Every finding on record at Terrell Healthcare Center

Based on interviews and record review, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience, or certification, and who completed specialized training in infection prevention and control, for one of one facility. The facility did not designate a qualified Infection Control Preventionist.This failure could place residents at risk for cross contamination and infection.Findings included:During an interview on 04/03/26 at 2:27 PM the ADON stated she was the in charge of infection control but did not have the certificate to be the infection control preventionist. The ADON stated the MDS nurse had certification for infection control preventionist. The ADON stated she was working on her certification of being the Infection Control Preventionist.During an interview 04/03/26 at 11:33 AM the MDS nurse said she does have her Infection Preventionist certification, but she no longer oversees anything with infection control. During an interview on 04/03/26 at 4:26 PM the DON said the MDS nurse had her certification for infection preventionist. The DON said the ADON was over logging the infections and tracking and trending and all that has to do with infection control. The DON said the ADON was not certified but she should have been certified as an infection preventionist. The DON said the failure placed a risk for something to be missed as far infection control. During an interview on 04/03/26 at 4:53 PM the Administrator said he knew the ADON should have had her certification completed to be the infection preventionist. The Administrator said the failure placed a risk for the ADON not following the infection control protocols correctly. Review of the ADON's personnel file reflected the ADON was hired on 02/01/26.Record review of the facility policy, reviewed 03/03/26, Infection Prevention and Control Program indicated 5. Coordination and Oversighta. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).Refer to Appendix PP.The regulatory requirements for the IP with tips on how to ensure compliance are listed below. See CMS's State Operating Manual Appendix PP updated 2-03-23 for F882 Infection Preventionist pages 801-806. Infection preventionist. The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's IPCP. The IP must:(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; (2) Be qualified by education, training, experience or certification; (4) Have completed specialized training in infection prevention and control.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 9 of 12 (Resident #19) residents reviewed for privacy and confidentiality.1.The facility failed to ensure LVN K logged out of her computer and protected Resident#19's Medication Administration Record. 2. The facility did not ensure residents had the right to promptly receive mail on Saturdays. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration records being accessible to others.Findings included: 1.Record review of Resident #19's face sheet, dated 04/03/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included wound infection, heart failure, stroke, and high blood pressure. Record review of Resident #19's quarterly MDS assessment, dated 03/30/26, indicated Resident #19 sometimes understood and was sometimes understood by others. Resident #19's BIMS score was 10, which meant he was moderately cognitively impaired The MDS indicated he took antibiotic medication during the 7-day look-back period. Record review of Resident #19's care plan dated 03/27/26, indicated Resident #19 was on intravenous medications related to wound infection. The intervention was for staff to monitor/document/report as needed of any signs and/or symptoms of leaking at the IV site: Edema at the insertion site, taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid out of the insertion site. Record review of Resident #19's physicians orders dated 04/01/26 indicated, Cefepime Intravenous Solution Reconstituted 2GM (Cefepime HCl) Use 2 gram intravenously every 8 hours for infection until 04/12/2026 for wound healing. During an observation and interview on 04/01/26 at 4:41 p.m., LVN K stepped away from the medication cart and entered Resident #19's room to remove his intravenous antibiotic. LVN K left the computer screen (on top of the medication cart) unlocked where the medication administration record of Resident#19 was clearly displayed. While LVN K was in the room unknown staff and residents were observed walking by the unlocked computer screen. LVN K said she left the computer screen open for Resident #19 because she was in a hurry. She said she should have closed the MAR before entering Resident #19's room. She said it was a HIPAA violation to keep the MAR open where others could see Resident #19's personal information. During an interview on 04/03/26 at 3:36 p.m., the DON said she expected the nurses and med aides to provide full visual privacy and confidentiality of information for all residents. She said if the staff left the MAR open anyone could walk up to it and see personal information. The DON said failure not to protect the residents' information could cause poor self-esteem and embarrassment for the residents. During an interview on 04/03/26 at 5:32 p.m., the Administrator said he expected the MAR to be always closed when unattended because of resident information and privacy. 2. During a confidential group interview at an undisclosed date and time, 8 residents stated they did not always receive their mail on Saturdays. The residents stated they had to wait until Monday when the facility allowed the Activity Director to pass it out. During an interview on 04/01/26 at 11:42 a.m., the Activity Director stated there were times she delivered mail to residents from Saturday on Monday that was given to her by the Business Office Manager. The Activity Director stated it was important residents received their mail because it was their right. During a telephone interview on 04/01/26 at 6:08 p.m., Dietary Aide E stated she had a key to the mailbox that was left in the Dietary Manager office for her to check the mail. Dietary Aide E stated the Business Office Manager told her to check the mail on Saturdays and place it under her door. Dietary Aide E stated she was never told to pass out mail to residents on Saturdays. Dietary Aide E stated it was important for the residents to get their mail because it was their right. During an interview on 04/02/26 at 2:39 p.m., Dietary Aide D stated she checked the mail on Saturdays and if there was personal mail such as a letter or a package, she gave it to the residents and the other mail she put at the nursing station to be stored until Monday for the Business Office Manager. Dietary Aide D stated it was discussed in an all-staff meeting that she could not recall the date the dietary staff should check the mail on Saturdays and give it to the residents. Dietary Aide D stated it was important for the residents to get their mail because it was their right. During an interview on 04/03/26 at 3:30 p.m., the Business Office Manager stated the locked mailbox was located outside. The Business Office Manager stated the weekend dietary staff were responsible for checking the mailbox and distributing mail on the weekends. The Business Office Manager stated she did obtain mail from Saturdays and give the Activity Director the residents' mail to distribute. The Business Office Manager stated she was aware of the requirements for the residents to have access to their mail on Saturdays. The Business Office Manager stated it was important for residents to receive their mail because it was their right. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected mail to be delivered on Saturdays. The DON stated she was unsure who was supposed to monitor and oversee residents getting their mail on Saturdays. The DON stated this failure was a resident rights issue. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected mail to be delivered on Saturdays. The Administrator stated dietary staff were responsible for distributing mail to residents on Saturdays. The Administrator stated there was not a system in place to ensure residents receive their mail on Saturdays. The Administrator stated this failure could affect their rights. Record review of the facility's policy titled Statement of Resident Rights (Texas), undated, indicated, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. #6. privacy, including privacy during visits and telephone calls.#8. have facility information about you maintained as confidential. #17 receive unopened mail.

Based on interview and record review, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs for 4 of 6 residents (Resident #41, Resident # 25, Resident #11, and Resident #9) reviewed for PASRR. 1.The facility failed to coordinate with the appropriate state authority to ensure Resident #41 who had a mental disorder received a PASRR meeting (to see if she would qualify for other care and services) after she was positive on her PE on 01/12/26. 2. The facility failed to provide documentation of Resident #25's habilitation coordination and independent living skills services as requested in the PCSP Form.3.The facility failed to ensure the local authority was notified of Resident #11's Medicaid eligibility on 04/01/25 to ensure her PASRR services were started. 4. The facility did not ensure Resident #9's PASARR screening was completed to indicate a diagnosis of post-traumatic stress disorder.These failures could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1.Record review of Resident #41's face sheet, dated 04/03/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, schizophrenia disorder (a serious mental health condition that affects how people think, feel and behave), and depression (a feeling of sadness). Record review of Resident #41's admission MDS assessment, dated 12/30/25, indicated Resident #41 understood and was usually understood by others. Resident #41's BIMS score was 15, which indicated her cognition was intact. The MDS indicated Resident #41 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS reflected Resident #41 had an active diagnosis of Schizophrenia disorder. Record review of the PASRR Level 1 Screening form, dated 12/23/25, reflected Resident #41 had a mental illness. Record review of the PASRR Evaluation Screening form, dated 01/12/26, reflected Resident #41 had a mental illness. Record review of Resident #41's medical record did not indicate a PCSP meeting had occurred after receiving the positive PE. Record review of Resident #41's comprehensive care plan, dated 01/19/26, indicated, Resident #41 used an antidepressant medication. The intervention was for staff to give medication as ordered. Record review of Resident #41's Physician order dated 03/12/26 indicated Fluoxetine HCl Oral Solution 20 MG/5ML (Fluoxetine HCl) Give 15 ml via(through) gastrostomy (a medical tube inserted directly through the abdominal wall into the stomach to deliver nutrition, fluids, and medications) tube one time a day related to depressive disorder. During an interview on 04/03/26 at 11:28 a.m., the MDS Coordinator said she was responsible for ensuring the PCSP meeting was held. She said she had been told that Resident #41 had refused PASRR service by an unknown staff member. She said she did not ask Resident #41 if the information was true or reach out to the local authority to validate the information. During a phone interview on 04/03/26 at 1:11 p.m., the Local Authority said she did Resident #41's PE on 01/12/26. She said she was deemed with a mental illness and qualified for PASRR service. She said she did not talk to the normal MDS Coordinator but did let an unknown staff member know that Resident #41 was reluctant to receive PASRR services but said she never refused services. She said generally the facility would coordinate the PCSP meeting with the local authority. She said she could not see in her system where a PCSP meeting had occurred for Resident #41. During an interview on 04/03/26 at 3:08 p.m., Resident #41 said she would be interested in learning more about PASRR services. During an interview and record review on 04/03/26 at 3:28 p.m., the MDS Coordinator looked in Resident #41's medical records and did not see a PCSP meeting. She said she had not set up the PCSP meeting because usually the local authority set up the meetings. She said she did not reach out to the local authority once they had not contacted her for the meeting. She said she failed to follow up on the meeting. She said a risk could be that Resident #41 may not receive extra services that she may benefit from such as therapy, specialized wheelchair, or additional outside activity. During an interview on 04/03/26 at 3:39 p.m., the DON said she had attended 1 or 2 PCSP meetings in the past but was not familiar with the process. She said she expected the MDS Coordinator to complete the necessary paperwork for the process. She said she knew the PASRR service offered extended services but could not remember which kind. During an interview on 04/03/26 at 5:32 p.m., the Administrator said the MDS was responsible for the PCSP meetings. He said they should meet quarterly. He said if Resident #41 was positive on her PE, then the resident could qualify for services that could benefit her. 2. Record review of Resident #25's face sheet, dated 04/03/26, reflected Resident #25 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia (severe psychiatric disorder is characterized by persistent delusions of persecution, unwarranted suspicion, and often vivid hallucinations, anxiety (excessive worry), and delusional disorder (a fixed false belief based on an inaccurate interpretation of an external reality). Record review of Resident #25's quarterly MDS assessment, dated 01/02/26, reflected Resident #25 understood others, and made himself understood. Resident #25 BIMS score was 15, which reflected his cognition was intact. Record review of Resident #25's comprehensive care plan, revised 03/25/26, reflected Resident #25 had identified that he was in need of specialized services due to mental illness. The care plan interventions included: follow up with agency representative to ensure recommendations are fully implemented. Record review of the PCSP meeting dated 12/09/25 reflected that habilitation coordination and independent living skills services were recommended for Resident #25. Record review of Resident #25's EMR dated 04/01/26 reflected no documentation of habilitation coordination or independent living skills training notes. During a telephone interview on 04/02/26 at 10:37 a.m., the Habilitation Coordinator stated she came to the facility monthly to get a report from Resident #25 to ensure his needs were met. The Habilitation Coordinator stated she did not leave any documentation for the monthly visits at the facility. The Habilitation Coordinator stated she followed up with the nurses after each visit to see if there were any concerns with his care. During a telephone interview on 04/03/26 at 11:24 a.m., the Skill Trainer Community Advocate stated he came to the facility once a week on Mondays to visit Resident #25. The Skill Trainer Community Advocate stated he did not leave any documentation for the facility nor spoke with anyone after each visit. The Skill Trainer Community Advocate stated his documentation was left at the local authority office. During an interview on 04/03/26 at 11:28 a.m., The MDS Coordinator stated she was responsible for ensuring visits were conducted by the habilitation coordinator and skill trainer. The MDS Coordinator stated she was not aware when the skill trainer came to visit but the habilitation coordinator came every three months. The MDS Coordinator stated she did not coordinate with them after their visits. The MDS Coordinator stated it was important documentation was received after every visit to ensure they were receiving services. During an interview on 04/03/26 at 4:04 p.m., the DON stated she could not recall the exact services Resident #25 should be receiving but she expected some type of documentation to be provided after every visit to show the habilitation coordinator and skill trainer were in the building. The DON stated she did not know when the habilitation coordinator and the independent skill trainer came to the facility until she received an email from the habilitation coordinator to schedule the quarterly meeting. The DON stated she was not aware how often they came until the state surveyor intervention. The DON stated it was important to ensure documentation was provided for continuity of care. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he did not know what services Resident #25 was receiving until the state surveyor intervention. The Administrator stated he had not received recommendations to know how often Resident #25 should be seen. The Administrator stated in his experience that if the facility ever needed documentation, they would ask that provider to provide the documentation. The Administrator stated there was not a system in place to monitor the MDS Coordinator oversight of needs. The Administrator stated it was important to ensure documentation was provided to ensure Resident #25 was receiving his PASRR services. 3.Record review of Resident #11's face sheet dated 04/02/26 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included bipolar disorder (a chronic mental health condition characterized by extreme mood swings, ranging from high energy mania to deep depression), Post Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying or life-threatening, traumatic events), acute respiratory failure (critical condition where the lungs cannot transfer oxygen to the blood or remove carbon dioxide causing breathing problems), and muscle weakness. Record review of Resident #11's annual MDS dated [DATE] indicated she was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition with a diagnosis of a serious mental illness and an intellectual disability. The MDS also indicated Resident #11 made herself understood and understood others and she had a BIMS score of 15 which meant she was cognitively intact. Record review of Resident #11's comprehensive care plan dated 03/25/25 indicated she had a PASRR level 2 assessment completed related to mental illness of bipolar and anxiety. She should have been receiving habilitation coordination through PASRR services with interventions in place to follow up with agency representative to ensure that recommendations were fully implemented, assist the case worker with obtaining any needed information, and to ensure the local authority for PASRR was notified of any changes that may need further interventions. Record review of Resident #11's PASRR Comprehensive Service Plan Form dated 06/26/25 indicated her Medicaid eligibility was undetermined, but she was supposed to receive medication training, routine case management, and counseling services from PASRR. Record review of Resident #11's undated client/inquiry information form indicated Resident #11's eligibility for Medicaid began on 04/01/25. During an interview on 04/02/26 at 11:30 a.m., the MDS nurse said she was unsure if Resident #11 had Medicaid eligibility or not. She said the Local Authority representative was responsible for ensuring the meetings were held for positive PASRR residents and the Social Worker and herself should have kept up with it when the Local Authority representative emails the dates sent. The MDS nurse said the failure placed Resident #11 at risk of not getting any of the services that she had requested. During an interview on 04/02/26 at 4:40 PM Resident #11 said she still wanted the services from PASRR but she was unsure of what had happened. Resident #11 said she was not sure what all she chose. During an interview on 04/02/26 at 5:51 p.m., the Business Office Manager said she did not know who was responsible for PASRR services, but she knew Resident #11 had been approved for her Medicaid a while back about a month or two after she admitted . During an interview on 04/03/26 at 4:29 p.m., The DON said she had just heard about Resident #11's admitting Medicaid pending and then she was approved of Medicaid at some point and the Medicaid services back dated to the day they approved her. The DON said she was unsure of any dates, but the facility department heads about talked payor changes daily in the morning meetings. The DON said she expected the MDS nurse or Social Worker to have notified the Local Authority for PASRR when they were aware of the Medicaid being approved. The DON said the failure placed Resident #11 at risk of not receiving services and it was her right to receive the services she requested. During an interview on 04/03/26 at 5:21 p.m., the Administrator said Resident #11's Medicaid was approved about a month after she admitted . The Administrator said 2 months ago the interdisciplinary team discussed the positive PASRR residents, and to his understanding the meeting for her PASRR services to begin was set up at the time. The Administrator said he would make sure with the MDS nurse who was responsible for ensuring the meeting for PASRR services to begin was set up. The Administrator said the failure placed Resident #11 at risk of not receiving her PASRR services and affected every service she wanted because she was PASRR positive. 4. Record review of Resident #9's face sheet dated 4/3/26, reflected Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included chronic kidney disease, stage 5 ( Kidneys function at less than 15% capacity, causing severe buildup of waste, fluid, and toxins, which necessitates treatment like dialysis or a kidney transplant to sustain life), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), hallucinations (sensory experiences—seeing, hearing, smelling, tasting, or feeling things—that appear real but are created by the mind in the absence of external stimuli). and post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it). Record review of Resident #9's admission MDS assessment dated [DATE], reflected Resident #9 made himself understood and understood others. Resident #9's BIMS score was 15 which indicated the resident's cognition was fully intact. The MDS assessment reflected Resident #9 had an active diagnosis of post-traumatic stress disorder. Record review of Resident #9's Pre-admission Screening and Resident Review screening dated 1/23/26, indicated no diagnosis or history of post-traumatic stress disorder or any other mental illness. Record review of Resident #9's Social History Form- Trauma Informed Care dated 1/29/26 indicated the resident had a previously documented diagnosis of mental disorder and history of trauma. The form indicated the resident did have a diagnosis of post-traumatic stress disorder. The form indicated Resident #9 had experienced a serious accident and physical assault and had been in a situation that was extremely frightening as well as witnessed an extremely frightening situation. The Trauma Informed Care form indicated Resident #9 had triggers of loud noises, specific smells, restraints, and large crowds. The form indicated removing stimuli and medications prescribed for the trauma related diagnosis helped to alleviate the triggers. Record review Resident #9's base line care plan dated 1/31/26 revealed the resident had no mental health needs, no behavioral concerns, and no interventions for post-traumatic stress disorder. Record review of Resident #9's orders dated 4/3/26 indicated no monitoring for traumatic stress behaviors or triggers. In an interview on 4/1/26 the MDS Nurse stated she made a mistake by not doing a correct screening. The MDS Nurse stated she should have done a form 1012 to correct it. The MDS Nurse stated she just learned about the form for filing a correction. She stated it was important to screen and evaluate correctly so residents got the services they need and qualify for. In an interview on 4/3/26 at 4:40 pm, the DON stated the Social Worker was responsible for ensuring the diagnosis of post-traumatic stress disorder triggers trauma informed care on the resident's chart. The DON stated it is important to be aware if a resident requires trauma informed care to be able to provide the best possible care by avoiding triggers. In an interview on 4/3/26 at 5:55 pm, the Administrator stated he expects all residents with a diagnosis of post-traumatic stress disorder to have trauma informed care. The Administrator stated he expects all admission screenings to be done in the appropriate amount of time and all services available be offered. The Administrator stated the Social Worker was responsible for the trauma assessment, but the ADON and DON were also responsible for knowing of the diagnosis and proceeding accordingly. The Administrator stated it is important to care for residents with a post-traumatic stress disorder diagnosis appropriately for the safety of the residents and the staff. In an interview on 4/3/26 at 6:15 pm the Social Worker stated the trauma assessment was part of the initial admission assessment. The Social Worker stated she was responsible for that assessment. The Social Worker stated that Resident #9 did trigger for trauma informed care, but Resident #9 did not have issues. The Social Worker stated it was important to ensure a resident with post-traumatic stress disorder have trauma informed care so that the resident can get needs met and be most comfortable at the facility. Record review of the facility's undated policy titled PASRR Rationale, indicated, All individuals who are admitted to a Medicaid certified nursing facility must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), (mental retardation (MR) in federal regulation)/developmental disability (DD), or related conditions regardless of the resident's method of payment (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions). Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. Planning for Care: The Level II PASRR determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the State. The State is responsible for providing specialized services to individuals with MI or ID/DD. In some States specialized services are provided to residents in Medicaid-certified facilities (in other States specialized services are only provided in other facility types such as a psychiatric hospital). The nursing home is required to provide all other care and services appropriate to the resident's condition. The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination, and the evaluation report should be addressed in the plan of care.

Based on observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 3 of 3 residents (Residents #8, #23, and #70) reviewed for indwelling catheter. 1. The facility failed to ensure Resident #8's foley catheter (tube inserted into bladder) was secured on 03/31/26. 2.The facility failed to ensure Resident #23 had his catheter secured on 03/31/26 and 04/01/26. 3.The facility failed to have an appropriate diagnosis or indication for the use of the indwelling catheter for Resident #70. These failures could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: 1. Record review of Resident #8's face sheet, dated 04/03/26, reflected Resident #8 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included bladder neck obstruction (blockage at the base of the bladder that prevent it from opening properly) and retention of urine (inability to completely or partially empty the bladder). Record review of Resident #8's significant change in status assessment dated [DATE], reflected Resident #8 made himself understood and understood others. Resident #8 had a BIMS score of 13, which reflected his cognition was intact. Resident #8 had an indwelling catheter. Record review of Resident #8's comprehensive care plan, revised 04/01/26, reflected Resident #8 had an indwelling catheter 16 fr related to bladder outlet obstruction, retention and catheter should be secured with a leg strap at all times. The care plan interventions included: monitor and document for pain/discomfort due to catheter. Record review of Resident #8's physician order summary report dated 04/03/26, reflected an active physician's order to check foley leg strap placement and change PRN every shift for foley catheter with a start date 05/05/25. During an observation and interview on 03/31/26 at 12:32 p.m., Resident #8 was sitting in his wheelchair with his catheter tubing not secured. The state surveyor asked Resident #8 how long his catheter has not been secured, Resident #8 replied, a few weeks. During an interview on 03/31/26 at 12:36 p.m., LVN O stated Resident #8 catheter did not have to be secured because he was able to move the catheter bag easier from his wheelchair to keep the bag from getting in his way of his legs when he went back to bed. During an observation on 03/31/26 at 1:10 p.m., Resident #8 was sitting in his wheelchair with his catheter tubing not secured. During an interview on 03/31/26 at 1:12 p.m., LVN A stated Resident #8's catheter should always be secured. LVN A stated initially the nurse that placed the catheter should have made sure the catheter tubing was secured but if the device comes off the nurse should replace it, or the aide should report it to the nurse. LVN A stated he just noticed today (03/31/26) that his catheter was not secured LVN A stated it was important to ensure the catheter was secured to prevent trauma to the perineum area. During an interview on 03/31/26 at 1:23 p.m., CNA C stated she drained Resident #8's catheter bag this morning (03/31/26) but did not see if it was secured or not. CNA C stated she was not sure why the catheter should be secured. 2.Record review of Resident #23's face sheet dated 04/01/26 indicated he was a 68-yer-old male who re-admitted to the facility on [DATE] with the diagnoses which included major depressive disorder (a serious, common mental health condition characterized by low mood, loss of interest in activities, and low energy), paraplegia (a medical condition involving the loss of voluntary movement and/or sensation in the lower half of the body), heart failure (a chronic condition in which the heart becomes too weak to pump blood), retention of urine, and high blood pressure. Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated he made himself understood and he was understood by others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated Resident #23 required total assistance from staff for transfers, bed mobility, bathing, and he required setup assistance for eating. The MDS also indicated Resident #23 had an indwelling catheter. Record review of Resident #23's comprehensive care plan revised 12/08/25 indicated he had renal insufficiency related to retention of urine and had a suprapubic catheter in place with interventions to monitor for signs and symptoms of pain or discomfort. Record review of Resident #23's order summary report as of 04/01/26 indicated he had an order for: Check foley leg strap for placement and change as needed every shift for foley catheter with a start date of 07/31/25 and no end date. During an observation and interview on 03/31/26 at 11:21 a.m., Resident #23 was in his electric wheelchair with shorts on and had a piece of tape on his right leg for his catheter that was not attached to the catheter. Resident #23 said the facility did not have any supplies. During an observation and interview on 04/01/26 at 8:56 a.m., Resident #23 was in his bed with tape on his right leg but not attached to his catheter tubing. Resident #23 said he needed the actual securement device for his catheter because not having the device was making his stoma sore related to the catheter tubing moving around. During an observation and interview on 04/02/26 at 10:14 a.m., Resident #23 was in his bed and had his catheter securement device on his right leg. LVN K said Resident #23 was supposed to have his catheter always secured. LVN K said at times the facility runs out of the securement devices, but she always kept a stash of the securement devices to ensure her residents had one in place. LVN K said she applied Resident #23's securement device for his catheter on 04/02/26. During an interview on 04/03/26 at 3:17 p.m., the ADON said Resident #23 should always have a catheter strap on. The ADON said the failure placed a risk for him having catheter dislodgment or discomfort. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected catheters to always be secured by the charge nurse. The DON stated CNA C should have looked to see if Resident #8 catheter was secured and if she noticed it was not secured, she should have reported it to the nurse. The DON stated she monitored catheter securement by random rounds. stated it was important to ensure the catheter was secured to prevent dislodgment and caused trauma to the perineal area. 3.Record review of Resident #70's face sheet, dated 04/03/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, Chronic obstructive pulmonary disease also known as COPD (lung and airway diseases that restrict your breathing), diabetes ( a condition that happens when your blood sugar (glucose) is too high), and high blood pressure. Record review of Resident #70's medical records did not indicate a MDS assessment had been completed because it was not yet due. Record review of Resident #70's baseline care plan dated 03/27/26, indicated she had an indwelling catheter. No interventions were listed. Record review of Resident #70's physician's orders dated 03/27/26, indicated an indwelling catheter of 18 French with a 30 ml bulb, to be changed as needed. There was no indication for the catheter on the physician's order. Record review of Resident #70's medication administration records, dated 03/01/26 through 03/31/26, revealed the ordered indwelling catheter was still in place in the resident's bladder. Record review of Resident #70's medical record did not reveal an appropriate diagnosis for the catheter or any assessment for the resident's ongoing use of the catheter. During an observation and interview on 03/31/26 at 1:17 p.m., Resident #70 was lying in her bed. She had an indwelling catheter. Resident #70 said she did not know why she had the indwelling catheter but said she had it for an unknown time. During an observation on 04/01/26 at 9:28 a.m., Resident #70 was lying in bed with her oxygen set at 5 liters per nasal cannula. During an interview and record review on 04/02/26 at 2:20 p.m., RN G said he was Resident #70's nurse. He said he did not know why Resident #70 had an indwelling catheter. He looked at Resident #70's orders and did not see a diagnosis for the indwelling catheter. He said Resident #70's diagnosis should have been listed on her orders. He said she was admitted with the indwelling catheter from home, but he would see if he could find the diagnosis. He said it was important to know the diagnosis to see if she needed the indwelling catheter or not. During an interview on 04/03/26 at 3:36 p.m., the DON said the nurses were responsible for ensuring they received diagnosis for residents who admitted or received an indwelling catheter. The DON confirmed the indwelling catheter should not be in place without appropriate rationale and/or diagnosis for use. She said staff should be aware why a resident had an indwelling catheter for the risk of infection. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected catheters to be always secured. The Administrator stated anyone that had a catheter should have an order. The Administrator stated the aide should have checked to see if the catheter was secured and report it to the charge nurse. The Administrator stated the nurse was responsible for ensuring the catheter was secured, an order was placed in PCC. The Administrator stated the DON, or designee, was responsible for monitoring and overseeing catheter securement. The Administrator stated it was important to ensure the catheter was secured to prevent trauma in the perineal area and infection. The Administrator stated it was important an order was placed in the resident's chart to follow the MD orders. Record review of the facility's policy titled, Catheter Care, Urinary, Policy, undated, indicated, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. Changing Catheters: 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh).

Based on observation, interview and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 medication room (hall 100) refrigerator for 2 of 2 residents (Resident #54 and Resident #39), 1 of 3 medications carts(hall 300) for 1 of 3 residents (Resident #5), and for 2 of 24 residents (Resident #16 and Resident#23) reviewed for medication storage.1.The facility failed to ensure Resident #54's Lorazepam (antianxiety medication) and Morphine (pain medication) were secured behind two locks2.The facility failed to ensure Resident #39's Morphine (pain medication) was secured behind two locks.3.The facility failed to ensure an insulin pen was dated when opened on the 300-hall medication cart.4.The facility failed to ensure wound cleanser was not left in Resident #16's room on 03/31/26. 5 The facility failed to ensure Resident #23 did not have triad hydrophilic wound paste, triple antibiotic and hydrocortisone cream in his bedside dresser.These failures could place residents at risk of not receiving prescribed medications as ordered, therapeutic medication, drug diversions and injury. Findings included: 1.Record review of Resident #54's face sheet, dated 04/03/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, (memory loss), depression (sadness), stroke, and high blood sugar. Record review of Resident #54's admission MDS assessment, dated 03/28/26, indicated Resident #54 sometimes understood and was sometimes understood by others. Resident #54's BIMS score was 00, which meant he was severely cognitively impaired. The MDS indicated Resident #54 required help with toileting bed mobility, dressing, transfers, personal hygiene, and eating. The MDS indicated he took anxiety medication during the 7-day look-back period. Record review of Resident #54's care plan dated 03/31/26, indicated Resident #54 was on hospice. The intervention was for staff to observe residents closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Record review of Resident #54's physician order dated 03/20/26 indicated, Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 6 hours as needed for anxiety/agitation. Record review of Resident #54's physician order dated 03/20/26 indicated, Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hour as needed for shortness of breath/pain. Record review of Resident #54's narcotic sheet for lorazepam and Morphine did not indicate any missing medication. During an observation on 04/02/26 at 2:39 p.m., Resident #54 had 1 open bottle of Lorazepam and 2 unopened bottles of Morphine Sulfate in hall 100 medication room refrigerator door. These medications were not double locked in the refrigerator. 2.Record review of Resident #39's face sheet, dated 04/03/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia, (memory loss), depression (sadness), and stroke. Record review of Resident #39's quarterly MDS assessment, dated 02/16/26, indicated Resident #39 understood and was understood by others. Resident #39's BIMS score was 09, which meant he was moderately cognitively impaired. The MDS indicated Resident #39 required help with toileting bed mobility, dressing, transfers, personal hygiene, and eating. Record review of Resident #39's care plan dated 01/27/26, indicated Resident #39 had chronic pain The intervention was for staff to monitor/record/report to nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Record review of Resident #39's physician order dated 02/11/26 indicated, Morphine Sulfate Oral Solution 20 MG/1ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hour as needed for shortness of breath/pain. Record review of Resident #39's narcotic sheet for Morphine did not indicate any missing medication. During an observation on 04/02/26 at 2:39 p.m., Resident #39 had 1 open bottle of Morphine Sulfate in the hall 100 refrigerator door. This medication was not double locked in the refrigerator. During an observation and interview on 04/02/26 at 2:40 p.m., the DON saw the Resident #54's Lorazepam and Morphine and Resident #39's Morphine in the refrigerator not doubled locked. She said she was not aware of the bottles being in the refrigerator door. She said she thought if they were locked by the medication room and the refrigerator door it was considered double locked. She said the risk could be drug diversion. 3.Record review of Resident #5's face sheet, dated 04/03/26, reflected Resident #5 was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis which included diabetes (high blood sugars), dementia (memory loss), depression (sadness), and muscle weakness. Record review of Resident #5's admission MDS assessment, dated 01/30/26, reflected Resident #5 made himself understood, and was understood by others. Resident #5's BIMS score was 15, which reflected his cognition was intact. The MDS indicated he received insulin during the 7-day look back period. Record review of Resident #5's care plan revised date of 07/18/25, indicated he was diabetic and received Lispro, Glargine, and metformin. The interventions were to give medications as ordered. Record review of Resident #5's physician ordered dated 01/24/26, indicated, Insulin Glargine Subcutaneous Solution (Insulin Glargine), Inject 30 units subcutaneously at bedtime related to diabetes. During an observation on 04/02/26 at 9:15 a.m., the 300-hall medication cart revealed 1 insulin pen in top drawer opened with no date with Resident #5's name handwritten on it. During an observation and interview on 04/03/26 at 9:40 a.m., RN G saw the insulin pen in the drawer without a written date of being opened. He said the insulin pen should have been dated when opened to ensure the resident would not receive expired medication. During an interview on 04/03/26 at 2:47 p.m., LVN K said when Resident #5 was moved to her floor (unknown date) the Glargine pen was already open with his name on it. She said she was not sure of the date of opening and said it was good for 28 days. She said she was sure it was not older than 28 days, but she could not prove when it was opened. She said the risk could be receiving expired medication. She said the nurse who opened the insulin should have dated it. 4 Record review of Resident #16's face sheet, dated 04/03/26, reflected Resident #16 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included dementia (memory loss), depression (sadness), and muscle weakness. Record review of Resident #16's quarterly MDS assessment, dated 01/27/26, reflected Resident #16 made herself understood, and was understood by others. Resident #16's BIMS score was 14, which reflected her cognition was intact. Record review of Resident #16's comprehensive care plan, revised 03/02/26, indicated, Resident #16 was at risk for increase in falls/injury due to use of personal safety device related to motorized wheelchair. Resident #16 had an actual wound (laceration) to her left shin. The intervention was for staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or firm surface. Record review of Resident #16's physician order, dated 03/27/26 indicated, wound #3 cleanse with wound cleanser, apply xeroform and bordered dressing. every other day for wound care. During an observation and interview on 03/31/26 at 12:05 p.m., Resident # 16 had a bottle of wound cleanser on her nightstand table. She said unknown staff had left it in her room. During an interview on 04/03/26 at 9:55 a.m., RN G said he was Resident #16's nurse. He said wound cleanser should not be in a resident's room because they could drink it. During an interview on 04/03/26 at 3:39 p.m., the DON narcotic medication should be always stored under double lock including medications in the refrigerator. She said the nurses should be counting the narcotics each shift. She said if they were not counting medication some could be missing or have a drug diversion. She said she was doing random checks and saw no omits in the narcotic sign out sheets but would change the process of checking narcotics. The DON said the nurses were responsible for ensuring they removed any products (chemicals or medication) brought into the room with them and then stored them in a medication cart or in a medication room. She said wound cleanser should not be left in the room because it contained chemicals and a resident could ingest it. The DON said insulin pens should be dated when they were opened, and when to discord them. She said failure to date the insulin pen could cause residents to receive expired medication. She said this could affect the effectiveness of the medication. She said they did not have an effective system for checking the medication carts and rooms for undated or expired medications. During an interview on 04/03/26 at 5:32 p.m., the Administrator said the nurses should make sure the narcotic medication kept in the refrigerator were always in the locked box. He said the nurses should be counting narcotics every shift. The Administrator said the DON was responsible for monitoring and overseeing by rounding. He said if the nurses were not counting the medications there could be a discrepancy, or missing medications. The Administrator said wound cleanser should not be left in a resident's room for risk of swallowing. He said the nurses were responsible for ensuring they removed wound cleanser before exiting a resident's room. The Administrator said all items opened should have an open date written on it. He said the potential negative outcome could be not knowing how long the medication had been on the cart and it may not work how it should. 5.Record review of Resident #23's face sheet dated 04/01/26 indicated he was a 68-yer-old male who re-admitted to the facility on [DATE] with the diagnoses which included major depressive disorder (a serious, common mental health condition characterized by low mood, loss of interest in activities, and low energy), paraplegia (a medical condition involving the loss of voluntary movement and/or sensation in the lower half of the body), heart failure (a chronic condition in which the heart becomes too weak to pump blood), retention of urine, and high blood pressure. Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated he made himself understood and he was understood by others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated Resident #23 required total assistance from staff for transfers, bed mobility, bathing, and he required setup assistance for eating. Record review of Resident #23's comprehensive care plan revised on 02/17/26 indicated he had sacral region moisture associated skin damage with an order to cleanse with wound cleanser, apply triad hydrophilic wound paste and leave it open to air as well as notify medical director, nurse practitioner, and responsible party of and wound development. Record review of Resident #23's order summary report indicated he had an order to apply triad to sacrum every evening shift for sacrum with a start date of 12/26/25 and no end date. The order summary report did not indicate an order for hydrocortisone cream nor triple antibiotic ointment. During an observation on 04/01/26 at 10:05 a.m., Resident #23 had triad hydrophilic wound paste wound care medications in his bedside drawer and had a tube of triple antibiotic ointment and 2 tubes hydrocortisone cream 1% on bedside table in a clear opened storage container. During observation and interview on 04/02/26 at 2:56 p.m., Resident #23 continued to have two tubes of hydrocortisone cream 1% and a tube of triple antibiotic ointment in a clear storage container on the bedside table by his door in his room. LVN K said she attempted to remove the two tubes of hydrocortisone cream and the triple antibiotic ointment, but Resident #23 had a fit, would not let her take it, and said he bought that over the counter, and she could not take his belongings. LVN K said she reported the incident to DON and Administrator. During an interview on 04/02/26 at 2:59 p.m., Resident #23 said he did not see why he could not have his creams in his room that he needs because he hates having to wait on the nurse for things. During an interview on 04/02/26 at 5:08 p.m., LVN K said she was aware of them having the barrier cream for his buttocks, but she said she thought the triad was discontinued so she was unsure why the triad was in Resident #23's bedside drawer. LVN K said Resident #23 should not have any medications in his room. LVN K said the reason the medications needed to be removed was because it was dangerous and any residents could get a hold of the medications and take them. LVN K said she removed the triad but Resident #23 would not let her remove the hydrocortisone cream nor the triple antibiotic ointment because he bought it himself. During an interview on 04/02/26 at 4:09 p.m., LVN A said the triad hydrophilic wound dressing paste was what the nurses had an order for to use for Resident #23's buttocks. LVN A said the triad hydrophilic wound dressing paste should not have been in the resident room and the failure placed a risk for safety because any resident could have taken the medications and misuse or ingest the medications. LVN A said he thought Resident #23 bout the medication himself but Resident #23 could not have hydrocortisone cream or the triple antibiotic ointment in his room either. During an interview on 04/03/26 at 3:17 p.m., the ADON said there should be no medications in Resident #23's room on his bedside table. The ADON said all medications should be stored on the nurse's cart. The ADON said the failure placed a risk for the patient self-medicating without the nurse knowing. The ADON also placed a risk for wandering residents getting the medications and misusing. During an interview on 04/03/26 at 4:29 p.m., the DON said Resident #23 should not have had any medications in his room. The DON said she would retrieve the medications and get orders for the nurse to administer, and the facility should have had a self-administration assessment completed if Resident #23 was going to keep his medications in the room safely. The DON said the medications should have been stored in the nurse's cart and the failure placed a risk for another resident to get a hold of the medications and self-administer and possibly ingest it. During an interview on 04/03/26 at 5:16 p.m., the Administrator said the medications should have been kept with the nurse in the medication room or nurse's cart. The Administrator said the DON was responsible for ensuring there were no medications in residents' rooms. The Administrator said the failure placed a risk for residents self-medicating against MD orders and staff or other residents getting a hold of medications and using the medication. Record review of the undated facility policy, Controlled Substances, indicated, Policy Statement The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. Record review of the facility's policy titled, Storage of Medications, undated, indicated, Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation:2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly.12. Only persons authorized to prepare and administer medications have access to locked medications.13. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Security access to controlled medication 14. Access to controlled medications is limited to authorized personnel. Personnel access to controlled medications is recorded. Record review of the facility's policy titled, Insulin Administration, undated, indicated, Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 2. Check blood glucose per physician order or facility protocol.3. Remove insulin vial from storage point. 4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date, and time on the vial (follow manufacturer recommendations for expiration after opening) .

