. CNA A was unable to provide the nurses' name, the date, or the time of the discussion. During an interview on 08/01/2025 at 05:53 p.m., LPN E stated she worked double weekends, Saturday and Sunday from 06:00 a.m. to 10:00 p.m. She stated she worked the prior weekend, 07/26/2025 and 07/27/2025 and Resident #1 was one of her assigned residents. LPN E stated she knew the therapist went in and evaluated Resident #1. She was unsure if the therapist evaluated Resident #1 on Saturday or Sunday. LPN E stated Resident #1 was assessed as requiring minimal assistance. She stated Resident #1 did not ask her for a shower on Saturday or Sunday. She stated she was not sure about a shower list, but to her, regardless of a list, if a resident asked for a shower, she would try to give the resident a shower. She stated Resident #1 could have been given a shower on Saturday, 07/26/2025. During an interview on 08/01/2025 at 05:22 p.m., the DON stated residents were already on the shower list upon admission because the list was by room number. The DON stated the shower list was divided by bed A and bed B and by room number, so a limited number of showers were scheduled per day and per shift. The DON stated a resident might have to wait for therapy to evaluate prior to a shower, but it would depend on the resident's admitting hospital records and if they did not have weight baring status. The DON stated she was unaware of Resident #1 having missed a shower or having asked for one. The DON stated if a resident requested a shower, the weekend RN would have been present in the facility and could have assessed the resident or made sure the right staff member knew the resident had requested one. The DON stated the bottom line was that if a resident requested a shower, the staff are to provide it. During an interview on 08/01/2025 at 06:14 p.m., the ED stated the facility staff would need to have a conversation with the involved staff members to determine the reason a resident's shower was missed. He stated there might have been a physical limitation or something with the shower. He stated the staff are supposed to notify the charge nurse if they are unable to perform a shower and the charge nurse was supposed to document why the staff were unable to give the shower or document that the resident was refusing. The ED stated he had not received any reports of showers not having been provided on the scheduled shower day, or at least not recently. Record review of facility policy, Shower/Tub Bath, date revised October 2020, reflected, PurposeThe purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.DocumentationThe following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. the date and time the shower/tub bath was performed. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.Reporting 1. Notify the supervisor if the resident refuses the shower/tub bath. 3. Report other information in accordance with facility policy and professional standards of practice. Record review of facility policy, Resident Rights, date revised February 2021, reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 nursing treatment carts out of 3 nursing carts reviewed for storage. The facility failed when on 06/09/2025 the nursing treatment cart was left unlocked and unattended by the Treatment Nurse when she entered the room to wash her hands and when wound care was provided to Resident #3. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings included: Record review of Resident #3's admission Record (Facesheet), dated 06/09/2025, revealed he was admitted to the facility on [DATE] with diagnosis which included heart failure, high blood pressure, and open wound of right toes. Record review of Resident #3's Physician Order Summary Report, revealed an order for Povidone-Iodine Solution 10% apply to 2nd toe topically every day shift with a start date of 05/23/2025. Record review of Resident #3's admission MDS, an assessment dated [DATE], revealed his BIMS score of 15 which indicated his cognitive skills for daily decision making were intact, and he was admitted with an open lesion on his foot. Record review of Resident #3's care plans for wounds with a start date of 04/21/2025 revealed interventions which included administer treatments as ordered. Observation on 06/09/2025 from 8:50 AM to 8:59 AM revealed when the Treatment Nurse entered Resident #3's room to wash her hands in the bathroom, she left the nursing treatment cart in the hallway unattended, out of her line of sight, and unlocked with the lock sticking out with the red portion of the lock handle visible indication it was unlocked. Further observation revealed the Treatment Nurse removed betadine from the treatment cart and applied the betadine to Resident #3's toes as part of the wound care treatment.The Treatment nurse came out of the bathroom, closed the door to Resident #3's room without locking the nursing treatment cart that had the lock sticking out in the unlocked position while she provided wound care to Resident #3. After wound care was provided, the Treatment Nurse opened the door to Resident #3's room and pulled open a drawer on the unlocked nursing treatment cart to remove an item, then the Treatment Nurse locked the cart. In an interview on 06/09/2025 at 9:00 AM, the Treatment Nurse stated she thought she had locked the treatment cart when she was in Resident #3's room because she usually would lock it when she goes into a resident's room. Observation on 06/09/2025 at 9:26 AM revealed the Treatment Nurse removed triad cream from the treatment cart. In an interview on 06/09/2025 at 10:56 AM, the DON stated the nursing treatment cart should be locked when unattended so that medications would not be removed from the cart, and the harm could be that someone or a resident could remove a medication from the cart they were not supposed to have access to. Record review of the Storage of Medications policy, revised April 2007, revealed The facility shall store all drugs and biologicals in a safe, secure and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (R#8) reviewed for misappropriation of resident property. The facility failed to ensure that Resident #8 was not subject to financial misappropriation or exploitation from Housekeeper E from the time period 11/10/2024 to 11/11/2024. Housekeeper E accepted a check for $350 from Resident #8. This deficient practice was determined to be Past Non-Compliance from 11/10/2024 to 11/11/2024, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. The findings included: Record review of Resident #8's face sheet dated 11/11/2024 revealed the resident was a [AGE] year-old male admitted on [DATE] and discharged [DATE]. The resident's diagnoses included: Rhabdomyolysis (a serious medical condition where damaged skeletal muscle tissue breaks down, releasing its contents into the bloodstream), alcohol abuse with intoxication, hypertension (high blood pressure), anxiety disorder (excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life) and depression (a persistent sadness that interferes with daily life). A family member was listed as the resident's RP. Record review of Resident #8s admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The