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents, and 1 of 1 meal was reviewed for palatability, attractiveness, and appetizing. The facility failed to provide food that was palatable and at an appetizing temperature for 8 confidential residents for lunch on 4/1/26. These failures could place residents at risk of decreased food intake, hunger, and unintended weight loss.Findings Included:In a Resident Council Meeting on 4/1/2026 at 10:00 am, 8 of 8 residents said the food was bland and served warm. During an observation on 4/1/26 at 12:48 pm the last food temperature was checked on the warming table, trays prepared, and service began at 12:52 pm. The test tray was prepared at 12:59pm. During an observation on 4/1/26 at 1:08pm the tray cart with the test tray left the kitchen preparation area, was checked by the nurses and went to hall 300. The test tray arrived to the conference room at 1:14pm. During a test tray interview with Dietary Manager by State Surveyors on 4/1/26 at 1:15 pm, the Dietary Manager stated the fried pork chops with white gravy could be warmer. It was not over seasoned or under seasoned. The dietary manager stated the candied yams were ok, but he would add more butter and sugar because they were kind of bland. The dietary manager stated the cauliflower with cheese sauce was nice and warm and had an ok flavor. The Dietary Manager stated the lemon pudding could be cooler. The Dietary Manager stated that overall, the flavor was ok, but it could be warmer. Observation of the plate of food revealed the food was unattractive. During an interview on 4/2/26 at 2:02 pm, the Dietary Manager stated he was responsible for ensuring the food was palatable and was hot when the resident received his or her meal tray. The Dietary Manager stated he has had complaints about the food in the last three months. The Dietary Manager stated it was important for the food to be presented in an appealing manner, be palatable, and the proper temperatures for residents to get the needed nutrition and prevent weight loss. During an interview on 4/2/26 at 5:55 pm, the Administrator stated he expected the food to appear appetizing, taste good, and be delivered hot. The Administrator stated the dietary manager was responsible for the residential dining experience. The Administrator said the food should look appetizing because a person eats with his or her eyes first. The Administrator stated it was important to serve palatable meals so the residents avoid weight loss and have adequate nutrition. Record review of the food temperature log, dated 4/1/26, indicated the regular meat's temperature at the time of serving was 183 degrees Fahrenheit, the white gravy was 170 degrees, the candied yams were 183 degrees, the cauliflower with cheese sauce was 145 degrees, the cornbread was 114 degrees, and the lemon pudding was 60 degrees. Record review of Food and Nutrition Services policy dated 10/2022 and revised 6/23/25, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy also stated the food will appear palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure the grease in the fryer was fresh and free of burnt food particles floating in it. 2. The facility failed to ensure the bags of food in the refrigerator were used or disposed of by the expiration date according to facility policy. 3. The facility failed to ensure the juice nozzle had no black film inside per facility policy. 4. The facility failed to ensure employees in the kitchen wore hair nets according to facility policy.5. The facility failed to ensure employees in the kitchen wore beard guards according to facility policy. These failures could place residents at risk of foodborne illness and food contamination.Findings include: During the initial tour of the kitchen on 3/31/26 at 10:25 am, upon entry to the kitchen, the dietary manager was not wearing a hair net or a beard cover. [NAME] R was not wearing a beard cover, and Dietary Aid D was not wearing a hair net. The microwave had a red sticky substance splattered on the walls and top. There were two bags of unopened shredded carrots with the expiration date of 3/18/26 stored in the refrigerator. The grease in the deep fryer was dark brown and had burnt food particles floating on the top. The inside of the juice nozzle was covered in a black film. During an interview on 3/31/26 at 10:30am, the Dietary Manager stated his hair and beard were less than one inch long and he did not need a hair net. He stated he was responsible for ensuring he and his staff are wearing hair restraints. He stated it was important to prevent food contamination. The Dietary Manager stated the microwave was to be cleaned as needed. The Dietary Manager stated that all kitchen staff are responsible for noticing and removing out-of-date and expired items in the refrigerator. He stated he was responsible for ensuring this was done. The Dietary Manager stated the deep fryer grease was changed four or five days ago and that it needed to be cleaned out. The Dietary Manager stated old grease made the food not taste as good. The Dietary Manager stated the juice nozzle was dirty and needed to be cleaned. The Dietary Manager stated it is important to remove out-of-date food and keep kitchen equipment clean to prevent food borne illnesses. In an interview on 3/31/26 at 11:00am, [NAME] R stated he did not know he needed a cover for his beard. He stated it was important to cover all hair so that no hair got in the food. [NAME] R stated he did not see the out-of-date food in the refrigerator. [NAME] R stated everyone was responsible for cleaning the kitchen equipment as they used it, and making sure the food in the refrigerator is good. [NAME] R stated dirty kitchen equipment and expired food can make people sick. In an interview on 3/31/26 at 11:05 am, Dietary Aid E stated she forgot she needed a hair net. Dietary Aid E stated it was important to wear a hair net to prevent hair from getting in the food. Dietary Aid E stated everyone was responsible for cleaning the kitchen equipment and checking the food in the refrigerator. Dietary Aid E stated it was important for equipment to be clean and food to be in date to prevent food borne illness. In an interview on 4/3/26 at 5:45 pm, the Administrator stated he expected anyone who entered the kitchen to wear proper hair restraints. The Administrator stated that he expects the kitchen equipment to be cleaned on a regular basis, and the deep fryer grease to be fresh and free of floating food particles from previous use. The Administrator stated he expects there to be no out-of-date or expired food anywhere in the kitchen. The Administrator stated the Dietary Manager was responsible for all these things. The Administrator stated wearing hair nets, clean kitchen equipment, no expired food, and clean deep fryer grease were important to protect residents from food borne illnesses. Record review of the facility policy titled Kitchen and Equipment Cleaning and Sanitation dated 12/2020 stated the kitchen and dining service equipment and food contact services shall be maintained in a clean and sanitized condition. Record review of the Food and Drug Administration Food Code 2022, dated 1/18/23, Chapter 2 Part 4 states Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on observation, interview, and record review, the facility failed to ensure resident were treated with respect, dignity, and care in a manner and in an environment, that promotes maintenance or enhancement of her quality of life, for 1 of 6 residents reviewed for dignity issues (Resident #70).The facility failed to ensure they had a privacy bag for Resident #70's indwelling catheter.This failure could place residents at risk of feeling uncomfortable, increase anxiety and loss of dignity.Record review of Resident #70's face sheet, dated 04/03/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, Chronic obstructive pulmonary disease also known as COPD (lung and airway diseases that restrict your breathing), diabetes ( a condition that happens when your blood sugar (glucose) is too high), and high blood pressure.Record review of Resident #70's medical records did not indicate a MDS assessment had been completed because it was not yet due.Record review of Resident #70's baseline care plan dated 03/27/26, indicated she had an indwelling catheter. No interventions were listed.Record review of Resident #70's physician's orders dated 03/27/26, indicated an indwelling catheter of 18 French with a 30 ml bulb, to be changed as needed. There was no indication for the catheter on the physician's order.Record review of Resident #70's physician's orders dated 03/27/26, indicated a privacy bag or covering over urine collection bag for dignity every shift.Record review of Resident #70's medication administration records, dated 03/01/26 through 03/31/26, revealed the ordered indwelling catheter was still in place in the resident's bladder.Record review of Resident #70's medication administration records, dated 03/01/26 through 03/31/26, revealed the order for privacy bag was signed every shift indicating the privacy bag was intact.During an observation and interview on 03/31/26 at 1:17 p.m., Resident #70 was lying in her bed. She had an indwelling catheter hanging with no privacy bag. Resident #70 said she did not realize her indwelling catheter bag was not covered.During an observation on 04/01/26 at 9:28 a.m., Resident #70 was lying in bed with her oxygen set at 5 liters per nasal cannula. She had her indwelling catheter exposed without a cover.During an interview and record review on 04/02/26 at 2:20 p.m., RN G said he was Resident #70's nurse. He said he did not know why Resident #70 privacy bag was not on her indwelling catheter. He said he put a new privacy bag on Resident #70 indwelling catheter on 04/01/26. He said Resident #70 should have had a privacy bag for her indwelling catheter. He said sometimes when staff move a resident from chair to bed or bed to chair, they forget to reapply the privacy bag. He said the risk of no privacy bag could be a dignity issue.During an interview on 04/03/26 at 3:36 p.m., the DON said all residents who had indwelling catheters should have a privacy bag for dignity issues and all nursing staff were responsible for ensuring the privacy bag was in place. During an interview on 04/03/26 at 4:49 p.m., the Administrator said anyone that had a catheter should have an order and privacy bag. The Administrator said the nurse was responsible for ensuring the catheter was secured, an order was placed in PCC, and the resident had a privacy bag. The Administrator said the DON, or designee was responsible for monitoring and overseeing catheters. The Administrator staid it was important an order was placed in the resident's chart to follow the MD orders and a privacy bag was over the catheter bag to prevent dignity issue.Record review of the facility's policy titled, Catheter Care, Urinary, Policy, undated, indicated, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. Changing Catheters: 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh).

Based on record review and interview, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment for 1 of 6 residents (Resident #9) reviewed for consents. The facility failed to obtain informed consent from Resident #9 for the antipsychotic Zyprexa (Olanzapine) to be administered starting on 1/25/26. The facility's failure to obtain and document informed consent for antipsychotic medication places the resident at risk for unnecessary chemical restraint, adverse side effects, and violation of the resident's rights to make informed decisions regarding their care and treatment. Findings included: Record review of Resident #9's face sheet dated 4/3/26, reflected Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and hallucinations (sensory experiences-seeing, hearing, smelling, tasting, or feeling things-that appear real but are created by the mind in the absence of external stimuli). Record review of Resident #9's admission MDS assessment dated [DATE], reflected Resident #9 made himself understood and understood others. Resident #9's BIMS score was 15 which indicated the resident's cognition was fully intact. The MDS assessment reflected Resident #9 was taking an antipsychotic and there was an indication noted for medication in this drug class. Record review of the order summary report dated 4/3/26 , reflected Resident #9 was ordered one Olanzapine oral tablet 5 mg by mouth two times a day for hallucinations on 1/25/26. Record review of the Medication Administration Review dated 4/3/26 indicated Resident #9 was administered Olanzapine tablet 5mg by mouth two times a day at the 8:00 am medication pass and at the 8:00 pm medication pass daily since 1/25/26. Record review of Resident #'s EMR accessed on 4/2/26 at 3:30pm revealed no consent form signed by the resident. Record review of the Pharmaceutical Review dated 1/31/26 indicated the recommendation to please ensure signed consent form is scanned into PCC for the following medication: Olanzapine (on Texas form 3713). Point Click Care (PCC) is an electronic medical record platform. Record review of Resident #9's EMR accessed 4/3/26 at 5:00 pm revealed Texas Health and Human Services Form 3713 titled Consent for Antipsychotic or Neuroleptic Medication Treatment signed by Resident #9 and the medical director and dated 4/3/26 for the medication Olanzapine. In an interview on 4/2/26 at 5:42 pm, the Executive Director stated all consents should be in the EMR. The Executive Director stated the ADON and the DON were responsible for ensuring consents for all medications that needed consent to be completed and uploaded into the chart prior to administration. The Executive Director stated it was important for residents to be informed of the side effects of the medications, and have the right to chose to take it. In an interview on 4/3/26 at 4:30 pm, the DON stated the nurses were responsible for getting the proper consents prior to administering the medication. The DON stated she is responsible for monitoring the charts to ensure all the necessary consents were present. The DON stated it was important to obtain the informed consent so residents were informed of risks versus benefits. In an interview on 4/3/26 at 5:25 pm, the Administrator stated that he expected all consents to be obtained prior to the administration of medications that require one. The Administrator stated that it was the ADON and the DON's responsibility to ensure consents are obtained. The Administrator stated it was important to obtain consent prior to administration because a resident should know about the side effects and be able to make the choice to take it or not. Record review of the facility's policy titled, Psychotropic/ Psychoactive Medication Policy last reviewed 6/24/25, indicates all residents have full rights to participate or refuse treatment. Before initiating or increasing psychotropic medication the resident and or responsible party must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication. The risk and benefits should be clearly explained. Consent needs to be completed and signed by the Resident or Responsible party. Explain the medication, why it is administered, what are side effects, and black box warning.

Based on interview, observation, and record review the facility failed to ensure the resident had a right to reasonable accommodations of resident needs for 1 of 8 residents (Resident #64) reviewed for accommodations of needs for call light availability. The facility failed to ensure Resident #64's call button was within reach.This failure could place residents at risk of a delay in assistance and decreased quality of life, self-worth, and dignity.Findings included:Record review of Resident #64's face sheet, dated 04/03/26 indicated Resident #64 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), depression (sadness), and muscle weakness.Record review of Resident #64's quarterly MDS, dated [DATE], reflected Resident #64 understood others and made herself understood. Resident #64's BIMS score was a 13, which reflected her cognition was intact. Resident #64 required total assistance with toileting, personal hygiene, transfer, and bathing, and maximal assistance with eating. Record review of Resident #64's comprehensive care plan dated 03/15/21 reflected Resident #64 was a risk for falls related to deconditioning, psychoactive drug use, and unaware of safety needs. The intervention was for staff to anticipate and meet Resident #64's needs. Be sure the call light was within reach and respond promptly to all requests for assistance.During an observation and interview on 03/31/26 at 11:10 a.m., Resident #64 was in bed with her eyes open. Her call light was noted on her bedside table, not in reach. Resident #64 said she usually had to holler out if she needed assistance.During an observation and interview on 03/31/26 at 3:53 p.m., Resident #64 was in bed with her eyes closed. Her call light was noted on her bedside table, not in reach. CNA H entered the room and verified Resident #64's call light was not in reach. She said all residents should have their call lights in reach in case they needed something. She said Resident #64's call light cord was not long enough but placed her call light on her bed. During an observation and interview on 04/01/26 at 4:25 p.m., LVN K said she was the charge nurse for Resident #64. She looked and said Resident #64 does have a call light but because the pull cord was not long enough for the resident, she would not be able to reach it. LVN K said Resident #64 could move her right and left hand a little related to her contractures but could benefit from the push pad call light. She said the risk of not having a call light could be Resident #64 would not get the help she needed in a timely manner. She said she would get a push pad call light system for Resident #64.During an observation on 04/02/26 at 11:00 a.m., Resident #64 was in bed with a push pad call light system in reach.During an interview on 04/03/26 at 3:39 p.m., the DON said all staff should be checking on the residents and ensuring they had a call light within reach. She said she was not aware Resident #64 did not have a call light she could use. She said she expected call lights to always be within reach of residents. The DON said failure to have or keep call lights within reach could cause a resident to fall, receive a bump, bruise, or even a fracture.During an interview on 04/03/26 at 5:32 p.m., the Administrator said he expected call lights to work, have a string long enough for the residents to use and if they needed a special call light then they should have it. He said if call lights were not in reach of residents, then their needs would not be met, and it could place them at a greater risk of falling. He said all staff were responsible for ensuring residents had call lights.Record review of the facility's policy titled, Call System, Residents, dated 09/22, indicated, Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #48) reviewed for MDS assessment accuracy. The facility failed to code Resident #48's quarterly MDS dated [DATE] with the primary language of Spanish. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #48's face sheet, dated 04/03/26, reflected Resident #48 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included the progressive loss of cognitive function and brain tissue associated with aging. Record review of Resident #48's quarterly MDS assessment, dated 01/10/26, reflected Resident #48's preferred language was English and did not need/want an interpreter to communicate with a doctor or health care staff. Resident #48 made herself understood and understood others. Resident #48 had a BIMS score of 4, which reflected her cognition was severely impaired. Resident #48 could repeat 3 words after first attempt. Record review of Resident #48's comprehensive care plan, revised on 11/05/24, reflected Resident #48 had a communication problem related to Language barrier-Spanish speaking and did not speak English well and got embarrassed in group settings. The care plan interventions included: anticipate/meet needs and discuss with resident/family concerns or feelings regarding communication difficulty. Record review of the facility's undated/untitled form reflected Resident #48 spoke in a non-dominant language. During an interview on 04/02/26 at 3:10 p.m., The MDS Coordinator stated she was responsible for Resident #48's quarterly MDS assessment. After reviewing Resident #48's electronic medical records, the MDS Coordinator stated her primary language should have been coded Spanish instead of English and a translator was needed to communicate with facility staff. The MDS Coordinator stated she had not had an in-depth conversation but was able to make her needs known. The MDS Coordinator stated a communication board or translator would be effective communication. The MDS Coordinator stated it was important to ensure the assessment was coded correctly because it painted the picture of the resident on how to ensure her needs were being met. During a telephone interview on 04/03/26 at 1:43 p.m., the Regional MDS Coordinator stated she came to the facility at least quarterly but was available anytime the MDS Coordinator needed her. After reviewing Resident #48's electronic medical records, the Regional MDS Coordinator stated according to her care plan she was Spanish speaking only and her MDS assessment should have stated her primary language was Spanish. The Regional MDS Coordinator stated the MDS Coordinator and Social Worker were responsible for ensuring that it was correctly coded. The Regional MDS Coordinator stated she monitored by random audits but had not particularly looked at Resident #48's assessment. The Regional MDS Coordinator stated it was important to ensure the correct primary language was coded for Resident #48's quarterly MDS assessment to provide accurate and good care to the residents to meet all their needs. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected Resident #48's quarterly MDS assessment to state her primary language was Spanish. The DON stated she had never had a full conversation with Resident #48. The DON stated in passing Resident #48 would say hello in Spanish. The DON stated the MDS Coordinator was responsible for coding the assessment correctly. The DON stated the [NAME] MDS Coordinator was responsible for monitoring. The DON stated it was important to code the assessment correctly to ensure she received proper care. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected the MDS assessment to be coded accurately. The Administrator stated the care plan and the MDS should reflect whatever the situation of the resident is. The Administrator stated he had not had a full conversation with Resident #48. The Administrator stated he had spoken to staff, and they stated Resident #48 spoke English and Spanish. The Administrator stated the MDS was responsible for ensuring the assessment was coded correctly and the Regional MDS Coordinator should be monitoring assessments for accuracy. The Administrator stated it was important to code the assessment correctly to get a clear pic of who the resident was and their needs. Record review of the undated facility's policy titled MDS Coding, reflected. the facility affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.Record review of the Resident Assessment Instrument 3.0 Manual, dated 10/2025, reflected .1. Ask the resident's preferred language.3. If the resident-even with the assistance of an interpreter is unable to respond a family member, significant other, and/or guardian/legally authorized representative should be asked.

Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for 1 of 6 residents sampled (Resident #23). The facility failed to ensure CNA B did not apply triad hydrophilic wound dressing paste (a medication cream to manage chronic wound, pressure ulcers, and dermal lesions) to bilateral buttocks of Resident #23 without qualifications to do so. This failure could place residents at risk for not receiving appropriate care and treatment outlined in their comprehensive care plan.Findings include:Record review of Resident #23's face sheet dated 04/01/26 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses which included major depressive disorder (a serious, common mental health condition characterized by low mood, loss of interest in activities, and low energy), paraplegia (a medical condition involving the loss of voluntary movement and/or sensation in the lower half of the body), heart failure (a chronic condition in which the heart becomes too weak to pump blood), retention of urine, and high blood pressure. Record review of Resident #23's quarterly MDS assessment dated [DATE] indicated he made himself understood and he understood by others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated Resident #23 required total assistance from staff for transfers, bed mobility, bathing, and he required setup assistance for eating. Record review of Resident #23's comprehensive care plan revised on 02/17/26 indicated he had sacral region moisture associated skin damage with an order to cleanse with wound cleanser, apply triad paste and leave it open to air as well as notify medical director, nurse practitioner, and responsible party of any wound development. Record review of Resident #23's order summary report indicated he had an order to apply triad to sacrum every evening shift for sacrum with a start date of 12/26/25 and no end date. During an observation and interview on 04/01/26 at 10:05 AM CNA B provided catheter care to Resident #23 using infection control practices but applied Triad hydrophilic wound dressing paste, that he retrieved from Resident #23's nightstand drawer, to Resident #23's bilateral buttocks prior to putting on his clothes. CNA B said he used the triad daily for Resident #23, but he said he thought Resident #23 had an order for it as well as another order for butt paste. CNA B said the nurse usually handed the CNAs the barrier cream to apply to the residents in a clear medication cup. During an interview on 04/02/26 at 4:09 PM LVN A said the triad hydrophilic wound dressing paste was what the nurses had an order for to use for Resident #23's buttocks. LVN said the CNA cannot place the triad hydrophilic wound dressing paste on the resident's buttocks because it was out of their scope of practice and the nurse should have placed the triad hydrophilic wound dressing paste in order to assess the area and see the progress. During an interview on 04/02/26 at 10:14 AM LVN K said she was aware of Resident #23 having a wound to his bottom and left foot. LVN K said CNAs should not have applied the triad cream to Resident #23's buttocks because it was out of their scope of practice. During an interview on 04/03/26 at 1:16 PM CNA B said he thought the triad cream that was in Resident #23's nightstand drawer was the cream that the charge nurse usually handed him in a clear medication cup. CNA B said he was not a nurse and should not have applied the triad cream to Resident #23's buttock. CNA B said he did not know what the risk was. During an interview on 04/03/26 at 3:18 PM the ADON said CNAs should not have been applying prescription medications to residents. The ADON said administering the triad was in the nurse's scope of practice because they should have been assessing the area during each treatment. The ADON said the failure placed a risk of not having a good assessment, not knowing what side effects to look for, and CNAs practicing out of their scope of practice. During an interview on 04/03/26 at 4:29 PM The DON said CNAs should not apply any chemical grade medications/prescription medications. The DON said the failure created a risk for the CNA not correctly applying the medication and causing adverse effects. The DON said she was responsible for ensuring CNAs did not give medications.During an interview on 04/03/26 at 5:16 PM the Administrator said anything that is a medication should be given by a nurse or someone certified to give medications. The Administrator said the failure placed a risk for not being applied correctly because medications were not authorized for CNAs to administer. The Administrator said the DON was responsible for ensuring the CNAs knew what their scope of practice was. Record review of the facility policy, revised on 03/05/26, indicated: Medication Administration Purpose: To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. General Standards: 1. Only individuals licensed or legally authorized in this state may prepare, administer, and document medications. 2. The Director of Nursing or designee supervises and oversees all personnel involved in medication administration.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 2 of 2 residents (Residents #48 and #46) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Residents #48 and #46. These failures could place residents at risk for declining and diminishing quality of life.Findings included: 1.Record review of Resident #48's face sheet, dated 04/03/26, reflected Resident #48 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included the progressive loss of cognitive function and brain tissue associated with aging. Record review of Resident #48's quarterly MDS assessment, dated 01/10/26, reflected Resident #48's preferred language was English and did not need/want an interpreter to communicate with a doctor or health care staff. Resident #48 made herself understood and understood others. Resident #48 had a BIMS score of 4, which reflected her cognition was severely impaired. Resident #48 could repeat 3 words after first attempt. Record review of Resident #48's comprehensive care plan, reflected Resident #48 had a communication problem related to Language barrier-Spanish speaking and did not speak English well and got embarrassed in group settings. The care plan interventions included: anticipate/meet needs and discuss with resident/family concerns or feelings regarding communication difficulty. Record review of the facility's undated/untitled form reflected Resident #48 spoke in a non-dominant language. During an interview and observation on 03/31/26 at 12:53 p.m., Resident #48 was sitting on the side of the bed eating her lunch. The surveyor began talking to Resident #48 in English and asked if her needs were being met. Resident #48 stated she spoke with little English. There was no communication device observed in her room. During a telephone interview on 04/01/26 at 9:26 a.m., Resident #48's family member stated one of her concerns was language barrier between Resident #48 and staff. Resident #48's family member stated Resident #48 was able to speak a few words here and there in English but her preferred language was Spanish and her communication should be Spanish. Resident #48's family member stated when Resident #48 was first admitted the prior Administrator was bilingual and was able to translate for Resident #48. Resident #48's family member stated she felt no one was able to advocate for her. During an interview on 04/01/26 at 12:13 p.m., LVN F stated Resident #48 spoke Spanish most of the time. LVN F stated she communicated with Resident #48 by hand gestures and sometime writing it on a piece of paper. LVN F stated there were times she had used google to help translate. LVN F stated she did not know about an app on a tablet to help communicate with Resident #48. LVN F stated it was important to ensure effective communication to understand exactly what Resident #48 said and make sure her needs were met. During an interview on 04/02/26 at 1:55 p.m., CNA B stated Resident #48 spoke and understood very little English. CNA B stated her primary language was Spanish. CNA B stated prior to 04/01/26 he communicated with Resident #48 using hand gestures while speaking. CNA B stated Resident #48 did not understand full sentences just short phrases like food and shower. CNA B stated the Administrator sent out a text on 04/01/26 to staff about an app to use to translate for residents who could not understand English. CNA B stated it was important to ensure effective communication because if the communication was not fluent you could not fulfill the needs of the residents. During an interview on 04/02/26 at 2:25 p.m., CNA C stated Resident #48 spoke very little English but would speak back in Spanish and broken English. CNA C stated she communicated with Resident #48 by hand gestures and if she did not understand what the resident was trying to say she would ask her to point at it. CNA C stated the MDS Coordinator had told her last Saturday (03/28/26) to use an app on a tablet to help translate English to Spanish, but she did not use the tablet because the tablet was not always available. CNA C stated it was important to ensure effective communication to ensure their needs were being met. During an interview on 04/02/26 at 3:27 p.m., LVN A stated Resident #48's primary language was Spanish. LVN A stated Resident #48 understood simple words in English. LVN A stated a communication board or translator would be effective for staff that only spoke English to meet Resident #48's needs. LVN A stated he was not aware of an app on a tablet to be used to translate for Resident #48. LVN A stated it was important to effectively communicate with Resident #48 to ensure her wants/needs were met and if there was a problem she could communicate with staff. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected Resident #48's quarterly MDS assessment to state her primary language was Spanish. The DON stated she had never had a full conversation with Resident #48. The DON stated in passing Resident #48 would say hello in Spanish. The DON stated the facility had an app on a tablet that could be used to translate, and she expected staff to use the app to communicate with Resident #48. The DON stated she was responsible for monitoring and ensuring residents had equipment that was needed to communicate by random rounds. The DON stated it was important to effectively communicate with Resident #48 to ensure her needs were being met. 2. Record review of Resident #46's face sheet, dated 04/03/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included blindness, stroke, and high blood pressure. Record review of Resident #46's quarterly MDS assessment, dated 03/05/26, indicated Resident #46 understood and was understood by others. Resident #46's BIMS score was 15, which meant she was cognitively intact. The MDS indicated Resident #46 required help total assist with toileting, bed mobility, dressing, transfers, personal hygiene, and eating. The MDS indicated her primary language was Spanish. Record review of Resident #46's care plan dated 01/13/26, indicated Resident #46 was at risk for perceived or actual physical harm during care interactions related to blindness, language barrier, and difficulty interpreting staff actions during meal assistance. The intervention was for staff to utilize certified interpreter services or facility-approved language assistance to support understanding during meals and care. Record review of the facility's undated/untitled form reflected Resident #46 spoke in a non-dominant language. During an interview and observation on 03/31/26 at 12:53 p.m., Resident #46 was in her bed. The surveyor began talking to Resident #46 in English and she started talking in Spanish. There was no communication device observed in her room. During an interview on 03/31/26 at 12:05 p.m., CNA L said Resident #46 spoke and understand very little English. CNA L said Resident #46 was blind. CNA L said her primary language was Spanish. CNA L said Resident #46 did not understand full sentences, just short phrases like food and water. CNA L said she did not speak Spanish but used her phone to communicate with Resident #46. She said at times she still had some communication issues. CNA L said communication was important to ensure the resident needs were being met. During an interview on 03/31/26 at 2:30 p.m., CNA H said Resident #46 spoke very little English. CNA H stated she communicated with Resident #46 by using an app on her phone. She said the facility had not provided any type of communication board or tool for Resident #46 that she was aware of. CNA H said it was important to ensure effective communication to ensure their needs were being met. During an interview on 04/02/26 at 3:27 p.m., LVN G said Resident #46's primary language was Spanish. LVN G said he was not aware of any communication board or translator for Resident #46. He said he used his phone to translate and felt he communicated well with Resident #46. He said it would be better if they had some type of translator for staff to use because a communication board may not be effective for Resident #46 because she was blind. He said it was important to be able to communicate with Resident #46 and for her to be able to communicate with staff. During an interview on 04/03/26 at 3:36 p.m., the DON said when she started at the facility last year, she learnt about an application on a tablet device during her orientation. She said she was not sure why staff was not aware of the application on the tablet device the facility provided. She said she had heard unknown staff saying they used the google application on their phones, but she did not know why or ask why. She said Human Resource was supposed to go over the tablet application during orientation. She said it was important to communicate with all residents to be able to ensure their needs were being met. She said without effective communication care could be missed. During an interview on 04/03/26 at 3:46 p.m., Human Resources said he does the general orientation. He said each department was responsible for reviewing any equipment staff needed to know to perform their job duties. He said he did not go over any computer/tablet applications staff were to use for any Spanish speaking residents. During an interview on 04/03/26 at 4:49 p.m., The Administrator stated he had not had a full conversation with Resident #48. The Administrator stated he had spoken to staff, and they stated Resident #48 spoke English and Spanish. The Administrator stated he had sent out a text message to all staff that anyone that has a language barrier should be using the app on the tablet or the detailed communication board that was located at the nursing station to communicate with residents. The Administrator stated the text was not specifically related to Resident #48. The Administrator stated he expected the translator to be used if that was what Resident #48 was comfortable with. The Administrator stated the DON was responsible for monitoring. The Administrator stated it was important to effectively communicate with Resident #48 to understand her wishes and needs clearly and so there was no communication barrier between her and staff. Record review of the facility's undated and untitled policy indicated, Policy Statement: We provide support for those in need of assistance with communication, whether it is for language services or access to technology. Policy Interpretation and Implementation:9. It is understood that providing meaningful access to services provided by this facility requires that the residents' needs and questions be accurately communicated to the staff. Oral interpretation services include interpretation from the resident's primary language back to English.10. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the individual.

Based on observations, interviews, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 10 residents (Resident #14) reviewed for range of motion. The facility did not ensure Resident #14 wore a left wrist roll (a device to prevent further decline in an extremity contracture) on 03/31/26, 04/01/26 and 04/02/26. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.Findings include:Record review of Resident #14's face sheet, dated 04/03/26, reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a group of disorders that affects a person's ability to move and maintain balance and posture), traumatic brain of injury (damage to the brain from a hit, fall, or object) and contracture of muscle (permanent or long-term shortening, stiffening, and tightening of muscles, tendons, or skin caused reduced joint mobility, painful ad fixed deformities. Record review of Resident #14's quarterly MDS assessment, dated 01/11/26, reflected Resident #14 rarely/never understood others, and rarely/never made himself understood. The assessment did not address Resident #14's BIMS score but reflected she had long-term and short-term memory problems. Resident #14 had functional limitation in range of motion on both sides, on the upper and lower extremities.Record review of Resident #14's comprehensive care plan, revised 02/13/25, reflected Resident #14 had limited physical mobility related shaken infant syndrome and contractures. The care plan interventions included: resident to wear left wrist roll daily, or as tolerated for contracture prevention/management. Record review of Resident #14's physician order summary report dated 04/03/26, reflected an active physician's order for Resident #14 to wear left roll daily or as tolerated for contracture prevention/management with a start date 12/23/25. During an observation and interview on 03/31/26 at 12:43 p.m., an attempted interview with Resident #14, reflected he was non-interviewable due to cognitive loss. Resident #14 was sitting up in a Broda chair (a wheelchair with ergonomic tilt and recline functions, designed to reduce pressure points, enhance comfort, and improve posture). Resident #14 did not have a wrist roll to his left wrist. Resident #14's wrist roll device was lying on his dresser. During an observation on 04/01/26 at 10:10 a.m., Resident #14 was sitting up in a Broda chair. Resident #14 did not have a wrist roll device to his left wrist. The wrist roll device continued to be on the Resident #14's dresser. During an observation on 04/01/26 at 4:41 p.m., Resident #14 was sitting up in a Broda chair being pushed by the Activity Director on the sidewalk outside of the facility. Resident #14 did not have a wrist roll to his left wrist. During an observation on 04/02/26 at 8:00 a.m., Resident #14 was lying in bed asleep. Resident #14 did not have a wrist roll to his left wrist. Resident #14's wrist roll continued to be on his dresser. During an interview on 04/02/26 at 2:25 p.m., CNA C stated the CNAs and LVNs were responsible for applying the hand roll to Resident #14's hand. CNA C stated she had seen the wrist roll on his dresser but was never told what hand it should go in, and she never asked the charge nurse either. CNA C stated she could not recall the last time she seen the hand roll in his hand. CNA C stated a hand roll was important for a resident with limited range of motion or contracture to prevent further contractures. During an interview on 04/02/26 at 3:27 p.m., LVN A stated Resident #14 should have a wrist roll in his left hand. LVN A stated Resident #14 did not refuse the wrist roll. LVN A stated the CNAs and nurses were responsible for ensuring the wrist roll was being applied. LVN A stated he had placed the wrist roll on his hand either Tuesday (04/31/26) or Wednesday (04/01/26) but could not recall the date. LVN A stated it was important for wrist roll to be placed in Resident #14's left hand to prevent the nails from going into his skin. During an interview on 04/02/26 at 4:22 p.m., the DOR stated Resident #14 should have the hand roll in his left hand during his daily functional task while sitting or lying. The DOR stated the CNAs and nurses were responsible for ensuring the wrist roll was applied to his left hand daily. The DOR stated the hand roll was not always in hands at times when therapy came to perform their treatment sections. The DOR stated she had not spoken to the DON about consistently with the left-wrist roll when she seen him two times a week. The DOR stated the wrist roll prevented contractures and maintained tone (limit a fix position). During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected the CNAs and nurses to place the wrist roll in Resident #14's left hand if they noticed it was not in there. The DON stated she was responsible for monitoring contracture prevention/management by daily random rounds. The DON stated during her random rounds she had noticed in the past the wrist roll was not applied. The DON stated she immediately in serviced staff on replacing the roll. The DON stated it was important for the wrist roll to be applied in the left hand to prevent further contractures and skin integrity. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he knew Resident #14 had contractures but did not know he was supposed to have a left wrist roll in his daily. The Administrator stated the person that implemented the interventions was the charge nurse. The Administrator stated the DON was responsible for oversight of the contracture prevention/management. The Administrator stated it was important to ensure the left wrist roll was applied to prevent contractures and skin digging in his hand. Record review of the facility's policy titled, Contracture Management Program, revised 03/04/26, reflected. To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of range of motion. 5) Interventions care planned by MDS or designee to ensure they are carried out.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents (Resident #70 and Resident #47) reviewed for respiratory care.1.The facility failed to ensure Resident #70, and Resident #47 had a physician order for the use of oxygen.2.The facility failed to ensure Resident #47's oxygen concentrator filter was clean. 3.The facility failed to ensure Resident #47 had the use of oxygen included on her care plan. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.Findings included: 1.Record review of Resident #70's face sheet, dated 04/03/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, Chronic obstructive pulmonary disease also known as COPD (lung and airway diseases that restrict your breathing), diabetes (a condition that happens when your blood sugar (glucose) is too high), and high blood pressure. Record review of Resident #70's medical records did not indicate a MDS assessment had been completed because it was not yet due. Record review of Resident #70's baseline care plan dated 03/27/26, indicated she used oxygen. No interventions. Record review of Resident #70's physician's orders dated 03/27/26, did not indicate an order for oxygen. During an observation and interview on 03/31/26 at 1:17 p.m., Resident #70 was in bed, alert. She had oxygen set at 5 liter per nasal cannula. She said she wore oxygen because it helped her breathe better. She said she thought it should be set to 3 liter per nasal cannula. During an interview and record review on 04/02/26 at 2:20 p.m., RN G said he was Resident #70's nurse. He said Resident #70 had a diagnosis of COPD and required oxygen. He said her oxygen should be set at 4 liters per nasal cannula. He looked at Resident #70's orders and did not see an order for oxygen. He said the order for oxygen was missing when he input Resident #70's orders. He said it was important to have orders so that other staff would know what Resident #70's oxygen should be set at. He said not enough or too much oxygen could cause respiratory distress. During an interview on 04/03/26 at 3:36 p.m., the DON said the nurses were responsible for writing physician orders when received. She said residents who wore oxygen should have orders written with the oxygen rate, diagnosis, and a sign place on their door. She said she did random rounds to check oxygen rates, dates on tubing and for signs on the door. She said it was important for nurses to know what the rate of oxygen to prevent respiratory distress. 2.Record review of Resident #47's face sheet dated 04/01/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure (disease in which the lungs cannot adequately provide oxygen to the blood), diabetes mellitus (chronic metabolic disorder characterized by high blood sugar due to the body's inability to produce insulin), high blood pressure, dementia (decline in mental ability severe enough to interfere with daily life caused by physical brain changes), and congestive heart failure (chronic progressive condition in which the heart cannot pump blood efficiently). Record review of Resident #47's quarterly MDS assessment dated [DATE] indicated she made herself understood and she understood others. The MDS also indicated she had a BIMS score of 13 which meant she was cognitively intact. The MDS also indicated she required total assistance from staff for all her activities of daily life. The MDS did not indicate Resident #47 required oxygen. Record review of Resident #47's comprehensive care plan last revised 12/21/2025 did not indicate the use of oxygen. Record review of Resident #47's order summary report dated 04/01/26 did not indicate an order for oxygen use. During an observation on 03/31/2026 11:37 AM, Resident #47 was lying in bed and had her oxygen on set at 2 liters per minute with the oxygen concentrator filter in place covered in gray matter. During an observation on 04/01/26 at 9:02 AM, Resident #47's oxygen filter continued to be covered in gray matter. During an observation on 04/02/26 at 11:27 AM, Resident #47's oxygen concentrator filter continued to be covered in gray matter. During an observation and interview on 04/03/26 at 3:03 PM, the ADON was at the nurse's station and said she thought that there should have been a schedule for the oxygen concentrators filters to be cleaned and nasal cannulas to be changed out. The ADON then walked in Resident #47's room and said resident was sent to the hospital but the oxygen concentrator filter appeared dirty and should have been cleaned and changed out the tubing weekly on Sundays by the 2-10 nurses. The ADON said the failure placed a risk for infection. During an interview on 04/03/26 at 4:30 PM, the DON said her expectation was for the nasal canula to be changed on a weekly basis and oxygen concentrator filter should be cleaned as well. The DON said Resident #47 should have had an order for oxygen use and it should have been placed on her care plan. The DON said the failure placed a risk for infection. The failure of not having the order placed Resident #47 at risk for receiving oxygen that she should not have been given. During an interview on 04/03/26 at 5:20 PM, the Administrator said the nurses should been changing and cleaning the oxygen concentrator filters and monitoring the cleanliness every Sunday. The Administrator said Resident #70 and Resident #47 should have an order for oxygen. He said Resident #47 should have had an order to clean the oxygen concentrator filter and change out the tubing. The Administrator said the failure of the oxygen concentrator filter being dirty placed a risk for Resident #47 breathing unclean oxygen and causing infection and increased breathing issues. The Administrator said the failure of not having order for oxygen in placed a risk for staff not knowing what settings to put the oxygen on and that could cause Resident #47 to get too much or not enough oxygen. Record review of the facility policy, reviewed 03/03/26, Oxygen Administration and Oxygen Safety indicated: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident.8.Regulator; and Tools used for oxygen equipment shall be kept free of grease, oil, etc.

Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 residents (Resident #9) reviewed for trauma-informed care. The facility failed to ensure Resident #9 had physician's orders for monitoring post-traumatic stress disorder behaviors The facility did not ensure Resident #9's care plan reflected a diagnosis of post-traumatic disorder and included interventions for post-traumatic stress disorder behaviors This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings Included:Record review of Resident #9's face sheet dated 4/3/26, reflected Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included chronic kidney disease, stage 5 ( Kidneys function at less than 15% capacity, causing severe buildup of waste, fluid, and toxins, which necessitates treatment like dialysis or a kidney transplant to sustain life), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), hallucinations (sensory experiences-seeing, hearing, smelling, tasting, or feeling things-that appear real but are created by the mind in the absence of external stimuli). and post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it). Record review of Resident #9's admission MDS assessment dated [DATE], reflected Resident #9 made himself understood and understood others. Resident #9's BIMS score was 15 which indicated the resident's cognition was fully intact. The MDS assessment reflected Resident #9 had an active diagnosis of post-traumatic stress disorder. Record review of Resident #9's Pre-admission Screening and Resident Review screening dated 1/23/26, indicated no diagnosis or history of post-traumatic stress disorder or any other mental illness. Record review of Resident #9's Social History Form- Trauma Informed Care dated 1/29/26 indicated the resident had a previously documented diagnosis of mental disorder and history of trauma. The form indicated the resident did have a diagnosis of post-traumatic stress disorder. The form indicated Resident #9 had experienced a serious accident and physical assault and had been in a situation that was extremely frightening as well as witnessed an extremely frightening situation. The Trauma Informed Care form indicated Resident #9 had triggers of loud noises, specific smells, restraints, and large crowds. The form indicated removing stimuli and medications prescribed for the trauma related diagnosis helped to alleviate the triggers. Record review Resident #9's base line care plan dated 1/31/26 revealed the resident had no mental health needs, no behavioral concerns, and no interventions for post-traumatic stress disorder. Record review of Resident #9's orders dated 4/3/26 indicated no monitoring for traumatic stress behaviors or triggers. In an interview on 4/3/26 at 4:40 pm, the DON stated the Social Worker was responsible for ensuring the diagnosis of post-traumatic stress disorder triggers trauma informed care on the resident's chart. The DON stated it is important to be aware if a resident requires trauma informed care to be able to provide the best possible care by avoiding triggers. In an interview on 4/3/26 at 5:55 pm, the Administrator stated he expects all residents with a diagnosis of post-traumatic stress disorder to have trauma informed care. The Administrator stated he expects all admission screenings to be done in the appropriate amount of time and all services available be offered. The Administrator stated the Social Worker was responsible for the trauma assessment, but the ADON and DON were also responsible for knowing of the diagnosis and proceeding accordingly. The Administrator stated it is important to care for residents with a post-traumatic stress disorder diagnosis appropriately for the safety of the residents and the staff. In an interview on 4/3/26 at 6:15 pm the Social Worker stated the trauma assessment was part of the initial admission assessment. The Social Worker stated she was responsible for that assessment. The Social Worker stated that Resident #9 did trigger for trauma informed care, but Resident #9 did not have issues. The Social Worker stated it was important to ensure a resident with post-traumatic stress disorder have trauma informed care so that the resident can get needs met and be most comfortable at the facility. Record review of the facility policy titled Trauma-Informed and Culturally competent Care, dated 10/22 and last reviewed 3/3/26, stated the facility will perform a universal screening of residents and use the screening to identify the need for further assessment and care. The facility will perform an assessment involving an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. The facility will utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. The facility will develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. The facility will identify and decrease exposure to triggers that may re-traumatize the resident. The facility will recognize the relationship between past trauma and current health concerns.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, administering and reconciliation to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled of all drugs and biologicals) for 1 of 1 storage area, and 1 of 2 medication rooms (hall 100) reviewed for pharmacy services.1.The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2.The facility failed to ensure staff counted narcotic medication in the refrigerator on hall 100 medication room which contained Lorazepam (antianxiety medication) and Morphine (pain medication).These failures could place residents at risk of drug diversion, or misappropriation of medication.Findings included:1.During an observation and interview on 04/02/26 at 02:44 PM, the following medications were observed in the controlled medication storage cabinet awaiting to be disposed:*Tramadol 50mg- 20 tablets,*Lorazepam 0.5mg- 27 tablets,*Tramadol 50mg- 7 tablets, and*Morphine 20mg/ml- 27.5 milliliters. The DON said the controlled medications waiting to be disposed were kept in the locked cabinet that had 2 locks in place. The DON said she was responsible for the discontinued medications, and she was the only one with the key to the locks on the cabinet. The DON said when she reconciled medications that need to be disposed of the medications were brought to her, she checked the narcotic medication count and verified the count with the nurse and she then logged the medication on the destruction log that was kept in the cabinet, and then placed the medication in the locked cabinet. The DON said she would usually log them as she received the medications but guessed someone stopped her in between because she could see where she started to log one of the medications that were not logged. The DON said the risk of her not logging the medications would be not knowing which medications were not accounted for and placed a risk for medication errors and drug diversions. Record review of the facility's medication destruction binder on 04/02/26, indicated the last medication destruction was completed on 02/20/26.During an interview on 04/03/26 at 5:44 PM, the Administrator said he expected the discontinued controlled medications to be logged when the DON received the medications and prior to the medication being placed in the destruction box. The Administrator said the failure placed a risk for the miscounting of medication or not knowing if any of the medications were missing. 2.During an observation on 04/02/26 at 2:39 p.m., revealed 1 open bottle of Lorazepam and Morphine and 2 unopened bottles of Morphine Sulfate in the hall 100 medication room refrigerator door.During an interview on 04/02/26 at 3:20 p.m., LVN K said she was the charge nurse on hall 100 this morning (04/02/26) for the 6am-2pm shift. She said she did not count the medication in the refrigerator. She said she did not know that those medications were in the refrigerator. She said failure to count all narcotics could lead to missing medication or a risk for drug diversion.During an interview on 04/02/26 at 4:20 p.m., LVN A said he was the charge nurse on hall 100 for the 2pm-10pm shift on 03/31/26 and 04/01/26. He said he did not count Resident #54's or #39's medication in the refrigerator for either day. He said he was aware they were inside the refrigerator sitting on the shelf inside the door. He said he knew they should have been placed in the lock box but did not place them in the box. He said the risk could be missing medication.During an attempted call on 04/02/26 at 5:00 p.m., LVN Q did not answer but a message was left (related to counting narcotics).During a phone interview on 04/02/26 at 5:01 p.m., LVN O said she was the charge nurse for hall 100 on Tuesday (03/31/26) for the 6am-2pm shift and does not recall counting any medications in the refrigerator. She said she started a week ago and had not counted any medications in the refrigerator. She said the oncoming and off going nurses were supposed to count all narcotics each shift. She said it was important to count to ensure all medication was accounted for and to prevent missing medications. During an interview on 04/03/26 at 3:39 p.m., the DON said the narcotic medications should be always stored under double lock including medications in the refrigerator. She said the nurses should be counting the narcotics each shift. She said if they were not counting medication, it could cause missing medication or have a drug diversion. She said she was doing random checks and saw no omits in the narcotic sign out sheets but would change the process of checking narcotics.During an interview on 04/03/26 at 5:32 p.m., the Administrator said the nurses should be counting narcotics every shift. He said if the nurses were not counting the medications there could be a discrepancy, or missing medications. The Administrator said the DON was responsible for monitoring and overseeing nurses by rounding. Record review of the undated facility policy, Controlled Substances, indicated, Policy Statement The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs 2 of 24 residents (Residents #14 and #18) reviewed for laboratory services. 1. The facility did not obtain a physician's ordered Tegretol level (to measure the medication's level in the blood to ensure it is within a safe, therapeutic range) for Resident #14. 2. The facility did not obtain a physician's ordered Vitamin D level (to measure the level of vitamin D in the blood, identifying deficiencies that can cause bone weakness, soft bones (osteomalacia), or fractures) for Resident #18. These failures could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: 1. Record review of Resident #14's face sheet, dated 04/03/26, reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included unspecified convulsion (muscle contract and relax quickly and cause uncontrolled shaking of the body). Record review of Resident #14's quarterly MDS assessment, dated 01/11/26, reflected Resident #14 rarely/never understood others, and rarely/never made himself understood. The assessment did not address Resident #14's BIMS score but reflected she had long-term and short-term memory problems. Record review of Resident #14's comprehensive care plan, revised 08/18/25, reflected Resident #14 had a seizure disorder related to shaken infant syndrome. The care plan interventions included: give medications as ordered, monitor lab, and report any sub therapeutic or toxic results to MD. Record review of Resident #14's physician order summary report dated 04/03/26, reflected an active physician's order for .Tegretol level every four-month starting on the last day of month with a start date 10/31/23. Record review of Resident #14's electronic medical record reflected his last Tegretol level was drawn on 10/31/25. 2. Record review of Resident #18's face sheet, dated 04/03/26, reflected Resident #18 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Vitamin D deficiency (inadequate levels of Vitamin D). Record review of Resident #18's quarterly MDS assessment, dated 03/20/26, reflected Resident #18 understood others, and made herself understood. Resident #18's BIMS score was 15, which indicated her cognition was intact.Record review of Resident #18's comprehensive care plan, revised 07/07/25, reflected had a nutritional problem or potential nutritional problem and was at risk for malnutrition related to malnutrition, vitamin deficiency, and cachexia (condition that caused significant weight loss and muscle loss). The care plan interventions included: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Record review of Resident #18's physician order summary report dated 04/03/26, reflected an active physician's order for .vitamin D with a start date 02/25/26. Record review of Resident #18's electronic health record did not reflect a vitamin D level that was drawn as ordered on 02/25/26. During an interview on 04/03/26 at 1:23 p.m., the ADON stated she was responsible for monitoring and reviewing labs by going into PCC every morning and clicking on the startup tab which was a summary of what happened in a 24-hr period such as lab orders that needed to be drawn. The ADON stated she had seen where the physician had put in a lab order for Residents #14's Tegretol level and Resident #18's vitamin D level to be drawn but when she reviewed the orders in the startup section, she clicked the box which reflected as completed. The ADON stated she should have contacted the lab to come out and complete the order and placed the lab requisition sheet in the lab book at the nursing station. The ADON stated she thought the labs had already been drawn so she marked it as completed, but it was for the labs to be drawn that day. The ADON stated she had not been trained on how to properly review the unreviewed lab results until yesterday (04/02/26) by the regional corporate nurse. The ADON stated when she first was hired, she received 3-day training by the regional corporate nurse, but she did not go over how to ensure the labs were drawn at the appropriate time. The ADON stated it was important to ensure labs were drawn per the physician order to ensure their levels were therapeutic and prevent deficiency in their health. During a telephone interview on 04/03/26 at 1:56 p.m., the Medical Director stated he expected labs to be drawn as ordered. The Medical Director stated he could not recall if the facility notified him about the missed labs. The Medical Director stated it was important to ensure labs were drawn per the physician order to keep the level of medication therapeutic.During an interview on 04/03/26 at 4:04 p.m., the DON stated once the order was received, a lab requisition should be filled out and placed in the lab book to be drawn at the nursing station. The DON stated the lab company comes in daily to draw labs. The DON stated the ADON was responsible for monitoring and overseeing labs. The DON stated it was important to ensure labs were drawn per the physician order to prevent toxicity and to ensure levels are therapeutic. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected labs to be drawn per physician order. The Administrator stated the nursing department heads were responsible for monitoring and overseeing. The Administrator stated it was important to ensure labs were drawn as scheduled for their overall health. Record review of the facility's policy titled Laboratory Services reviewed 03/03/26 reflected. It is the policy of this facility to ensure that laboratory services meet the needs of residents and that the results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, treatment, and that the facility has established policies and procedures. 1. The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services.3. The facility will provide or obtain laboratory services only when ordered by a physician, physician assistance or nurse practioner.