resident was continent of bowel and bladder and able to perform ADLs independently or with partial/moderate assistance. Record review of Resident #8's comprehensive care plan, accessed on 04/08/2025, revealed the resident took psychotropic medications to treat his depression and anxiety. Interventions included monitoring for involuntary behaviors and weight loss and protecting the resident from self-harm or harm to others. During a telephone interview on 04/07/2025 at 12:28 PM, Resident #8's family member stated she had control of Resident #8's checkbook. She took it to the facility for the resident to sign some checks for his bills and left it there. When she returned to pick it up on 11/10/2024, she noticed one check was gone and confronted Resident #8 about it. At first, the resident did not know where it went, then he said, She needed help for a trip. When asked who needed help, Resident #8 stated, The housekeeper. Resident #8 saw the family member got upset and stopped talking. She did not know the amount of the check. The family member was livid. She approached the receptionist at the front desk and told her she was extremely upset and wanted it handled immediately and was told by the receptionist she would pass it along. The Administrator called her two days later, apologized immensely, and stated he instructed the housekeeper to bring cash back. The Administrator said Housekeeper E did not understand it was not okay to receive money from the resident. Resident #8 had dementia brought on by alcoholism. Two days later the Administrator said he had the cash but did not want to give it to the resident. She came to the facility and picked up an envelope of cash containing $350. During an interview on 04/10/2025 at 10:35 AM, the facility's receptionist stated she received training on abuse and neglect yearly and knew what to do if she became aware of such an incident; she would report the incident to the abuse coordinator, the Administrator. She vaguely remembered the incident but not the day. Resident #8's family member came to her mid-morning or after lunch. She was very upset and stated there was money missing, taken from Resident #8. The receptionist apologized to the family member and texted the Administrator immediately. She tried calling the DON but the DON was busy with a resident. She did not speak with the DON. During an interview on 04/11/2025 at 11:17 AM, the Administrator stated a staff member told him on 11/10/24 a family member called and they were upset someone cashed a check from a resident. He (the Administrator) did not recall who told him about the incident. The case was investigated by the facility's former DON. Housekeeper E returned the money before she went on vacation. She acknowledged she knew what she was doing was wrong but Resident #8 insisted she take the money. Housekeeper E went on vacation for 2 weeks and when she returned to duty, she was terminated. He did not report the incident to the police and he did not have a case number. He did not know why. The Administrator later stated on 04/11/2025 at 1:05 PM he did not notify law enforcement because Resident #8 had a BIMS of 15, he gave the Housekeeper the check voluntarily, and therefore the act did not fit the definition of misappropriation and instead fell under the category of accepting gifts from residents. During an interview on 04/11/2025 at 1:30 PM, the Housekeeping Director stated Housekeeper E talked about her past in [NAME] with Resident #8 and he stated he was going to help her out and take care of her. He was going to give her a check between him (Resident #8) and Housekeeper E, from him to her. Housekeeper E said she could not accept it but took it. She did not tell him (the Housekeeping Director) about it. She was not one of those who had ever done anything like that. He did not know what she was thinking. The DON found out about it and sent her home. She (the DON) told him about it. When he talked to Housekeeper E, she said they sent her home because she took some money that a patient gave her. He said it was going to be between us. The housekeepers knew they were not supposed to take it. She knew the right thing to do. She said she was going to tell me about it. He told her soon as she got that check she should have come to him. She had his phone number, she could have called him, but she did not. Record review of a statement provided by Housekeeper E dated 11/10/2024 revealed she cleaned the room for Resident #8, had a conversation with him, told him she was going on vacation, he asked her how much money she needed and gave her $350. Record review of facility's Reportable Incident Protocol dated August 2024 read: In reporting accidents/incidents, the following protocol must be observed: External Reportable Incidents: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: .Misappropriation of Patient Funds: The taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real, or personal, or anything of value belonging to or under the legal control of a Patient, without the effective consent of the Patient or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct related to the custody or disposition of property of a Patient . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of patient property and exploitation (collectively Patient Abuse) by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians, friends, or other individuals. Reporting of crimes: The facility must report to the State Agency and law enforcement in which the facility is located any reasonable suspicion of a crime against any individual who is a patient of or is receiving care from the facility. The facility MUST report immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. It was determined this failure placed residents in Past Non-Compliance from 11/10/2024 - 11/11/2024. The facility took the following actions to correct the non-compliance: 1. Record review of Housekeeper E's employment record revealed she was suspended from employment pending investigation of the incident on 11/10/2024. She had taken a 14-day planned leave of absence and was terminated upon her return to duty. 2. Record review of facility's Inservice training dated 11/10/2024 revealed 32 employees were trained by the abuse coordinator on not accepting gifts and financial abuse. 3. Facility investigation and reporting of incident to HHSC on 11/11/2024. 4. Emergency QAPI completed. 5. Money retrieved from Housekeeper E and returned to Resident #8's family member. Interviews conducted on 04/10/2025 from 12:27 PM - 3:18 PM and 4/11/2025 from 9:42 AM - 2:10 PM with LVNs A, H and I; CNAs C, D, F, G and J; the Housekeeping Supervisor, Nutrition Supervisor and Social Worker revealed they were familiar with the abuse policy, could define abuse, neglect and misappropriation, knew who the abuse coordinator was and how to report allegations of abuse or neglect. Interviews on 04/11/2025 from 09:45 AM - 10:15 AM with 15 residents from Halls 100, 200, 300, 500 and 600 revealed they felt safe at the facility with no concerns of abuse or neglect, no concerns with staff, and no observations of abuse or neglect from staff or resident to resident.

Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #2) reviewed for privacy, in that: CNA C and CNA D did not completely close Resident #2's privacy curtain while providing incontinent care on 4/11/25. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #2's face sheet, dated 04/11/2025, revealed an admitted [DATE], with diagnoses which included: Non traumatic acute subdural hemorrhage (bleeding between the layers surrounding the brain), Dysphagia (difficulty swallowing), Malignant neoplasm of prostate (prostate cancer), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (high blood pressure), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's Cognitive and Swallowing assessment dated [DATE], revealed the resident had a BIMS score of 12, indicating he was moderately impaired. Record review of Resident #2's Admission progress note dated 04/07/2025, revealed the resident required extensive assistance with his activity of daily living and was always incontinent of bowel and bladder. Record review of Resident #2's care plan, dated 04/09/2025, revealed a problem of Pressure Ulcer Prevention, with an intervention of Incontinent care provided every 2 hours and as needed. Observation on 04/11/2025 at 9:42 a.m. revealed CNA C and CNA D did not completely close the privacy curtain while they provided incontinent care for Resident #2, exposing the resident's genital area during care. The privacy curtain was too short to surround the bed. The resident's end of the bed was completely uncovered. An Housekeeper opened the room's door and started entering before she was stopped by this surveyor and CNA C and CNA D. During an interview with CNA C and CNA D on 04/11/2025 at 9:46 a.m., CNA C and CNA D confirmed the privacy curtain was not completely closed while they provided care for Resident #2 but it should have been. CNA D added the privacy curtain had been changed because it was long enough to close completely the day before. They confirmed they received resident rights training within the year. During an interview with the Administrator on 04/11/2024 at 1:30 p.m., the Administrator confirmed privacy must be provided during nursing care and Resident #2's privacy curtain should have been closed completely. He confirmed the staff had received training on resident rights within the year. Review of State Long-Term Care Ombudsman Program. Your Rights in a Nursing Facility, dated January 2025, revealed you have the right to: privacy, including during visits, phone calls and while attending to personal needs.

Based on observation, interview, and record review, the facility failed to ensure environment remains as free of accident hazards as is possible; for residents for 1 of 8 units (unit 800) observed for environment, in that: 1. The facility failed to ensure potential hazards Clorox (disinfecting wipes) were locked up and kept out of resident rooms. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Review of Resident #1's face sheet dated 04/09/2025, revealed an admitted [DATE] with diagnoses which included: Hydrocephalus (Buildup of fluids in the brain), Dementia (decline in cognitive abilities), Hypertension (high blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), Anxiety disorder (A group of mental illnesses that cause constant fear and worry). Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 00, indicating he was severely impaired. Review of Resident #1's care plan dated 10/07/2024 revealed the resident had a self-care deficit and required assistance with ADLs. Observation on 04/10/2025 at 10:30 a.m. revealed a container of Clorox (disinfecting wipes) on top of the bedside table in Resident's 1's room. The container had a hazard statement causes eye irritation. During an interview on 04/10/2025 at 10:35 a.m. with LVN A, the LVN verbally confirmed the Clorox wipes container should not have been left in the room. RA B added Resident #1's wife had brought the container of wipes. During an interview on 04/10/2025 at 1:44 p.m. with the Administrator, he verbally confirmed the disinfecting wipes should not have been kept in a resident's room. He added Resident #1's family member had brought the container of wipes and she had been educated in the past about not bringing certain items to the facility. Review of the State Long-Term Care Ombudsman Program. You rights in a Nursing Facility flyer, dated January 2025, revealed You have the right to live in safe, decent and clean conditions.

Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 8 residents (Resident #8) reviewed for abuse, neglect, exploitation, or mistreatment and report to one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. The facility failed to report to a law enforcement entity of an allegation of exploitation on 11/10/2024, where Housekeeper E received a check in the amount of $350 from Resident #8. This failure had the potential to affect the residents in the facility by placing them at risk for exploitation and/or misappropriation of resident property. The findings included: Record review of Resident #8's face sheet dated 11/11/2024 revealed the resident was a [AGE] year-old male admitted on [DATE] and discharged [DATE]. The resident's diagnoses included: Rhabdomyolysis (a serious medical condition where damaged skeletal muscle tissue breaks down, releasing its contents into the bloodstream), alcohol abuse with intoxication, hypertension (high blood pressure), anxiety disorder (excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life) and depression (a persistent sadness that interferes with daily life). A family member was listed as the resident's RP. Record review of Resident #8s admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The resident was continent of bowel and bladder and able to perform ADLs independently or with partial/moderate assistance. Record review of Resident #8's comprehensive care plan, accessed on 04/08/2025, revealed the resident took psychotropic medications to treat his depression and anxiety. Interventions included monitoring for involuntary behaviors and weight loss and protecting the resident from self-harm or harm to others. During a telephone interview on 04/07/2025 at 12:28 PM, Resident #8's family member stated she had control of Resident #8's checkbook. She took it to the facility for the resident to sign some checks for his bills and left it there. When she returned to pick it up on 11/10/2024, she noticed one check was gone and confronted Resident #8 about it. At first, the resident did not know where it went, then he said, She needed help for a trip. When asked who needed help, Resident #8 stated, The housekeeper. Resident #8 saw the family member got upset and stopped talking. She did not know the amount of the check, and she was livid. She approached the receptionist at the front desk and told her she was extremely upset and wanted it handled immediately and was told by the receptionist she would pass it along. The Administrator called her two days later, apologized immensely, and stated he instructed the housekeeper to bring cash back. The Administrator said Housekeeper E did not understand it was not okay to receive money from the resident. The family member told the Administrator Resident #8 had dementia brought on by alcoholism, she knew it was not okay, but wanted the matter escalated and inquired as to whether she needed to call the police department or he would do it. The Administrator told her he would take care of it. Two days later the Administrator said he had the cash but did not want to give it to the resident. She came to the facility and picked up an envelope of cash. During an interview on 04/11/2025 at 11:17 AM, the Administrator stated a staff member told him on 11/10/2024 a family member called and they were upset someone cashed a check from a resident. He (the Administrator) did not recall who told him about the incident. The case was investigated by the facility's former DON. Housekeeper E returned the money before she went on vacation. She acknowledged she knew what she was doing was wrong but Resident #8 insisted she take the money. Housekeeper E went on vacation for 2 weeks and when returned to duty, she was terminated. He did not report the incident to the police and he did not have a case number. He did not know why. The Administrator later stated on 04/11/2025 at 1:05 PM he did not notify law enforcement because Resident #8 had a BIMS of 15, he gave the Housekeeper the check voluntarily, and therefore the act did not fit the definition of misappropriation and instead fell under the category of accepting gifts from residents. During an interview on 04/11/2025 at 1:30 PM, the Housekeeping Director stated Housekeeper E talked about her past in [NAME] with Resident #8 and he stated he was going to help her out and take care of her. He was going to give her a check between him (Resident #8) and Housekeeper E, from him to her. Housekeeper E said she could not accept it but took it. She did not tell him (the Housekeeping Director) about it. She was not one of those who had ever done anything like that. He did not know what she was thinking. The DON found out about it and sent her home. She (the DON) told him about it. When he talked to Housekeeper E, she said they sent her home because she took some money that a patient gave her. He said it was going to be between us. The housekeepers knew they were not supposed to take it. She knew the right thing to do. She said she was going to tell me about it. He told her soon as she got that check she should have come to him. She had his phone number, she could have called him, but she did not. Record review of a statement provided by Housekeeper E dated 11/10/2024 revealed she cleaned the room for Resident #8, had a conversation with him, told him she was going on vacation, he asked her how much money she needed and gave her $350. Record review of Provider Investigaion Report dated 11/10/2024 revealed under section were other parties notified?, Physician and Responsible Party. Record review of facility's Reportable Incident Protocol dated August 2024 read: In reporting accidents/incidents, the following protocol must be observed: External Reportable Incidents: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: .Misappropriation of Patient Funds: The taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real, or personal, or anything of value belonging to or under the legal control of a Patient, without the effective consent of the Patient or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct related to the custody or disposition of property of a Patient . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation of patient property and exploitation (collectively Patient Abuse) by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient, family members, legal guardians, friends, or other individuals. Reporting of crimes: The facility must report to the State Agency and law enforcement in which the facility is located any reasonable suspicion of a crime against any individual who is a patient of or is receiving care from the facility. The facility MUST report immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 5 residents (Residents #86) reviewed for dignity. The facility failed to ensure the urinary collection bag for Resident #86's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings include: Record review of Resident #86's face sheet, dated 06/27/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] had diagnoses which included hypertension (blood is pumping with more force than normal through your arteries), gastroesophageal reflux disease (condition in which the stomach contents move up into the esophagus), acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), muscle weakness (lack of muscle strength), & cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, or following instructions). Record review of Resident #86's admission MDS Assessment, dated 05/28/2024, reflected a BIMS score of 15, which indicated the resident is cognitively intact. Resident #86 admission MDS assessment also revealed Resident #86 had an indwelling catheter and was always incontinent of bowel. Record review of Resident #86's care plan, dated 06/26/2024, reflected Resident #86 was care planned for risks for infection r/t indwelling catheter and enhanced barrier precautions implemented r/t urinary catheter. During an interview and observation on 06/25/2024 at 11:26am, Resident #86 was observed in his room with his urinary collection bag almost full with no privacy bag covering it. Resident #86 stated he did not know his catheter bag was not covered. Resident #86 stated he was not sure how long it had not been covered. Resident #86 stated that he would like for his catheter bag be covered at all times. In an interview on 06/27/2024 at 11:35am, LVN A stated that a resident's catheter drainage bag should always be covered. LVN A stated that it was everyone's responsibility to ensure that all residents drainage bag were covered. LVN A stated that anyone can put a resident's catheter bag in a privacy bag. LVN A stated if a resident's catheter bag was not covered then that would be an infection control and a dignity issue. In an interview on 06/27/2024 at 1:55pm, the DON stated that a residents catheter drainage bag should always be covered. The DON stated it was the nurse's responsibility to ensure that the resident's catheter drainage bag was covered. The DON stated that if a resident's catheter drainage bag was not covered it would be a dignity issues. In an interview on 06/27/2024 at 2:10pm, the ADM stated that a residents catheter drainage bag should always be covered. The ADM stated he believed it would be the nurse's responsibility for ensuring the resident's catheter bag was covered. The ADM stated that it was his expectation for residents with catheter drainage bags to always be covered. Record review of the facility's policy titled, Resident Rights, dated December 2016, reflected Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity;

Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices for 1 of 4 Residents (Resident #1) reviewed for accidents and hazards, in that: NA A failed to adequately supervise Resident #1 when she pushed her in the wheelchair which resulted in Resident #1 falling face first onto the ground hitting her face and head and requiring a trip to the emergency room for evaluation. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke). Generalized muscle weakness, [CONDITION(S)] without behavioral disturbance (a condition caused by lack of blood that carries oxygen to parts of the brain resulting in problems with reasoning, planning, judgment and memory), repeated falls, and [CONDITION(S)] [CONDITION(S)] (a heart condition with irregular heartbeat). Record review of Resident #1's physician orders dated [DATE] revealed an order for [MEDICATION(S)] (a blood thinner) 5 mg tablet two times a day for treatment of [CONDITION(S)] (a heart condition). Record review of Resident #1's Care Plan dated [DATE] revealed the resident had impaired cognition related to the diagnoses of [CONDITION(S)] with interventions which included: maintain consistent routine; introduce change slowly when possible to reduce confusion. Record review of Resident #1's Care Plan dated [DATE] revealed the resident was at risk for falls related to impaired cognition and a history of repeated falls, impaired vision and hearing .with interventions which included: assess reason for fall, staff education on proper positioning in the chair. Record review of Resident #1's quarterly assessment dated [DATE] revealed a BIMs of 5 (scale of ,d+[DATE]) which indicated a severe cognitive impairment. Record review of Resident #1's quarterly assessment dated [DATE] revealed Resident #1 was unable to ambulate (walk) and required extensive assistance of staff to transfer, change position and move around the facility in a wheelchair. Record review of Resident #1's quarterly assessment dated [DATE] revealed Resident #1 was not steady and was only able to stabilize with staff assistance with balance during transitions. Record review of Resident #1's quarterly assessment dated [DATE] revealed Resident #1 had a history of two or more falls since admission. Record review of Resident #1's nursing progress notes dated [DATE] at 6:00 p.m. revealed: Reported by NA A, resident was sitting in wheelchair being pushed into bedroom by NA A. Residents feet were not lifted off the ground and got stuck under the chair: as stated by NA. Resident hit her forehead on the ground. No pain or discomfort noted, vital signs stable, resident does have carpet burn noted to forehead with increased swelling. Ice placed on resident's forehead. Notified NP, RP, and DON .orders to send out resident for a CT. Resident sent out of the building at 6:45 p.m.Documented by RN B. Record review of an accident/incident report dated [DATE] revealed Resident #1 had a witnessed fall from chair on [DATE] at 6:00 p.m. when Resident #1 was sitting in wheelchair pushed into bedroom by NA A. Resident #1's feet were not lifted off the ground and got stuck under the chair. Resident #1 hit her forehead on the ground .carpet burn noted to forehead with increased swelling. Resident #1 was sent to a local hospital emergency room for evaluation and treatment at 6:45 p.m. The primary injury was listed as contusions/hematoma, head involved. The DON was notified of the incident on [DATE] at 