Based on observation, interview, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 24 residents (Resident #18) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #18's preference for double vegetables. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #18's face sheet, dated 04/03/26, reflected Resident #18 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Vitamin D deficiency (inadequate levels of Vitamin D) and unspecified severe protein-calorie malnutrition. Record review of Resident #18's quarterly MDS assessment, dated 03/20/26, reflected Resident #18 understood others, and made herself understood. Resident #18's BIMS score was 15, which indicated her cognition was intact. Record review of Resident #18's comprehensive care plan, revised 07/07/25, reflected Resident #18 had a nutritional problem or potential nutritional problem and was at risk for malnutrition related to malnutrition, vitamin deficiency, and cachexia (condition that caused significant weight loss and muscle loss). The care plan interventions included: provide and serve diet as ordered. Record review of Resident #18's physician order summary report dated 04/03/26, reflected an active physician's order to add double veggies to meals per patient request with a start date 6/20/25. Record review of the lunch meal ticket dated 04/01/26 for Resident #18 reflected extra vegetables. During an observation and interview 04/01/26 at 12:37 p.m., Resident #18 received one serving of cauliflower with cheese sauce. After reviewing the lunch meal ticket with CNA C and the Executive Director they both agreed Resident #18 did not receive double vegetables. During an interview on 04/03/26 at 9:07 a.m., LVN P stated she was responsible for ensuring Resident #18 received double vegetables with her lunch meal on 04/01/26. LVN P stated she was unaware she needed double vegetables. LVN P stated she should have read the complete ticket all the way to the bottom. LVN P stated it was important for Resident #18's food preference to be followed to prevent the potential of weight loss. During an interview on 04/03/26 at 11:41 a.m., [NAME] N stated she was aware Resident #18 should have received double vegetables with her meal, but she overlooked the ticket by mistake. [NAME] N stated she should have looked at the ticket as she prepared the tray to ensure she received the correct portions. [NAME] N stated it was important for their food preferences to be followed because it was their right. During an interview on 04/03/26 at 2:58 p.m., the Dietary Manager stated he was aware that Resident #18 wanted double vegetables with her lunch and dinner. The Dietary Manager stated he assumed Resident #18 wanted double vegetables related to her health. The Dietary Manager stated [NAME] N was responsible for ensuring Resident #18 received double vegetables. The Dietary Manager stated he monitored by pulling a random breakfast and lunch tray to ensure the ticket matched the tray. The Dietary Manager stated it was important for their food preferences to be followed because it was their right. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected Resident #18's food preferences to be followed. The DON stated the nurse should be checking the trays prior to serving the residents. The DON stated she monitored by randomly observing meal service. The DON stated if she noticed the tray did not match the ticket, she would take it back to dietary for correction. The DON stated it was important for their food preferences to be followed because Resident #18 may not eat which could lead to nutritional issues such as weight loss and poor wound healing. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected food preferences to be followed. The Administrator stated the cooks were the first line of defense and the nurses were the second line of defense of being responsible to ensure the residents received the correct dietary preferences. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing meal service. The Administrator stated it was important to follow dietary preferences and guidelines because it was the resident right. Record review of the facility's policy titled Food and Nutrition Service Menus revised 06/23/25 reflected. Each resident is provided with a nourishing, palatable, well-balanced diet that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. 7 (a) if an incorrect meal is provided to a resident, or a meal. nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 24 residents (Resident #18) reviewed for therapeutic diets. The facility did not ensure Resident #18 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included: Record review of Resident #18's face sheet, dated 04/03/26, reflected Resident #18 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Vitamin D deficiency (inadequate levels of Vitamin D) and unspecified severe protein-calorie malnutrition. Record review of Resident #18's quarterly MDS assessment, dated 03/20/26, reflected Resident #18 understood others, and made herself understood. Resident #18's BIMS score was 15, which indicated her cognition was intact. Recor review of Resident #18's comprehensive care plan, revised 07/07/25, reflected had a nutritional problem or potential nutritional problem and was at risk for malnutrition related to malnutrition, vitamin deficiency, and cachexia (condition that caused significant weight loss and muscle loss). The care plan interventions included: provide and serve diet as ordered. Record review of Resident #18's physician order summary report dated 04/03/26, reflected an active physician's order for double protein with a start date 06/22/25. Record review of the lunch meal ticket dated 04/01/26 for Resident #18 reflected double protein portion. During an observation and interview 04/01/26 at 12:37 p.m., Resident #18 received a single serving of the entree which was a pork chop. After reviewing the lunch meal ticket with CNA C and the Executive Director they both agreed Resident #18 did not receive two serving of pork chops. During an interview on 04/03/26 at 9:07 a.m., LVN P stated she was responsible for ensuring Resident #18 received double protein with her lunch meal on 04/01/26. LVN P stated she was unaware she needed two servings of the entree. LVN P stated she should have read the complete ticket all the way to the bottom. LVN P stated it was important to ensure residents received the correct diet order to prevent further weight loss. During an interview on 04/03/26 at 11:41 a.m., [NAME] N stated she was aware Resident #18 should have received two servings of pork chops with her meal, but she overlooked the ticket by mistake. [NAME] N stated she should have looked at the ticket as she prepared the tray to ensure she received the correct portions. [NAME] N stated it was important to ensure Resident #18 received the correct diet order to prevent weight loss. During an interview on 04/03/26 at 2:58 p.m., the Dietary Manager stated [NAME] N was responsible for ensuring Resident #18 received two pork chops with her meal on 04/01/26. The Dietary Manager stated he monitored by pulling a random breakfast and lunch tray to ensure the ticket matched the tray. The Dietary Manager stated it was important to ensure Resident #18 received the correct diet order to prevent further weight loss. During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected Resident #18 to have double protein with each lunch and dinner. The DON stated the nurse should be checking the trays prior to serving the residents. The DON stated she monitored by randomly observing meal service. The DON stated if she noticed the tray did not match the ticket, she would take it back to dietary for correction. The DON stated it was important Resident #18 received double protein portions to prevent weight loss and poor wound healing. During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected double protein to be given, and order followed for Resident #18. The Administrator stated the cooks were the first line of defense and the nurses were the second line of defense of being responsible to ensure the residents received the correct dietary preferences. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing meal service. The Administrator stated it was important Resident #18 received double protein portions to prevent weight loss. Record review of the facility's policy titled Food and Nutrition Service Menus revised 06/23/26 reflected. Each resident is provided with a nourishing, palatable, well-balanced diet that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. 7 (a) if an incorrect meal is provided to a resident, or a meal. nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to protect Resident #45 when an allegation of abuse occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025. The facility failed to protect Resident #45 from abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. The facility failed to prevent abuse when RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. The Abuse Coordinator failed to protect Resident #45 from abuse when he took her to MA C and asked Resident #45 if she had laughed at her. The Abuse Coordinator failed to protect Resident #45 from potential abuse when he took her to MA B and asked Resident #45 if MA B was mean to her. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged the left side of the brain). Record review of Resident #45's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated: Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes. Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] witnessed nurses [RN A], nurse [RN D], the D.O.N. making fun of a resident [Resident #45] on hall #1. Banging their heads on the wall in the same like manner as the resident because [Resident #45] was angry about something. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. I did not know who I could trust to talk to. But I knew that I had to do something. These residents deserve to be treated with the utmost respect. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper). During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E became teary-eyed and started crying. Housekeeper E said she was in the hallway cleaning, and the DON, RN D and RN A were at the nurses' station. Housekeeper E said Resident #45 was upset and had wheeled up and was banging her head on the wall. Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head on the wall. RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator. During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell Resident #45 where to hit her head on the wall or to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. RN A said she did not laugh or make fun of Resident #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said the Administrator told her maybe it was the tone she had used, and Housekeeper E perceived it as she was telling Resident #45 to kill herself. RN A said when the incident occurred, she was giving report to RN D and the DON was also there and a CNA and they were laughing about something different they were not laughing at Resident #45. During an interview on 03/27/2025 at 9:54 AM, the DON said last week RN D, RN A, and herself were at the nurses' station. She said maybe it was the Friday before last, but she did not remember the day. The DON said she remembered it was during shift change and they were at the nurses' station. The DON said RN A did not tell Resident #45 to hit her head on the wall. The DON said they were not laughing at Resident #45. The DON said she was at the nurses' station, and they were talking and laughing, and then Resident #45 pulled over and started banging her head. The DON said she told her to stop banging her head, if she kept banging her head, she was going to hurt herself. The DON said she did not witness RN A frustrated at Resident #45. The DON said the Administrator told her the Admissions Coordinator had taken Housekeeper E to him, and Housekeeper E said the DON was present and laughing at Resident #45. The DON said she told the Administrator to let Housekeeper E write the witness statement and send it to corporate. The DON said she told the Administrator whatever corrective actions needed to be taken to take them. The DON said she did not laugh at Resident #45. The DON said the Administrator told her he had sent the witness statement to corporate, and they said it was not abuse because they did not laugh. The DON said she did not get suspended. During an interview in 03/27/2025 at 10:04 AM, MA B stated RN A put her hand on the same spot Resident #45 was hitting her head to prevent injury. MA B stated she was not laughing at Resident #45. MA B stated the Administrator spoke to her about the incident and brought Resident #45 to her. The Administrator asked Resident #45 if MA B had ever been mean to her. Resident #45 stated no. MA B stated she was in-serviced, but not suspended. During an attempted interview on 03/27/2025 at 10:05 AM, RN D did not answer the phone. During an interview on 03/27/2025 at 10:09 AM, the Administrator said he was the abuse coordinator. The Administrator said Housekeeper E had gone to him and reported some of the staff were laughing at Resident #45 at the nurses' station. The Administrator said he thought it was on March 21st, Thursday (3/20/2025) or Friday (03/21/2025). The Administrator said he told her to write a statement and he talked to Resident #45, and Resident #45 told him they were not laughing at her. The Administrator said the nurses told him they were sitting at the nurses' station having a conversation. The Administrator said he had taken a staff member to Resident #45 and asked her if the staff member was mean to her. The Administrator said Resident #45 had identified the staff member and said she was not mean to her. The Administrator said he did an in-service on customer service with all of them (the DON, RN D, RN A, MA B, and MA C). The Administrator said what Housekeeper E told him was not an allegation of abuse. The Administrator said Housekeeper E said Resident #45 was hitting her head on the wall and the nurses were laughing at the nurses' station. The Administrator said he had spoken to all the staff, and they told him they were having a conversation before Resident #45 pulled up to them. The Administrator said when Housekeeper E reported the incident to him it was more of a grievance. The Administrator said before he suspended any staff, he notified his team and talked to all the staff. The Administrator said he talked to all the staff involved and they gave him the same story, therefore, it was a grievance. The Administrator said abuse was willful infliction of pain that it could be emotional, psychological, sexual, or financial. The Administrator said staff laughing at a resident could cause psychological issues and it was emotional abuse. The Administrator said he asked the staff if they were banging their heads on the wall, and they said they were doing it to demonstrate to the resident she could hurt herself. The Administrator said he talked to the resident immediately and to the staff involved and the resident said it did not happen. The State Surveyor asked the Administrator if Resident #45 with a BIMS of 4 was a reliable interviewee. The Administrator was silent and did not answer the question. The Administrator said as the abuse coordinator it was his duty to protect the residents from abuse. The Administrator did not respond when asked how he protected Resident #45 from abuse. During an interview on 03/27/2025 at 10:30 AM, MA C stated she was not laughing at Resident #45. MA C stated the Administrator called her to his office to discuss the incident. MA C stated the Administrator brought Resident #45 to her. The Administrator asked Resident #45 if she knew MA C and Resident #45 stated, yes. The Administrator asked Resident #45 if MA C had ever laughed at her and Resident #45 stated no. During an interview on 03/27/2025 at 10:34 AM, the Regional Nurse stated she learned of the incident today (03/27/2025), and she considered the incident to be abuse. During an interview on 03/27/2025 at 10:44 AM, the Regional Director of Operations stated she was not aware of the incident until today (03/27/2025), and after reading the statement that was provided by the Administrator, she stated Housekeeper E's statement was an allegation of abuse. The Regional Director of Operations stated the victim of an abuse allegation should never be taken to the perpetrator. The Regional Director of Operations said these failures placed the residents at risk for abuse. During an interview on 03/27/2025 at 12:13 PM, Housekeeper E confirmed the incident occurred on 03/19/2025 around 2-2:30 PM. Housekeeper E said she did not see if Resident #45 did what the nurses demonstrated to her to do, but Resident #45 continued banging her head against the wall throughout the day. During an interview on 03/27/2025 at 12:16 PM, the Executive Director stated the Administrator contacted him and told him about the incident with staff laughing at a resident. The Executive Director stated the Administrator told him he spoke with the staff, and they told him they were not laughing at the resident. The Administrator told the Executive Director he spoke with the resident, and she did not have any complaints. The Executive Director stated he redirected the Administrator to contact corporate. The Executive Director stated the incident was an allegation of abuse. The Executive Director stated taking the resident to the perpetrator exposed her to harm, and stated you never take the victim to the alleged perpetrator. During an interview on 03/27/2025 at 12:30 PM, Resident #45 said staff had laughed at her. Resident #45 was unable to provide details. When questioned further she said she did not know. During an attempted phone interview on 03/29/2025 at 8:43 AM, RN D did not answer the phone. Record review of an in-service record with topic, Professionalism/Customer Service, conducted by the Administrator, dated 03/21/2025, indicated it was signed by MA C, the DON, MA B, RN A, and RN D. Record review of the facility's Abuse Prohibition Policy, reviewed 05/17/2024 indicated, 2. Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to (abuse/neglect and intervene appropriately. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring .1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately . 1. All residents will be immediately protected from harm . This was determined to be an Immediate Jeopardy (IJ) on 03/27/2025 at 12:30 PM. The Regional Director of Operations was notified. The Regional Director of Operations was provided with the IJ template on 03/27/2025 at 2:06 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 03/28/2025 at 10:17 AM and included the following: March 27,2025 POR F600 On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety. On 3/27/2025, RN A, RN D, DON, MA C, MA B and Administrator were suspended pending the outcome of the investigation. On 3/24/2025 DON referred resident #45 for a psychological evaluation and was seen on 3/25/2025. On 3/27/2025, Corporate Clinical Specialist in-serviced ADON and MDS nurse regarding Abuse and Neglect policies and procedures. Competency was verified by quiz. Completed on 3/27/2025. On 3/27/2025, ADON and MDS nurse in-serviced all staff regarding Abuse and Neglect policies and procedures. Competency was verified by quiz. Started on 3/27/2025 and ongoing until all staff are in-serviced. Staff will not be able to work until completed. The above training will continue to be implemented in new hire orientation. On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect. Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed on 3/27/2025 Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025. To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee. On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information. During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months. During an interview on 03/28/2025 at 1:45 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures. During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the interim abuse coordinator along with her contact information. During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator. Record review completed of Resident #45's psych evaluation dated 03/25/2025. Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025. Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker. Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures. Record review completed of all the staffs' posttests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025. The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to ensure Housekeeper E reported an allegation of abuse immediately to the Abuse Coordinator on 03/19/2025 due to fear of retaliation. The Abuse Coordinator failed to follow the facility's abuse policy when he did not report an allegation of abuse to HHSC within 2 hours and did not thoroughly investigate when Housekeeper E reported to him on 03/20/2025 that RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself, RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself, and RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. The Abuse Coordinator failed to follow the facility's abuse policy when he did not protect Resident #45 from potential abuse when he took her to MA C and asked Resident #45 if she had laughed at her. The Abuse Coordinator failed to follow the facility's abuse policy when he did not protect Resident #45 from potential abuse when he took her to MA B and asked Resident #45 if she was mean. The Abuse Coordinator failed to follow the facility's abuse policy when he did not suspend RN A, RN D, the DON, MA C, and MA B after an allegation of abuse was made against them on 03/20/2025. The Abuse Coordinator failed to identify an allegation of abuse and acknowledge and act upon it to prevent alleged perpetrators to have continued access to Resident #45 and others. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life. Findings included: Record review of the facility's Abuse Prohibition Policy, reviewed 05/17/2024 indicated, . Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to (abuse/neglect and intervene appropriately. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring . Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately . The facility will thoroughly investigate all alleged violations and take appropriate actions. The Abuse Coordinator will report such allegations to the state agency in' accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation .Identification and suspension from employment of the person or persons accused of the abuse allegation(s) is mandatory .1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension, without pay, pending investigation .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation . 1. Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged the left side of the brain). Record review of Resident #45's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated: Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes. Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] witnessed nurses [RN A], nurse [RN D], the D.O.N. making fun of a resident [Resident #45] on hall #1. Banging their heads on the wall in the same like manner as the resident because [Resident #45] was angry about something. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. I did not know who I could trust to talk to. But I knew that I had to do something. These residents deserve to be treated with the utmost respect. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper). During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E became teary-eyed and started crying. Housekeeper E said the DON, RN D and RN A were at the nurses' station, and Resident #45 was upset and had wheeled up and was banging her head on the wall. Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head on the wall. RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator. During an interview on 03/27/2025 at 9:17 AM, the Housekeeping/Laundry Manager said Housekeeper E had come to her the day after she witnessed an incident maybe a couple days ago or last week. The Housekeeping/Laundry Manager said Housekeeper E told her the staff was laughing and making fun of Resident #45. She said Housekeeper E said they were gathered around Resident #45 and were telling her just hit your head on the corner if you really want to hit your head and hurt yourself hit your head on the corner. The Housekeeping/Laundry Manager said she reported it to the Admissions Coordinator because she was the department head available. The Housekeeping/Laundry Manager said she did not think she could write a grievance because she was contracted. The Housekeeping/Laundry Manager said she could not remember the staff members names, but she knew it was a nurse, the DON, and some CNAs. The Housekeeping/Laundry Manager said the incident reported to her by Housekeeper E could be considered abuse. During an interview on 03/27/2025 at 9:33 AM, the Admissions Coordinator said last week some day she did not remember the day, the Housekeeping/Laundry Manager told her that Housekeeper E had a concern about what happened the day before. Then, Housekeeper E went to her office and told her there were a couple of the nurses that were laughing at Resident #45 because she was hitting her head on the wall and said something to her. The Admissions Coordinator said Housekeeper E told her the nurses were gathered around Resident #45 laughing at her while she was hitting her head. The Admissions Coordinator said she told Housekeeper E, I have to report that, and she went and reported it to the Administrator. The Admissions Coordinator said the Administrator took over. During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell Resident #45 where to hit her head on the wall or to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. RN A said she did not laugh or make fun of Resident #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said the Administrator told her maybe it was the tone she had used, and Housekeeper E perceived it as she was telling Resident #45 to kill herself. RN A said when the incident occurred, she was giving report to RN D and the DON was also there and a CNA and they were laughing about something different they were not laughing at Resident #45. During an interview on 03/27/2025 at 9:54 AM, the DON said last week RN D, RN A, and herself were at the nurses' station. She said maybe it was the Friday before last, but she did not remember the day. The DON said she remembered it was during shift change and they were at the nurses' station. The DON said RN A did not tell Resident #45 to hit her head on the wall. The DON said they were not laughing at Resident #45. The DON said she was at the nurses' station, and they were talking and laughing, and then Resident #45 pulled over and started banging her head. The DON said she told her to stop banging her head, if she kept banging her head, she was going to hurt herself. The DON said she did not witness RN A frustrated at Resident #45. The DON said the Administrator told her the Admissions Coordinator had taken Housekeeper E to him, and Housekeeper E said the DON was present and laughing at Resident #45. The DON said she told the Administrator to let Housekeeper E write the witness statement and send it to corporate. The DON said she told the Administrator whatever corrective actions needed to be taken to take them. The DON said she did not laugh at Resident #45. The DON said the Administrator told her he had sent the witness statement to corporate, and they said it was not abuse because they did not laugh. The DON said she did not get suspended. During an interview in 03/27/2025 at 10:04 AM, MA B stated RN A put her hand on the same spot Resident #45 was hitting her head to prevent injury. MA B stated she was not laughing at Resident #45. MA B stated the Administrator spoke to her about the incident and brought Resident #45 to her. The Administrator asked Resident #45 if MA B had ever been mean to her. Resident #45 stated no. MA B stated she was in-serviced, but not suspended. During an attempted interview on 03/27/2025 at 10:05 AM, RN D did not answer the phone. During an interview on 03/27/2025 at 10:09 AM, the Administrator said he was the abuse coordinator. The Administrator said depending on the severity of the abuse some are reported within 2 hours and others within 24 hours. The Administrator said all allegations of abuse should be reported to HHSC. The Administrator said Housekeeper E had gone to him and reported some of the staff were laughing at Resident #45 at the nurses' station. The Administrator said he thought it was on March 21st, Thursday (3/20/2025) or Friday (03/21/2025). The Administrator said the Admissions Coordinator had taken him to Housekeeper E for her to tell him what happened. The Administrator said he told her to write a statement and he talked to Resident #45, and Resident #45 told him they were not laughing at her. The Administrator said he did a customer service in-service with the staff. The Administrator said the nurses told him they were sitting at the nurses' station having a conversation. The Administrator said he had taken a staff member to Resident #45 and asked her if the staff member was mean to her. The Administrator said Resident #45 had identified the staff member and said she was not mean to her. The Administrator said he did an in-service on customer service with all of them (the DON, RN D, RN A, MA B, and MA C). The Administrator said what Housekeeper E told him was not an allegation of abuse. The Administrator said Housekeeper E said Resident #45 was hitting her head on the wall and the nurses were laughing at the nurses' station. The Administrator said he had spoken to all the staff, and they told him they were having a conversation before Resident #45 pulled up to them. The Administrator said when Housekeeper E reported the incident to him it was more of a grievance. The Administrator said before he suspended any staff, he notified his team and talked to all the staff. The Administrator said he talked to all the staff involved and they gave him the same story, therefore, it was a grievance. The Administrator said abuse was willful infliction of pain that it could be emotional, psychological, sexual, or financial. The Administrator said staff laughing at a resident could cause psychological issues and it was emotional abuse. The Administrator said the allegation should have been reported to the state immediately. The Administrator said he asked the staff if they were banging their heads on the wall, and they said they were doing it to demonstrate to the resident she could hurt herself. The Administrator said he talked to the resident immediately and to the staff involved and the resident said it did not happen and they said it did not happen. The Administrator said when he received an allegation of abuse he should report it to the state first, and then investigate it. The State Surveyor asked the Administrator if Resident #45 with a BIMS of 4 was a reliable interviewee. The Administrator was silent and did not answer the question. During an interview on 03/27/2025 at 10:30 AM, MA C stated she was not laughing at Resident #45. MA C stated the Administrator called her to his office to discuss the incident. MA C stated the Administrator brought Resident #45 to her. The Administrator asked Resident #45 if she knew MA C and Resident #45 stated, yes. The Administrator asked Resident #45 if MA C had ever laughed at her and Resident #45 stated no. During an interview on 03/27/2025 at 10:34 AM, the Regional Nurse stated she learned of the incident today (03/27/2025), and she considered the incident to be abuse. The Regional Nurse stated the incident should have been reported within 2 hours to the state, and the staff involved should have been suspended pending investigation and all statements necessary should have been gathered. The Regional Nurse said the incident not being reported placed the residents at risk for abuse. During an interview on 03/27/2025 at 10:44 AM, the Regional Director of Operations stated she was not aware of the incident until today (03/27/2025). The Regional Director of Operations stated the Administrator should have made her aware of the incident. After reading the statement that was provided by the Administrator, she stated Housekeeper E's statement was an allegation of abuse. The Regional Director of Operations said the allegation of abuse should have been reported within 2 hours and staff suspended pending investigation. The Regional Director of Operations stated the victim of an abuse allegation should never be taken to the perpetrator. The Regional Director of Operations said these failures placed the residents at risk for abuse. During an interview on 03/27/2025 at 12:13 PM, Housekeeper E confirmed the incident occurred on 03/19/2025 around 2-2:30 PM. Housekeeper E said she did not see if Resident #45 did what the nurses demonstrated to her to do, but Resident #45 continued banging her head against the wall throughout the day. During an interview on 03/27/2025 at 12:16 PM, the Executive Director stated the Administrator contacted him and told him about the incident with staff laughing at a resident. The Executive Director stated the Administrator told him he spoke with the staff, and they told him they were not laughing at the resident. The Administrator told the Executive Director he spoke with the resident, and she did not have any complaints. The Executive Director stated he redirected the Administrator to contact corporate. The Executive Director stated the incident was an allegation of abuse, and it should have been reported within 2 hours to the state. The Executive Director said the staff involved should have been suspended pending investigation. The Executive Director stated taking the resident to the perpetrator exposed her to harm, and stated you never take the victim to the alleged perpetrator. During an interview on 03/27/2025 at 12:30 PM, Resident #45 said staff had laughed at her. Resident #45 was unable to provide details. When questioned further she said she did not know. During an attempted phone interview on 03/29/2025 at 8:43 AM, RN D did not answer the phone. Record review of an in-service record with topic, Professionalism/Customer Service, conducted by the Administrator, dated 03/21/2025, indicated it was signed by MA C, the DON, MA B, RN A, and RN D. This was determined to be an Immediate Jeopardy (IJ) on 03/27/2025 at 12:30 PM. The Regional Director of Operations was notified. The Regional Director of Operations was provided with the IJ template on 03/27/2025 at 2:06 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 03/28/2025 at 10:17 AM and included the following: March 27,2025 POR F607 On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety. On 3/27/2025, RN A, RN D, DON, MA C, MA B and Administrator were suspended pending the outcome of the investigation. On 3/27/2025, Corporate Clinical Specialist in-serviced ADON and MDS nurse regarding Abuse and Neglect policies and procedures, to include ensuring implementation. Competency was verified by quiz. Completed on 3/27/2025. On 3/27/2025, ADON and MDS nurse in-serviced all staff regarding Abuse and Neglect policies and procedures, to include ensuring implementation. Competency was verified by quiz. Started on 3/27/2025 and ongoing until all staff are in-serviced. Staff will not be able to work until completed. The above training will continue to be implemented in new hire orientation. On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect. Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed 3/27/2025 To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee. Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025 On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information. During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months. During an interview on 03/28/2025 at 1:45 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures. During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the interim abuse coordinator along with her contact information. During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator. Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025. Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker. Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures. Record review completed of all the staffs' posttests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025. The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to investigate/protect/correct when an allegation of abuse allegedly occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025 and prevent potential abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. The facility failed to prevent potential abuse when RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. The Abuse Coordinator failed to protect Resident #45 from potential abuse when he took her to MA C and asked Resident #45 if she had laughed at her. The Abuse Coordinator failed to protect Resident #45 from potential abuse when he took her to MA B and asked Resident #45 if she was mean. The Abuse Coordinator failed to protect Resident #45 from further potential abuse when he did not suspend RN A, RN D, the DON, MA C, and MA B after an allegation of abuse was made on 03/20/2025. The Abuse Coordinator failed to recognize the allegation of abuse and acknowledge and act upon it to prevent alleged perpetrators to have continued access to Resident #45 and others. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and further injuries of unknown source. Findings included: 1. Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged the left side of the brain). Record review of Resident #45's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated: Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes. Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] witnessed nurses [RN A], nurse [RN D], the D.O.N. making fun of a resident [Resident #45] on hall #1. Banging their heads on the wall in the same like manner as the resident because [Resident #45] was angry about something. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. I did not know who I could trust to talk to. But I knew that I had to do something. These residents deserve to be treated with the utmost respect. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper). During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E became teary-eyed and started crying. Housekeeper E said the DON, RN D and RN A were at the nurses' station, and Resident #45 was upset and had wheeled up and was banging her head on the wall. Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head on the wall. RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator. During an interview on 03/27/2025 at 9:17 AM, the Housekeeping/Laundry Manager said Housekeeper E had come to her the day after she witnessed an incident maybe a couple days ago or last week. The Housekeeping/Laundry Manager said Housekeeper E told her the staff was laughing and making fun of Resident #45. She said Housekeeper E said they were gathered around Resident #45 and were telling her just hit your head on the corner if you really want to hit your head and hurt yourself hit your head on the corner. The Housekeeping/Laundry Manager said she reported it to the Admissions Coordinator because she was the department head available. The Housekeeping/Laundry Manager said she did not think she could write a grievance because she was contracted. The Housekeeping/Laundry Manager said she could not remember the staff members names, but she knew it was a nurse, the DON, and some CNAs. The Housekeeping/Laundry Manager said the incident reported to her by Housekeeper E could be considered abuse. During an interview on 03/27/2025 at 9:33 AM, the Admissions Coordinator said last week some day she did not remember the day, the Housekeeping/Laundry Manager told her that Housekeeper E had a concern about what happened the day before. Then, Housekeeper E went to her office and told her there were a couple of the nurses that were laughing at Resident #45 because she was hitting her head on the wall and said something to her. The Admissions Coordinator said Housekeeper E told her the nurses were gathered around Resident #45 laughing at her while she was hitting her head. The Admissions Coordinator said she told Housekeeper E, I have to report that, and she went and reported it to the Administrator. The Admissions Coordinator said the Administrator took over. During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell Resident #45 where to hit her head on the wall or to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. RN A said she did not laugh or make fun of Resident #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said the Administrator told her maybe it was the tone she had used, and Housekeeper E perceived it as she was telling Resident #45 to kill herself. RN A said when the incident occurred, she was giving report to RN D and the DON was also there and a CNA and they were laughing about something different they were not laughing at Resident #45. During an interview on 03/27/2025 at 9:54 AM, the DON said last week RN D, RN A, and herself were at the nurses' station. She said maybe it was the Friday before last, but she did not remember the day. The DON said she remembered it was during shift change and they were at the nurses' station. The DON said RN A did not tell Resident #45 to hit her head on the wall. The DON said they were not laughing at Resident #45. The DON said she was at the nurses' station, and they were talking and laughing, and then Resident #45 pulled over and started banging her head. The DON said she told her to stop banging her head, if she kept banging her head, she was going to hurt herself. The DON said she did not witness RN A frustrated at Resident #45. The DON said the Administrator told her the Admissions Coordinator had taken Housekeeper E to him, and Housekeeper E said the DON was present and laughing at Resident #45. The DON said she told the Administrator to let Housekeeper E write the witness statement and send it to corporate. The DON said she told the Administrator whatever corrective actions needed to be taken to take them. The DON said she did not laugh at Resident #45. The DON said the Administrator told her he had sent the witness statement to corporate, and they said it was not abuse because they did not laugh. The DON said she did not get suspended. During an interview in 03/27/2025 at 10:04 AM, MA B stated RN A put her hand on the same spot Resident #45 was hitting her head to prevent injury. MA B stated she was not laughing at Resident #45. MA B stated the Administrator spoke to her about the incident and brought Resident #45 to her. The Administrator asked Resident #45 if MA B had ever been mean to her. Resident #45 stated no. MA B stated she was in-serviced, but not suspended. During an attempted interview on 03/27/2025 at 10:05 AM, RN D did not answer the phone. During an interview on 03/27/2025 at 10:09 AM, the Administrator said he was the abuse coordinator. The Administrator said Housekeeper E had gone to him and reported some of the staff were laughing at Resident #45 at the nurses' station. The Administrator said he thought it was on March 21st, Thursday (3/20/2025) or Friday (03/21/2025). The Administrator said the Admissions Coordinator had taken him to Housekeeper E for her to tell him what happened. The Administrator said he told her to write and statement and he talked to Resident #45, and Resident #45 told him they were not laughing at her. The Administrator said he did a customer service in-service with the staff. The Administrator said the nurses told him they were sitting at the nurses' station having a conversation. The Administrator said he had taken a staff member to Resident #45 and asked her if the staff member was mean to her. The Administrator said Resident #45 had identified the staff member and said she was not mean to her. The Administrator said he did an in-service on customer service with all of them (the DON, RN D, RN A, MA B, and MA C). The Administrator said what Housekeeper E told him was not an allegation of abuse. The Administrator said Housekeeper E said Resident #45 was hitting her head on the wall and the nurses were laughing at the nurses' station. The Administrator said he had spoken to all the staff, and they told him they were having a conversation before Resident #45 pulled up to them. The Administrator said when Housekeeper E reported the incident to him it was more of a grievance. The Administrator said before he suspended any staff, he notified his team and talked to all the staff. The Administrator said he talked to all the staff involved and they gave him the same story, therefore, it was a grievance. The Administrator said abuse was willful infliction of pain that it could be emotional, psychological, sexual, or financial. The Administrator said staff laughing at a resident could cause psychological issues and it was emotional abuse. The Administrator said the allegation should have been reported to the state immediately. The Administrator said he asked the staff if they were banging their heads on the wall, and they said they were doing it to demonstrate to the resident she could hurt herself. The Administrator said he talked to the resident immediately and to the staff involved and the resident said it did not happen and the said it did not happen. The Administrator said when he received an allegation of abuse he should report it to the state first, and then investigate it. The State Surveyor asked the Administrator if Resident #45 with a BIMS of 4 was a reliable interviewee. The Administrator was silent and did not answer the question. During an interview on 03/27/2025 at 10:30 AM, MA C stated she was not laughing at Resident #45. MA C stated the Administrator called her to his office to discuss the incident. MA C stated the Administrator brought Resident #45 to her. The Administrator asked Resident #45 if she knew MA C and Resident #45 stated, yes. The Administrator asked Resident #45 if MA C had ever laughed at her and Resident #45 stated no. During an interview on 03/27/2025 at 10:34 AM, the Regional Nurse stated she learned of the incident today (03/27/2025), and she considered the incident to be abuse. The Regional Nurse stated the incident should have been reported within 2 hours to the state, and the staff involved should have been suspended pending investigation and all statements necessary should have been gathered. The Regional Nurse said the incident not being reported placed the residents at risk for abuse. During an interview on 03/27/2025 at 10:44 AM, the Regional Director of Operations stated she was not aware of the incident until today (03/27/2025). The Regional Director of Operations stated the Administrator should have made her aware of the incident. After reading the statement that was provided by the Administrator, she stated Housekeeper E's statement was an allegation of abuse. The Regional Director of Operations said the allegation of abuse should have been reported within 2 hours and staff suspended pending investigation. The Regional Director of Operations stated the victim of an abuse allegation should never be taken to the perpetrator. The Regional Director of Operations said these failures placed the residents at risk for abuse. During an interview on 03/27/2025 at 12:13 PM, Housekeeper E confirmed the incident occurred on 03/19/2025 around 2-2:30 PM. Housekeeper E said she did not see if Resident #45 did what the nurses demonstrated to her to do, but Resident #45 continued banging her head against the wall throughout the day. During an interview on 03/27/2025 at 12:16 PM, the Executive Director stated the Administrator contacted him and told him about the incident with staff laughing at a resident. The Executive Director stated the Administrator told him he spoke with the staff, and they told him they were not laughing at the resident. The Administrator told the Executive Director he spoke with the resident, and she did not have any complaints. The Executive Director stated he redirected the Administrator to contact corporate. The Executive Director stated the incident was an allegation of abuse, and it should have been reported within 2 hours to the state. The Executive Director said the staff involved should have been suspended pending investigation. The Executive Director stated taking the resident to the perpetrator exposed her to harm, and stated you never take the victim to the alleged perpetrator. During an interview on 03/27/2025 at 12:30 PM, Resident #45 said staff had laughed at her. Resident #45 was unable to provide details. When questioned further she said she did not know. During an attempted phone interview on 03/29/2025 at 8:43 AM, RN D did not answer the phone. Record review of an in-service record with topic, Professionalism/Customer Service, conducted by the Administrator, dated 03/21/2025, indicated it was signed by MA C, the DON, MA B, RN A, and RN D. Record review of the facility's Abuse Prohibition Policy, reviewed 05/17/2024 indicated, . Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to (abuse/neglect and intervene appropriately. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring . Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately . The facility will thoroughly investigate all alleged violations and take appropriate actions. The Abuse Coordinator will report such allegations to the state agency in' accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation .Identification and suspension from employment of the person or persons accused of the abuse allegation(s) is mandatory .1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension, without pay, pending investigation .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation . This was determined to be an Immediate Jeopardy (IJ) on 03/27/2025 at 12:30 PM. The Regional Director of Operations was notified. The Regional Director of Operations was provided with the IJ template on 03/27/2025 at 2:06 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 03/28/2025 at 10:17 AM and included the following: March 27,2025 POR F610 On 3/24/2025, ADON referred resident #45 for psychological evaluation and was seen on 3/25/2025. On 3/27/2025, RN A, RN D, DON, MA C, MA B, and Administrator were suspended pending investigation. On 3/27/2025, The Corporate Clinical Specialist in serviced ADON and MDS nurse regarding Abuse and Neglect, highlighting Investigating/Protecting/Correcting the alleged violations. These elements include timely reporting, immediately initiate investigation, suspending alleged perpetrators, ensuring resident safety immediately, and appropriate notifications. Competency verified by quiz. Completed 3/27/2025. On 3/26/2025, the ADON and MDS in serviced all staff regarding Abuse and Neglect, emphasis on Investigating/Protecting/Correcting the alleged violations. These elements include timely reporting, immediately initiate investigation, suspending alleged perpetrators, ensuring resident safety immediately, and appropriate notifications. Staff will not be allowed to work until completion. Started on 3/27/2025 and ongoing until all staff are in-serviced. The above training will continue to be implemented in new hire orientation. On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect and any allegation of abuse is investigated, residents protected and corrected . Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed 3/27/2025. Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025 If the outcome of the investigation, and personnel review, allows for return to work, those suspended will receive all education noted above with competency quiz to validate along with disciplinary action prior to returning. To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee. On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information. During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2024 at 11:43 AM, Housekeeper E said she was in-serviced on abuse and neglect, to report immediately, and she was provided a number to report to if she was fearful of retaliation or had concerns of allegations not being deemed serious. During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months. During an interview on 03/28/2025 at 1:43 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures. During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the interim abuse coordinator along with her contact information. During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator. Record review completed of Resident #45's psych evaluation dated 03/25/2025. Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025. Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker. Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures. Record review completed of all the staffs' posttests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025. The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #45) reviewed for behavioral services. The facility failed to provide Resident #45 with additional psychiatric services until 3/24/25 when the surveyor Intervened. The facility failed to document Resident #45's behaviors on the EMAR accurately reflecting her behavioral status. The facility failed to review and revise Resident #45's care plan to implement interventions to prevent self-harm when Resident #45's behavior of hitting her head increased on 03/24/25. The facility failed to prevent on 3/24/25 Resident #45's three episodes of self-harm when she hit her head on the wall. The facility failed to prevent on 3/25/25 Resident #45's 4 episodes of self-harm when she hit her head on the wall twice and hit her head on the glass facility entrance door twice. The facility failed to notify Resident #45's physician or the NP about increased behaviors including self-harm. The facility failed to notify the psych doctor in a timely manner on 03/24/25. An IJ was identified on 03/26/2025 at 09:40 AM. The IJ template was provided to the facility on [DATE] at 10:17 AM. While the IJ was removed on 03/27/2025 at 5:00 PM, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for the lack of behavioral health services with the potential for diminished quality of life, accidents and injury, mental distress, and adjustment issues. Findings include: Record review of Resident #45's face sheet dated 03/27/25 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses schizoaffective disorder, ( a mental health condition characterized by psychotic symptoms such as hallucinations and delusions), bi-polar disorder(a mental disorder characterized by episodes of mood swings that range from depressive lows to manic highs), hemiplegia (paralysis of one side of the body) affecting left side and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic(dead) tissue in the brain) affecting left non-dominant side, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #45's admission MDS dated [DATE] indicated that she had a BIMS score of 4 which meant she had severe cognitive impairment. The MDS also indicated Resident #45 had verbal behaviors, behavioral symptoms directed toward others and other behavioral symptoms not directed toward others (for example- physical symptoms such as hitting or scratching self) that occurred 1 to 3 days in a week's time that were not directed at others that put the resident at significant risk for physical illness or injury and interfered with resident's care and participation in activities that occurred 1 to 3 days in a week's time that were not directed at others that put the resident at significant risk for physical illness or injury and interfered with resident's care and participation in activities. Record review of Resident #45's care plan dated 01/15/25 indicated she had a behavior problem that included her banging her head against the wall when she became frustrated. The care plan interventions in place were to monitor behavior episodes, attempt to determine underlying causes, document behavior and potential causes. The care plan also indicated Resident #45 threatened self-harming behaviors to get 911 called and frequently demanded to go to the hospital. Record review of Resident #45's care plan dated 1/15/25 and revised after surveyor intervention on 03/26/25 indicated Resident #45 was on 1:1 observation (when a staff member will be with resident at all times monitoring her behavior) due to her behaviors. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated she had orders for: 1)Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. 2)Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. 3)Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. 4)Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. 5)Psych consult with a date of 03/24/25. Record review of Resident #45's medication administration record dated March 2025 and printed on 03/25/25 indicated she received Seroquel tablet 200mg by mouth three times a day every day from 03/01/25-03/25/25. The administration record also indicated Resident #45 had 0 documented three times a day from 03/01/25-03/25/25 which meant she did not have any behaviors. Record review of Resident #45's progress note dated 03/24/25 at 06:42 PM completed by RN D indicated Resident noted hitting her head on the wall. no physical injuries noted at this time. Record review of the psych note dated 03/25/25 indicated resident was being seen for anxiety and management of her psychotropic medications and side effects. The psych note also indicated Resident #45 reported she was not getting things including medication when she asked for it and she would bang her head when the requests were denied. During an observation on 03/24/25 at 05:20 PM Resident #45 was in her wheelchair sitting by the dining room and began to hit her head on the wall. She was re-directed by the administrator. Resident #45 started hitting her head again after the Administrator walked off. During an observation on 03/25/25 at 08:45 AM Resident #45 was hitting her head on the wall in the hallway and several staff intervened and re-directed her. During an observation on 03/25/25 at 11:21 AM Resident #45 was hitting her head on the wall next to the dining room. Several staff intervened and re-directed resident. During an observation on 03/25/25 at 02:30 PM Resident #45 was getting agitated and pulled herself up out of her wheelchair at the front entrance glass doors and began hitting her head against the glass. The Dietary supervisor attempted to re-direct and then she returned to the kitchen. During an observation on 03/25/25 at 02:32 PM Resident #45 rolled herself away from the dining room and went to the front glass door and began hitting her head on the glass again. During an interview on 03/24/25 at 11:31 AM Resident #45 said she had a question about her Seroquel medication, and she did not know if she was taking it. She repeated medicine mad loudly and she wanted medicine. During an interview on 03/25/25 at 11:38 AM the DON said when Resident #45 would hit her head the staff would re-direct, perform neuro checks(evaluation of a resident's nervous system), and at times she was sent to the emergency room . She said they had tried to get a helmet but Resident #45 refused to wear a helmet. When asked the DON said she was unable to provide the helmet for the survey team. During an interview on 03/25/25 at 02:41 PM the Administrator said the facility was trying to help Resident #45. The Administrator said Resident #45 was referred to a behavior facility. The Administrator said Resident #45 was taken to the behavioral facility but Resident #45 wanted to return because she could not smoke at the behavior facility. The Administrator said they attempted to have Resident #45 use a helmet, but he was unable to provide the helmet. He said he expected the staff to re-direct Resident #45 and prevent her form harming herself. During an interview on 03/25/25 at 02:43 PM the DON said Resident #45 would be placed 1 on 1 observation after surveyor intervention. She said the failures placed Resident #45 at risk of hurting herself. The DON said Resident #45's injuries could have included a concussion, seizures, and other injuries. The DON said she was not aware of any injuries to Resident #45 because of hitting her head on walls and doors. She said she expected the staff to document behaviors but could not answer why they had not always documented the behaviors. During an interview on 03/25/2025 at 3:43 PM, the Administrator said Resident #45 told another resident she wanted to harm herself, so the other resident called 911. During an interview on 03/25/2025 at 5:10 PM, the Medical Director said he was not notified Resident #45 having increased behaviors, but the facility normally would call the Psychiatric Doctor for behavior issues. During an interview on 03/25/2025 at 7:17 PM, RN D said she notified the psychiatric doctor via text message on 03/05/2025 and 03/06/2025 of Resident #45 having behaviors, but she did not document it. She said usually when a resident was having behaviors they called the psychiatric physician, and the psychiatric physician usually gave instructions to monitor the resident every 15 minutes until they arrived for a visit. During an interview on 03/26/25 at 7:53 AM the Psychiatric physician for the facility said he had seen Resident #45 in February 2025, but he was unsure of the date and on 03/05/25 but he was unaware of any increased or worsened behaviors that Resident #45 was having until he spoke with the facility staff on 03/25/25 and he had a Telemed visit(a virtual doctor visit on an electronic device) with Resident #45 on 03/26/25 and spoke with her and discussed the dangers associated with her hitting her head. The Psychiatric Doctor said he expected the facility to contact him if Resident #45 had worsened or increased behaviors in order for him to make changes to prevent dangers that could occur with Resident #45 hitting her head. The dangers included fractures, concussions, or brain bleeds. Attempted interview on 3/26/25 at 1:17 PM with Resident #45's POA, but there was no answer. Record review of the facility policy Behavioral Health Services reviewed 05/17/24 indicated: Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental, trauma, post-traumatic stress disorder and substance use disorders (SUD). Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff who demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities. The facility will provide necessary behavioral health care and services which include: 1. Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care . 2. Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. 3. Providing meaningful activities which promote engagement and positive meaningful relationships between residents and staff, families, other residents, and the community . 4. Rule out underlying causes for the resident's behavioral health care needs through assessment, diagnosis, and treatment by qualified professionals, such as physicians, including psychiatrists or neurologists . 5. Demonstrate reasonable attempts to secure professional behavioral health services, when needed. 6. Utilize and implement non-pharmacological approaches to care, based upon the comprehensive assessment and plan of care, and in accordance with the resident's abilities, customary daily routine, life-long patterns, interests, preferences, and choices. 7. Ensuring that pharmacological interventions are only used when non-pharmacological. interventions are ineffective or when clinically indicated. As well as Implementing non pharmacological interventions implement in a person-centered care approach designed to meet the individual goals and needs of each resident. 8. Monitor and provide ongoing assessment of the resident's behavioral health needs, as to whether the interventions are improving or stabilizing the resident's status or causing adverse consequences; or attempt alternate approaches to care for the resident's assessed behavioral health needs, if necessary . Individualized Assessment and Person-Centered Planning In addition to the facility-wide approaches that address resident's emotional and psychosocial well being, the facility will ensure that resident's individualized behavioral health needs are met through the Resident Assessment Instrument (RAI) Process . This was determined to be an Immediate Jeopardy (IJ) situation on 03/26/25 at 09:40 AM. The Administrator was notified on 03/26/25 at 10:15 AM. The Administrator was provided with the IJ template on 03/26/25 at 10:17 AM and a Plan of Removal (POR) was requested. The Plan of Removal (POR) was accepted on 03/26/25 at 06:20 PM and indicated the following: Immediate action: Immediately on 3/26/2025, resident was placed on 1:1 to ensure safety. Immediately notified physician regarding resident increased behaviors. On 3/26/2025, Corporate Clinical Specialist serviced Administrator and DON regarding behavior health. This includes monitoring resident behavior and EMAR for change of condition. Intervening early by implementing plan ensuring resident safety. Accurate and thorough documentation of the type of behaviors, notifications to physician, DON, Admin, and psych services as needed. Competency verified by quiz. On 3/26/2025, DON/designee in serviced licensed nurses regarding behavior health. This includes monitoring resident behavior and EMAR for change of condition. Intervening early by implementing plan ensuring resident safety. Accurate and thorough documentation of the type of behaviors, notifications to physician, DON, Admin, and psych services as needed. Competency verified by quiz. Staff will not be allowed to work until in-services complete. Completed on 3/26/2025. The above content was incorporated into new hire orientation by Administrator effective 3/26/2025. On 3/26/2025, the DON and ADON completed audit reviewing all psych diagnosis and/or behaviors to ensure intervention is in place for resident safety. Medical Director was notified on 3/26/2025. To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff. The facility QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA Committee. Monitoring included: During an observation on 03/27/25 at 08:05 AM CNA V was on 1 on 1 observation duty for Resident #45 and CNA V said they began the shift at 6:00 AM to ensure resident did not have any self-harming behaviors. During an interview on 03/27/25 at 11:44 AM the Medical Director said the facility called him on 03/26/25 and made him aware of the deficient findings related to accidents and behaviors. During interviews on 03/27/25 from 11:44AM until 05:00 PM, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with the Administrator, DON, ADON, Maintenance Director, Social Worker, Admission's Coordinator, Human Resources Director, Director of Rehabilitation, MDS Coordinator, Laundry Supervisor, CNA O, LVN S, Housekeeper AA, CNA GG, Housekeeper E, Certified Occupational Therapy Assistant HH, CNA KK, RN R, MA P, CNA M, CNA LL, Dietary Aide MM, CNA Y, LVN EE, LVN F, and CNA NN. The in-service consisted of behavioral health services, encompassing resident's whole emotional and mental well-being, types of behaviors, monitoring, and early interventions. Record review of the In-service and quiz dated 3/26/2025 that included the Corporate Clinical Specialist in-serviced the facility Administrator and DON regarding behavior health. Record review of the In-service and quiz dated 3/26/2025 that included the ADON in-serviced the facility staff regarding behavior health. Record review of the New Hire packet on 03/27/25 for the facility indicated the Quiz over Behavior health and interventions was included. Record review of the DON/ADON psych diagnosis and behavior audit completed on 03/26/25 indicated interventions were included in residents care plans for behaviors. Record review of the signature sheet for the QA committee meeting held on 03/26/25 that included the Medical Director, DON, ADON, and Administrator. On 03/27/25 at 05:00 PM, the Regional Director of Operations was informed the IJ was removed; however, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 23 residents (Resident #45) reviewed for abuse and neglect reporting. The facility failed to ensure Housekeeper E reported an allegation of abuse immediately to the Abuse Coordinator on 03/19/2025 due to fear of retaliation. The Abuse Coordinator failed to identify and report an allegation of abuse to HHSC within 2 hours when Housekeeper E reported to him on 03/20/2025 that RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself, RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself, and RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged the left side of the brain). Record review of Resident #45's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated: Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes. Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] witnessed nurses [RN A], nurse [RN D], the D.O.N. making fun of a resident [Resident #45] on hall #1. Banging their heads on the wall in the same like manner as the resident because [Resident #45] was angry about something. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. I did not know who I could trust to talk to. But I knew that I had to do something. These residents deserve to be treated with the utmost respect. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper). During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E became teary-eyed and started crying. Housekeeper E said the DON, RN D and RN A were at the nurses' station, and Resident #45 was upset and had wheeled up and was banging her head on the wall. Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head on the wall. RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator. During an interview on 03/27/2025 at 9:17 AM, the Housekeeping/Laundry Manager said Housekeeper E had come to her the day after she witnessed an incident maybe a couple days ago or last week. The Housekeeping/Laundry Manager said Housekeeper E told her the staff was laughing and making fun of Resident #45. She said Housekeeper E said they were gathered around Resident #45 and were telling her just hit your head on the corner if you really want to hit your head and hurt yourself hit your head on the corner. The Housekeeping/Laundry Manager said she reported it to the Admissions Coordinator because she was the department head available. The Housekeeping/Laundry Manager said she did not think she could write a grievance because she was contracted. The Housekeeping/Laundry Manager said she could not remember the staff members names, but she knew it was a nurse, the DON, and some CNAs. The Housekeeping/Laundry Manager said the incident reported to her by Housekeeper E could be considered abuse. During an interview on 03/27/2025 at 9:33 AM, the Admissions Coordinator said last week some day she did not remember the day, the Housekeeping/Laundry Manager told her that Housekeeper E had a concern about what happened the day before. Then, Housekeeper E went to her office and told her there were a couple of the nurses that were laughing at Resident #45 because she was hitting her head on the wall and said something to her. The Admissions Coordinator said Housekeeper E told her the nurses were gathered around Resident #45 laughing at her while she was hitting her head. The Admissions Coordinator said she told Housekeeper E, I have to report that, and she went and reported it to the Administrator. The Admissions Coordinator said the Administrator took over. During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell Resident #45 where to hit her head on the wall or to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself. RN A said she did not laugh or make fun of Resident #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said the Administrator told her maybe it was the tone she had used, and Housekeeper E perceived it as she was telling Resident #45 to kill herself. RN A said when the incident occurred, she was giving report to RN D and the DON was also there and a CNA and they were laughing about something different they were not laughing at Resident #45. During an interview on 03/27/2025 at 9:54 AM, the DON said last week RN D, RN A, and herself were at the nurses' station. She said maybe it was the Friday before last, but she did not remember the day. The DON said she remembered it was during shift change and they were at the nurses' station. The DON said RN A did not tell Resident #45 to hit her head on the wall. The DON said they were not laughing at Resident #45. The DON said she was at the nurses' station, and they were talking and laughing, and then Resident #45 pulled over and started banging her head. The DON said she told her to stop banging her head, if she kept banging her head, she was going to hurt herself. The DON said she did not witness RN A frustrated at Resident #45. The DON said the Administrator told her the Admissions Coordinator had taken Housekeeper E to him, and Housekeeper E said the DON was present and laughing at Resident #45. The DON said she told the Administrator to let Housekeeper E write the witness statement and send it to corporate. The DON said she told the Administrator whatever corrective actions needed to be taken to take them. The DON said she did not laugh at Resident #45. The DON said the Administrator told her he had sent the witness statement to corporate, and they said it was not abuse because they did not laugh. The DON said she did not get suspended. During an interview in 03/27/2025 at 10:04 AM, MA B stated RN A put her hand on the same spot Resident #45 was hitting her head to prevent injury. MA B stated she was not laughing at Resident #45. MA B stated the Administrator spoke to her about the incident and brought Resident #45 to her. The Administrator asked Resident #45 if MA B had ever been mean to her. Resident #45 stated no. MA B stated she was in-serviced, but not suspended. During an attempted interview on 03/27/2025 at 10:05 AM, RN D did not answer the phone. During an interview on 03/27/2025 at 10:09 AM, the Administrator said he was the abuse coordinator. The Administrator said depending on the severity of the abuse some are reported within 2 hours and others within 24 hours. The Administrator said all allegations of abuse should be reported to HHSC. The Administrator said Housekeeper E had gone to him and reported some of the staff were laughing at Resident #45 at the nurses' station. The Administrator said he thought it was on March 21st, Thursday (3/20/2025) or Friday (03/21/2025). The Administrator said the Admissions Coordinator had taken him to Housekeeper E for her to tell him what happened. The Administrator said he told her to write and statement and he talked to Resident #45, and Resident #45 told him they were not laughing at her. The Administrator said he did a customer service in-service with the staff. The Administrator said the nurses told him they were sitting at the nurses' station having a conversation. The Administrator said he had taken a staff member to Resident #45 and asked her if the staff member was mean to her. The Administrator said Resident #45 had identified the staff member and said she was not mean to her. The Administrator said he did an in-service on customer service with all of them (the DON, RN D, RN A, MA B, and MA C). The Administrator said what Housekeeper E told him was not an allegation of abuse. The Administrator said Housekeeper E said Resident #45 was hitting her head on the wall and the nurses were laughing at the nurses' station. The Administrator said he had spoken to all the staff, and they told him they were having a conversation before Resident #45 pulled up to them. The Administrator said when Housekeeper E reported the incident to him it was more of a grievance. The Administrator said before he suspended any staff, he notified his team and talked to all the staff. The Administrator said he talked to all the staff involved and they gave him the same story, therefore, it was a grievance. The Administrator said abuse was willful infliction of pain that it could be emotional, psychological, sexual, or financial. The Administrator said staff laughing at a resident could cause psychological issues and it was emotional abuse. The Administrator said the allegation should have been reported to the state immediately. The Administrator said he asked the staff if they were banging their heads on the wall, and they said they were doing it to demonstrate to the resident she could hurt herself. The Administrator said he talked to the resident immediately and to the staff involved and the resident said it did not happen and the said it did not happen. The Administrator said when he received an allegation of abuse he should report it to the state first, and then investigate it. The State Surveyor asked the Administrator if Resident #45 with a BIMS of 4 was a reliable interviewee. The Administrator was silent and did not answer the question. During an interview on 03/27/2025 at 10:30 AM, MA C stated she was not laughing at Resident #45. MA C stated the Administrator called her to his office to discuss the incident. MA C stated the Administrator brought Resident #45 to her. The Administrator asked Resident #45 if she knew MA C and Resident #45 stated, yes. The Administrator asked Resident #45 if MA C had ever laughed at her and Resident #45 stated no. During an interview on 03/27/2025 at 10:34 AM, the Regional Nurse stated she learned of the incident today (03/27/2025), and she considered the incident to be abuse. The Regional Nurse stated the incident should have been reported within 2 hours to the state, and the staff involved should have been suspended pending investigation and all statements necessary should have been gathered. The Regional Nurse said the incident not being reported placed the residents at risk for abuse. During an interview on 03/27/2025 at 10:44 AM, the Regional Director of Operations stated she was not aware of the incident until today (03/27/2025). The Regional Director of Operations stated the Administrator should have made her aware of the incident. After reading the statement that was provided by the Administrator, she stated Housekeeper E's statement was an allegation of abuse. The Regional Director of Operations said the allegation of abuse should have been reported within 2 hours and staff suspended pending investigation. The Regional Director of Operations stated the victim of an abuse allegation should never be taken to the perpetrator. The Regional Director of Operations said these failures placed the residents at risk for abuse. During an interview on 03/27/2025 at 12:13 PM, Housekeeper E confirmed the incident occurred on 03/19/2025 around 2-2:30 PM. Housekeeper E said she did not see if Resident #45 did what the nurses demonstrated to her to do, but Resident #45 continued banging her head against the wall throughout the day. During an interview on 03/27/2025 at 12:16 PM, the Executive Director stated the Administrator contacted him and told him about the incident with staff laughing at a resident. The Executive Director stated the Administrator told him he spoke with the staff, and they told him they were not laughing at the resident. The Administrator told the Executive Director he spoke with the resident, and she did not have any complaints. The Executive Director stated he redirected the Administrator to contact corporate. The Executive Director stated the incident was an allegation of abuse, and it should have been reported within 2 hours to the state. The Executive Director said the staff involved should have been suspended pending investigation. The Executive Director stated taking the resident to the perpetrator exposed her to harm, and stated you never take the victim to the alleged perpetrator. During an interview on 03/27/2025 at 12:30 PM, Resident #45 said staff had laughed at her. Resident #45 was unable to provide details. When questioned further she said she did not know. During an attempted phone interview on 03/29/2025 at 8:43 AM, RN D did not answer the phone. Record review of an in-service record with topic, Professionalism/Customer Service, conducted by the Administrator, dated 03/21/2025, indicated it was signed by MA C, the DON, MA B, RN A, and RN D. Record review of the facility's Abuse Prohibition Policy, reviewed 05/17/2024 indicated, . Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to (abuse/neglect and intervene appropriately. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring . Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately . The facility will thoroughly investigate all alleged violations and take appropriate actions. The Abuse Coordinator will report such allegations to the state agency in' accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation .Identification and suspension from employment of the person or persons accused of the abuse allegation(s) is mandatory .1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension, without pay, pending investigation .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation . This was determined to be an Immediate Jeopardy (IJ) on 03/27/2025 at 12:30 PM. The Regional Director of Operations was notified. The Regional Director of Operations was provided with the IJ template on 03/27/2025 at 2:06 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 03/28/2025 at 10:17 AM and included the following: March 27,2025 POR F609 On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety. On 3/27/2025, RN A, RN D, DON, MA C, MA B and Administrator were suspended pending the outcome of the investigation. On 3/24/2025 ADON referred resident #45 for a psychological evaluation and was seen on 3/25/2025. On 3/27/2025, Corporate Clinical Specialist in-serviced ADON and MDS nurse regarding Abuse and Neglect policies and procedures, with emphasis on reporting guidelines, to include how to report if fearful of retaliation or concerns of allegations not being deemed serious. Competency was verified by quiz. Completed on 3/27/2025. The Corporate Clinical Specialist educated the housekeeper on reporting and how to report if fearful of retaliation or concerns of allegations not being deemed serious. This was completed on 3/27/2025. On 3/27/2025, ADON and MDS nurse in-serviced all staff regarding Abuse and Neglect policies and procedures, with emphasis on reporting guidelines, to include how to report if fearful of retaliation or concerns of allegations not being deemed serious. Competency was verified by quiz. Started on 3/27/2025 and ongoing until all staff are in-serviced. Staff will not be able to work until completed. The above training will continue to be implemented in new hire orientation. On 3/27/2025 the MDS/designee will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect. Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed on 3/27/2025. Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025 If the outcome of the investigation, and personnel review, allows for return to work, those suspended will receive all education noted above with competency quiz to validate along with disciplinary action prior to returning. To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee. On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information. During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz. During an interview on 03/28/2024 at 11:43 AM, Housekeeper E said she was in-serviced on abuse and neglect, to report immediately, and she was provided a number to report to if she was fearful of retaliation or had concerns of allegations not being deemed serious. During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months. During an interview on 03/28/2025 at 1:43 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures. During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the interim abuse coordinator along with her contact information. During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator. Record review completed of Resident #45's psych evaluation dated 03/25/2025. Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025. Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker. Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures. Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures. Record review completed of all the staffs' post tests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025. The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 8 residents (Resident #45) reviewed for accidents and hazards. The facility failed to ensure Resident #45 did not smoke a cigarette in the facility on 03/25/25 at 8:38 AM and did not implement measures to prevent another occurrence. The facility failed to ensure Resident #45 did not smoke a cigarette in the facility on 03/25/25 at 12:57 PM The facility failed to ensure Resident #45 was reassessed for smoking safety after she lit a cigarette inside the facility on 3/25/25 until after the second time she was found smoking inside the facility. The facility failed to notify the NP or the physician of Resident #45 smoking in the facility. The facility failed to in-service on prevention of unsafe smoking until after surveyor intervention on 03/25/25. The facility failed to prevent Resident #45 from eloping on 02/25/25. Resident #45 left the facility, and she was last seen around the end of supper at 6:00 PM. Resident #45 was found 0.2 miles from the facility beside the bank and a main highway at approximately 6:30 PM. The facility failed to prevent Resident #45 from leaving the facility to an unsafe place on 02/27/25. Resident #45 left the facility, and she was last seen around 15 minutes before Resident #45 was found on the left side of the building by the busy road while Resident #45 was supposed to be on Q 15-minute monitoring. The facility failed to develop/implement a patient centered care plan with interventions to ensure Resident #45's safety. The facility failed to In-service staff on monitoring residents for risk of elopements and/or leaving an unsupervised area until 03/25/25 after surveyor intervention. An IJ was identified on 03/26/25 at 09:40 AM. The IJ template was provided to the facility on [DATE] at 10:17 AM. While the IJ was removed on 03/27/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings included: Record review of Resident #45's face sheet dated 03/27/25 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses schizoaffective disorder( a mental health condition characterized by psychotic symptoms such as hallucinations and delusions), bi-polar disorder(a mental disorder characterized by episodes of mood swings that range from depressive lows to manic highs), hemiplegia (paralysis of one side of the body) affecting left side and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic(dead) tissue in the brain) affecting left non-dominant side, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #45's admission MDS dated [DATE] indicated that she had a BIMS score of 4 which meant she had severe cognitive impairment. The MDS also indicated Resident #45 had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others (for example- physical symptoms such as hitting or scratching self) that occurred 1 to 3 days in a week's time that were not directed at others that put the resident at significant risk for physical illness or injury and interfered with resident's care and participation in activities. The MDS also indicated Resident #45 had no wandering behaviors. Record review of Resident #45's care plan dated 01/15/25 indicated she was at risk for injury due to her smoking preference with interventions in place to educate resident on smoking and hazards and safety. The care plan did not indicate any elopement or wandering issues. The care plan did not indicate Resident #45 required any supervision while smoking. Record review of Resident #45's care plan dated 1/15/25 and revised after surveyor intervention on 03/25/25 indicated Resident #45 was at risk for injury due to her smoking preference and she required supervision with smoking with interventions in place to educate resident on smoking and hazards and safety. Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated she had orders for : 1)Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025. 2)Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025. 3)Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. 4)Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025. Record review of Resident #45's smoking/vaping safety evaluation dated 01/07/25 indicated Resident #45 was not able to use full functioning of both hands at maximum capabilities because Resident #45 had a stroke that affects left side. The evaluation also indicated Resident #45 was a safe smoker. Record review of Resident #45's smoking/vaping safety evaluation dated 03/25/25 at 1:28 PM indicated Resident #45 was not able to use full functioning of both hands at maximum capabilities because Resident #45 had a stroke that affects left side. The evaluation also indicated it was completed because fire safety was compromised and that she was confirmed to not be a safe smoker related to being caught smoking in the facility. Record review of Resident #45's care plan revised on 03/26/25 also indicated Resident #45 was a wandering risk related to cognitive impairment and wandering and Resident #45 was currently on 1 on 1 monitoring by a staff member - no with no device (wander guard used for residents at risk for elopement) in place at this time. Record review of Resident #45's Nex wander data collection (the facility wandering/elopement assessment) dated 03/26/25 after surveyor intervention indicated she had a high risk for wandering and elopement. Record review of Resident #45's electronic medical record on 03/26/25 indicated she did not have any other wandering/elopement assessments prior to surveyor intervention on 03/25/25 to determine if she was at risk for wandering or elopement. Record review of Resident #45's progress noted dated 02/25/25 at 08:06 PM completed by RN D indicated Resident found outside and redirected to the facility. Admin/DON/ADON notified and an order to place resident on Q 15 minute monitoring was received. Unable to reach her POA (family member) at this time. Record review of Resident #45's progress noted dated 02/27/25 at 08:21 PM completed by RN D indicated Resident found outside and redirected to the facility. Admin/DON/ADON notified and an order to place resident on Q 15 minute monitoring was received. Unable to reach her POA (family member) at this time. Record review of Resident #45's order summary report dated 03/25/25 indicated she had an order for wander guard bracelet related to wandering/exit seeking behaviors Nurse to check placement Q shift including skin check under bracelet with a start date of 03/01/2025 that was discontinued but with no end dated noted. Record review of Resident #45's progress noted dated 03/25/2025 at 08:38 AM completed by RN A indicated Resident found smoking inside the facility. Assessment done and per facility smoking protocol resident made supervised smoker. Her cigarette and vape were taken from her. This made resident angry and she started banging her head on the wall, cursing staff members using the f-word and yelling at everyone. Record review of the one on one monitoring forms dated 03/25/25 indicated she was observed 1 on 1 by staff from the time she returned from the hospital and documented. During an interview on 03/25/2025 at 5:07 PM, the Medical Director said he was not notified Resident #45 was smoking in the facility. The Medical Director said he was not notified of Resident #45 ever being found outside of the facility, but the NP took most of the calls. He said he did not agree with resident's being able to sign out and go anywhere they wanted because he believed if they were in the facility, it was because they needed care and should not be allowed to sign themselves out. During an interview on 03/25/2025 at 5:15 PM, the NP said she was not notified of any of the incidents where Resident #45 was found outside of the facility or resident smoking in the facility. During an observation on 03/25/25 at 12:57 PM Resident #45 had a lit cigarette in hand smoking it in the hallway coming from the back hall to the smoking area. During an observation made on 03/25/2025 at 5:21 PM of where Resident #45 was found on 02/25/25, it was approximately 0.2 miles (1056 feet) from the facility and located beside a bank and a main highway. During an interview on 03/25/2025 at 5:50 PM, the Administrator said on 02/25/2025 saw Resident #45. The Administrator said Resident #45 had a high BIMS score, so she was able to make her own decisions. He said Resident #45 was very alert and oriented. The Administrator said the day they saw her at the bank he talked to the nurses, and they started every 15-minute checks and put a wander guard (a device used on residents who are at risk for elopement ) on her. After that, the psychiatric doctor came to the facility, evaluated her, and removed the wander guard. The Administrator said he was under the assumption Resident #45's BIMS was higher than a 4. He said an elopement was a resident getting out of the facility without the staffs' knowledge. The Administrator said if a resident was missing, all the staff were supposed to start looking for the resident, checking all the rooms, checking inside the facility, and call the sheriff and the police. The Administrator said if the resident was found on the facility premises, she was safe. The Administrator said someone with a BIMS of 4, found where Resident #45 was found, was not safe. He said they could get in harm's way or get harmed or injured. During an interview on 03/25/25 at 6:00 PM RN D said on 2/25/25 after dinner, about 6:00 PM, RN QQ was going to get her lunch and saw Resident #45 and called RN D on her cell phone to see if she had signed out or if she was supposed to be outside. RN D said she told RN QQ no, and that's when RN D and other staff went to go look for Resident #45. RN D said RN QQ had attempted to turn around to get Resident #45 but she couldn't find Resident #45. RN D said while the staff were outside searching for Resident #45, a couple said they had seen her right there by the local bank. RN D said she was the charge nurse responsible for Resident #45 RN D said Resident #45 was found in front of the bank and when asked Resident #45 said she was headed to another city to find her POA. RN D said she notified Administrator, the DON, and the POA. RN D said the Administrator told her to place Resident #45 on Q15 minute checks. During an interview on 03/25/25 at 6:20 PM RN D said on 2/27/25 during the Q15 minute checks Resident #45 could not be found. RN D said it had only been 15 minutes since she last saw Resident #45 and while searching for Resident #45 she was found by the sidewalk closer to the highway in the back of the facility. RN D said she notified the Administrator, the DON, and POA. RN D said a wander guard was placed on Resident #45 but she threw a tantrum to have it removed. She said the failure placed the resident at risk for being run over or injured outside the facility. RN D said she was the charge nurse responsible for Resident #45 During an interview on 03/25/25 at 06:40 PM the DON said for the 02/25/25 elopement, RN D texted her that Resident #45 was outside. The DON said she told RN D that Resident #45 was not supposed to go outside. The DON said RN D told her that Resident #45 followed a family member out of the facility. RN D told the DON that the Administrator instructed her to start Resident #45 on Q 15-minute checks. The DON said Resident #45 was placed on a wander guard and corporate was called as well. The DON said she called the Psychiatric Doctor and he saw her on 02/26/25. The DON said the wander guard was also put in place. When asked why the start date on the wander guard was dated 3/1/25 (5 days after incident) she said if it happened the night or weekend, the staff would have placed the order and the wander guard on the next weekday. The DON said she realized the wander guard was placed the second time she left the facility, since Resident #45 was found outside of the facility twice. The DON said an elopement assessment should be completed for Resident #45 on admission and quarterly. She said when Resident #45 was noted at risk she should have been re-assessed. The DON said elopement was when a resident was found outside of the property without supervision. The process when a resident was missing was all staff should have searched and alerted the entire team of the missing resident. The DON said the failure of the elopement not being care planned placed Resident #45 at risk for further elopement and could have caused the charge nurse to not be able to provide proper care. The DON said when Resident #45 was found outside she should have questioned more or asked to be shown where she was found. During an interview on 03/26/25 at 10:51 AM RN A said LVN EE found Resident #45 smoking in the lobby around lunch time on 03/25/25. RN A said she accidentally input the time incorrect in the charting. She said Resident #45 had never smoked in the facility before but had always kept her cigarettes on her. RN A said when they complete the smoking assessments, they check the ability to light the cigarette and to place the ashes in the tray and the cognitive abilities. She said with Resident #45's cognitive abilities she felt Resident #45 was a safe smoker. She said Resident #45 had only one side paralysis. She said she wheels herself and she removes her linens and was able to use her right hand very well. RN A said Resident #45 knew the codes to get out of the facility doors. RN A said she does recall the time Resident #45 went off the premises and they brought her back into the facility and she was placed on Q 15 minute monitoring for a while. RN A said she was only aware of one time Resident #45 left and vaguely remembered a wander guard being put in place. RN A said Resident #45 knew the codes to the door so a wander guard would not benefit. RN A said the failures placed Resident #45 at risk for further elopement incidents in the neighborhood with dangerous roads and getting hit by a vehicle or other injuries. Attempted interview on 3/26/25 at 1:17 PM with Resident #45's POA, but there was no answer. Attempted interview on 3/26/25 at 2:00 PM with RN QQ, but there was no answer. Record review of the facility policy Facility Smoking Policy-Supervised and Unsupervised revised 11/2024 indicated: Safe Smoking Environment It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: 1. Residents who smoke. including possible ad verse effects on treatment 2. Passive smoke to others 3. Fire Smoking Accommodation This policy does not include chewing tobacco. Residents may maintain their own tobacco supplies in their room and do not have to be supervised .The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, or area within facility. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with non-smoking area signs. Record review of the facility policy Wanderer Management, Monitoring System & Resident Elopement Protocol reviewed 01/2023 indicated: Purpose 4. To monitor safety of residents at risk for elopement. 5. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy o It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. o All residents will be assessed for behaviors or conditions that may place them at risk for elopement. o All residents, so identified, will have these issues addressed in their individual care plans. This was determined to be an Immediate Jeopardy (IJ) situation on 03/26/25 at 09:40 AM. The Administrator was notified on 03/26/25 at 10:15 AM. The Administrator was provided with the IJ template on 03/26/25 at 10:17 AM and a Plan of Removal (POR) was requested. The Plan of Removal (POR) was accepted on 03/26/25 at 06:20 PM and indicated the following: Immediate action: On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety and no recurrence of smoking in the facility or leaving safe supervised area. Smoking items were placed under staff supervision. Smoking assessment completed and now requires supervision when smoking. The physician was notified of both the smoking in the facility and resident leaving safe supervised area. On 3/25/2025 DON referred resident #45 for psychological evaluation. All smoking assessments and elopement risk assessments were reviewed for accuracy. Care plans updated as indicated. All smoking items of residents requiring supervision was placed under staff supervision. On 3/26/2025, The Corporate Clinical Specialist in serviced Administrator and DON regarding Accident/Hazard Supervision, with focus on smoking safety and residents remaining in safe supervised area, elopements, increased supervision after elopement and unapproved/unsupervised departure from building/property. Competency verified by quiz. Completed 3/26/2025. On 3/26/2025, facility Administrator and DON in-serviced all staff regarding Accident/Hazard Supervision, with focus on smoking safety and residents remaining in safe supervised area, elopements, increased supervision after elopement and unapproved/unsupervised departure from building/property . Competency verified by quiz. Staff will not be allowed to work until completion. Completed on 3/26/2025. The above training will be implemented into new hire orientation effective 3/26/2025. To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff completed 3/26/2025 The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee. Monitoring included: During an observation on 03/27/25 at 8:00 AM Resident #45's cigarettes were in a container at the nurse station kept by the nursing staff. During an observation on 03/27/25 at 08:05 AM CNA V was on 1 on 1 observation duty for Resident #45 and CNA V said they began the shift at 6:00 AM to ensure resident did not have any self-harming behaviors. During an interview on 03/27/25 at 11:44 AM the Medical Director said the facility called him on 03/26/25 and made him aware of the deficient findings related to accidents and behaviors. During interviews on 03/27/25 from 11:44AM until 05:00 PM, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with the Administrator, DON, ADON, Maintenance Director, Social Worker, Admission's Coordinator, Human Resources Director, Director of Rehab, MDS Coordinator, Laundry Supervisor, CNA O, LVN S, Housekeeper AA, CNA GG, Housekeeper E, Certified Occupational Therapy Assistant HH, CNA KK, RN R, MA P, CNA M, CNA LL, Dietary Aide MM, CNA Y, LVN EE, LVN F, and CNA NN. The in-service consisted of accident/hazard supervision, with focus on smoking safety and residents remaining in safe supervised area, elopements, increased supervision after elopement and unapproved/unsupervised departure from building/property. Record review of Record review of the in-services dated 03/25/25 indicated the staff were in-serviced over smoking safety, and where residents were safe to smoke, and the smoking policy. The in-services also indicated the staff were in-serviced elopement/missing residents, and the elopement policy, and quizzed over the elopement policy information. Record review of the list all residents who required supervision with smoking and did not require supervision with smoking indicated the assessments were reviewed for residents with dates of assessments, accuracy of assessments, and if their care plans were updated. Record review of all resident's elopement assessments and updated care plans indicated they were completed, and care planned on 03/27/25. Record review of the New Hire packet on 03/27/25 for the facility indicated the learning information and Quiz over smoking, elopement, and elopement policy were included. Record review of the form to be used by the DON for residents to be monitored through observations and communication with staff. Record review of the signature sheet for the QA committee meeting held on 03/26/25 that included the Medical Director, DON, ADON, and Administrator. On 03/27/25 at 05:00 PM, the Regional Director of Operations was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 23 residents (Resident #72) reviewed for pain management. 1. The facility did not ensure that effective pain management was provided to the resident. 2. The facility did not ensure RN S acknowledged Resident #72's pain when she was yelling, prior to, during and after wound care. 3. The facility did not ensure RN S evaluated Resident #72's pain during wound care. 4. The facility did not ensure RN S effectively managed Resident #72's pain prior to her receiving wound care. 5. The facility did not ensure RN S provided Resident #72 with any pain relief or pain interventions when the resident was yelling during wound care. These failures could place residents who received wound care, who had chronic pain conditions, who received as needed pain medication, or who received routine pain medications at risk for not having their pain addressed causing undue suffering. Findings included: Record review of Resident #72's face sheet, dated 03/28/25, reflected Resident #72 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly). Record review of Resident #72's physician order summary report, dated 03/24/25, indicated an active physician's order to cleanse RLE with wound cleaner, apply medical grade honey (honey-based formula) and cover with bordered gauze (wound dressing) daily with a start date 03/01/25. Record review of Resident #72's admission MDS, dated [DATE], reflected Resident #72 usually made herself understood, and usually understood others. Resident #72's BIMS score was 4, which indicated her cognition was severely impaired. Resident #72 had 1 venous and arterial ulcers (skin wounds caused by poor circulation) present. Record review of the comprehensive care plan, revised on 03/24/25, reflected Resident #72 had a venous/stasis ulcer of the RLE related venous insufficiency (a condition where the veins in the legs fail to return blood effectively back to the heart). The care plan interventions included encourage good nutrition/hydration to promote healthier skin and wound healing, evaluate wound for size, depth, and weekly treatment documentation to include measurement of each area of skin breakdown. Record review of the MAR dated 03/01/25-03/31/25 reflected Resident #72 had an order for Tylenol 325 mg: 2 tablets by every 6 hours PRN for pain. The MAR reflected Resident #72 received only 2 administrations on 03/02/25 and 03/24/25 in the month of March. Record review of the MAR dated 03/01/25-03/31/25 reflected Resident #72 had an order for Tramadol 50 every 6 hours for pain. The MAR reflected Resident #72 did not receive any administration for March. During an interview and observation on 03/24/25 beginning at 10:47 a.m. Resident #72 was lying in bed yelling my leg hurt. RN S did not acknowledge Resident #72 stating her leg hurt until after she administered her nasal spray around 10:50 am. RN S asked which leg hurt and she stated, my right leg. RN S stated to Resident #72 that she was about to perform wound care to her RLE. RN S removed the blanket, and the state surveyor noticed a wound dressing dated 3/22/25. RN S grabbed her wound supplies from the treatment cart all while Resident #72 was yelling my leg hurts. RN S walked over and placed the supplies on Resident #72's bedside table and removed the dressing from Resident #72's right shin. Resident #72 yelled it hurts and RN S continued to perform wound care without ever acknowledging Resident #72's verbalization of pain. RN S completed the wound care, discarded the soiled wound dressings, gathered her supplies, and exited the room without ever acknowledging Resident #72's verbalization of pain. RN S stated Resident #72 yelling out was a demonstration of pain. RN S stated she should have obtained pain medication when Resident #72 first started complaining of pain. RN S stated she should have paid more attention to her when she was yelling out that she was in pain prior to, during and after wound care and administered the PRN Tylenol. RN S stated she was nervous with the state surveyor been present. RN S stated she did not stop and assess Resident #72 because she thought when she released the bandage the pain would have subsided. Resident #72 was subjected to unnecessary pain prior to, during and after the 1 hour and 7 min of wound care and repositioning. During an interview on 03/24/25 at 11:49 a.m., the DON stated RN S should have medicated Resident #72 30 minutes prior to performing wound care. The DON stated RN S should have followed up to ensure Resident #72 was comfortable prior to performing wound care. The DON stated when Resident #72 continued to yell out while she was performing wound care, she should have stopped the procedure and obtained pain medication. The DON stated she has watched RN S perform wound care and has not noticed any of these issues. The DON stated RN S had been in-serviced and performed a visual check off, but the information was not documented on paper. The DON stated if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an interview on 03/24/25 at 12:15 p.m., the Administrator stated he expected RN S to administer pain medication prior to providing wound care. The Administrator stated RN S should ensure the resident was comfortable first before wound care was done. The Administrator stated the DON was responsible for monitoring and overseeing for compliance. The Administrator stated if a resident's pain was not managed properly, it could affect their day-to-day activity. Record review of the facility policy titled, Pain Management Program Policy reviewed 01/25 . reflected The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choice, related to pain management . 5. Pain should be assessed before potentially painful procedures, such as wound care, and medication should be administered in advance to reduce discomfort .