6:20 p.m. by RN B. Record review of Resident #'1 hospital record dated [DATE] revealed the results of a CT scan of the head and cervical spine which indicated the resident had small left para midline (left of midline or left side of forehead) frontal scalp [CONDITION(S)] and hematoma (swelling and bruising or collection of blood outside of the blood vessels typically caused by trauma) without fracture (break in bone) or intracranial change (changes inside the brain). Record review of Resident #1's nursing progress notes dated [DATE] at 12:59 a.m. revealed: Resident #1 returned from the local hospital alert/confused to place, time per usual. Abrasion to forehead open to air, neuro checks WNL (within normal limits) .no new orders received. Documented by LVN D. Record review of Resident #1's nursing progress notes dated [DATE] at 9:36 a.m. revealed Resident #1's RP (Responsible Party) here in facility to follow up post fall from yesterday evening. Resident denies discomfort. Resident able to make most needs known to staff .family requests to send Resident #1 out to a local hospital in an adjacent city. Documented by LVN C. During an interview on [DATE] at 3:43 p.m. LVN C stated on the morning on [DATE] she received in report (unknown staff) that Resident #1 was being pushed in a wheelchair on [DATE] during the evening shift when she fell forward. LVN C stated she did not know who was pushing Resident #1 in the wheelchair when the fall occurred. LVN C stated Resident #1's RP arrived at the facility on [DATE] shortly after 8:00 a.m. and as soon as she saw Resident #1, she became upset. LVN C stated Resident #1 had a bump on her forehead and was complaining of a little headache. LVN C stated she performed an assessment on the resident who presented as her normal appearance, with normal cognition for the resident at baseline with no acute changes. LVN C stated Resident #1 had normal vital signs and ate some of her breakfast. LVN C stated the RP spoke to several staff members (unknown) who told her Resident #1's CT exam was normal. LVN C stated the RP requested Resident #1 go to another hospital in an adjacent city for a second opinion. LVN C stated she notified the DON of the family's request and Resident #1 was sent to the hospital in an adjacent city per RP request. During an interview on [DATE] at 4:16 p.m. NA A stated on [DATE] at approximately 6:00 p.m. Resident #1 was self-propelling (using her feet to move herself in the wheelchair) down the hallway toward her room. NA A stated Resident #1 was not very far from her bedroom, approximately ,d+[DATE] doorway. NA A stated she needed to change Resident #1's brief, so she decided to push the resident the remainder of the way in the wheelchair. NA A stated she told Resident #1 let's go change you and began pushing the wheelchair forward. NA A stated she did not wait for the resident to respond to her because the resident did not normally respond. NA A stated Resident #1 was sitting forward on the seat of the wheelchair and was not sitting with her back against the backrest. NA A stated Resident #1's buttock and back were approximately 3 finger widths away from the back of the wheelchair. NA A stated, I should have pulled her back in the chair, but I didn't and when we turned the corner her feet got stuck underneath the wheelchair. NA A stated Resident #1 fell forward. She stated her feet went under the seat and she fell forward. NA A stated she tried to grab Resident #1's shirt, but it happened so quick. NA A stated Resident #1 fell forward and hit her forehead on the carpeted floor. NA A stated it happened so quick that Resident #1 was not able to put her arms out to stop or break the fall. NA A stated while pushing Resident #1 she noticed the resident was unable to hold her feet up while the wheelchair was moving. She stated Resident #1's feet kept going up and down. NA A stated she did not use footrests because Resident #1 does not have footrests on the wheelchair because she normally self-propels, and she needs them off the chair to be mobile. NA A stated, I should have pulled her back in her seat and this would not have happened, I know better than that. I go above and beyond for all my patients it was an accident and it happened so quick. NA A stated after Resident #1 fell she notified the ADON, identified as LVN E who assessed the resident. NA A stated Resident #1 stated she was okay even when the ambulance took her out of the facility. NA A stated no one from management had asked her to write a witness statement. NA A stated on [DATE] the DON asked her what had happened. NA A stated she told the DON the same thing she told stated in this interview. NA A stated after speaking to the DON she was sent home. She stated she completed new orientation competencies and training and had participated in lots of in-service trainings but could not remember what the trainings covered. She stated had participated in a resident movement training that address patient positioning, but she had not had any training specifically addressing pushing wheelchairs or wheelchair safety. NA A stated she had not been asked to complete or participate in any trainings since Resident #1's fall incident. During an interview on [DATE] at 4:55 p.m. LVN E stated she was the facilities Infection Preventionist and a member of the facility management team and a former ADON (as of [DATE]) for the facility. LVN E stated on [DATE] she was sitting in her office at approximately 6:00 p.m. LVN E stated Resident #1 peaked into her office to talk. LVN E stated Resident #1 who had dementia would often say hi and them move along the hallway by self-propelling in her wheelchair. LVN E stated she heard NA A if she wanted or needed to go to the bathroom and heard Resident #1 respond, yes. LVN E stated she looked up and saw the back of NA A pushing Resident #1 in the wheelchair towards her room. LVN E stated quickly after observing, NA A came and got her and stated Resident #1 had a fall. LVN E stated when she arrived at the resident, she was lying on the floor on her left side just inside the doorway to her room. LVN E stated she asked NA A Weren't you with her? LVN E stated NA A stated, Yes, but I could not catch her. LVN E stated she assessed Resident #1 and obtained vitals and then notified Resident #1's charge nurse, RN B stated Resident #1 had an abrasion to her forehead and she said her head hurt, but she did not have any other complaints of pain and she was alert. RN B. LVN E stated she told