Based on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 3 residents reviewed for discharges. The facility failed to ensure Resident #1 had a safe discharge leading to his hospitalization and threats of suicide on 03/08/24. An IJ was identified on 03/19/24. The IJ template was provided to the facility on [DATE] at 4:40 p.m. While the Immediate Jeopardy was removed on 03/20/24 at 5:39 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy with potential for more than minimal harm because all staff had not been trained on proper discharge planning with the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure placed residents at risk of unsafe discharges, worsened health conditions, and hospitalization s. The findings included: Record review of Resident #1's face sheet, dated 03/20/24, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), stroke, and high blood pressure. Record review of Resident #1's quarterly MDS assessment, dated 02/05/24, indicated Resident #1 understood and understood others. Resident #1's BIMS score was 15, which indicated he was cognitively intact. Resident #1 required assistance with bed mobility, transfer, and toileting and was independent with eating. The MDS did not indicate any mood or behavior concerns. Record review of Resident # 1's MAR dated 03/01/24 through 03/31/24 indicated: Haloperidol Oral Tablet 20 MG (Haloperidol) Give 1 tablet by mouth at bedtime related to Psychotic Disorder with Delusions. Record review of Resident # 1's MAR dated 03/01/24 through 03/31/24 indicated: Cymbalta Oral Capsule Delayed-Release Particles 60 MG (Duloxetine HCI) Give 1 capsule by mouth in the morning for mood. Record review of Resident # 1's comprehensive care plan, dated 4/4/22, indicated Resident #1 had an ADL self-care deficit related to activity intolerance, hemiplegia, and impaired balance. Record review of Resident # 1's comprehensive care plan, dated 11/21/22, indicated he anticipated he would be a long-term care resident. Resident #1 was dependent on staff to meet his emotional, intellectual, physical, and social needs related to his immobility and physical limitations. Resident #1 required the use of Haldol (an antipsychotic medication) related to his diagnosis of schizophrenia. Record review of Resident # 1's comprehensive care plan dated 1/23/24 indicated Resident #1 had depression. He took Cymbalta (a medication used to treat depression). Record review of Resident # 1's EMR reflected he was discharged on [DATE] at 4:45 am. Record review of Resident # 1's EMR did not reveal any behaviors from 02/18/24 through 03/07/24. Record review of Resident # 1's Hospital history and physical dated 03/08/24. Resident #1 said he would use a gun to kill other people and himself and that the gun was in his family member's apartment. He was discharged to a shelter form the nursing home but felt it was not feasible for him given that the shelter didn't have the support to assist him with his ADLs. Resident #1 reports that these events led to his current psychiatric symptoms and presented to the ER for further evaluation. During a phone interview on 03/18/24 at 10:18 a.m., the hospital social worker said Resident #1 presented to the local hospital with suicidal ideations after being discharged from the nursing home on 03/08/24. The hospital social worker said Resident #1 was left on the side of the road waiting to enter a shelter, but the shelter would not accept him because he required help with his ADLs. The hospital social worker said Resident #1 was not able to remember how or when to take his medications. He said the facility did not provide an adequate and safe discharge for Resident #1. During an interview on 03/18/24 at 4:24 p.m., the Ombudsman said she was not aware of Resident #1's 30-day discharge notice or that he was discharged from the facility. During a phone interview on 03/18/24 at 5:10 p.m., Resident #1 said he was aware of the 30-day letter the facility had given him because of some altercations he had with other residents in the facility. He said he was aware he was going to a shelter but he was under the impression that he was accepted to the shelter. He said the facility told him about standing in line for intake but he thought that was just a formality. He said he waited in line and when they talked with him at the shelter, they told him he would not be accepted because he required help with his care and wore briefs. He said he did not know what to do. It was cold and had started raining, so he wheeled himself to the train station that was nearby and then went to the local hospital. He said he told the admitting doctor that if he had to be homeless, he would shoot himself. He said he meant it. He said he would not have agreed to go to the homeless shelter if he had known he was not accepted. During a phone interview on 03/19/24 at 9:00 a.m., Social Worker D over the intake department at the shelter said she never talked to a facility about Resident #1. She said if she or any other staff member of the shelter talked with a nursing home staff member, their first question would have been, Could he/she do everything for themselves? She said the shelter was about 3 acres and they did not have the staff to ensure people who required help would be taken care of. She said they only accepted guests (what they call people who were accepted to the shelter) who were self-sufficient for themselves. She said if they accepted guests who required assistance with their ADLs, they would be liable for their care. She said most people have a misconception about a homeless shelter. She said the guests must be able to do for themselves which included getting down to a bed on the floor and getting up to go to the bathroom located outside of where they slept. She said they had to go to the dining area for a meal and to the shower room themselves. She said her intake staff were nurses and knew what questions to ask. She said the people who called them for intakes did not always give truthful answers and that was why they screened guests before they accepted them. She said if Resident #1 required help, he was denied admission to the shelter. She said she did not remember Resident #1 or what might have happened to him after he was denied admission. She said they had at least 600 intakes a day but could only accept 300 a day. She looked in her electronic system and email for a referral on Resident #1 and said she did not see any emails, or a chart made for Resident #1. She said their goal was to provide food and shelter. She said if they were full or a person was not accepted, they would offer other options with other shelters in the area. The social worker said the closest train station was about a half mile away from the shelter. During a phone interview on 03/19/24 at 10:40 a.m., Resident #1's RP said the facility had called her and told her about the 30-day discharge letter. She said they asked if he could live with her and she said he could not. They asked about other family members or friends and he did not have any that were able to meet his needs. She said they did tell her about the shelter but she thought he would be admitted . She said she did not have much knowledge about the shelter but thought it was okay since the social worker at the facility made the recommendations. She said she was not aware the facility would just drop him off and leave him there. During a phone interview on 3/19/24 at 11:06 a.m., the SW of the facility said Resident #1 had been given a 30-day notice. She said they had been looking for another facility to accept him for an unknown amount of time before they issued the 30-day notice. She said she had called several facilities but they had all denied him. She said she called 3 shelters and one of the shelters seemed to fit his needs. She said he told her he would like to get help with independent living. She said she called the shelter, gave the information they asked for, and told her he needed to be at the shelter by 6:00 am for intake. She said she asked the nursing staff to have him ready and at the shelter by 6:00 am. She said the intake person told her he needed to have some form of independence and he did. She said she read the website and felt he would be a suitable candidate for the shelter since they had counselors on staff and partnered with the local hospital, they could help him better transition into an independent life. She said she was not aware of how shelters worked. She said she thought Resident #1 needed staff assistance x1 with grooming and wore briefs. She said the facility made sure he had some briefs available when he left the facility. During an interview on 3/19/24 at 11:30 a.m., the ADON said she was not directly involved in Resident #1's discharge. She said the SW was over the discharge process. She said she had asked the social worker about Resident #1's discharge and asked her if she thought she had done a safe discharge and the SW indicated she did. She said at the time she asked the SW she was not aware Resident #1 was not accepted to the shelter but did not know much about the shelter and its guidelines. During an interview on 3/19/24 at 12:45 p.m., the AIT Administrator said they had given Resident #1 a 30-day discharge notice because of his behaviors and failure to comply with facility policies. She said she had given the letter to Resident #1 and he was able to read and ask questions. She said afterwards she signed the 30-day letter. She said they had placed him on 1 on 1 monitoring as they searched for other facilities. She said she was told by the SW that the other facilities had denied him. She said the SW was making all the discharge plans for Resident #1. She said she was aware of the discharge to the shelter but was unaware of their guidelines. During an interview on 3/19/24 at 12:52 p.m., the RDO said the facility does not have a policy on 30-day notices. He said they issued the letter, and if the family and the resident agreed then they discharged before the 30-day. He said he was not personally involved with the discharge process with the shelter for Resident #1, but he believed the SW was managing the process. During a phone interview on 3/19/24 at 1:38 p.m., the Medical Director said he was not notified of Resident #1's discharge until the surveyor questioned him about his discharge. He also said he was unfamiliar with the rules of a homeless shelter. He said if the shelter said he needed to be independent then a shelter would not be a safe discharge. He said the facility might have reached out to his NP. He said to call the NP. During a phone interview on 3/19/24 at 1:55 p.m., the NP said she could not remember if the facility notified her of Resident #1's discharge. She looked through her phone and said she did not have a text from the facility about Resident #1's discharge. The NP said she was unaware of Resident #1 being discharged to a homeless shelter. She said she was not sure if Resident #1 would know how to take his medications properly but knew he could not live independently in a shelter. She said he required the assistance of 1 staff member for his ADL care. During a phone interview on 3/19/24 at 4:45 p.m., LVN A said she was the nurse who released Resident #1. She said she did not call a report to the homeless shelter, do medication teaching, have a doctor's order to discharge, or do a discharge summary for Resident #1. She said she was under the impression the shelter was aware he was coming. She said she did not think about teaching him about his medications or doing a discharge summary. She said she was unsure if she had notified the doctor related to Resident #1's discharge. LVN A said she knew she was supposed to educate the resident about his medication and notify the doctor of his discharge. LVN A said she was able to see how all these things needed to be done for the continuation of his care. During a phone interview on 3/19/24 at 4:53 p.m., Van Driver B said he took Resident #1 along with CNA C to the shelter on the morning of 03/08/24. He said he was told to have him at the shelter for intake at about 6:00 am. He said CNA C went inside to let the shelter know Resident#1 was outside, and they left. He said it was cold that morning but Resident #1 had on a jacket. Van Driver B said he was not aware Resident #1 was not accepted into the shelter. He said he would have never left him if he knew he was not accepted. Record review of the 30-day discharge letter dated 03/06/24 signed by AIT Administrator. The letter was addressed to Resident #1 RP and stated, This is to inform you that Resident #1 is being discharged from this facility. The reason for discharge, in accordance with federal regulations, is as follows: [X] the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; Resident has had infarctions regarding destruction of property, unsafe use of his motorized wheelchair, theft and smoking in the facility.[ X] the safety of individuals in the facility is endangered; Resident has had multiple infarctions regarding physical and verbal aggression towards other residents, theft and smoking inside the facility. The effective date of discharge is April 6, 2024. Record review of the facility's policy titled, Transfer or Discharge Notice, reviewed January 2023, indicated, Policy statement Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge . 2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility3. Expect as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. the safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered, c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/or e. The resident has not resided in the facility for thirty (30) days. 5. The resident and representative are notified in writing of the following information: a. the specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. an explanation of the resident's rights to appeal the transfer or discharge to the state; f. The name, address, and telephone number of the Office of the State Long-term care ombudsman .; 6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 7. Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals . 8. The reasons for transfer or discharge are documented in the resident's medical record Record review of the facility's policy titled, Transfer or Discharge Documentation and Notice, reviewed January 2023, indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provide. 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless- a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; 4. When a resident is transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met; (b)this facility's attempt to meet those needs; and (c) the receiving facility's service(s) that are available to meet those needs. b. That an appropriate notice was provided to the resident and/or legal representative, c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition; g. Disposition of personal effects; a. disposition of medications; i-others as appropriate or as necessary; and j. The signature of the person recording the data in the medical record. 5. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's attending physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility or b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. 6. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by a physician: a. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, or b. The health of individuals in the facility would otherwise be endangered. 7. Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: a. The basis for the transfer or discharge . b. Contact information of the practitioner responsible for the care of the resident; c. Resident representative information including contact information; d. Advance directive information; e. All special instructions or precautions for ongoing care, as appropriate; f. Comprehensive care plan goals; and g. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The AIT Administrator was notified on 03/19/24 at 4:39 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 03/19/24 at 4:40 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 03/20/24 at 12:21 p.m. and included the following: Resident #1 was no longer a resident at the facility as of March 8, 2024. Administrator notified Medical Director of IJ on 03-19-2024. Ad hoc QAPI (off cycle meeting) completed with the Medical Director on 03-19-2024. The regional SW/LNFA conducted in-service with facility IDT team that included the SW regarding ensuring safe discharges on 03-19-2024. This training included transfer and discharge requirements (being aware of residents' needs when discharging and validating the accepting provider is appropriate), documentation and appropriate notifications. Facility administration/SW are responsible for discharge planning/notices. Ombudsman notified of IJ on 03-19-2024. Administrator/designee to in-service all staff (including C.N.A.'s, housekeeping and dietary) on safe discharging, including accepting facility, medications. The staff may be approached by a resident at a given time regarding a desire to discharge and they will have an understanding of what that may entail. This training began on 03-19-2024. This will be completed on 03-20-2024. Staff that may be out on leave will be in-serviced remotely. ADON to complete audit on 03-19-2024 of residents that have been discharged since March 8, 2024, to ensure they were discharged safely. This audit will include an audit of any residents expected to discharge in the near future. There are no other residents with a 30-day discharge notice currently. Nursing staff will be retrained by ADON on 03-19-2024 regarding medical director notification on discharges. The administrator/ADON have been re-trained by RDO on ombudsman notification on 03-19-2024. Monitoring: In interviews on 03/20/24 from 1:00 p.m. until 5:29 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 6 am-2 pm shift 1 LVN (LVN P), 2 RNs (RN L, RN M), 1 MA (MA T), and 2 CNAs (CNA Y, CNA ZZ, and CNA EE), 2 pm-10 pm 1 LVN (LVN O), 2 RNs (RN K and RN N),1 MA (MA V), and 3 CNAs (CNA BB, CNA CC and CNA DD), 10 pm-6 am 1 LVN (LVN FF), and 2 CNAS (CNA X and CNA C). Dietary staff 2 Cooks (Cook KK and Cook MM), 3 kitchen aides (Kitchen Aide LL, Kitchen Aide MM, and Kitchen Aide OO), housekeeping department 4 housekeepers (Housekeeper E, Housekeeper M, Housekeeper F, and Housekeeper G), Therapy Department 5 therapist (DOR GG,PT HH, PT PP, PT, and OT II) and the ADON, MDS, SW, HR, Dietary Manager, and the Activity Director all who indicated they had received a written in-service regarding the process of safe discharges (such as what to do: who to notify, when to do it and how to complete the process for a resident who was planning on discharging from the facility). They verbalized they understood the discharge process. During an interview on 03/20/24 at 2:27 p.m., the Ombudsman said she was aware of the IJ received by the facility related to the unsafe discharge of Resident #1. During an interview on 03/20/24 at 2:34 p.m., the Medical Director said he was aware of the IJ received by the facility related to the unsafe discharge of Resident #1. During an observation and interview on 03/20/24 at 4:34 p.m., the ADON completed an audit of the discharges of residents since 03/08/24 which included 7 residents, and all the residents had a safe discharge. The ADON and the surveyor reviewed the audit sheet. She indicated no further discharges were planned and no 30-day discharge notices were pending. Record review of an in-service training report dated 03/19/24, Topic: Discharge Planning Process given by the AIT Administrator to all staff indicated, The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals effectively and transitional them to post-discharge care. Identify specific discharge needs, involve the IDT team, notify the resident's physician, notify the ombudsman, and ensure an acceptable provider is appropriate for the resident. The in-service was reviewed and revealed that 52 staff members had signed. Record review of an in-service training report dated 03/19/24, Topic: Safe Discharge Process given by the Regional Social Worker to the IDT indicated, F624 provide examples that serve as good reminders of things not to forget. This includes working with the resident representative slash family to ensure that all of the resident's possessions are not lost or left behind. Facilities also must explain to the residents why they are going to another location or leaving the facility and must ensure that staff handle these transfers or discharges in a way that minimizes the resident's anxiety or depression. The staff must be able to recognize a resident's reaction that has been identified by the resident's assessment and care plan. The in-service was reviewed and revealed that 7 management members had signed. F622-When the facility transfers or discharges a resident under any of the circumstances specific in paragraphs (C) (1) (i) (A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical records and appropriate information is communicated to the receiving healthcare institution or provider. i. Documentation in the resident's medical record must include. A. The basis for the transfer per paragraph C1I of this section. B. In the case of paragraph (C) (1) (i) (A) of this section, the specific resident's need that cannot be met, the facility attempts to meet the resident's need, and the service available at the facility to meet the need. ii. The documentation required by paragraph C2I of this section must be made by- A. The resident physician when transferred or discharged is necessary under paragraph (C) (1) (A) or (B) of this section; And B. A physician when transferred or discharged is necessary under paragraph (C) (1) (I) (C) or(D) of this section. iii. Information provided to the receiving provider must include a minimum of the following: B. Contact information of the practitioner responsible for the care of the resident C. Resident representative information including contact information. D. Advance Directive information E. All special instructions or precautions for ongoing care, as appropriate. F. Comprehensive care plan goals. G. All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21 (c) (2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. Record review of an in-service training report dated 03/19/24, Topic: Safe Discharge Notification was given by RDO to the AIT Administrator and the ADON. They discussed ensuring the whole discharge process was complete and accurate. They ensured the physician and the Ombudsman were notified of any discharges. Record review of an in-service training report dated 03/19/24, Topic: Discharge given by ADON to all nurses, indicated, When we discharge residents, only the physician nurse practitioner or physician assistant can give you orders. You are not to take orders from anyone else. When a discharge is being worked on the nurse should follow up with the physician and document, write discharge orders, and open the discharge summary. The in-service was reviewed and revealed that 11 nurses had signed. Record review of the QAPI meeting dated 03/19/24, signed by the MDS, DOR, ADON, AIT Administrator, SW, DM, and medical director on the phone. During an interview on 03/20/24 at 5:14 p.m., the ADON said all residents who would be discharged must be discharged to a safe place. She said the doctor should be notified so that the nurses could receive an order to discharge the resident. She said nurses must document all pertinent information about where the resident was going, and how he/she traveled (to other facility or home). She said they must call a report to the other entity to ensure they would be able to meet the resident's needs. She said all the above information must be documented in the resident's chart. She said that the nurses would start a discharge summary for each resident they discharged . She said she was part of the discharge process for the residents who had received a 30-day notice. The ADON said she and the Administrator were responsible for notifying the Ombudsman and the physicians of potential 30-day discharges. She said she was given an in-service by the Regional Social Worker and RDO administrator about the discharge process. During an interview on 03/20/24 at 5:24 p.m., the AIT Administrator said she was part of the discharge process. She said she was to ensure the transfer was documented in the nurses' notes and the receiving facility could meet the residents' needs. She said the nursing staff were to notify the physician and the family. She said the IDT should have a care plan structured with goals and ongoing care. She said she was responsible for notifying the Ombudsman and the Medical Director. On 03/20/24 at 5:29 p.m., the AIT Administrator was informed the IJ was removed: however, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems

47006 Based on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 6 residents (Resident's #23, #43, and #56) reviewed for abuse. 1. The facility failed to protect Resident #56 from physical abuse from Resident #25 on 01/27/2024. Resident #56 stated he did not feel safe in the facility. 2. The facility failed to protect Resident #23 from Resident #25 after the occurrence of physical abuse on 04/11/2023. Resident #23 stated she did not feel safe in the facility. 3. The facility failed to protect Resident #43 from misappropriation from Resident #25 on 01/27/2024. 3a. The facility failed to ensure Resident #43 did not stay in the room with Resident #25 after Resident #25 took his money, and Resident #43 expressed desire to relocate due to feeling fearful of Resident #25. An Immediate Jeopardy (IJ) was identified on 02/12/2024 at 1:53 PM. While the IJ was removed on 02/14/2024 at 12:23 PM, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The findings included: 1. Record review of a face sheet dated 02/15/2024 indicated Resident #25 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included psychotic disorder with delusions due to known physiological condition (mental disorder which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #25 was able to make himself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #25 did not have inattention, disorganized thinking, or altered level of consciousness. Resident #25's mood interview did not indicate he had little interest or pleasure in doing things or felt down, depressed, or hopeless. The MDS assessment did not indicate Resident #25 hallucinated or had delusions and did not indicate physical, verbal, or other behavioral symptoms or rejection of care. The MDS assessment did not indicated Resident #25 wandered. The MDS assessment indicated Resident #25 was independent with eating, required set-up or clean-up assistance with oral hygiene, resident refused toileting hygiene, dependent with shower/bathe self, lower body dressing, personal hygiene, and substantial/maximal assistance required for upper body dressing. The MDS assessment indicated Resident #25 was independent with sitting to lying and lying to sitting on the side of the bed and required supervision or touching assistance with sitting to standing. The MDS assessment indicated Resident #25 was able to wheel himself independently 150 feet. The MDS assessment indicated Resident #25 had active diagnoses of depression, psychotic disorder, and schizophrenia. Record review of Resident #25's care plan last revised 11/16/2023 indicated the following focuses: The resident has a behavior problem related to makes statements that are less than factual at times. 09/11/22 resident went into other residents' rooms and took their belongings without their permission, Staff was told resident exposed self to others. Resident slapped staff and a resident. 08/22/22 Resident was seen by staff taking other residents' cigarettes from the nursing station and retaliated against staff for stating factual information and stated staff would not give him medications/cigarettes. Resident is non-compliant with facility smoking policy. 10/10/22 one on one implemented daily every 15-minute checks at bedtime. 05/13/23 resident was seen taking another resident's soda drinks at the nurse's station. 05/30/23 resident was seen with a stack of money that did not belong to him and spent some of it. 06/02/23 Resident initiated physical aggression by grabbing another resident's arm. 01/12/24 Resident was smoking in the building. The resident has potential to be physically aggressive, resident slapped another resident and staff member with date initiated 09/13/2022. Resident #25's care plan included the following interventions: 08/22/22 If reasonable, discuss the resident's behavior. explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 09/11/22 Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. resident on 1 on 1 monitoring for behaviors (1:1 was an intervention initiated after an incident it is unknown for how long he remained on 1:1) 04/11/23 resident was told to move out of the way by another resident on the smoking patio, resident told the other resident Fuck you bitch and the other resident slapped him, so this resident slapped her back. this resident referred to psych services (mental health services), in-serviced and educated on appropriate behavior ongoing. 05/15/23 discussed the resident's behavior in a care plan meeting. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. 05/30/23 explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 05/30/23 every 30-minute monitoring in place. 06/02/23 consult psychology services 06/02/23 educate resident on how to handle confrontations from other residents. 06/02/23 law enforcement (police) notified. 06/02/23 every 15-minute assessments continued. Administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, praise any indication of the resident's progress/improvement in behavior, and provide a program of activities that is of interest and accommodates resident's status with date initiated 08/18/2022. Record review of Resident #25's Order Summary Report dated 02/14/2024 indicated: Cymbalta Oral Capsule Delayed Release Particles 30 MG (medication used to treat depression) Give 1 capsule by mouth one time a day with a start date of 01/04/2024. Cymbalta Oral Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth one time a day with a start date of 01/04/2024. Divalproex Sodium Oral Tablet Delayed Release 125 MG (medication used for mood disorders) Give 5 tablet by mouth two times a day with a start date of 02/04/2024. Haloperidol Oral Tablet 20 MG (medication used to treat mood disorders) Give 1 tablet by mouth at bedtime with a start date of 01/04/2024. Haloperidol Oral Tablet 5 MG Give 3 tablets by mouth in the morning with a start date of 01/04/2024. Trazodone Oral Tablet 50 MG (medication used to treat insomnia) Give 1 tablet by mouth at bedtime with a start date of 01/04/2024. Resident placed on 1 on 1 related to behaviors every shift with at start date of 02/12/2024. Record review of Resident #25's progress notes indicated: 01/27/2024 LVN P indicated it was reported to me that resident hit other resident on chest and right leg resident was separated and placed on 15-minute monitoring family notified. 02/08/2024 the Social Worker indicated Resident #25 had a BIMS of 15, resident was cognitively intact and denies presence of behaviors or symptoms of depression. The Social Worker indicated she would provide assistance with resources, referrals, and support as needed. Record review of Resident #25's electronic health record indicated his last visit from psychological services was on 01/23/2024. The psychological services progress note dated 01/23/2024 indicated Resident #25 did not have aggressive or sexual behaviors. The progress note indicated the plan for the next session was to continue to enhance healthy coping responses, improved self-care and increased psychosocial support by seeking friendships and participating in facility activities with sessions schedule one time a week. Record review of the incident report, dated 01/27/2024 at 1:50 PM, revealed staff reported to LVN P that Resident #25 was involved in a resident-to-resident altercation with Resident #56. Resident #25 stated Resident #56 ran into him with his wheelchair and he hit him. 2. Record review of the face sheet, dated 02/15/2024, revealed Resident #56 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis and an inability to move all four arms and legs) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the admission MDS assessment, dated 10/17/2023, revealed Resident #56 had clear speech and was understood by staff. The MDS revealed Resident #56 was able to understand others. The MDS revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #56 had no behaviors or refusal of care. The MDS revealed Resident #56 was dependent on staff for all ADLs, which included: eating, oral hygiene, toilet use, bathing, dressing, transferring, and bed mobility. Record review of the comprehensive care plan, initiated on 01/09/2024, revealed Resident #56 had an ADL self-care performance deficit related to quadriplegia. The interventions revealed Resident #56 was dependent on staff for all ADLs, which included: eating, oral hygiene, toilet use, bathing, dressing, transferring, and bed mobility. Record review of Resident #56's progress notes revealed: 01/27/2024 at 1:53 PM - LVN P wrote it was reported to her that Resident #56 ran his electric wheelchair into Resident #25 by accident. Resident #25 then started hitting Resident #56 in the chest and right leg. LVN P wrote she assessed Resident #56's chest with no redness or injuries were observed. 01/28/2024 at 1:09 AM - LVN Q wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN Q wrote no issues were noted but will continue to monitor. 01/28/2024 at 9:02 AM and 3:13 PM - LVN P wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN P wrote Resident #56 was assessed due to being hit on 01/27/2024. LVN P wrote no delayed injuries or complaints of pain or discomfort were noted. 01/29/2024 at 1:44 AM - The ADON wrote Resident #56 was on every 15-minute checks related to an altercation with another resident. The ADON wrote Resident #56 had remained in his bed since the start of her shift and had no complaints of pain or discomfort. The ADON wrote Resident #56 had no late emotional effects related to the incident. 01/31/2024 at 2:57 AM - LVN Q wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN Q wrote no issues were noted but will continue to monitor. Resident #56 had no progress notes from the Social Worker regarding a follow up after the resident-to-resident altercation. Record review of Resident #56's incident report, dated 01/27/2024 at 1:50 PM, revealed staff reported that Resident #56 was in a resident-to-resident altercation with Resident #25. Resident #56 stated I ran my wheelchair into Resident #25 by accident and he started hitting me in the chest. The report further revealed Resident #56 did not want to go to bed so LVN P assessed his chest area only with no redness or injuries noted. Record review of the Weekly Body Skin Check, dated 01/27/2024, revealed Resident #56 had no skin problems. Record review of Housekeeper TT's witness stated, dated 01/27/2024, revealed I saw Resident #56 bump into Resident #25's wheelchair, then I saw Resident #25 hit Resident #56 in the chest area. I called for help and the residents were immediately separated. Record review of the Administrator's statement, dated 01/29/2024, revealed I . spoke with both residents [Resident #25 and Resident #56] regarding the incident that occurred over the weekend. According to Resident #25, Resident #56 began calling him names and bumped him with his wheelchair. Resident #25 stated he responded by hitting him on the legs. When I spoke with Resident #56, he stated he accidently ran into Resident #25 with his wheelchair, Resident #25 then hit him three times in the chest. Then the nurse came to assess him and asked him questions about how he was feeling. Record review of CNA BB's statement, dated 01/30/2024, revealed Housekeeper TT came and told me that Resident #25 and Resident #56 were having an altercation. The DON and I immediately separated them. When I asked Resident #56 what happened, he said Resident #25 hit him 3 times in the chest . Record review of the provider investigation report, dated 02/02/2024, revealed Resident #56 and Resident #25 were seen having an altercation. The provider investigation report revealed Resident #25 stated that Resident #56 called him names and bumped into his wheelchair on purpose. The provider investigation report revealed Resident #56 stated he bumped into Resident #25 by accident and then Resident #25 hit him in the chest three times. 3. Record review of the face sheet, dated 02/15/2024, revealed Resident #23 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of hemiplegia affected right dominant side (paralysis of one side of the body) and cerebral infarction (stroke). Record review of the quarterly MDS assessment, dated 01/16/2024, revealed Resident #23 had clear speech and was understood by staff. The MDS revealed Resident #23 was able to understand others. The MDS revealed Resident #23 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #23 had no behaviors or refusal of care. The MDS revealed Resident #23 had an impairment on one-side of the upper extremity and lower extremity that interfered with daily functions or placed resident at risk of injury. The MDS revealed Resident #23 was dependent on staff for toileting hygiene, dressing, toilet transfer, and walking. Record review of the comprehensive care plan, revised on 08/01/2023, revealed Resident #23 was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan further revealed Resident #23 had an ADL self-care performance deficit related to hemiplegia. Record review of the incident report dated 04/11/2023 at 10:30 AM, Resident #23 stated she was going into building and Resident #25 was in the way. Resident #23 attempted to get by Resident #25 and her wheelchair bumped into him. Resident #23 asked him to move and then both residents started cursing at each other. Resident #23 then stated Resident #25 hit her and then she hit him back. 4. Record review of a face sheet dated 02/15/2024 indicated Resident #43 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), bipolar II disorder (mental health condition defined by periods or episodes of extreme mood disturbances that affect mood, thoughts, and behavior), and unspecified psychosis not due to a substance or known physiological condition (a mental state characterized by a loss of touch with reality this condition may involve hallucinations, delusions, disordered thinking, and behavioral changes). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #43 was able to make himself understood and understood others. The MDS assessment indicated Resident #43 had a BIMS score of 7, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #43 had physical, verbal, or other behavioral symptoms towards others. The MDS assessment indicated Resident #43 was independent for eating and dependent for all other ADLs. Record review of Resident #43's care plan with a target date of 04/28/2024 indicated he had impaired cognitive function and impaired thought processes related to dementia with interventions which included cue reorient and supervise as needed. Record review of the Provider Investigation Report dated 02/02/2024 indicated, Resident #43 reported that his money was taken from his room. While the CNA was making the beds in Resident #43's and Resident #25's room, she came across some money under Resident #43's room-mate's pillow. Investigation was initiated. The investigation revealed that the other CNA that was in the room saw some dollar bills in Resident #25's pocket. Resident #25 then revealed to the CNA that he had given another resident money to purchase him cigarettes. When the CNA approached the other resident, the other resident confirmed that he was given money by Resident #25. It was revealed that all of the bills had Resident #43's initials on them. The money was returned to Resident #43, but it was not the total amount he was missing. Resident #43 was educated on using the lock box that he was previously provided for the safe keeping of his items. During an interview on 02/11/2024 at 2:55 PM, Resident #25 was in his room, and he said, All I do is eat and sleep. Resident #25 said he had taken his roommates money because the voices in his head had told him to take the money. Resident #25 said he had taken the money from Resident #43's nightstand, and then gave it all back. Resident #25 said he was no longer hearing the voices he had only heard them when the incident with Resident #43 occurred. Resident #25 said he had taken some peanut butter jelly from another resident's room, but he denied taking anybody else's money or cigarettes. Resident #25 said he had hit a young boy in a motorized wheelchair (Resident #56) because he ran into his wheelchair when they were outside in the smoking area. Resident #25 said he hit him in the leg. Resident #25 said there were no staff supervising when the incident with Resident #56 occurred. Resident #25 said he slapped Resident #23 while they were smoking unsupervised because she stirred up everything, called him a mother fucking negro, and ran into his wheelchair. Resident #25 said he did not require supervision when smoking and he smoked unsupervised. During an interview on 02/11/2024 at 3:17 PM, Resident #56 stated he remembered the resident-to-resident altercation with Resident #25. Resident #56 stated Resident #25 stood up in front of him while in the smoking area and pulled his pants down. Resident #56 stated he asked Resident #25 to move, and he told him No. Resident #56 stated he attempted to get past Resident #25. Resident #25 then reared back and punched him the chest 3 times. Resident #56 stated he then rammed Resident #25 with the wheelchair. Resident #56 stated staff then intervened. Resident #56 stated the incident was completely unprovoked and unprompted. Resident #56 stated he told the facility staff he did not want Resident #25 in the facility. Resident #56 stated he agreed to not press charges under the assumption Resident #25 would have been leaving the facility. Resident #56 stated he did not feel safe in the facility and staff had allowed Resident #25 to be in the same vicinity as him, since the incident had occurred. During an interview on 02/11/2024 at 3:34 PM, LVN P said Resident #43 reported missing money, and the money was found in his roommates (Resident #25) bed and under the bed and some on Resident #25 and another resident had been given money by Resident #25. LVN P said they knew it was Resident #43's money because his family member placed Resident #43's initials on the bills. LVN P said now the nurses kept Resident #43's billfold on the medication care and when he needed money, he had to ask the nurses for it, and it was signed out to him. LVN P said Resident #25 had manipulative behaviors to get what he wanted. LVN P said in the past he had hit residents and staff and was sent out to a behavioral hospital. LVN P said prior to being sent out to the behavioral health hospital they had to call the police and when the police arrived Resident #25 told them he knew they would just send him to the behavioral health hospital to get his medications adjusted. LVN P said Resident #25 had not reported hearing voices to her. LVN P said Resident #25 was not supposed to be smoking unsupervised because he was caught smoking in the hallway a couple months ago. LVN P said they tried to watch Resident #25 more closely and after the incidents occurred, he was placed on 15-minute watch. LVN P was unable to specify for how many hours/days the 15-minute watches were maintained. During an interview on 02/11/2024 at 5:05 PM, CNA BB stated she did not witness the event between Resident #56 and Resident #25 on 01/27/2024, but she sat with Resident #56 after the incident. CNA BB stated Resident #56 told her that Resident #25 got up from his wheelchair and pulled his pants down. CNA BB stated Resident #56 stated Resident #25 told him to smell his bottom, so he rammed Resident #25 with his wheelchair. CNA BB stated Resident #56 told her that was when Resident #25 punched him. CNA BB stated Resident #25 and Resident #56 had previous issues, with words. CNA BB stated no interventions were put in place to keep Resident #56 and Resident #25 separated. CNA BB stated the cops were called to scare Resident #25 but Resident #25 did not care. During an interview on 02/12/2024 at 8:02 AM, Resident #23 stated Resident #25 was a loser, scum on the bottom of her shoe. Resident #23 stated Resident #25 only hit people who could not fight back or women. Resident #23 stated Resident #25 slapped the shit out of her for no reason. Resident #23 stated she was fearful of Resident #25 and no interventions had been put in place by the facility to try and keep them safe. Resident #23 stated she did not feel like the facility had taken steps to make her feel safe. Resident #23 stated Resident #25 had taken a lot of things. Resident #23 stated Resident #25 had ransacked her room twice at the facility. Resident #23 stated a nurse had waken her up with a basket full of her things that Resident #25 had taken. During an interview on 02/12/2024 9:10 AM, Resident #43 said his neighbor (roommate) Resident #25 got his money while he was sleeping. Resident #43 said he had $100 because his family member gives him that amount on the 31st of every month. Resident #43 said he did not feel safe in the same room with Resident #25 because Resident #25 still went through his personal items and moved them around. Resident #43 said he told the boss man he did not feel safe staying in the room with Resident #25. Resident #43 was unable to provide a name for the boss man. Resident #43 said he had also told the nurses Resident #25 was going through his personal items and taking them and the nurses told him not to bother Resident #25 and Resident #25 would not bother him. During an interview on 02/12/2024 at 10:05 AM, the ADON said Resident #25 had been at the facility for almost 2 years. The ADON said Resident #25 had a history of schizophrenia and major depressive disorders. The ADON said Resident #25 liked to go and bother other people, and then he would say he did not do it when the staff knew he had. The ADON said Resident #25 would take peoples things like clothes, snacks, and then he would deny it, but the staff would find it in his room. The ADON said she was aware that Resident #25 had stolen Resident #43's money, but she was not aware why they had remained in the same room because the Social Worker and Administrator had handled the situation. The ADON said interventions for Resident #25's resident to resident altercations and stealing money included separating the residents when the incident occurred and putting him on 15-minute checks for 72 hours or until psych services released them. The ADON said no residents had reported to her not feeling safe around Resident #25. During an interview on 02/12/2024 at 10:25 AM, the Executive Director said when he was the administrator Resident #25 had a couple of behavior issues where he was going into peoples' rooms and taking their things and lying. The Executive Director said he had stopped being the administrator at the facility in October of 2023. The Executive Director said he was unable to recall specific incidents because Resident #25 had been involved in so many things. The Executive Director said interventions they had put in place for Resident #25 were sending him out to a behavioral hospital for treatment, 15-minute checks, placing him on 1 on 1, moving him rooms (in the past when Resident #25 had been involved in other resident to resident altercations and misappropriation allegations), and seeking alternative placement for Resident #25. The Executive Director said these interventions were put in place after incidents Resident #25 was involved in. The Executive Director was unable to provide long-term interventions to address Resident #25's behaviors and protect the other residents from further incidents. During an interview on 02/12/2024 at 10:42 AM, the Administrator said she had received a call reporting Resident #25 had stolen money from Resident #43. The Administrator said the CNA had found dollar bill with Resident #43's initials on them in Resident #25's bed. Resident #25 denies stealing the money. The Administrator said Resident #43 was only given back the recovered money because they were unable to verify how much money Resident #43 had. The Administrator said Resident #43 said it was $100 but when the Social Worker spoke with his family member, his family member said that was not the amount she gave him. The Administrator said after the incident Resident #43 was provided education on using his lock box, but Resident #43 preferred to keep his money on him. The Administrator said after the incident education was provided to Resident #25 on not touching his roommate's things. The Administrator said Resident #25 was the type of resident that did not accept culpability. The Administrator said the same day Resident #25 stole his roommate's money, he hit Resident #56. The Administrator said Resident #56 said he accidentally bumped into Resident #25's wheelchair, and Resident #25 felt it was intentional, so they started exchanging words and Resident #25 punched Resident #56 three times in the chest area. The Administrator said Resident #25 did not accept fault for his actions and said he had hit Resident #56 in the leg three times. The Administrator said the incident was witnessed by a housekeeper and the housekeeper verified she had seen Resident #56 bump into resident #25, and then Resident #25 hit Resident #56 in the chest area and the housekeeper called for help. The Administrator said the residents were separated and placed on 15-minute monitoring for the duration of the investigation. The Administrator said they had tried and were still trying to find a lotion to accept Resident #25. The Administrator said they had care plan meetings with Resident #25's family, and they monitor Resident #25 to ensure he was not being aggressive to anyone. The Administrator said they had not asked the residents directly if they felt safe around Resident #25. The Administrator said they had only asked the residents if they felt safe in the facility. The Administrator said she had not asked Resident #43 if he felt comfortable remaining in the room with Resident #25 or if he wanted to be moved after the incident where Resident #25 stole Resident #43's money. During an interview on 02/12/2024 at 11:38 AM, the Social Worker said Resident #25 had a history of theft, and most recently he had taken money from his roommate. The Social Worker said she did not know a real trigger for his behaviors. The Social Worker said there was an incident where Resident #25 struck Resident #56 on his legs. The Social Worker said Resident #56 did not want to file charges against Resident #25. The Social Worker said she believed this incident prompted a care plan meeting with the family to let them know things were getting serious with Resident #25's behavior problems. The Social Worker said the last care plan meeting they had with Resident #25's family they had explained they would have to look at a 30-day notice for discharge due to his aggressive behaviors. The Social Worker said she had tried to refer Resident #25 to other facilities but was unsuccessful due to Resident #25's behavioral issues. The Social Worker said the last time she had tried to refer Resident #25 to a different facility was more than a month ago. Record review of the facility's policy revised, 11/07/2023, titled, Abuse Prohibition Policy, indicated, Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents . Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment . 1. All residents will be immediately protected from harm . Resident to Resident Incidents: The following guidelines will be implemented when resident to resident incidences occur: 1. The staff observing the incident will immediately separate the residents involved. 2. The charge nurse will assess the victim to determine any injury. 3. Physician and family of both victim and perpetrator will be notified of incident. 4. An incident report will be completed for the perpetrator and the victim. 5. The Abuse Coordinator will be immediately contacted. 6. The interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following: oImmediate discharge from the facility due to potential for harm to other residents. oCan the behavior be controlled by location monitoring? Need for referral to a psychologist/psychiatrist. The family and physician of the perpetrator will be notified of the next steps. 7. If the perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. 8. If the perpetrator is on a behavioral contract, facility staff will be in serviced accordingly, and the resident and family will be notified of consequences. 9. If the perpetrator continues to exhibit inappropriate behaviors/or violates the behaviors identified on the behavioral contract, staff will immediately notify the Administrator /DON. 10. The team will conduct an emergency review to determine further course of action such as immediate discharge. 11. The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family . The Administrator was notified on 02/12/24 at 1:53 PM that an Immediate Jeopardy (IJ) situation was identified due

47006 Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 3 of 6 residents (Resident's #23, #43, and #56) reviewed for abuse. 1. The facility did not implement the policy by providing ongoing monitoring and interventions for Resident #25 when he had a history of physical aggression and taking others personal property. 2. The facility did not implement the policy to keep Resident's #23, #43, and #56 safe from further abuse. An Immediate Jeopardy (IJ) was identified on 02/12/2024 at 1:53 PM. While the IJ was removed on 02/14/2024 at 12:23 PM, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The findings included: 1. Record review of the facility's policy revised, 11/07/2023, titled, Abuse Prohibition Policy, indicated, The facility's abuse prevention program includes the following components: screening .prevention .identification . The policy further revealed Screening: . the facility will attempt to screen for potentially abusive residents via the admission process .Prevention: .facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring .Residents identified as exhibiting abuse behaviors will be reviewed and have their treatment plans modified as appropriate .the screening and training policies will be adhered to as outlined above .Identification: . the facility will track all occurrences, trends, or patterns that could potentially constitute abuse or neglect .the facility supervisor staff will monitor behaviors of .residents to identify potential for abuse, neglect, and misappropriation of resident funds .Protection: All residents will be immediately protected from harm .if another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern .Resident to Resident Incidents: .the interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following: immediate discharge from the facility due to potential for harm to other residents .can the behavior be controlled by location monitoring? .need for referral to a psychologist/psychiatrist .the team will conduct an emergency review to determine further course of action such as immediate discharge . 2. Record review of a face sheet dated 02/15/2024 indicated Resident #25 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included psychotic disorder with delusions due to known physiological condition (mental disorder which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #25 was able to make himself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #25 did not have inattention, disorganized thinking, or altered level of consciousness. Resident #25's mood interview did not indicate he had little interest or pleasure in doing things or felt down, depressed, or hopeless. The MDS assessment did not indicate Resident #25 hallucinated or had delusions and did not indicate physical, verbal, or other behavioral symptoms or rejection of care. The MDS assessment did not indicated Resident #25 wandered. The MDS assessment indicated Resident #25 was independent with eating, required set-up or clean-up assistance with oral hygiene, resident refused toileting hygiene, dependent with shower/bathe self, lower body dressing, personal hygiene, and substantial/maximal assistance required for upper body dressing. The MDS assessment indicated Resident #25 was independent with sitting to lying and lying to sitting on the side of the bed and required supervision or touching assistance with sitting to standing. The MDS assessment indicated Resident #25 was able to wheel himself independently 150 feet. The MDS assessment indicated Resident #25 had active diagnoses of depression, psychotic disorder, and schizophrenia. Record review of Resident #25's care plan last revised 11/16/2023 indicated the following focuses: The resident has a behavior problem related to makes statements that are less than factual at times. 09/11/22 resident went into other residents' rooms and took their belongings without their permission, Staff was told resident exposed self to others. Resident slapped staff and a resident. 08/22/22 Resident was seen by staff taking other residents' cigarettes from the nursing station and retaliated against staff for stating factual information and stated staff would not give him medications/cigarettes. Resident is non-compliant with facility smoking policy. 10/10/22 one on one implemented daily every 15-minute checks at bedtime. 05/13/23 resident was seen taking another resident's soda drinks at the nurse's station. 05/30/23 resident was seen with a stack of money that did not belong to him and spent some of it. 06/02/23 Resident initiated physical aggression by grabbing another resident's arm. 01/12/24 Resident was smoking in the building. The resident has potential to be physically aggressive, resident slapped another resident and staff member with date initiated 09/13/2022. Resident #25's care plan included the following interventions: 08/22/22 If reasonable, discuss the resident's behavior. explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 09/11/22 Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. resident on 1 on 1 monitoring for behaviors (1:1 was an intervention initiated after an incident it is unknown for how long he remained on 1:1) 04/11/23 resident was told to move out of the way by another resident on the smoking patio, resident told the other resident Fuck you bitch and the other resident slapped him, so this resident slapped her back. this resident referred to psych services (mental health services), in-serviced and educated on appropriate behavior ongoing. 05/15/23 discussed the resident's behavior in a care plan meeting. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. 05/30/23 explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 05/30/23 every 30-minute monitoring in place. 06/02/23 consult psychology services 06/02/23 educate resident on how to handle confrontations from other residents. 06/02/23 law enforcement (police) notified. 06/02/23 every 15-minute assessments continued. Administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, praise any indication of the resident's progress/improvement in behavior, and provide a program of activities that is of interest and accommodates resident's status with date initiated 08/18/2022. Record review of Resident #25's Order Summary Report dated 02/14/2024 indicated: Cymbalta Oral Capsule Delayed Release Particles 30 MG (medication used to treat depression) Give 1 capsule by mouth one time a day with a start date of 01/04/2024. Cymbalta Oral Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth one time a day with a start date of 01/04/2024. Divalproex Sodium Oral Tablet Delayed Release 125 MG (medication used for mood disorders) Give 5 tablet by mouth two times a day with a start date of 02/04/2024. Haloperidol Oral Tablet 20 MG (medication used to treat mood disorders) Give 1 tablet by mouth at bedtime with a start date of 01/04/2024. Haloperidol Oral Tablet 5 MG Give 3 tablets by mouth in the morning with a start date of 01/04/2024. Trazodone Oral Tablet 50 MG (medication used to treat insomnia) Give 1 tablet by mouth at bedtime with a start date of 01/04/2024. Resident placed on 1 on 1 related to behaviors every shift with at start date of 02/12/2024. Record review of Resident #25's progress notes indicated: 01/27/2024 LVN P indicated it was reported to me that resident hit other resident on chest and right leg resident was separated and placed on 15-minute monitoring family notified. 02/08/2024 the Social Worker indicated Resident #25 had a BIMS of 15, resident was cognitively intact and denies presence of behaviors or symptoms of depression. The Social Worker indicated she would provide assistance with resources, referrals, and support as needed. Record review of Resident #25's electronic health record indicated his last visit from psychological services was on 01/23/2024. The psychological services progress note dated 01/23/2024 indicated Resident #25 did not have aggressive or sexual behaviors. The progress note indicated the plan for the next session was to continue to enhance healthy coping responses, improved self-care and increased psychosocial support by seeking friendships and participating in facility activities with sessions schedule one time a week. Record review of the incident report, dated 01/27/2024 at 1:50 PM, revealed staff reported to LVN P that Resident #25 was involved in a resident-to-resident altercation with Resident #56. Resident #25 stated Resident #56 ran into him with his wheelchair and he hit him. 3. Record review of the face sheet, dated 02/15/2024, revealed Resident #56 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis and an inability to move all four arms and legs) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the admission MDS assessment, dated 10/17/2023, revealed Resident #56 had clear speech and was understood by staff. The MDS revealed Resident #56 was able to understand others. The MDS revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #56 had no behaviors or refusal of care. The MDS revealed Resident #56 was dependent on staff for all ADLs, which included: eating, oral hygiene, toilet use, bathing, dressing, transferring, and bed mobility. Record review of the comprehensive care plan, initiated on 01/09/2024, revealed Resident #56 had an ADL self-care performance deficit related to quadriplegia. The interventions revealed Resident #56 was dependent on staff for all ADLs, which included: eating, oral hygiene, toilet use, bathing, dressing, transferring, and bed mobility. Record review of Resident #56's progress notes revealed: 01/27/2024 at 1:53 PM - LVN P wrote it was reported to her that Resident #56 ran his electric wheelchair into Resident #25 by accident. Resident #25 then started hitting Resident #56 in the chest and right leg. LVN P wrote she assessed Resident #56's chest with no redness or injuries were observed. 01/28/2024 at 1:09 AM - LVN Q wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN Q wrote no issues were noted but will continue to monitor. 01/28/2024 at 9:02 AM and 3:13 PM - LVN P wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN P wrote Resident #56 was assessed due to being hit on 01/27/2024. LVN P wrote no delayed injuries or complaints of pain or discomfort were noted. 01/29/2024 at 1:44 AM - The ADON wrote Resident #56 was on every 15-minute checks related to an altercation with another resident. The ADON wrote Resident #56 had remained in his bed since the start of her shift and had no complaints of pain or discomfort. The ADON wrote Resident #56 had no late emotional effects related to the incident. 01/31/2024 at 2:57 AM - LVN Q wrote Resident #56 was on every 15-minute monitoring for behavioral issues. LVN Q wrote no issues were noted but will continue to monitor. Resident #56 had no progress notes from the Social Worker regarding a follow up after the resident-to-resident altercation. Record review of Resident #56's incident report, dated 01/27/2024 at 1:50 PM, revealed staff reported that Resident #56 was in a resident-to-resident altercation with Resident #25. Resident #56 stated I ran my wheelchair into Resident #25 by accident and he started hitting me in the chest. The report further revealed Resident #56 did not want to go to bed so LVN P assessed his chest area only with no redness or injuries noted. Record review of the Weekly Body Skin Check, dated 01/27/2024, revealed Resident #56 had no skin problems. Record review of Housekeeper TT's witness stated, dated 01/27/2024, revealed I saw Resident #56 bump into Resident #25's wheelchair, then I saw Resident #25 hit Resident #56 in the chest area. I called for help and the residents were immediately separated. Record review of the Administrator's statement, dated 01/29/2024, revealed I . spoke with both residents [Resident #25 and Resident #56] regarding the incident that occurred over the weekend. According to Resident #25, Resident #56 began calling him names and bumped him with his wheelchair. Resident #25 stated he responded by hitting him on the legs. When I spoke with Resident #56, he stated he accidently ran into Resident #25 with his wheelchair, Resident #25 then hit him three times in the chest. Then the nurse came to assess him and asked him questions about how he was feeling. Record review of CNA BB's statement, dated 01/30/2024, revealed Housekeeper TT came and told me that Resident #25 and Resident #56 were having an altercation. The DON and I immediately separated them. When I asked Resident #56 what happened, he said Resident #25 hit him 3 times in the chest . Record review of the provider investigation report, dated 02/02/2024, revealed Resident #56 and Resident #25 were seen having an altercation. The provider investigation report revealed Resident #25 stated that Resident #56 called him names and bumped into his wheelchair on purpose. The provider investigation report revealed Resident #56 stated he bumped into Resident #25 by accident and then Resident #25 hit him in the chest three times. Record review of the Weekly Body Skin Check, dated 01/27/2024, revealed Resident #56 had no skin problems. Record review of Housekeeper TT's witness stated, dated 01/27/2024, revealed I saw Resident #56 bump into Resident #25's wheelchair, then I saw Resident #25 hit Resident #56 in the chest area. I called for help and the residents were immediately separated. Record review of the Administrator's statement, dated 01/29/2024, revealed I . spoke with both residents [Resident #25 and Resident #56] regarding the incident that occurred over the weekend. According to Resident #25, Resident #56 began calling him names and bumped him with his wheelchair. Resident #25 stated he responded by hitting him on the legs. When I spoke with Resident #56, he stated he accidently ran into Resident #25 with his wheelchair, Resident #25 then hit him three times in the chest. Then the nurse came to assess him and asked him questions about how he was feeling. Record review of CNA BB's statement, dated 01/30/2024, revealed Housekeeper TT came and told me that Resident #25 and Resident #56 were having an altercation. The DON and I immediately separated them. When I asked Resident #56 what happened, he said Resident #25 hit him 3 times in the chest . Record review of the provider investigation report, dated 02/02/2024, revealed Resident #56 and Resident #25 were seen having an altercation. The provider investigation report revealed Resident #25 stated that Resident #56 called him names and bumped into his wheelchair on purpose. The provider investigation report revealed Resident #56 stated he bumped into Resident #25 by accident and then Resident #25 hit him in the chest three times. 4. Record review of the face sheet, dated 02/15/2024, revealed Resident #23 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of hemiplegia affected right dominant side (paralysis of one side of the body) and cerebral infarction (stroke). Record review of the quarterly MDS assessment, dated 01/16/2024, revealed Resident #23 had clear speech and was understood by staff. The MDS revealed Resident #23 was able to understand others. The MDS revealed Resident #23 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #23 had no behaviors or refusal of care. The MDS revealed Resident #23 had an impairment on one-side of the upper extremity and lower extremity that interfered with daily functions or placed resident at risk of injury. The MDS revealed Resident #23 was dependent on staff for toileting hygiene, dressing, toilet transfer, and walking. Record review of the comprehensive care plan, revised on 08/01/2023, revealed Resident #23 was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan further revealed Resident #23 had an ADL self-care performance deficit related to hemiplegia. Record review of the incident report dated 04/11/2023 at 10:30 AM, Resident #23 stated she was going into building and Resident #25 was in the way. Resident #23 attempted to get by Resident #25 and her wheelchair bumped into him. Resident #23 asked him to move and then both residents started cursing at each other. Resident #23 then stated Resident #25 hit her and then she hit him back. 5. Record review of a face sheet dated 02/15/2024 indicated Resident #43 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), bipolar II disorder (mental health condition defined by periods or episodes of extreme mood disturbances that affect mood, thoughts, and behavior), and unspecified psychosis not due to a substance or known physiological condition (a mental state characterized by a loss of touch with reality this condition may involve hallucinations, delusions, disordered thinking, and behavioral changes). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #43 was able to make himself understood and understood others. The MDS assessment indicated Resident #43 had a BIMS score of 7, which indicated his cognition was severely impaired. The MDS assessment did not indicate Resident #43 had physical, verbal, or other behavioral symptoms towards others. The MDS assessment indicated Resident #43 was independent for eating and dependent for all other ADLs. Record review of Resident #43's care plan with a target date of 04/28/2024 indicated he had impaired cognitive function and impaired thought processes related to dementia with interventions which included cue reorient and supervise as needed. Record review of the Provider Investigation Report dated 02/02/2024 indicated, Resident #43 reported that his money was taken from his room. While the CNA was making the beds in Resident #43's and Resident #25's room, she came across some money under Resident #43's room-mate's pillow. Investigation was initiated. The investigation revealed that the other CNA that was in the room saw some dollar bills in Resident #25's pocket. Resident #25 then revealed to the CNA that he had given another resident money to purchase him cigarettes. When the CNA approached the other resident, the other resident confirmed that he was given money by Resident #25. It was revealed that all of the bills had Resident #43's initials on them. The money was returned to Resident #43, but it was not the total amount he was missing. Resident #43 was educated on using the lock box that he was previously provided for the safe keeping of his items. During an interview on 02/11/2024 at 2:55 PM, Resident #25 was in his room, and he said, All I do is eat and sleep. Resident #25 said he had taken his roommates money because the voices in his head had told him to take the money. Resident #25 said he had taken the money from Resident #43's nightstand, and then gave it all back. Resident #25 said he was no longer hearing the voices he had only heard them when the incident with Resident #43 occurred. Resident #25 said he had taken some peanut butter jelly from another resident's room, but he denied taking anybody else's money or cigarettes. Resident #25 said he had hit a young boy in a motorized wheelchair (Resident #56) because he ran into his wheelchair when they were outside in the smoking area. Resident #25 said he hit him in the leg. Resident #25 said there were no staff supervising when the incident with Resident #56 occurred. Resident #25 said he slapped Resident #23 while they were smoking unsupervised because she stirred up everything, called him a mother fucking negro, and ran into his wheelchair. Resident #25 said he did not require supervision when smoking and he smoked unsupervised. During an interview on 02/11/2024 at 3:17 PM, Resident #56 stated he remembered the resident-to-resident altercation with Resident #25. Resident #56 stated Resident #25 stood up in front of him while in the smoking area and pulled his pants down. Resident #56 stated he asked Resident #25 to move, and he told him No. Resident #56 stated he attempted to get past Resident #25. Resident #25 then reared back and punched him the chest 3 times. Resident #56 stated he then rammed Resident #25 with the wheelchair. Resident #56 stated staff then intervened. Resident #56 stated the incident was completely unprovoked and unprompted. Resident #56 stated he told the facility staff he did not want Resident #25 in the facility. Resident #56 stated he agreed to not press charges under the assumption Resident #25 would have been leaving the facility. Resident #56 stated he did not feel safe in the facility and staff had allowed Resident #25 to be in the same vicinity as him, since the incident had occurred. During an interview on 02/11/2024 at 3:34 PM, LVN P said Resident #43 reported missing money, and the money was found in his roommates (Resident #25) bed and under the bed and some on Resident #25 and another resident had been given money by Resident #25. LVN P said they knew it was Resident #43's money because his family member placed Resident #43's initials on the bills. LVN P said now the nurses kept Resident #43's billfold on the medication care and when he needed money, he had to ask the nurses for it, and it was signed out to him. LVN P said Resident #25 had manipulative behaviors to get what he wanted. LVN P said in the past he had hit residents and staff and was sent out to a behavioral hospital. LVN P said prior to being sent out to the behavioral health hospital they had to call the police and when the police arrived Resident #25 told them he knew they would just send him to the behavioral health hospital to get his medications adjusted. LVN P said Resident #25 had not reported hearing voices to her. LVN P said Resident #25 was not supposed to be smoking unsupervised because he was caught smoking in the hallway a couple months ago. LVN P said they tried to watch Resident #25 more closely and after the incidents occurred, he was placed on 15-minute watch. LVN P was unable to specify for how many hours/days the 15-minute watches were maintained. During an interview on 02/11/2024 at 5:05 PM, CNA BB stated she did not witness the event between Resident #56 and Resident #25 on 01/27/2024, but she sat with Resident #56 after the incident. CNA BB stated Resident #56 told her that Resident #25 got up from his wheelchair and pulled his pants down. CNA BB stated Resident #56 stated Resident #25 told him to smell his bottom, so he rammed Resident #25 with his wheelchair. CNA BB stated Resident #56 told her that was when Resident #25 punched him. CNA BB stated Resident #25 and Resident #56 had previous issues, with words. CNA BB stated no interventions were put in place to keep Resident #56 and Resident #25 separated. CNA BB stated the cops were called to scare Resident #25 but Resident #25 did not care. During an interview on 02/12/2024 at 8:02 AM, Resident #23 stated Resident #25 was a loser, scum on the bottom of her shoe. Resident #23 stated Resident #25 only hit people who could not fight back or women. Resident #23 stated Resident #25 slapped the shit out of her for no reason. Resident #23 stated she was fearful of Resident #25 and no interventions had been put in place by the facility to try and keep them safe. Resident #23 stated she did not feel like the facility had taken steps to make her feel safe. Resident #23 stated Resident #25 had taken a lot of things. Resident #23 stated Resident #25 had ransacked her room twice at the facility. Resident #23 stated a nurse had waken her up with a basket full of her things that Resident #25 had taken. During an interview on 02/12/2024 9:10 AM, Resident #43 said his neighbor (roommate) Resident #25 got his money while he was sleeping. Resident #43 said he had $100 because his family member gives him that amount on the 31st of every month. Resident #43 said he did not feel safe in the same room with Resident #25 because Resident #25 still went through his personal items and moved them around. Resident #43 said he told the boss man he did not feel safe staying in the room with Resident #25. Resident #43 was unable to provide a name for the boss man. Resident #43 said he had also told the nurses Resident #25 was going through his personal items and taking them and the nurses told him not to bother Resident #25 and Resident #25 would not bother him. During an interview on 02/12/2024 at 10:05 AM, the ADON said Resident #25 had been at the facility for almost 2 years. The ADON said Resident #25 had a history of schizophrenia and major depressive disorders. The ADON said Resident #25 liked to go and bother other people, and then he would say he did not do it when the staff knew he had. The ADON said Resident #25 would take peoples things like clothes, snacks, and then he would deny it, but the staff would find it in his room. The ADON said she was aware that Resident #25 had stolen Resident #43's money, but she was not aware why they had remained in the same room because the Social Worker and Administrator had handled the situation. The ADON said interventions for Resident #25's resident to resident altercations and stealing money included separating the residents when the incident occurred and putting him on 15-minute checks for 72 hours or until psych services released them. The ADON said no residents had reported to her not feeling safe around Resident #25. During an interview on 02/12/2024 at 10:25 AM, the Executive Director said when he was the administrator Resident #25 had a couple of behavior issues where he was going into peoples' rooms and taking their things and lying. The Executive Director said he had stopped being the administrator at the facility in October of 2023. The Executive Director said he was unable to recall specific incidents because Resident #25 had been involved in so many things. The Executive Director said interventions they had put in place for Resident #25 were sending him out to a behavioral hospital for treatment, 15-minute checks, placing him on 1 on 1, moving him rooms (in the past when Resident #25 had been involved in other resident to resident altercations and misappropriation allegations), and seeking alternative placement for Resident #25. The Executive Director said these interventions were put in place after incidents Resident #25 was involved in. The Executive Director was unable to provide long-term interventions to address Resident #25's behaviors and protect the other residents from further incidents. During an interview on 02/12/2024 at 10:42 AM, the Administrator said she had received a call reporting Resident #25 had stolen money from Resident #43. The Administrator said the CNA had found dollar bill with Resident #43's initials on them in Resident #25's bed. Resident #25 denies stealing the money. The Administrator said Resident #43 was only given back the recovered money because they were unable to verify how much money Resident #43 had. The Administrator said Resident #43 said it was $100 but when the Social Worker spoke with his family member, his family member said that was not the amount she gave him. The Administrator said after the incident Resident #43 was provided education on using his lock box, but Resident #43 preferred to keep his money on him. The Administrator said after the incident education was provided to Resident #25 on not touching his roommate's things. The Administrator said Resident #25 was the type of resident that did not accept culpability. The Administrator said the same day Resident #25 stole his roommate's money, he hit Resident #56. The Administrator said Resident #56 said he accidentally bumped into Resident #25's wheelchair, and Resident #25 felt it was intentional, so they started exchanging words and Resident #25 punched Resident #56 three times in the chest area. The Administrator said Resident #25 did not accept fault for his actions and said he had hit Resident #56 in the leg three times. The Administrator said the incident was witnessed by a housekeeper and the housekeeper verified she had seen Resident #56 bump into resident #25, and then Resident #25 hit Resident #56 in the chest area and the housekeeper called for help. The Administrator said the residents were separated and placed on 15-minute monitoring for the duration of the investigation. The Administrator said they had tried and were still trying to find a lotion to accept Resident #25. The Administrator said they had care plan meetings with Resident #25's family, and they monitor Resident #25 to ensure he was not being aggressive to anyone. The Administrator said they had not asked the residents directly if they felt safe around Resident #25. The Administrator said they had only asked the residents if they felt safe in the facility. The Administrator said she had not asked Resident #43 if he felt comfortable remaining in the room with Resident #25 or if he wanted to be moved after the incident where Resident #25 stole Resident #43's money. During an interview on 02/12/2024 at 11:38 AM, the Social Worker said Resident #25 had a history of theft, and most recently he had taken money from his roommate. The Social Worker said she did not know a real trigger for his behaviors. The Social Worker said there was an incident where Resident #25 struck Resident #56 on his legs. The Social Worker said Resident #56 did not want to file charges against Resident #25. The Social Worker said she believed this incident prompted a ca[TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 20 residents (Resident's #5, #16, #21, #25, and #56) reviewed for smoking. 1. The facility failed to ensure Resident #16 and #56 were provided supervision and wore a smoking apron during the scheduled smoking times. Resident #16 and Resident #56 were outside in the smoking area, unsupervised, while Resident #16 held the cigarette for Resident #56. Resident #16 and Resident #56 were not wearing a smoking apron while in the smoking area. 2. The facility failed to ensure Resident #21 was provided supervision during the scheduled smoking times. Resident #21 entered the smoking area during the smoke break and was smoking without supervision. 3. The facility failed to ensure Resident #5, and Resident #21 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #25 was re-assessed for smoking safety after he lit a cigarette in the building on 01/12/2024. An IJ was identified on 02/12/2024 at 1:53 PM. The IJ template was provided to the facility on [DATE] at 1:56 PM. While the IJ was removed on 02/14/2024, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm due to the facility's needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision while smoking. The findings included: 1. Record review of the face sheet, dated 02/15/2024, revealed Resident #56 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis and an inability to move all four arms and legs). Record review of the admission MDS assessment, dated 10/17/2023, revealed Resident #56 had clear speech and was understood by staff. The MDS revealed Resident #56 was able to understand others. The MDS revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #56 had no behaviors or refusal of care. The MDS revealed Resident #56 was dependent on staff for all ADLs. Record review of the comprehensive care plan, revised on 01/16/2024, revealed Resident #56 was at risk for injury due to his smoking preference. The goals included: I will not smoke without supervision through next review period. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas, and policy as needed. Record review of the Smoking Safety Evaluation, dated 12/07/2023, revealed Resident #56 required supervision and a smoking apron when smoking because he had upper and lower extremity limitions. The evaluation futher revealed he was not able to safety light his cigarette, did not hold the cigarette safely, did not dispose of ashes in the ashtray, did not respond quickly to fallen ashes, and was unable to extinguish his cigarette. 2. Record review of the face sheet, dated 02/15/2024, revealed Resident #16 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of paraplegia (form of paralysis that affects the lower half of the body) and chronic pain syndrome (persistent or intermittent pain that last for more than 3 months). Record review of the annual MDS assessment, dated 09/22/2023, revealed Resident #16 had clear speech and was understood by staff. The MDS revealed Resident #16 was able to understand others. The MDS revealed Resident #16 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #16 had no behaviors or refusal of care. The MDS revealed Resident #16 currently used tobacco. Record review of the comprehensive care plan, revised 04/21/2023, revealed Resident #16 was at risk for injury due to his smoking preference. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas, and policy as needed. The interventions further included: evaluate my smoking safety ability and provide appropriate interventions as indicated and allow me to smoke unsupervised. Record review of the Smoking Safety Evaluation, dated 05/12/2023, revealed Resident #16 required supervision and a smoking apron while smoking because he did not remove oxygen tubing while in the smoking area. 3. Record review of the face sheet, dated 02/15/2024, revealed Resident #21 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of encephalopathy (damage or disease that affects the brain structure or function), seizures (sudden, uncontrolled burst of electrical activity in the brain), and early onset Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Record review of the annual MDS assessment, dated 11/15/2023, revealed Resident #21 had clear speech and was understood by staff. The MDS revealed Resident #21 was able to understand others. The MDS revealed Resident #21 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #21 had no behaviors or refusal of care. The MDS revealed Resident #21 currently used tobacco. Record review of the comprehensive care plan, revised 12/14/2023, revealed Resident #21 was at risk for injury related to her smoking preference. The interventions included: Educate me and encourage me to follow facility smoking times, designated smoking areas and policy as needed. Record review of the Smoking Safety Evaluation, dated 12/08/2023, revealed Resident #21 required supervision while smoking because of her problematic long-term memory. 4. Record review of the face sheet, dated 02/15/2024, revealed Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of injury of the cervical spinal cord (neurological injury to spinal cord closes to the head and neck) and complete amputation (surgical removal) of both his legs. Record review of the annual MDS assessment, dated 07/17/2023, revealed Resident #5 had unclear speech and was usually understood by staff. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 currently used tobacco. Record review of the comprehensive care plan, revised 08/01/2023, revealed Resident #5 was at risk for injury due to his smoking preference. The goals included: I will not smoke without supervision through next review period. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas and policy as needed. Record review of the Safety Smoking Evaluation, dated 12/07/2023, revealed Resident #5 required supervision and a smoking apron while smoking because he had problematic short and long-term memory, weak grasps, in which he dropped items, diminished reflex response, did not safely light his cigarette, and did not dispose of ashes in the ashtray . The evaluation did not address the storage of his smoking materials. 5. Record review of a face sheet dated 02/15/2024 indicated Resident #25 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included psychotic disorder with delusions due to known physiological condition (mental disorder which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #25 was able to make himself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #25 did not have inattention, disorganized thinking, or altered level of consciousness. Resident #25's mood interview did not indicate he had little interest or pleasure in doing things or felt down, depressed, or hopeless. The MDS assessment did not indicate Resident #25 hallucinated or had delusions and did not indicate physical, verbal, or other behavioral symptoms or rejection of care. The MDS assessment did not indicated Resident #25 wandered. The MDS assessment indicated Resident #25 was independent with eating, required set-up or clean-up assistance with oral hygiene, resident refused toileting hygiene, dependent with shower/bathe self, lower body dressing, personal hygiene, and substantial/maximal assistance required for upper body dressing. The MDS assessment indicated Resident #25 was independent with sitting to lying and lying to sitting on the side of the bed and required supervision or touching assistance with sitting to standing. The MDS assessment indicated Resident #25 was able to wheel himself independently 150 feet. Record review of Resident #25's care plan last revised 11/16/2023 indicated the following focuses: 08/22/22 Resident was seen by staff taking other residents' cigarettes from the nursing station and retaliated against staff for stating factual information and stated staff would not give him medications/cigarettes. Resident is non-compliant with facility smoking policy. 10/10/22 one on one implemented daily every 15-minute checks at bedtime. 01/12/24 Resident was smoking in the building. Resident #25 is at risk for injury due to his smoking preference. Resident #25's interventions included to educate and encourage him to follow the facility's smoking times, designated smoking areas and policy as needed, to educate him on the risk of smoking and hazards, and to evaluate his smoking safety ability and provide appropriate interventions as indicated and allow him to smoke unsupervised last revised 11/16/2023. Record review of Resident #25's Smoking Safety Evaluation dated 12/07/2023 indicated he could smoke unsupervised. There was no Smoking Safety Evaluation completed on or after 01/12/24. Record review of Resident #25's progress notes indicated: 01/12/2024 RN AA indicated at the beginning of my morning round, resident from 100 hall, observed at the end of 400 hall. this nurse headed to check 400 hall residents and smelled of cigarette the whole 400 hall this nurse finds this resident at the end of 400 hall smoking a cigarette resident hid his cigarette and said that I was reading a book. residents' room (400 hall) was closed. Resident came back from 400 hall to the dining room. This nurse, medication aide and HR and dietary supervisor was at hallway. dietary supervisor took cigarette away from resident. This nurse notified immediately the Administrator and DON. This nurse educated resident about the risk factor of smoking inside the building and explain that residents in use oxygen are at risk for fire. resident regretted and explained that I am going to stop it and said I'm sorry. resident aware not to smoke inside the building. resident verbalized understand. Will continue to monitor. During an observation on 02/11/2024 at 9:47 AM, Resident #21 was smoking in the designated smoking area unsupervised. During an interview on 02/11/2024 at 2:55 PM, Resident #25 said he did not require supervision when smoking and he smoked unsupervised. During an interview on 02/11/2024 at 3:34 PM, LVN P said on 01/27/2024 they found a pack of cigarettes in Resident #25's room, which he was not supposed to have. LVN P said the Administrator took the cigarettes from him. LVN P said Resident #25 had manipulative behaviors to get what he wanted. LVN P said Resident #25 was not supposed to be smoking unsupervised because he was caught smoking in the hallway a couple months ago. LVN P said they tried to watch Resident #25 more closely and after the incidents occurred, he was placed on 15-minute watch. LVN P was unable to specify for how many hours/days the 15-minute watches were maintained. During an observation and interview on 02/11/2024 between 4:08 PM to 4:35 PM, Resident #56 and Resident #16 were in the designated smoking area. Resident #16 was holding his cigarette and after taking approximately 2 or 3 puffs, he placed the cigarette up to Resident #56's mouth for him to take a few puffs. There was no staff supervision in the smoking area during this time and no smoking apron were worn or available in the smoking area. Resident #16 stated the residents did things like holding cigarettes for other residents to help each other out. Resident #21 entered the smoking area, pulled out her materials, and lit her cigarette and began smoking, unsupervised by staff. Resident #56 had small hole, the size of a cigarette tip, on his blanket that was pulled up near his face. At approximately 4:25 PM, all the residents left the smoking area except Resident #56. Resident #56 was unable to get back into the building as he was unable to move his arms or legs or operate his wheelchair. Resident #56 stated he was waiting on the CNA from his hall to come get him. Resident #56 stated the facility staff assisted him outside. Resident #56 stated that was the first time he had to wait in the smoking area for staff to assist him. Facility staff arrived at approximately 4:34 PM to assist Resident #56 back into the building. During an interview on 02/11/2024 beginning at 4:46 PM, the ADON stated some resident's needed supervision during smoking breaks and some residents did not. The ADON stated Resident #5 and Resident #56 were 2 of the 4 residents who required supervision. The ADON stated the residents who required supervision went to smoke during the designated smoking times. The ADON stated Resident #56 was non-complaint with the supervision and went outside when he wanted to. The ADON stated she instructed staff to encourage Resident #56 to allow someone outside with him while he was smoking. During an interview on 02/11/2024 at 4:53 PM, Anonymous #1 said Resident #25 usually smoked outside unsupervised. Anonymous #1 said to her knowledge there had not been any injuries related to the residents smoking unsupervised. Anonymous #1 said Resident #5, Resident #16, Resident #21, and Resident #56 smoked unsupervised. Anonymous #1 said she had told the nurses and they said they already knew about it. Anonymous #1 said she did not continue to voice her concerns because she was afraid of retaliation. During on observation on 02/11/2024 at 6:00 PM, Resident #21 was sitting outside in the front of the building, smoking a red-tipped cigarette unsupervised by facility staff. During an interview on 02/12/2024 at 7:49 AM, RN O said there were some alert and oriented residents that were able to smoke unsupervised. RN O said they had a smoke schedule for the residents that required supervision and staff were supposed to accompany them when they were smoking. RN O said there were some residents that could sign themselves out and smoke at any time they wanted to. RN O said Resident #25 went outside to smoke unsupervised. RN O said Resident #25 was not supposed to have his smoking paraphernalia on him, but sometimes they would find it on him. RN O said sometimes the family brings the residents smoking paraphernalia, and the residents kept it. RN O said some residents required a smoking apron for their safety so they couldn't burn themselves. RN O said the residents should not keep smoking materials because they had people on oxygen, and it could cause a fire. During an interview on 02/12/24 beginning at 7:54 AM, CNA U stated the residents who smoked had a schedule for certain times that staff would have accompanied them outside. CNA U stated the CNAs were responsible for taking the residents who required supervision out to smoke after breakfast, but she was unsure of the time. CNA U stated the residents usually went out to smoke on their own. CNA U stated Resident #56, Resident #16, and Resident #21 required supervision during smoking times. CNA U stated she had not observed any holes in their clothing or blankets. CNA U stated some residents could have had their smoking materials on them but some of them kept their smoking materials in the bag that was kept at the 100 Hall nurse's station. During an interview on 02/12/2024 beginning at 8:02 AM, Resident #21 was sitting on the edge of her bed in her room. Resident #21 had a small, red box of cigarettes on her bedside table. During an interview on 02/12/2024 beginning at 8:14 AM, LVN F stated the residents had designated smoking times. LVN F stated some residents required supervision. LVN F stated different staff were responsible for taking the residents to smoke at different times. LVN F stated she has observed staff taking the residents outside. LVN F stated Resident #56 was the only resident on 200 Hall that required supervision. LVN F stated some residents were able to keep their smoking materials and some kept them at the nurse's station. LVN F stated she had not noticed any holes in blankets or clothing. LVN F stated there had been no incidents involving cigarette burns. During an interview on 02/12/2024 beginning at 8:27 AM, Cook C stated the DAs sometimes assisted the residents out to smoke. During an interview on 02/12/2024 beginning at 8:29 AM, DA R stated she did not take the residents outside to smoke and was unsure who was responsible. DA R stated the DM would have known. During an interview on 02/12/2024 beginning at 8:32 AM, the DM stated the dietary staff used to take the residents outside to smoke in the morning. The DM stated but since the dietary department had to cut back on their budget, she had to cut the hours, which caused them to have to cut back on some duties they were no longer able to do, such as taking the residents out to smoke. During an interview on 02/12/2024 beginning at 8:45 AM, CNA RR stated the facility had a smoking schedule and it did not change. CNA RR stated the staff was supposed to keep the cigarette lights and residents were supposed to have had their cigarettes locked in a bag or cabinet. CNA RR stated the keys for the locked bag or cabinet should have been kept at the nurse's station. CNA RR stated she had witnessed resident's smoking alone. CNA RR stated the residents knew the code for the smoking doors to get outside. CNA RR stated she feared retaliation for telling the truth. During an interview on 02/12/2024 beginning at 8:54 AM, CNA T stated she had been a CNA at the facility for 4 years and worked the 6-2 and 2-10 shifts. CNA T stated she had witnessed residents smoking alone on both shifts that she worked. CNA T stated residents should have been monitored while smoking but responsible residents could have smoked alone if the resident had signed out at the nurse's desk. CNA T stated she had witnessed residents with cigarettes on their person but thought it was okay because cigarettes were being taken by other residents. CNA T stated residents who smoked should have worn a smoking apron. During an observation and interview on 02/12/2024 beginning at 9:00 AM, RN AA accompanied the surveyor into Resident #5's room. Resident #5 had 2 packs of cigarettes and a cigarette lighter in a yellow bag that was kept inside his room. RN AA stated Resident #5 was not supposed to have kept his cigarettes or lighter on his person. RN AA stated she was unsure who gave Resident #5 the cigarette lighter. Resident #5 stated his family member bought his cigarettes and his cigarette lighter. Resident #5 stated he did not know why he was unable to keep his cigarette lighter because other residents at the facility had their lighters on them when they were smoking. During an interview on 02/12/2024 at 10:42 AM, the Administrator said after the incident on 01/12/2024, where Resident #25 lit a cigarette in the hallway all his cigarettes and smoking paraphernalia were taken away. The Administrator said she believed it was care planned by the Social Worker, and they educated him on not smoking inside the facility. The Administrator said the residents were only supposed to smoke during the scheduled smoking times. The Administrator said the residents that did not require supervision could check themselves out and go off the facility premises to smoke. The Administrator said the residents should not be sharing cigarettes or helping each other to smoke. The Administrator said Resident #25 should not be smoking unsupervised. The Administrator said it was important for the supervised residents to have supervision because they could get burned and harmed. The Administrator said it was important for residents that required supervision to not keep their smoking paraphernalia on them because they could be tempted to smoke without supervision and harm themselves. During an interview on 02/13/2024 at 9:12 AM, the Executive Director said they currently had no DON, and she had left about 2 weeks ago. During an interview on 02/15/2024 at 6:36 PM, the Social Worker said she was responsible for completing the smoking evaluations, and they should be completed quarterly. The Social Worker said she currently did not have a system in place to ensure she was completing the smoking evaluations. The Social Worker said she was aware Resident #25 had lit a cigarette in the building, but she had not completed a smoking evaluation after the incident. The Social Worker said she did not think the smoking policy stipulated the frequency of the smoking evaluations. The Social Worker said she knew she had updated the residents smoking evaluations in June 2023 and December 2023. The Social Worker said it was important to complete the smoking evaluations for the resident's safety and for the safety of the residents around them in the smoking area. Record review of the facility's policy revised 08/11/2020, titled, Facility Smoking Policy, indicated, Safe Smoking Environment It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors, and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: o Residents who smoke, including possible adverse effects on treatment o Passive smoke to others o Fire . The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, ward, or compartment within facility with exception being the designated smoking room on first floor. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with non-smoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely . Residents who are deemed safe will be allowed to smoke unsupervised and may be permitted to keep cigarettes and/or lighter on their persons. If resident is deemed unsafe, they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials (e.g., cigarettes, E-Cigarettes, pipes, matches. lighters. lighter fluid) and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted, and resident will be required to smoke with supervision only, according to schedule. Smoking Infraction o The first infraction of the smoking policy results in a warning. This warning may be verbal. The warning is given to both the resident and their family member of contact. A safe smoking reassessment of that resident is performed to determine supervision required. o The second infraction of the smoking policy may result in notice of discharge. The reason for discharge would be endangerment to the health and safety of residents. The Administrator was notified on 02/12/24 at 1:53 PM that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 02/12/24 at 1:56 PM and the plan of removal was requested. The facility's plan of removal was accepted on 12/13/2024 at 3:12 PM and included the following: Immediate Jeopardy Plan of Removal - February 12, 2024 Problem: Action: o CCS/Designee meeting with resident council on February 12, 2024, at 3:05pm to review smoking policy. o Smoking assessments were completed by Corporate Clinical Specialist, MDS and ADON on Resident #56, Resident #21 and Resident #16 and care plans updated accordingly. o MDS/CCS/ADON will review all residents that smoke to ensure their smoking assessment is updated, accurate, and care planned on 02-12-2024. o Smoking items were removed from Resident #21 and Resident #5 rooms and/or person. An assessment was completed by MDS on 02-12-2024 to determine if resident #5 is safe to smoke. Residents deemed safe to smoke may keep smoking items on their person. o Ad Hoc QA will be completed on 02-12-24 at 6:15pm by IDT team to include Medical Director. o CCS completed training on facility resident smoking policy with ADM and ADON on 02-12-2024. This in-servicing will include ensuring residents deemed unsafe to smoke unsupervised do not have any smoking items on their person, that they have a staff member to supervise while smoking, and residents are not to hold/light smoking items for other residents who are unable to do themselves. o ADM and ADON will retrain all facility staff on facility resident smoking policy on 02-12-2024. Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This in-servicing will include ensuring residents deemed unsafe to smoke unsupervised do not have any smoking items on their person and that they have a staff member to supervise while smoking. The process for making staff aware of residents who require supervision is via a smoking list that is posted at each nurse's station. Additionally, staff are designated to supervised resident smoke breaks and have been notified of times and designation. This training also included which residents need smoking apron. Lastly, the training included no having a resident hold/light smoking items for residents who are unable to themselves. o Medical Director, notified by Facility Administrator on February 12, 2024, regarding the facility alleged failure to follow facility smoking policy. o Administrator/designee notified ombudsman of the failure to follow facility resident smoking policy. o MDS/CCS/ADON will review all residents that smoke to ensure their smoking assessment is updated, accurate, and care planned on 02-12-2024. o Administrator/designee will round entire facility on 02-12-2024 to ensure no smoking items are unsecured. o The above training material will be incorporated into the new hire orientation by Administrator on February 12, 2024, and ongoing. This material will include the facility resident smoking policy and procedures. On 02/14/2024 the surveyor conformed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of the resident council minutes, dated 02/12/2024, revealed the smoking policy was reviewed. 2. Record review of Resident's #16, #21, #56, #46, #18, #25, #9, #11, #53, #39, #6, #13, #31, #51, #47, #23, and #5 smoking assessments were updated on 02/12/2024. Resident's #2 and #41 smoking assessments were updated on 02/13/2024. 3. Record review of Resident's #16, #21, #56, #46, #18, #25, #9, #11, #53, #39, #6, #13, #31, #51, #47, #23, #5, #2, and #41 care plans were updated, to reflect current smoking status and level of supervision, between 02/12/2024 and 02/13/2024. 4. During an observation and interview on 02/14/2024 at 8:56 AM, Resident #5's smoking materials were kept at the 300 Hall nurses' station. The ADON stated Resident #21 was reassessed and deemed safe to smoke unsupervised, so she was able to keep her smoking materials. 5. Record review of the Ad Hoc QA meeting, held 02/12/2024 at 6:15 PM, revealed the Administrator, CCS, Medical Director, and Executive Director were in attendance, to discuss the immediate jeopardy situation and plan of removal. 6. During an interview on 02/14/2024 beginning at 11:44 AM, the Medical Director stated he attended the ad hoc QA meeting on 02/12/2024 and was notified of the IJs and the measures that were being implemented to correct the problems. 7. During an interview on 02/14/2024 beginning at 12:02 PM, the ADON stated she was provided education on ensuring residents who were deemed unsafe to smoke, did not smoke unsupervised or have any smoking materials on their person. The ADON was further educated on not allowing other residents to hold or light cigarettes for residents who were unable to do it themselves. 8. During an interview on 02/14/2024 beginning at 12:15 PM, the Administrator stated she was provided education on ensuring residents who were deemed unsafe to smoke, did not smoke unsupervised or have any smoking materials on their person. The Administrator stated she was further in-serviced on not allowing other residents to hold or light cigarettes for residents who were unable to do it themselves. 9. Record review of the Facility Smoking Policy in-service training report, dated 02/12/2024, revealed the ADON and Administrator were provided education on the smoking policy to include: Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room or area. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. The training report further revealed education was provided on Staff must ensure all unsupervised or unsafe residents are supervised. Staff must follow facility smoking schedule. Staff must ensure all smoking paraphernalia for supervised residents are stored in a secure room. 10. During interviews on 02/14/2024 between 8:44 AM and 12:33 PM, CNA B, LVN A, AD, Cook C, CNA D, HR, RN E, CNA G, MDS Coordinator, LVN H, CNA K, CNA L, RN O, LVN P, CNA M, BOM, DA N, LVN Q, DA R, CNA S, CNA T, MA V, MA W, Cook X, MA Y, DA Z, RN AA, CNA BB, DM, Housekeeping Supervisor, Housekeeper CC, DOR, LVN DD, ST EE, COTA HH, COTA LL, PT KK, Maintenance Supervisor, Housekeeper FF, and Housekeeper GG were able to verbalize residents who required supervision with smoking, were only able to smoke at designated smoking times with designated staff, which were posted at the nurses station. The staff were able to verbalize residents who required supervision with smoking were not able to have smoking materials on their person and needed a smoking apron while smoking. The staff were able to verbalize other residents were not allowed to hold or light smoking items for other residents who were unable to do it themselves. 11. Record review of the Facility Smoking Policy in-service training report, dated 02/12/2024, revealed CNA B, LVN A, AD, Cook C, CNA D, HR, RN E, CNA G, MDS Coordinator, LVN H, CNA K, CNA L, RN O, LVN P, CNA M, BOM, DA N, LVN Q, DA R, CNA S, CNA T, MA V, MA W, Cook X, MA Y, DA Z, RN AA, CNA BB, DM, Housekeeping Supervisor, Housekeeper CC, DOR, LVN DD, ST EE, COTA HH, COTA LL, PT KK, Maintenance Supervisor, Housekeeper FF, and Housekeeper GG were provided education on the smoking policy to include: Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room or [TRUNCATED]