RN B to notify Resident #1's physician because Resident #1 was on blood thinner medication and had hit her head. LVN E stated she asked NA A what happened and NA A stated Resident #1 put her feet down while she was pushing her in the wheelchair. LVN E stated there were no witnesses. LVN E stated she felt like NA A could have handled the transport of Resident #1 better. She could have communicated better with the resident. LVN E stated was important, even for someone with dementia. LVN E stated Resident #1 tends to come forward in the seat of the wheelchair when self-propelling and NA A should have scooter her back in the wheelchair. LVN E stated she also could have allowed Resident #1 the time to finish self-propelling to her room and could have asked the resident to follow her to the bathroom instead of pushing her. LVN E stated Resident #1 was close to her room when the incident occurred and even if the resident did not go all the way by herself, NA A should have cued the resident. LVN E stated she didn't hear NA A cue the resident before the incident occurred. During an interview on [DATE] at 5:25 p.m. RN B stated on [DATE] at an unknown time near change of shift, she was notified by LVN E that Resident #1 had fallen. RN B stated Resident #1 was still on the floor when she arrived. She stated Resident #1 denied pain but had carpet burn and swelling to her forehead when EMS arrived at the facility. RN B stated she did not witness the incident, but asked NA A what happened. RN B stated, NA A said she was wheeling the resident to her room when Resident #1 fell forward headfirst and hit her head on the floor, immediately inside the resident room. RN B stated she notified ADON G and the DON of the incident on [DATE] (unknown time). RN B stated NA A did not tell her that until all the notifications were complete. RN B stated, Resident #1 cognition was normal, with no changes in baseline and was sent to the ER because she was on anticoagulants medication as a precaution only. RN B stated the DON told her to call 911. During an observation/interview on [DATE] at 8:30 a.m., Resident #1 was observed in a hospital bed at hospital in an adjacent city. Resident #1 had her eyes closed and did not open her eyes or respond to voice. Resident #1 was observed with a large bruise and swelling to her forehead, midline and to the left, with several small, scabbed areas and one large approximately 4 cm x 2 cm abrasion/open area to her forehead. Resident #1 also had bruising and swelling to both eyes and a small amount of bruising to her left cheekbone. During an interview on [DATE] at 8:44 a.m. with a RN at the hospital revealed Resident #1 had dementia and was unable to answer interview questions due to dementia and antipsychotic medication. The RN stated Resident #1 had repeat CT scans on [DATE] of her head which showed no abnormalities related to the fall incident. The RN stated the resident was being treated for a urinary tract infection and metabolic [CONDITION(S)] (a condition in which brain function is disturbed due to abnormalities of water, electrolytes, vitamins or other chemicals that adversely affect brain function). During an interview on [DATE] at 11:40 a.m. the DON stated she was notified of Resident #1's fall incident by an unknown staff member on an unknown date and time. The DON stated she was informed Resident #1 hit her head and the staff was sending her out because she was on blood thinners to make sure she didn't have a brain bleed. The DON stated on [DATE] Resident #1's RP came to the facility and was upset. The DON stated, the Administrator and herself spoke with the RP. The DON stated the RP was crying and extremely distraught because she had another elderly relative who had died , she herself had not been feeling well and now her family member had fallen. The DON stated the RP kept saying She is all that I have left in this world. The DON stated they went over the CT scan results which were negative, but the RP still wanted Resident #1 transported to a hospital in an adjacent city for a second opinion. The DON stated the RP wanted to know what happened to her family member. The DON stated she informed the RP that as far as she knew it was a fall. She said she told the RP she would look into it and get back in contact with her. The DON stated she had other issues at the facility on [DATE] to address. On [DATE] a state surveyor was in the facility which changed her day. The DON stated on [DATE] she looked through fall reports again and asked NA A to come give a statement. The DON stated after speaking with NA A she gave the aide a training on positioning and transferring and she suspended NA A because she had not finished her investigation. The DON stated as of [DATE] she would begin an on-going in-service about something she that needed to be reiterated with staff. The DON stated she needed to finish her investigation before commenting further. The DON stated she had not reviewed Resident #1's medical records at the time of this interview. The DON stated patient safety is always priority when transporting a resident in a wheelchair. She stated she did not know what the facilities policies and procedures were for wheelchair use. She stated she would have to look into it, but staff should make sure residents were positioned correctly, back on the chair, feet out and if the resident could not hold their feet up, staff should use footrests. The DON stated proper positing in the wheelchair was important, so residents and staff did not get hurt. During an interview on [DATE] at 5: 23 p.m. RN B stated when she notified the DON, she did not have the information about Resident #1's feet getting stuck under the wheelchair, so she did not tell the DON that information. She stated she did not notify the DON after she learned this information because she documented it in Resident #1 nursing progress notes. RN B stated she put the details in the note for a reason and that reason was because the DON does an assessment after a fall occurs. RN B stated the DON would review the information and close the incident. RN B stated the DON typically reviewed a fall incident and closed it within 24 hours of occurrence. RN B stated as of the date and time of this interview neither the DON or the Administrator or any member of the management team had asked her what occurred during or after the incident and she had not been asked to write a witness statement. RN B stated she had had not had any training since the fall