Based on observations, interviews, and record review the facility failed to follow their own established smoking policy for the 1 of 1 smoking area reviewed for smoking policies. 1. The facility failed to ensure Resident's #56 and Resident #16 were supervised and wore a smoking apron during the smoking times. 2. The facility failed to ensure Resident #21 was supervised during the smoking times. 3. The facility failed to ensure Resident #5, and Resident #21 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #25 was re-assessed for smoking safety after he lit a cigarette in the building on 01/12/2024. 5. The facility failed to ensure cigarette butts were disposed of properly. An IJ was identified on 02/12/2024 at 1:53 PM. While the IJ was removed on 02/14/2024, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm due to the facility's needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking. The findings included: 1. Record review of the facility's policy revised 08/11/2020, titled, Facility Smoking Policy, indicated, Safe Smoking Environment It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors, and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: o Residents who smoke, including possible adverse effects on treatment o Passive smoke to others o Fire . The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, ward, or compartment within facility with exception being the designated smoking room on first floor. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with non-smoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely . Residents who are deemed safe will be allowed to smoke unsupervised and may be permitted to keep cigarettes and/or lighter on their persons. If resident is deemed unsafe, they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials (e.g., cigarettes, E-Cigarettes, pipes, matches. lighters. lighter fluid) and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted, and resident will be required to smoke with supervision only, according to schedule. Smoking Infraction o The first infraction of the smoking policy results in a warning. This warning may be verbal. The warning is given to both the resident and their family member of contact. A safe smoking reassessment of that resident is performed to determine supervision required. o The second infraction of the smoking policy may result in notice of discharge. The reason for discharge would be endangerment to the health and safety of residents. 2. Record review of the face sheet, dated 02/15/2024, revealed Resident #56 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis and an inability to move all four arms and legs). Record review of the admission MDS assessment, dated 10/17/2023, revealed Resident #56 had clear speech and was understood by staff. The MDS revealed Resident #56 was able to understand others. The MDS revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #56 had no behaviors or refusal of care. The MDS revealed Resident #56 was dependent on staff for all ADLs. Record review of the comprehensive care plan, initiated on 01/09/2024, revealed Resident #56 was at risk for injury due to his smoking preference. The goals included: I will not smoke without supervision through next review period. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas, and policy as needed. Record review of the Smoking Safety Evaluation, dated 12/07/2023, revealed Resident #56 required supervision and a smoking apron when smoking because he had upper and lower extremity limitations. The evaluation further revealed he was not able to safety light his cigarette, did not hold the cigarette safely, did not dispose of ashes in the ashtray, did not respond quickly to fallen ashes, and was unable to extinguish his cigarette. 3. Record review of the face sheet, dated 02/15/2024, revealed Resident #16 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of paraplegia (form of paralysis that affects the lower half of the body) and chronic pain syndrome (persistent or intermittent pain that last for more than 3 months). Record review of the annual MDS assessment, dated 09/22/2023, revealed Resident #16 had clear speech and was understood by staff. The MDS revealed Resident #16 was able to understand others. The MDS revealed Resident #16 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #16 had no behaviors or refusal of care. The MDS revealed Resident #16 currently used tobacco. Record review of the comprehensive care plan, revised 04/21/2023, revealed Resident #16 was at risk for injury due to his smoking preference. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas, and policy as needed. The interventions further included: evaluate my smoking safety ability and provide appropriate interventions as indicated and allow me to smoke unsupervised. Record review of the Smoking Safety Evaluation, dated 05/12/2023, revealed Resident #16 required supervision and a smoking apron while smoking because he did not remove oxygen tubing while in the smoking area. 4. Record review of the face sheet, dated 02/15/2024, revealed Resident #21 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of encephalopathy (damage or disease that affects the brain structure or function), seizures (sudden, uncontrolled burst of electrical activity in the brain), and early onset Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Record review of the annual MDS assessment, dated 11/15/2023, revealed Resident #21 had clear speech and was understood by staff. The MDS revealed Resident #21 was able to understand others. The MDS revealed Resident #21 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #21 had no behaviors or refusal of care. The MDS revealed Resident #21 currently used tobacco. Record review of the comprehensive care plan, revised 12/14/2023, revealed Resident #21 was at risk for injury related to her smoking preference. The interventions included: Educate me and encourage me to follow facility smoking times, designated smoking areas and policy as needed. Record review of the Smoking Safety Evaluation, dated 12/08/2023, revealed Resident #21 required supervision while smoking because of her problematic long-term memory. 5. Record review of the face sheet, dated 02/15/2024, revealed Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of injury of the cervical spinal cord (neurological injury to spinal cord closes to the head and neck) and complete amputation (surgical removal) of both his legs. Record review of the annual MDS assessment, dated 07/17/2023, revealed Resident #5 had unclear speech and was usually understood by staff. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 currently used tobacco. Record review of the comprehensive care plan, revised 08/01/2023, revealed Resident #5 was at risk for injury due to his smoking preference. The goals included: I will not smoke without supervision through next review period. The interventions included: educate me and encourage me to follow facility smoking times, designated smoking areas and policy as needed. Record review of the Safety Smoking Evaluation, dated 12/07/2023, revealed Resident #5 required supervision and a smoking apron while smoking because he had problematic short and long-term memory, weak grasps, in which he dropped items, diminished reflex response, did not safely light his cigarette, and did not dispose of ashes in the ashtray. The evaluation did not address the storage of his smoking materials. 6. Record review of a face sheet dated 02/15/2024 indicated Resident #25 was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included psychotic disorder with delusions due to known physiological condition (mental disorder which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #25 was able to make himself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #25 did not have inattention, disorganized thinking, or altered level of consciousness. Resident #25's mood interview did not indicate he had little interest or pleasure in doing things or felt down, depressed, or hopeless. The MDS assessment did not indicate Resident #25 hallucinated or had delusions and did not indicate physical, verbal, or other behavioral symptoms or rejection of care. The MDS assessment did not indicated Resident #25 wandered. The MDS assessment indicated Resident #25 was independent with eating, required set-up or clean-up assistance with oral hygiene, resident refused toileting hygiene, dependent with shower/bathe self, lower body dressing, personal hygiene, and substantial/maximal assistance required for upper body dressing. The MDS assessment indicated Resident #25 was independent with sitting to lying and lying to sitting on the side of the bed and required supervision or touching assistance with sitting to standing. The MDS assessment indicated Resident #25 was able to wheel himself independently 150 feet. Record review of Resident #25's care plan last revised 11/16/2023 indicated the following focuses: 08/22/22 Resident was seen by staff taking other residents' cigarettes from the nursing station and retaliated against staff for stating factual information and stated staff would not give him medications/cigarettes. Resident is non-compliant with facility smoking policy. 10/10/22 one on one implemented daily every 15-minute checks at bedtime. 01/12/24 Resident was smoking in the building. Resident #25 is at risk for injury due to his smoking preference. Resident #25's interventions included to educate and encourage him to follow the facility's smoking times, designated smoking areas and policy as needed, to educate him on the risk of smoking and hazards, and to evaluate his smoking safety ability and provide appropriate interventions as indicated and allow him to smoke unsupervised last revised 11/16/2023. Record review of Resident #25's Smoking Safety Evaluation dated 12/07/2023 indicated he could smoke unsupervised. There was no Smoking Safety Evaluation completed on or after 01/12/24. Record review of Resident #25's progress notes indicated: 01/12/2024 RN AA indicated at the beginning of my morning round, resident from 100 hall, observed at the end of 400 hall. this nurse headed to check 400 hall residents and smelled of cigarette the whole 400 hall this nurse finds this resident at the end of 400 hall smoking a cigarette resident hid his cigarette and said that I was reading a book. residents' room (400 hall) was closed. Resident came back from 400 hall to the dining room. This nurse, medication aide and HR and dietary supervisor was at hallway. dietary supervisor took cigarette away from resident. This nurse notified immediately the Administrator and DON. This nurse educated resident about the risk factor of smoking inside the building and explain that residents in use oxygen are at risk for fire. resident regretted and explained that I am going to stop it and said I'm sorry. resident aware not to smoke inside the building. resident verbalized understand. Will continue to monitor. During an observation on 02/11/2024 at 9:47 AM, Resident #21 was smoking in the designated smoking area unsupervised. There were multiple cigarette butts on the ground in the designated smoking area. During an interview on 02/11/2024 at 2:55 PM, Resident #25 said he did not require supervision when smoking and he smoked unsupervised. During an interview on 02/11/2024 at 3:34 PM, LVN P said on 01/27/2024 they found a pack of cigarettes in Resident #25's room, which he was not supposed to have. LVN P said the Administrator took the cigarettes from him. LVN P said Resident #25 had manipulative behaviors to get what he wanted. LVN P said Resident #25 was not supposed to be smoking unsupervised because he was caught smoking in the hallway a couple months ago. LVN P said they tried to watch Resident #25 more closely and after the incidents occurred, he was placed on 15-minute watch. LVN P was unable to specify for how many hours/days the 15-minute watches were maintained. During an observation and interview on 02/11/2024 between 4:08 PM to 4:35 PM, Resident #56 and Resident #16 were in the designated smoking area. Resident #16 was holding his cigarette and after taking approximately 2 or 3 puffs, he placed the cigarette up to Resident #56's mouth for him to take a few puffs. There was no staff supervision in the smoking area during this time and no smoking apron were worn or available in the smoking area. Resident #16 stated the residents did things like holding cigarettes for other residents to help each other out. Resident #21 entered the smoking area, pulled out her materials, and lit her cigarette and began smoking, unsupervised by staff. Resident #56 had small hole, the size of a cigarette tip, on his blanket that was pulled up near his face. At approximately 4:25 PM, all the residents left the smoking area except Resident #56. Resident #56 was unable to get back into the building as he was unable to move his arms or legs or operate his wheelchair. Resident #56 stated he was waiting on the CNA from his hall to come get him. Resident #56 stated the facility staff assisted him outside. Resident #56 stated that was the first time he had to wait in the smoking area for staff to assist him. Facility staff arrived at approximately 4:34 PM to assist Resident #56 back into the building. During an interview on 02/11/2024 beginning at 4:46 PM, the ADON stated some resident's needed supervision during smoking breaks and some residents did not. The ADON stated Resident #5 and Resident #56 were 2 of the 4 residents who required supervision. The ADON stated the residents who required supervision went to smoke during the designated smoking times. The ADON stated Resident #56 was non-complaint with the supervision and went outside when he wanted to. The ADON stated she instructed staff to encourage Resident #56 to allow someone outside with him while he was smoking. During an interview on 02/11/2024 at 4:53 PM, Anonymous #1 said Resident #25 usually smoked outside unsupervised. Anonymous #1 said to her knowledge there had not been any injuries related to the residents smoking unsupervised. Anonymous #1 said Resident #5, Resident #16, Resident #21, and Resident #56 smoked unsupervised. #1 said she had told the nurses and they said they already knew about it. Anonymous #1 said she did not continue to voice her concerns because she was afraid of retaliation. During on observation on 02/11/2024 at 6:00 PM, Resident #21 was sitting outside in the front of the building, smoking a red-tipped cigarette unsupervised by facility staff. During an interview on 02/12/2024 at 7:49 AM, RN O said there were some alert and oriented residents that were able to smoke unsupervised. RN O said they had a smoke schedule for the residents that required supervision and staff were supposed to accompany them when they were smoking. RN O said there were some residents that could sign themselves out and smoke at any time they wanted to. RN O said Resident #25 went outside to smoke unsupervised. RN O said Resident #25 was not supposed to have his smoking paraphernalia on him, but sometimes they would find it on him. RN O said sometimes the family brings the residents smoking paraphernalia, and the residents kept it. RN O said some residents required a smoking apron for their safety so they couldn't burn themselves. RN O said the residents should not keep smoking materials because they had people on oxygen, and it could cause a fire. During an interview on 02/12/24 beginning at 7:54 AM, CNA U stated the residents who smoked had a schedule for certain times that staff would have accompanied them outside. CNA U stated the CNAs were responsible for taking the residents who required supervision out to smoke after breakfast, but she was unsure of the time. CNA U stated the residents usually went out to smoke on their own. CNA U stated Resident #56, Resident #16, and Resident #21 required supervision during smoking times. CNA U stated she had not observed any holes in their clothing or blankets. CNA U stated some residents could have had their smoking materials on them but some of them kept their smoking materials in the bag that was kept at the 100 Hall nurse's station. During an interview on 02/12/2024 beginning at 8:02 AM, Resident #21 was sitting on the edge of her bed in her room. Resident #21 had a small, red box of cigarettes on her bedside table. During an interview on 02/12/2024 beginning at 8:14 AM, LVN F stated the residents had designated smoking times. LVN F stated some residents required supervision. LVN F stated different staff were responsible for taking the residents to smoke at different times. LVN F stated she has observed staff taking the residents outside. LVN F stated Resident #56 was the only resident on 200 Hall that required supervision. LVN F stated some residents were able to keep their smoking materials and some kept them at the nurse's station. LVN F stated she had not noticed any holes in blankets or clothing. LVN F stated there had been no incidents involving cigarette burns. During an interview on 02/12/2024 beginning at 8:27 AM, Cook C stated the DAs sometimes assisted the residents out to smoke. During an interview on 02/12/2024 beginning at 8:29 AM, DA R stated she did not take the residents outside to smoke and was unsure who was responsible. DA R stated the DM would have known. During an interview on 02/12/2024 beginning at 8:32 AM, the DM stated the dietary staff used to take the residents outside to smoke in the morning. The DM stated but since the dietary department had to cut back on their budget, she had to cut the hours, which caused them to have to cut back on some duties they were no longer able to do, such as taking the residents out to smoke. During an interview on 02/12/2024 beginning at 8:45 AM, CNA RR stated the facility had a smoking schedule and it did not change. CNA RR stated the staff was supposed to keep the cigarette lights and residents were supposed to have had their cigarettes locked in a bag or cabinet. CNA RR stated the keys for the locked bag or cabinet should have been kept at the nurse's station. CNA RR stated she had witnessed resident's smoking alone. CNA RR stated the residents knew the code for the smoking doors to get outside. CNA RR stated she feared retaliation for telling the truth. During an interview on 02/12/2024 beginning at 8:54 AM, CNA T stated she had been a CNA at the facility for 4 years and worked the 6-2 and 2-10 shifts. CNA T stated she had witnessed residents smoking alone on both shifts that she worked. CNA T stated residents should have been monitored while smoking but responsible residents could have smoked alone if the resident had signed out at the nurse's desk. CNA T stated she had witnessed residents with cigarettes on their person but thought it was okay because cigarettes were being taken by other residents. CNA T stated residents who smoked should have worn a smoking apron. During an observation and interview on 02/12/2024 beginning at 9:00 AM, RN AA accompanied the surveyor into Resident #5's room. Resident #5 had 2 packs of cigarettes and a cigarette lighter in a yellow bag that was kept inside his room. RN AA stated Resident #5 was not supposed to have kept his cigarettes or lighter on his person. RN AA stated she was unsure who gave Resident #5 the cigarette lighter. Resident #5 stated his family member bought his cigarettes and his cigarette lighter. Resident #5 stated he did not know why he was unable to keep his cigarette lighter because other residents at the facility had their lighters on them when they were smoking. During an interview on 02/12/2024 at 10:42 AM, the Administrator said after the incident on 01/12/2024, where Resident #25 lit a cigarette in the hallway all his cigarettes and smoking paraphernalia were taken away. The Administrator said she believed it was care planned by the Social Worker, and they educated him on not smoking inside the facility. The Administrator said the residents were only supposed to smoke during the scheduled smoking times. The Administrator said the residents that did not require supervision could check themselves out and go off the facility premises to smoke. The Administrator said the residents should not be sharing cigarettes or helping each other to smoke. The Administrator said Resident #25 should not be smoking unsupervised. The Administrator said it was important for the supervised residents to have supervision because they could get burned and harmed. The Administrator said it was important for residents that required supervision to not keep their smoking paraphernalia on them because they could be tempted to smoke without supervision and harm themselves. During an interview on 02/13/2024 at 9:12 AM, the Executive Director said they currently had no DON, and she had left about 2 weeks ago. During an interview on 02/15/2024 at 6:36 PM, the Social Worker said she was responsible for completing the smoking evaluations, and they should be completed quarterly. The Social Worker said she currently did not have a system in place to ensure she was completing the smoking evaluations. The Social Worker said she was aware Resident #25 had lit a cigarette in the building, but she had not completed a smoking evaluation after the incident. The Social Worker said she did not think the smoking policy stipulated the frequency of the smoking evaluations. The Social Worker said she knew she had updated the residents smoking evaluations in June 2023 and December 2023. The Social Worker said it was important to complete the smoking evaluations for the resident's safety and for the safety of the residents around them in the smoking area. During an interview on 02/15/2024 at 6:53 PM, the Executive Director said the Maintenance Director was not available for interview regarding the cigarette butts on the ground because he had left for the day due to a family emergency. The facility's plan of removal was accepted on 12/13/2024 at 3:12 PM and included the following: Immediate Jeopardy Plan of Removal - February 12, 2024 Problem: Action: o CCS/Designee meeting with resident council on February 12, 2024, at 3:05pm to review smoking policy. o Smoking assessments were completed by Corporate Clinical Specialist, MDS and ADON on Resident #56, Resident #21 and Resident #16 and care plans updated accordingly. o MDS/CCS/ADON will review all residents that smoke to ensure their smoking assessment is updated, accurate, and care planned on 02-12-2024. o Smoking items were removed from Resident #21 and Resident #5 rooms and/or person. An assessment was completed by MDS on 02-12-2024 to determine if resident #5 is safe to smoke. Residents deemed safe to smoke may keep smoking items on their person. o Ad Hoc QA will be completed on 02-12-24 at 6:15pm by IDT team to include Medical Director. o CCS completed training on facility resident smoking policy with ADM and ADON on 02-12-2024. This in-servicing will include ensuring residents deemed unsafe to smoke unsupervised do not have any smoking items on their person, that they have a staff member to supervise while smoking, and residents are not to hold/light smoking items for other residents who are unable to do themselves. o ADM and ADON will retrain all facility staff on facility resident smoking policy on 02-12-2024. Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This in-servicing will include ensuring residents deemed unsafe to smoke unsupervised do not have any smoking items on their person and that they have a staff member to supervise while smoking. The process for making staff aware of residents who require supervision is via a smoking list that is posted at each nurse's station. Additionally, staff are designated to supervised resident smoke breaks and have been notified of times and designation. This training also included which residents need smoking apron. Lastly, the training included no having a resident hold/light smoking items for residents who are unable to themselves. o Medical Director, notified by Facility Administrator on February 12, 2024, regarding the facility alleged failure to follow facility smoking policy. o Administrator/designee notified ombudsman of the failure to follow facility resident smoking policy. o MDS/CCS/ADON will review all residents that smoke to ensure their smoking assessment is updated, accurate, and care planned on 02-12-2024. o Administrator/designee will round entire facility on 02-12-2024 to ensure no smoking items are unsecured. o The above training material will be incorporated into the new hire orientation by Administrator on February 12, 2024, and ongoing. This material will include the facility resident smoking policy and procedures. On 02/14/2024 the surveyor conformed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of the resident council minutes, dated 02/12/2024, revealed the smoking policy was reviewed. 2. Record review of Resident's #16, #21, #56, #46, #18, #25, #9, #11, #53, #39, #6, #13, #31, #51, #47, #23, and #5 smoking assessments were updated on 02/12/2024. Resident's #2 and #41 smoking assessments were updated on 02/13/2024. 3. Record review of Resident's #16, #21, #56, #46, #18, #25, #9, #11, #53, #39, #6, #13, #31, #51, #47, #23, #5, #2, and #41 care plans were updated, to reflect current smoking status and level of supervision, between 02/12/2024 and 02/13/2024. 4. During an observation and interview on 02/14/2024 at 8:56 AM, Resident #5's smoking materials were kept at the 300 Hall nurses' station. The ADON stated Resident #21 was reassessed and deemed safe to smoke unsupervised, so she was able to keep her smoking materials. 5. Record review of the Ad Hoc QA meeting, held 02/12/2024 at 6:15 PM, revealed the Administrator, CCS, Medical Director, and Executive Director were in attendance, to discuss the immediate jeopardy situation and plan of removal. 6. During an interview on 02/14/2024 beginning at 11:44 AM, the Medical Director stated he attended the ad hoc QA meeting on 02/12/2024 and was notified of the IJs and the measures that were being implemented to correct the problems. 7. During an interview on 02/14/2024 beginning at 12:02 PM, the ADON stated she was provided education on ensuring residents who were deemed unsafe to smoke, did not smoke unsupervised or have any smoking materials on their person. The ADON was further educated on not allowing other residents to hold or light cigarettes for residents who were unable to do it themselves. 8. During an interview on 02/14/2024 beginning at 12:15 PM, the Administrator stated she was provided education on ensuring residents who were deemed unsafe to smoke, did not smoke unsupervised or have any smoking materials on their person. The Administrator stated she was further in-serviced on not allowing other residents to hold or light cigarettes for residents who were unable to do it themselves. 9. Record review of the Facility Smoking Policy in-service training report, dated 02/12/2024, revealed the ADON and Administrator were provided education on the smoking policy to include: Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room or area. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. The training report further revealed education was provided on Staff must ensure all unsupervised or unsafe residents are supervised. Staff must follow facility smoking schedule. Staff must ensure all smoking paraphernalia for supervised residents are stored in a secure room. 10. During interviews on 02/14/2024 between 8:44 AM and 12:33 PM, CNA B, LVN A, AD, Cook C, CNA D, HR, RN E, CNA G, MDS Coordinator, LVN H, CNA K, CNA L, RN O, LVN P, CNA M, BOM, DA N, LVN Q, DA R, CNA S, CNA T, MA V, MA W, Cook X, MA Y, DA Z, RN AA, CNA BB, DM, Housekeeping Supervisor, Housekeeper CC, DOR, LVN DD, ST EE, COTA HH, COTA LL, PT KK, Maintenance Supervisor, Housekeeper FF, and Housekeeper GG were able to verbalize residents who required supervision with smoking, were only able to smoke at designated smoking times with designated staff, which were posted at the nurses station. The staff were able to verbalize residents who required supervision with smoking were not able to have smoking materials on their person and needed a smoking apron while smoking. The staff were able to verbalize other residents were not allowed to hold or light smoking items for other residents who were unable to do it themselves. 11. Record review of the Facility Smoking Policy in-service training report, dated 02/12/2024, revealed CNA B, LVN A, AD, Cook C, CNA D, HR, RN E, CNA G, MDS Coordinator, LVN H, CNA K, CNA L, RN O, LVN P, CNA M, BOM, DA N, LVN Q, DA R, CNA S, CNA T, MA V, MA W, Cook X, MA Y, DA Z, RN AA, CNA BB, DM, Housekeeping Supervisor, Housekeeper CC, DOR, LVN DD, ST EE, COTA HH, COTA LL, PT KK, Maintenance Supervisor, Housekeeper FF, and Housekeeper GG were provided education on the smoking policy to include: Smoking is prohibited in any room, ward, or compartment within the facility with exception being the designated smoking room or area. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. The training report further revealed education was provided on Staff must ensure all unsupervised or unsafe residents are supervised. Staff must follow facility smoking schedule. Staff must ensure all smoking paraphernalia for supervised residents a [TRUNCATED]