incident with Resident #1. During an interview on [DATE] at 4:16 p.m. ADON G stated she was the Assistant Director of Nurses for the side of the building in which Resident #1 resided. She stated her job duties included overseeing everything on that side of the building and reporting any abuse/neglect concerns for allegations directly to the Administrator and DON. ADON G stated she was on a break on [DATE] at approximately 7:00 p.m. when RN B came and told her Resident #1 fell . ADON G stated RN B said NA A was pushing the resident when her feet got caught under the wheelchair causing her to fall and hit her head. ADON G stated she was concerned because Resident #1 was on [MEDICATION(S)] (a blood thinner). She stated Resident #1 had a hematoma (swelling and bruising) to her forehead and was sent to a local ER but came back to the facility the same night at approximately 10:00 p.m. ADON G stated there was no change to Resident #1 cognitive status. She stated since she was new to the ADON position she did not know what her job responsibilities entailed. ADON G stated she didn't know what her responsibility was and what she should leave for the DON. ADON G stated she did discuss with LVN E, NA A's comment I guess I could have pulled her back in the wheelchair first on the day of the incident ([DATE]). She stated she did not report the comment to the DON or the Administrator because it was hearsay. ADON G stated she did not have any concerns that needed to be reported because she had worked with NA A for a while and had never seen her do anything to harm a resident. During an interview on [DATE] at 5:50 p.m. the DON stated she trained staff to ask the residents to pick up their legs during wheelchair movement. The DON stated if a resident was unable to hold up their legs, then leg rests should be used or alternately another staff member could hold up the resident's legs, although it was not good mechanics. The DON stated there was no training specific to proper use of a wheelchair. The staff training was geared most towards resident transfer. The DON stated the training given to NA A was resident transfer and proper positioning in a chair. The DON stated she monitored staff for proper use of a wheelchair and proper positioning by watching staff and rounding constantly. She stated she watches staff by watching them change the resident, answer the call lights, monitor the state of the resident rooms and how the resident and their skin looks. The DON stated she did not have a monitoring program for proper wheelchair use, short of the education staff received during orientation which included transfer training, there was no specific competency for wheelchair use. The DON stated she ensured staff was using a wheelchair appropriately by observing. She stated it is wheelchair, staff are not supposed to be running down the hall. She stated a wheelchair has two brakes one on each side, handles on the back and a seat, and staff push it forward. The DON stated customized wheelchairs require training because they are specific to the resident. The DON stated Resident #1 did not have a customized wheelchair. She stated there was nothing special about it. The DON stated she helped staff all the time. She stated if she saw a resident who was not properly positioned in the wheelchair, she would help reposition the resident. The DON stated she communicated with other members of the management team including the Administrator during morning and afternoon meetings. During an interview on [DATE] at 12:45 p.m., the Administrator stated/ fall incidents were discussed during meetings the next day. He stated the DON was responsible for reviewing fall incidents and accidents. The Administrator stated the DON had the ability to pull records, to look at lists and sometimes staff will notify her of the incident. The Administrator stated he was not notified of Resident #1's fall incident on [DATE]. He stated the first he heard of it was the following day, [DATE]. He stated he was notified that Resident #1 had a fall. He stated he asked if she had an injury, and someone (unknown staff) stated she hit her head on carpet when she fell forward and was to the ER because she was on blood thinners to rule out a brain bleed. He stated this occurred during morning meeting, which was interrupted because Resident #1's RP arrived at the facility. The Administrator stated Resident #1's fall incident was discussed during the meeting. The Administrator stated the DON looks at fall incidents every day and then makes recommendations for interventions. The Administrator stated NA A stated she wished she would have done things differently, The Administrator stated he was not saying it was neglect, but it suggested we failed to do something which caused an injury. The Administrator stated normally the DON would start the investigation right away, but the facility thought it was just a freak accident. Record review of a safety information on www.[MEDICATION(S)].bmscustomerconnect.com by the manufacturer of [MEDICATION(S)] (a blood thinner) reviewed on [DATE] revealed: [MEDICATION(S)] can cause bleeding, which can be serious, and rarely may lead to death. This is because [MEDICATION(S)] is a blood thinner medicine that reduces blood clotting. While taking [MEDICATION(S)], you may bruise more easily, and it may take longer than usual for any bleeding to stop. Record review of a facility policy, titled Wheelchair-use of dated [DATE]. 2006 and last revised ,d+[DATE] revealed: Assist patient into wheelchair, using proper transfer techniques. Lower footrests and place patient's feet on footrests. Position feet and legs in good body alignment. Assist patient to the area of the facility as desired. Encourage and instruct patient in proper procedures for safety propelling the wheelchair. Record review of a facility policy, titled Accidents/Incidents dated [DATE] revealed 1. An Accident/Incident Report must be completed immediately upon facility staff becoming aware of the occurrence of an accident/incident involving a Patient and, if necessary, the patients Care Plan must be updated. Each Accident/Incident Report must be reviewed at the facility's daily stand-up meeting until all sections of the report are complete. Each Accident/Incident Report for an accident/incident occurring during a month must be signed by the Executive Director and Director of Nursing within 48 hours of the occurrence. 2. A witness statement must be completed at the time of the accident/incident.