Based on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 63 (Resident #42) residents reviewed for quality of care. The facility failed to identity and treat timely Resident #42 wound on right lower leg. Wound was noted on Resident #42's right lower leg on 2/11/24. The facility did not address the wound until 2/12/24. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization . The findings included: Record Review of Resident #42's face sheet dated 2/21/24 at 8:16 a.m., indicated Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of congestive and diastolic heart failure (heart is unable to pump enough force to push enough blood into circulation), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), Cellulitis (a serious bacterial infection of the skin, usually affects the leg and the skin appears as swollen and red and painful), hypertension (high blood pressure), and changes in skin texture. Record Review of Resident #42's MDS assessment dated [DATE] indicated, Resident #42 usually understood others and usually made himself understood. The MDS assessment indicated Resident #42 had a BIMS score of 15, which indicated Resident #42 was cognitively intact. The MDS assessment indicated Resident #42's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #42's care plan, revised on 1/16/24, indicated Resident #42 had potential impairment to skin integrity Related to history of burns and fragile skin. The care plan dated on 1/1/23 indicated a wound to Resident #42's left leg. The Care plan interventions did not indicate oxygen concentrator filter change or cleaning. The care plan interventions for Resident #42 indicated, Follow facility protocols for treatment of injury, avoid scratching, and keep hands and body parts from excessive moisture. Keep fingernails short, left leg clean with normal saline, pat dry, apply santly collagenase, apply sock 0.4 Dakin solution, AND cover with abdominal gaze pad wrap with kefix gauze. The care plan did not indicate Resident #42's wound to right leg. During an observation and interview on 2/11/24 at 10:21 a.m., Resident #42's legs were red in color on the left and right inner calf. Resident #42 had an open wound on his right leg inner calf. Resident #42's right leg was draining a clear substance. Resident #42's wound was not dressed. Resident #42 stated she did not know that she had an open wound on her right leg. Resident #42 stated she was in pain because of her legs. Resident #42 stated she did not inform staff that she was in pain. Resident #42 stated the nursing staff were dressing both legs daily. Resident #42 stated the wound care treatment cream that was placed on his legs burned her legs and caused more pain. Resident #42 stated she did not inform staff that the cream placed on her legs burned. During observation and interview on 2/12/24 at 4:25 p.m., Resident #42's wound was not dressed. Resident #42 had a wound on the right leg that appeared red in color and was draining a clear substance. On a scale of 0 to 10, with 0 meaning no pain and 10 meaning the worst pain ever felt, Resident #42 stated her pain level was at a scale of 8. Resident #42 stated she notified staff because she had leg pain, and the staff gave her pain medication. Resident #42 stated she was still in pain, but the pain was tolerable after she received her pain medication. Record Review of active orders for Resident #42 dated 10/19/2022 indicated, Resident to have weekly skin check. Record Review of active orders for Resident #42 dated 1/12/24 indicated, Left leg clean with non-sterile, pat dry, apply santly collagenase, apply sock 0.4 Dakin solution, AND cover with abdominal gauze pad wrap with kefix gauze every day shift for wound care. Record Review of the order summary report dated 2/12/24 did not indicate active orders to address unidentified wound on Resident #42's right leg. Record Review of the facility's wound log report received on 2/12/24 indicated, Resident #42 was not listed as having an identified wound on her right leg. Record Review of the wound progress note dated 2/12/24 indicated, There was a 2xl.5x0 wound noted on the right leg of the resident. It was draining and had odor and redness around the wound. The wound was treated, and the Resident medicated with pain medication and Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Note Text: Trimethoprim) stat order. Patient became more comfortable with the call light within reach. Record Review of the skin assessments dated 2/1/24 at 5:00 p.m., indicated, Resident #42 a selection of Yes was selected on if Resident #42 had skin issues, a selection of No' was indicated for no new skin issues and for wound observation assessment, or skin observation tool stated a selection of Not applicable was selected. The assessment did not indicate wound on Resident #42's right leg. Record Review of the wound assessment dated [DATE] at 5:55 p.m., indicated, Resident #42 had a wound on Resident #42 right leg and wound was acquired at the facility. The wound assessment description indicated, The right lower leg has an area measuring 2 in cm (length), 1.5 in cm (width) and 0 in cm (depth) with 100% slough (yellow, tan, white, stringy). The assessment indicated the facility was getting doppler completed on Resident #42 on 2/12/24 at night. The assessment indicated the wound was not foul or loud. The assessment indicated peri wound tissue was edematous. The assessment indicated the wound edges were intact. The assessment indicated infection was suspected. The assessment indicated the signs and symptoms of infection during assessment was Erythema ( Redness of the skin-may be intense bright red to dark red or purple), new or increasing swelling at affected site, fever, increased drainage. The assessment indicated pain associated to Resident #42 wound occurred prior to wound treatment and during wound treatment. The assessment indicated Resident #42 rate of pain was 5. The assessment indicated an updated treatment plan. The assessment indicated dressing was applied. The assessment indicated Wrap her leg loosely. The assessment did not indicate which leg to wrap loosely. The assessment indicated that the wound on Resident #42 was first observed, and no reference was indicated. The assessment indicated the MD was notified on 2/12/24. The assessment indicated the family representative was notified on 2/12/24.The assessment indicated a wound medical doctor referral would be made in the morning of 2/13/24. Record Review of the facility's infection control log received on 2/12/24 indicated, On 1/9/24: Resident #42 had swelling to legs, weeping, and skin irritation; In December of 2023: Resident #42 had swelling; On 11/7/23: Resident #42 had cellulitis, swelling, warmth to bilateral lower extremities, and in September of 2023: Resident #42 had rash to Left lower extremities. Record Review of Resident #42's wound progress note from RN OO dated on 2/12/24 at 8:00 p.m., written during the survey, indicated, There was a 2x1.5x0 wound noted on the right leg of the resident. It was draining and had odor and redness around the wound. The wound was treated, and the resident medicated with pain medication and Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) stat order. Patient became more comfortable with the call light within reach. Record Review of the Radiology doppler results on Resident #42 dated 2/15/24 indicated, Resident #42, Impression:(1) Findings consistent with mild peripheral vascular disease without occlusion, right lower extremity. (2) Findings consistent with moderate peripheral vascular disease without occlusion, left lower extremity. Follow-up magnetic resonance angiogram or Computed tomography angiography's may be obtained as clinically warranted. (3.) Moderate stenosis (50-75%) of the left posterior tibial artery. (4) Mild to moderate plaque is noted within visualized arteries. During an interview on 2/12/24 at 4:30 p.m., RN OO stated she had been employed at the facility for two weeks. RN OO was made aware of Resident #42's wound on her right leg on 2/12/24 by a CNA at the facility during shift change on 2/12/24. The RN OO did not name the CNA who informed her during shift change on 2/12/24. RN OO stated she last saw Resident #42 on 2/9/24 (Friday) and Resident #42 did not have an open wound on her right leg. RN OO stated she did not perform wound care on Resident #42 on 2/9/24. RN OO stated Resident #42's wound on her left leg was an old wound that had healed, dried up. RN OO stated she did not document Resident #42's wounds because Resident #42's left leg wounds were dry and healed. RN OO stated she did not document Resident #42's wounds on her right leg because she was new at the facility. RN OO stated she did not receive training on medical record documentation. RN OO stated she had not completed any in-services since being employed at the facility. RN OO stated she did not inform the ADON, the Physician, or the family member of Resident #42 regarding wound on right leg on 2/12/24. RN OO was not able to inform the state surveyors of when Resident #42's wound was last treated. RN OO stated that Resident #42's wound on the right leg was 1.5 inches long and 2.3 inches wide. The wound appeared to be draining, drainage color was brown and clear, wound appeared to be a Stage 2, (A stage 2 pressure ulcer is characterized by a shallow, open wound that has broken through both the top and bottom layers of the skin). RN OO stated the resident's temperature was 98.2 degrees Fahrenheit. RN OO stated it was important to document wound care so the facility could monitor when there were changes to the wound and if the wound was healing. During an interview with the ADON on 2/12/24 at 4:49 p.m., the ADON stated she and the Administrator oversaw care at the facility. The ADON stated she was not aware of Resident #42's wound on her right leg. The ADON stated Resident #42 did have a wound on her left leg that had healed. The ADON stated Resident #42's wound on her right leg did not appear to be a new wound. The ADON stated Resident #42's wound had an odor with yellow discharge draining from Resident #42's wound. The ADON stated the odor was not a bad odor, but stated the wound did have an odor. The ADON stated Resident #42's wound appeared as if the wound occurred last week around last (Monday) on 2/5/24. During an interview with the ADON on 2/13/24 at 7:39 a.m., the ADON stated she completed a wound care assessment, a skin assessment, gave pain medication to Resident #42, consulted with a wound care specialist, notified the physician, and informed the son of Resident #42's right leg wound. The ADON stated staff should have saw Resident #42's wound prior to the State finding Resident #42's wound. The ADON stated the wound to Resident #42 leg did not appear to be a new wound. The ADON stated the failure of not treating Resident #42 was quality of life, resident could be at risk for septic infection, and pain. During an interview on 2/13/24 at 9:00 a.m., the Regional Administrator stated wound care was oversaw by the ADON. The Regional Administrator stated he was not aware of a wound on Resident #42's right leg. The Regional Administrator stated skin assessments should be completed weekly. The Regional Administrator stated he did not remember if there was a wound on the left leg. The Regional Administrator stated he was not made aware that wound care assessments were not getting completed and the last wound care assessment completed prior to survey was on 12/11/22. During a phone interview on 2/14/24 at 12:04 p.m., the previous DON stated that wound care was her responsibility. The previous DON stated the ADON was responsible for completing wound assessments. The previous DON stated skin assessments were to be completed weekly. The Previous DON stated both she and the ADON were responsible for splitting the halls and ensuring the resident's assessments and competency checks were completed for staff. During an interview on 2/14/24 at 1:35 p.m., the Medical Director stated he just started as the medical director a few weeks ago. The medical director stated he was not made aware of Resident #42's wound on her right leg prior to survey. The Medical Director stated the ADON notified him on 2/12/24 at 6:07 p.m. regarding the wound on Resident #42. The Medical Director stated he stayed informed about the resident's change of conditions by either phone call or text from the administrator, the ADON or the charge nurses. The Medical Director stated the process in place for reporting and documenting changes in a resident's condition documentation were to document orders and progress notes in the resident's medical record. The Medical Director stated the wound care team assessed the resident's wounds, but he was not sure how often . The Medical Director stated if a resident needed wound care that he would put in an order for a wound care consult. The Medical Director stated it was important for the staff to notify regarding resident's medical changes so that, he as the physician, could further assess the resident's needs. The Medical Director stated the Physician Assistant would give the state surveyor a call to discuss the diagnosis of Resident #42. During an interview on 02/15/24 at 11:52 a.m., the Physician Assistant stated, I looked at Resident #42's wound this morning. The Physician Assistant stated, Resident #42 currently had cellulitis and was started on Bactrim DS and was recently changed to doxycycline (a broad-spectrum antibiotic). The Physician Assistant stated she started Resident #42 on an antifungal medication and ordered some lab work. The Physician Assistant stated Resident #42 doppler results revealed Resident #42 had moderate peripheral vascular disease to her left leg and mild peripheral vascular disease to her right leg. The Physician Assistant stated she was going to refer Resident #42 to a vascular surgeon, but Resident #42 was already seeing a vascular surgeon. The Physician Assistant stated she was going to reach out to the vascular surgeon to consult. The Physician Assistant stated if Resident #42 did not improve in the next couple of days, she would send her to the hospital for intravenous antibiotics. The Physician Assistant stated Resident #42 had chronic lymphedema and a history of cellulitis. The Physician Assistant stated she expected staff to perform skin assessments and report new skin issues. Record Review of the facility skin integrity prevention and treatment program revised dated 7/2018, Wound care (a) Will follow the Non-Sterile Dressing Change Competency Protocol b. Emphasizes resident comfort, expectations, and pain management. Adheres to infection control best practices d. If a resident refuses dressing changes/treatments, administrative nursing is notified, and intervenes with education. If refusals continue, a psych evaluation may be warranted and/or physician re-evaluation. Clinicians should document refusals, notification of administrative nursing, the physician, and RP Care Plan should be updated to reflect refusals and attempts to obtain compliance to care Nexion. Record Review of the facility physician services policy revised dated on February 2021 indicated, Supervising the medical care of residents includes (but is not limited to): a. participating in the resident's assessment and care planning; b. monitoring changes in resident's medical status; c. providing consultation or treatment when called by the facility; d. prescribing medications and therapy; e. ordering transfers to the hospital if necessary; f. conducting routine required visits; g. delegating and supervising follow-up visits by non-physician practitioners (Nurse Practitioners, Physician Assistants, Clinical Nurse Specialist's); and h. overseeing a relevant plan of care for the resident. Record Review of the facility Skin Integrity Prevention and Treatment Program policy revised on 2/2022 indicated, Weekly Skin Integrity Checks (a) Weekly assessment looking for new wounds-completed by a licensed nurse (b) Documented on/in Treatment Record (c) If new area found > if pressure injury- complete new wound evaluation / assessment if non-pressure area-complete new wound evaluation / assessment (d) Notify MD-obtain treatment orders (e) Notify RP/ or family if they are RP or Resident has directed family to be updated (f) Update care plan (g) Note on 24 hour report (h) Referrals to therapy, dietician or other consultant as deemed necessary (I) Monitor weekly via weekly wound reporting and skin integrity quality assurance processes; Weekly Wound Assessment (a) Each identified skin issue/area is assessed weekly in electronic medical record (b) If treatment or interventions change or wound presentation is reclassified - update care plan (c) Referrals to therapy, dietician or other consultant as deemed necessary (d) Physician updated (j) RP/ or family if they are RP or Resident has directed family to be updated; Weekly Pressure / Wound QA (a) Conducted with facility QAPI and IDT, (b) Summarized and presented as part of the facility quarterly QA process/meeting

Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 2 of 22 residents reviewed for accidents hazards (Resident #110 and Resident #12). 1. The facility failed to perform a proper transfer on Resident #110 to prevent a fall with major injury (fracture femur). 2. The facility failed to ensure CNA Q and CMA O transferred Resident #12 appropriately using a Hoyer lift. These failures could place residents at risk to have falls and falls with serious injury. Findings include: 1. Consolidated physician orders (no date) for Resident #110 indicated she was a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #110 had a diagnoses of fracture left femur, abnormal gait and mobility and encounter for orthopedic aftercare. Record Review of Resident #110's MDS dated [DATE] indicated she had a BIMS score of 11 for moderately impaired. Section G of the MDS indicated Resident #110 needed extensive assistance with transfers and one-person physical assist. Section G0600 indicated Resident #110 used a wheelchair for mobility. Section I of the MDS indicated resident #110's primary medical condition was fractures and other multiple traumas, and she had an active diagnosis of hip fracture, fracture of left femur and orthopedic aftercare. Section J of the MDS indicated Resident #110 had pain frequently at a scale of 5. Section J2000 indicated Resident #110 had surgery 100 days prior to admission. Record Review of Resident #110's care plan dated 10/20/22 indicated the focus was ADL self-care performance deficit related to impaired balance and femur fracture. No goal was indicated. The intervention included, resident is totally dependent on x1 staff for transferring. Record review of the incident report dated 10/14/22 indicated the ADON was called to Resident #110s room by the restorative aide and found resident sitting in her wheelchair. Resident #110 reported she was getting out of the bed and her leg gave way. Resident was transferred to the hospital. Record review of the nurse's progress note dated 10/14/22 indicated the DON had been called to resident #110s room and she was sitting in her wheelchair and her left thigh was swollen. A cool compress was applied to the site, PA notified, family member notified, and emergency call made to Care flite. Record Review of the discharge paperwork from the hospital dated 10/16/22 on Resident #110 revealed Resident #110 was brought to the ER after an unwitnessed fall at the facility and an x-ray indicated a femur fracture and periprosthetic fracture around the internal prosthetic left hip point. Record review of the in-service training on 10/14/22 for CNA E on transfers and gait belts indicated CNAs should always wear a gait belt when transferring residents that were stand by assist or residents who can bear weight with at least one lower extremity. Record review of the skills check off, dated 11/3/22 for CNA E on incontinent care, handwashing, transfer techniques, mechanical lift scale, wheelchairs, and peri care indicated all areas were met. During a phone interview on 12/12/22 at 3:39 p.m., Resident #110s family member stated two 2 CNAs were transferring the Resident from her bed to the wheelchair and dropped her. Family member reported he was not at the facility when the incident occurred, he was informed by Resident #110 of the incident. Family member stated that resident #110 had dementia and might not be able to recall everything about the incident. Stated the facility had notified him of the fall when it happened, and Resident #110 was hospitalized for 2.5 weeks. Resident #110 was discharged to a different nursing facility after she discharge from the hospital. Family member stated Resident #110 had surgery 3 weeks prior to admission to facility and was admitted to the facility for rehab post hip surgery. Family member stated Resident #110 had an additional fall just a couple of days prior to the incident. During an interview on 12/12/22 at 3:50 p.m. with Resident #110, she stated 2 CNAs attempted to transfer her from the bed to the wheelchair and dropped her while she was hanging in the air. Resident #110 denied having to use a hoyer lift or any other falls prior. Resident #110 stated the CNA's panicked and called for help. During an interview on 12/13/22 at 8:00 a.m., CNA E stated she was walking by Resident #110s room and she saw her sitting up on the side of the bed. CNA E stated, I thought she was going to transfer herself to the wheelchair next to bed, so I went into the room without my gait belt and assisted her before she got up on her own. CNA E stated once Resident #110 was standing and she was holding resident with one hand under her elbow and her other hand was grasping her hand, Resident #110s leg buckled and she lowered her to the floor. CNA E did not know which leg buckled. CNA E stated she then yelled for help and the DON and ADON came to assist her. CNA E stated resident would not stay on the floor and kept trying to get back into her wheelchair. CNA E stated she assisted Resident #110 back into the wheelchair. CNA E stated it was her first day working with Resident #110 and another CNA had given her report that Resident #110 was a 1-person transfer with minimal assist. CNA E did not know how to access the plan of care in the facility tablets. Stated she charted on ADLs in the tablet daily but did not remember seeing any information on how residents were transferred. During an interview and observation on 12/13/22 at 8:29 a.m., LVN H stated physical therapy was responsible for evaluating residents when they were admitted to the facility and for notifying the charge nurse on how to transfer residents correctly. LVN H stated the charge nurse was responsible for communicating to the CNAs on how residents should be transferred. LVN H stated the DON was responsible for completing the resident care plans and used the care plan to make an ADL sheet to hang in residents' rooms. LVN H was unable to find an ADL sheet hung in the room closest to her and stated, Staff was in serviced at one time on having the ADL sheets in resident rooms, but she no longer saw them in the rooms. LVN H stated CNAs had no other place to look that instructed them on how to transfer residents other than communication from the charge nurse. LVN H stated CNAs were responsible for providing information during their 24-hour report on how to transfer new residents. During an interview on 12/15/22 at 8:42 a.m., Nurse A stated gait belts should have been used with all one person transfers to ensure safety. If gait belts are not used, the resident could fall. During an interview on 12/13/22 at 9:30 a.m. with CNA G, stated she always used a gait belt with transfers. CNA G stated every patient had to be evaluated by therapy and that is how the CNAs know how to transfer a resident the right way. CNA G stated she always transferred every resident using 2-person assist and never transferred any residents by herself. During an interview on 12/13/22 at 9:39 a.m. with CNA R, stated the nurses would tell the CNAs how to transfer a new resident. CNA R stated, when she started working with the resident, she could tell how much help the resident would need with transferring. CNA R stated she did not know how to access resident ADL care in the tablets. During an interview on 12/13/22 at 11:40 a.m. with PT, stated they were working with Resident #110 on transfer training to include transfers from the bed to the wheelchair, standing and pivots. PT stated Resident #110 was a 1-person transfer with gait belt and the gait belt should have been used for resident safety and safety for the employees. 2. Record review of Resident #12's order summary report, dated 12/14/2022, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), shaken infant syndrome (brain injury that occurs when a baby or a toddler is shaken violently), and contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.) Record review of Resident #12's MDS assessment, dated 11/05/2022, revealed Resident #12 was rarely/never understood by staff or able to understand staff. The MDS revealed Resident #12 had poor short-term and long-term memory. The MDS revealed Resident #12's cognition was severely impaired. The MDS revealed no behavioral problems. The MDS revealed Resident #12 required total dependence with 2 staff assistance with transfers. The MDS revealed Resident #12 was only able to stabilize with staff assistance during transfers. The MDS revealed impairment to both upper and lower extremities that interfered with daily functions. Record review of Resident #12's comprehensive care plan, last revised 08/08/2022, revealed Resident #12 had an ADL self-care performance deficit. The interventions included: Transfer: The resident is total assist x 2 staff and Hoyer lift. During an observation on 12/12/2022 between 12:11PM and 12:40PM, CNA Q and CMA O transferred Resident #12 from the wheelchair to a shower bed using his shoulders and legs. No incontinent pad, draw sheet, or Hoyer lift pad was used during the observed transfer. Incontinent care was provided by CNA Q and CMA O. CNA Q and CMA O then transferred Resident #12 back from the shower bed to his wheelchair using his shoulders and legs. No incontinent pad, draw sheet, or Hoyer lift pad was used during the observed transfer. During an interview on 12/13/2022 at 8:31 PM, the Rehab Manager stated Resident #12 was transferred using a Hoyer lift. The Rehab Manager stated Resident #12 should never be transferred using his shoulders and his legs. The Rehab Manager stated the failure for transferring Resident #12 inappropriately would be serious injury to Resident #12 or the employees. During an interview on 12/13/2022 at 10:15 AM, CMA O stated Resident #12 was a two-person assistance or a Hoyer lift with transfers. CMA O stated it was appropriate to lift Resident #12 under his shoulders and his legs. CMA O stated the charting system would have the transfer status of each resident. CMA O stated the charting system was not checked prior to transferring Resident #12. During an interview on 12/15/2022 at 2:22 PM, CMA O stated Resident #12 should not have been transferred using his shoulders and legs. CMA O stated the appropriate way to transfer Resident #12 was a Hoyer lift. CMA O stated the failure for transferring Resident #12 without a Hoyer lift was increased risk of serious injury. During an attempted telephone interview on 12/15/2022 at 3:37 PM, CNA Q did not answer the phone. A message was left with no return call before exit. During an attempted telephone interview on 12/15/2022 at 3:59 PM, CNA Q did not answer the phone. A message was left with no return call before exit. During an interview on 12/15/2022 at 4:20 PM, RN K stated Resident #12 was transferred using a Hoyer lift. RN K stated Resident #12 was not transferred under his shoulders and legs. RN K stated the charting system had the transfer status of all residents and should be referred to if a transfer status was unknown. RN K stated the failure for not transferring Resident #12 appropriately, would be serious injury to Resident #12. During an interview on 12/15/2022 at 5:54 PM, the ADON stated Resident #12 was supposed to be transferred using a Hoyer lift. The ADON stated Resident #12 should never be transferred using his shoulders or legs. The ADON stated she expected staff to use the charting system to find the transfer status of each resident. The ADON stated check-off competencies and return demonstrations on appropriate transfers were performed by direct care staff, including CNA Q and CMA O. The ADON stated direct care staff were in-serviced on how to find the transfer status of each resident. The ADON stated the potential harm for transferring Resident #12 inappropriately would be serious injury to Resident #12. During an interview on 12/15/2022 at 6:26 PM, the ADM stated he expected staff to always follow policy and guidelines for safe transfers. The ADM stated if a Hoyer lift was required, he expected it to be used. The ADM stated he expected the staff to verify in the transfer status in the charting system if they were unsure. The ADM stated the failure for transferring Resident #12 inappropriately would be serious injury or accident. Record Review of the Policy on Safe Patient Handling and Moving Protocol reviewed on 10/8/20 indicated the use of gait belt during all weight bearing transfer activities. Under expectation of assessment and communication: In order to ensure the accurate level of assistance is communicated the charge nurse will notify current floor staff providing care; write information on the ADL flow sheet/C.N.A communication sheets or any additional facility specific communication process such as visual identifiers and electronic health record ADL and care guide setup. Observation made on 12/14/22 at 4:02 p.m. of CNA G transfer a resident that was 1-person assist using a gait belt appropriately. During an observation on 12/14/2022 at 4:13 p.m. CNA S and CNA T performed a Hoyer lift transfer with no issues observed. Observation made on 12/14/22 at 4:15 p.m. of CNA F transfer a resident that was 1-person assist using a gait belt appropriately. Observation made on 12/14/22 at 4:26 p.m. of Nurse K transfer a resident from wheelchair to bed appropriately. Observation made on 12/14/22 at 4:30 p.m. of CNA G and CNA F transfer a resident that requires 2-person assist using a hoyer lift and no issues noted. Observation made on 12/14/22 at 4:39 p.m. of the Director of Rehab transfer a resident from bed to wheelchair appropriately. During an observation on 12/14/2022 at 5:15 PM CNA U performed a one-person transfer with the gait belt. No issues were observed. During an interview on 12/15/22 at 10:13 a.m., the ADON stated she should have asked more questions and further investigated the incident when Resident #110 fell . The ADON stated if residents are not transferred correctly it could lead to staff getting hurt or resident injury. During an interview on 12/13/22 at 8:42 a.m., the DON stated therapy had been walking Resident #110 and she was a 1-person transfer with a gait belt. The DON stated CNA E was expected to wear a gait belt when she transferred Resident #110. The DON reported CNAs were expected to follow the plan of care on how to transfer residents correctly and all CNAs had access to tablets. During an interview on 12/15/22 at 11:44 a.m., the ADMIN stated a gait belt should have been used when transferring Resident #110. The ADMIN stated gait belts should always be used for safety and to protect the residents. The ADMIN stated not using gait belts could lead to unsafe transfers and could harm residents.

Based on observation, interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 4 of 12 residents (Residents #26, #16, #14, and #11) reviewed for laboratory services. The facility did not ensure Resident #26 had her [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] levels monitored as ordered by the physician. Resident #26 suffered [CONDITION(S)] activity that lasted 50 minutes on 8/6/21. Stat labs were obtained on 10/12/21 after surveyor intervention. Resident #26's [MEDICATION(S)] level from the 10/12/21 specimen was 45 ug/ml (micrograms per milliliter). The reference range for [MEDICATION(S)] was 10-20 ug/ml. The facility did not ensure Resident #16 had a [MEDICATION(S)] level obtained. The facility did not ensure Resident #14 had a [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)] levels obtained. The facility did not ensure Resident #11 had a [MEDICATION(S)] or [MEDICATION(S)] level obtained. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 5:02 p.m. on 10/12/21. While the IJ was removed on 10/14/21, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of subtherapeutic or toxic levels of [CONDITION(S)] medications. Findings included: 1.Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #26 usually understood others and usually made herself understood. The MDS indicated Resident #26 had moderate cognitive impairment (BIMS of 9); the MDS indicated Resident #26 had rejected care 1-3 days during the 7 day look back period. The MDS indicated Resident #26 required extensive assistance with bed mobility, dressings, eating, toilet use; and personal hygiene. The MDS indicated she always incontinent of bowel and bladder. The MDS indicated Resident #26 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the care plan revised on 7/8/21 indicated Resident #26 had a [CONDITION(S)] disorder and was prescribed [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The care plan interventions included; administer [CONDITION(S)] medications as ordered; obtain lab work as ordered; monitor lab work for subtherapeutic or toxic levels; report results to physician; and follow up as indicated. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient) two times a day related to [CONDITION(S)]. On 10/12/21 this order was discontinued the following new order was written; [MEDICATION(S)] 125mg /ml give 7.5 ml via G-tube once a day related to [CONDITION(S)]. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 4/22/21 and new order with a start date of 4/22/21 was [MEDICATION(S)] 250 mg/5ml give 10 ml via G-tube two times daily for [CONDITION(S)]. This order was still active. Record review of the MAR (medication administration record) for April 2021 indicated Resident #26 had been administered 10 ml of [MEDICATION(S)] (100 mg/ml) via her G-tube three times a day with no missed doses. The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR for May 2021 indicated Resident #26 had been administered 10 ml [MEDICATION(S)] (250mg/ml) twice a day (morning and evening) except for the missed doses on the following date and time; 5/4/21 at 9:00 p.m. The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the MAR for June 2021 indicated Resident #26 had been administered 10 ml of [MEDICATION(S)] (100 mg/ml) via her G-tube three times a day with no missed doses. The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *7/14/21 at 2:00 p.m.; *7/16/21 at 2:00 p.m.; *7/19/21 at 2:00 p.m.; and *7/22/21 at 2:00 p.m. Record review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *7/14/21 at 2:00 p.m.; *7/16/21 at 2:00 p.m.; *7/19/21 at 2:00 p.m.; and *7/22/21 at 2:00 p.m. Record Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR (medication administration record) for September 2021 indicated Resident #26 had been administered 10 ml of [MEDICATION(S)] (100 mg/ml) via her G-tube three times a day except for a missed dose on 9/16/21 at 2:00 p.m. The September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *9/2/21 at 9:00p.m.; and *9/16/21 at 2:00 p.m. Record review of the MAR (medication administration record) for October 2021 (from 10/1/21 to 10/14/21) indicated Resident #26 had been administered 10 ml of [MEDICATION(S)] (100 mg/ml) via her G-tube three times a day with no missed doses. The October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 MAR (from 10/1/21 to 10/12/21) indicated Resident #26 was administered [MEDICATION(S)] 7.5ml (125mg/ml) via her G-tube two times a day with no missed doses. The October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 6/17/21. The order recap report indicated Resident #26 had and order on 3/10/21 to obtain [MEDICATION(S)] and [MEDICATION(S)] levels now (3/10/21) and then every four months. This order was discontinued, and a new order was written on 4/16/21 to obtain [MEDICATION(S)] and [MEDICATION(S)] levels now (4/16/21) and then every four months. This order was discontinued, and a new order was written 6/17/21 to obtain [MEDICATION(S)] and [MEDICATION(S)] levels now (6/17/21) and then every four months. This order was still active. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order recap report indicated Resident #26 continued to have an active order for [MEDICATION(S)] and [MEDICATION(S)] levels every four months since 6/17/21. Record review of Resident #26's EMR (electronic medical record) for lab results on 10/12/21 indicated Resident #26 had a [MEDICATION(S)] level of 35 ug/ml on 7/30/21. The normal range for [MEDICATION(S)] was 10-150 ug/ml. The lab results indicated Resident #26 had a [MEDICATION(S)] level of 14.9 mg/L (milligrams per liter) on 11/20/20. The normal range for [MEDICATION(S)] was 10-20 mg/L (mg/L is equivalent to ug/ml). The lab results listed no result of a [MEDICATION(S)] level. During an interview and observation on 10/12/21 at 9:30 a.m., Resident #26 was laying in her bed. Resident #26 said she did not know when she last had lab work. During an interview on 10/12/21 at 10:12 a.m., the ADON said there were no additional lab results for [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)] levels for Resident #26. The ADON said she did not have an explanation as to why there were not any current labs for the [MEDICATION(S)] and [MEDICATION(S)] levels. Record review of Resident #26's nursing notes from 1/1/21 to 10/14/21 indicated Resident #26 had seizures on the following dates and times; *4/3/21 at 10:33 p.m. (duration 5 minutes documented by LVN C); *7/2/21 at 10:00 p.m. (duration 15 seconds documented by LVN B); and *8/6/21 at approximately 5:55 p.m. (duration 50 minutes documented by the DON). During an interview on 10/12/21 at 10:19 a.m., LVN A said he worked Monday through Friday on the 6:00 a.m.-2:00 p.m. shift and always took care of Resident #26. LVN A said Resident #26's last [CONDITION(S)] had occurred about 2 months ago. LVN A said he was not actually there when the last [CONDITION(S)] occurred and believed it occurred on LVN B's shift. LVN A said he was not sure what her [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)] levels were before the [CONDITION(S)] a couple months ago. He said he was not sure when her last [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)] levels were obtained. LVN A said nurses were responsible to ensure labs were drawn as ordered. LVN A the lab usually just comes and draws what was needed once the order was placed. LVN A said he believed the DON had a system in place to ensure residents who had ordered labs levels, such as levels for [CONDITION(S)] medications, were obtained and followed up on. LVN A said it was important for residents on [CONDITION(S)] medications to have levels monitored because if the levels were too low seizures could occur and if the levels were to high toxicity could occur. LVN A said he had just received a STAT (common medical abbreviation for urgent or rush) order from the ADON to obtain [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] levels for Resident #26 and was about to obtain them. During an interview on 10/12/21 at 11:28 a.m., LVN B said she worked at the facility Tuesday- Friday on the 2:00 p.m.-10:00 p.m. shift and took care of Resident #26 regularly. LVN B said she could not remember when Resident #26's last [CONDITION(S)] was. LVN B said if Resident #26 had orders to have her [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] levels checked it should be done. LVN B said it was important for residents on [CONDITION(S)] medications to have levels monitored because if the levels were too low seizures could occur and if the levels were too high toxicity could occur. She said the DON or ADON were responsible to ensure ordered labs were followed up on. LVN B said she could not remember but was sure she was aware of what Resident #26's [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] levels were when she had documented Resident #26 had a [CONDITION(S)] in July. She clarified; it was so long ago. I can't remember what the levels were but I'm sure I looked During an interview on 10/12/21 at 11:40 a.m., The PA (physician assistant) said residents that were stable (having no seizures with no new [CONDITION(S)] medications or changes in dosage) should have their [CONDITION(S)] medications checked at least twice a year. He said if a resident was still having seizures the medication levels should be checked quarterly. The PA indicated it was important to monitor levels to ensure therapeutic management and avoid toxicity. During an interview on 10/14/21 at 9:00 a.m., LVN C said he worked the 10:00 p.m.- 6:00 a.m. shift and regularly took care of Resident #26. LVN C said if Resident #26 had orders to have her [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] levels checked it should be done. LVN C said it was important for residents on [CONDITION(S)] medications to have their levels monitored because if the levels were too low seizures could occur and if the levels were too high toxicity could occur. LVN C said it had been a long time since Resident #26 had a [CONDITION(S)] and he could not recall what her recent [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)] levels were. LVN C said nurses were responsible to ensure ordered labs were followed up on even though the lab usually draws routine labs. LVN C said he was not sure if he was aware of Resident #26's most recent [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] levels when he documented she had a [CONDITION(S)]. During an interview on 10/14/21 at 10:10 a.m., the DON said she expected nurses to ensure ordered labs were obtained and the physician was notified of the results. The DON said it was important for residents on [CONDITION(S)] medications to have levels monitored because if the levels were too low the medications could be subtherapeutic and the resident's seizures continue and if the levels were too high toxicity could occur. The DON said she was not aware of Resident #26 had no result for [MEDICATION(S)] level on 8/6/21 and no result for [MEDICATION(S)] level since 11/12/20 when she witnessed Resident #26's 50-minute episode of intermittent [CONDITION(S)] activity. The DON said she instructed LVN B to follow up after the event which she felt LVN B would understand to mean notify the physician and obtain orders. The DON said ultimately she was responsible for labs not being obtained as ordered but the ADON had a system in place to follow up on ordered labs. During an interview on 10/14/21 at 11:36 a.m., the ADON said the DON was incorrect when she (the DON) said she (the ADON) had a system to follow up on ordered labs. The ADON said she rounded in the mornings to ask nursing staff what labs the lab had drawn. The ADON said she would track these labs and ensure results were obtained and reported to the physician. The ADON said she did not have a system in place to check for ordered labs that had not been obtained or levels that should be monitored but did not yet have orders in place. The ADON said she assumed the DON had a system in place to track these items. The ADON said she obtained STAT orders for Resident #26 on 10/12/21 when she realized Resident #26 had not had a [MEDICATION(S)] level since 11/12/20 and no [MEDICATION(S)] level could be found. The ADON said it was important the labs were monitored because if the levels were too low the medications could be subtherapeutic and the resident could continue to have seizures that could be prevented and if the levels were too high toxicity could occur. 2. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] indicated Resident#16 does not speak, is rarely/never understood, and rarely never had the ability to understand others. This resident was unable to interview for BIMS test. Resident#16 is severely cognitively impaired. The assessment indicated he did not reject evaluation of care. Resident#16 is totally dependent on staff for all ADLs (Activity of Daily Living). He required a 2 person assist for bed mobility, transfer, dressing, eating and toilet use. Record review of the most updated care plan dated 9/15/2021 indicated Resident#16 required [MEDICATION(S)] for [CONDITION(S)] disorder. The care plan interventions included to give medication, obtain and monitor labs and report any sub therapeutic or toxic results to medical doctor. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview and observation on 10/13/2021 at 2:20 p.m. Resident#16 did not complain of any side effects typically associated with a toxic level of [MEDICATION(S)] (CNS depression, lethargy and [CONDITION(S)], respiratory depression, nausea/vomiting and [CONDITION(S)]). Record review of Resident#16 progress notes from 10/11/2020 to 10/14/2021 did not reveal any notes regarding a seizures or convulsions. No prior lab report for Resident#16's [MEDICATION(S)] level was provided by the facility. (by who?) During an interview on 10/14/2021 at 1025 a.m., LVN F said a level was needed on [MEDICATION(S)] to make sure Resident#16 did not receive a toxic amount, or not enough to be effective. She said if there was no order for this the level, the nurse would call the doctor. She said the new order would be put in Point Click Care and on the 24-hour report. The order would be placed in the lab collection book for the contracted lab company to obtain the specimen. 3. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] Resident#14 could usually make himself-understood and could usually understands others. He was assessed to be moderately cognitively impaired, with a BIMs score of 11. The assessment indicated Resident#14 did not reject care. He required one person assist with dressing, personal hygiene and setup help with toileting and eating. Resident#14 required total dependence with showering. The assessment indicated Resident#14 received antipsychotic medication on a routine basis. Record review of the most updated care plan dated 09/01/2021 indicated Resident#14 required [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] for [CONDITION(S)] disorder. The care plan included to give medication as ordered, obtain and monitor lab/diagnostic work as ordered and report any sub therapeutic or toxic levels to MD. Record review of Resident#14 progress notes from 10/10/2020 to 10/13/2021 did not reveal any notes regarding a seizures or convulsions. The most recent lab report obtained from the facility dated 05/25/2021 for Resident#14 indicated [MEDICATION(S)] level of 24.2 ug/mL, or micrograms per milliliter The proposed therapeutic range for [CONDITION(S)] control is 5-30 ?g/mL [MEDICATION(S)] level of 24 mcg/ml (microgram per milliliter) The therapeutic range for [MEDICATION(S)] is 50-100 mcg/mL The toxic level is >100 mcg/mL. A lab report dated 5/31/2021 indicated a [MEDICATION(S)] level of 20.5 (therapeutic ranges for most adults have been established at 10.0-20.0 mcg/mL). During an interview and observation on10/13/2021 at 2:04 p.m., Resident#14 denied having any symptoms and none were observed (Unusual weight gain or loss. tremors. blurred or double vision, uncontrolled eye movements. Mood swings) of toxic levels of [MEDICATION(S)]. Resident#14 denied any symptoms, and no signs were observed of [MEDICATION(S)] toxicity (fast, uncontrollable eye movements or double vision, dizziness, drowsiness, or confusion, lack of coordination of fingers, hands, arms, legs, or body, slurred speech, nausea or vomiting, or decreased appetite, decreased activity, abdominal bloating). During an interview on 10/14/2021 at 10:20 a.m., LVN F said lab levels are needed on [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] to prevent toxic levels, and ensure a dosage that was effective. She said if there was no lab level ordered, the nurse would call doctor for an order. The new order would be part of the 24-hour report to ensure that it was collected in a timely manner. The order would be placed in the lab collection book for the contracted lab company to obtain the specimen 4. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] revealed Resident#11 made himself understood, understands others, and is cognitive intact. He required 2 persons assist to walk in his room and is not steady on his feet. Resident#11 uses a cane/walker and wheelchair for mobility. Resident#11 required 2 persons assist for toileting and personal hygiene. Record review of the most updated care plan dated 08/31/2021 indicated Resident#11 requires [MEDICATION(S)] for [CONDITION(S)] disorder. The care plan interventions include: to give medications as ordered, monitor labs and report any sub therapeutic or toxic results to MD, monitor lab/diagnostic work as ordered. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & Q3 months related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The order summary report indicated no additional levels for [MEDICATION(S)] and [MEDICATION(S)]. Record review of Resident#11 progress notes from 10/12/2020 to 10/13/2021 did not reveal any notes regarding seizures or convulsions. No lab report of the most recent levels for [MEDICATION(S)] and [MEDICATION(S)] were listed in Point Click Care EMR (electronic medical record) or provided by the facility staff on 10/13/2021. During an interview on 10/13/2021 at 2:22 p.m., Resident#11 said he had [CONDITION(S)] the past 2 months. He denied any other symptoms at this time. No signs (CNS depression, lethargy and [CONDITION(S)], respiratory depression, nausea/vomiting and [CONDITION(S)]) of [MEDICATION(S)] toxicity were observed. Resident# did not show any signs/symptoms of [MEDICATION(S)] toxicity (extreme drowsiness, agitation, aggression, shallow breathing, weakness, or [CONDITION(S)]). During interview on 10/14/2021 at 10:20 a.m., LVN F said lab levels were necessary for [MEDICATION(S)], and [MEDICATION(S)] to ensure resident did not receive toxic level or not enough medication to be effective. LVN F said the nurse would call the doctor if there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order would be placed in the lab collection book for the contracted lab company to obtain the specimen. During an interview on 10/14/21 at 10:10 a.m., the DON said she expected nurses to ensure ordered labs were obtained and the physician was notified of the results. The DON said it was important for residents on [CONDITION(S)] medications including Resident #16, #14, #11, and #26 to have levels monitored because if the levels were too low the medications could be subtherapeutic and the resident's seizures continue and if the levels were too high toxicity could occur. During an interview on 10/14/21 at 11:44 a.m., the Administrator said she expected nurses to ensure labs were obtained as ordered/needed for residents on [CONDITION(S)] medications including Resident #16, #14, #11, and #26. The Administrator said, ultimately it was the DON's responsibility that the labs were not obtained. Record review of the facility's policy and procedure titled Lab and Diagnostic Results revised November 2018 stated, .(1) The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. (2) The staff will process test requisitions and arrange for tests .(4) A nurse will try to determine whether the test was done: (a) as a routine screen or follow up; (b) to assess a condition change or recent onset of signs and symptoms; or (c)To monitor a drug level. (1) the reason for getting a test often affects the urgency of acting upon the result. (2) If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms .Identifying Situations that Warrant Immediate Notification .(2) High or toxic serum medications If a test was obtained to monitor the blood level of a medication and the level is reported as high(above therapeutic range) or toxic the nurse will notify the physician promptly . Record review of The National Center for Biotechnology part of the United States National Library of Medicine (NLM) a branch of the National Institutes of Health (NHI) website accessed at https://www.ncbi.nlm.nih.gov/books/NBK 4/ on 10/15/21 stated .The neurotoxic effects (of [MEDICATION(S)]) are concentration dependent and can range from mild [CONDITION(S)] to ataxia, slurred speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high concentrations, [MEDICATION(S)] can lead to seizures. Symptoms correlate well with the unbound plasma [MEDICATION(S)] concentration. However, this laboratory value is seldom obtained. The following is a loose correlation of side effects with total plasma [MEDICATION(S)] concentrations (the value obtained in most laboratories);Less than 10 mg/L: Rare side effects; 10 to 20 mg/L: Occasional mild horizontal [CONDITION(S)] on lateral gaze; 20 to 30 mg/L: [CONDITION(S)]; 30 to 40 mg/L: Ataxia, slurred speech, tremor, nausea, and vomiting; 40 to 50 mg/L: Lethargy, confusion, hyperactivity; Greater than 50 mg/L: Coma and seizures . The Administrator was notified on 10/12/21 at 5:12 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 10/12/21 at 5:13 p.m. The facility's Plan of Removal was accepted on 10/13/21 at 11:08 a.m. and included: Immediately on October 12, 2021, RN CCS (corporate clinical specialist) in-serviced the DON and ADON on lab services. The lab services in-service covered residents receiving medications that require lab monitoring must have labs monitored as ordered/appropriate to prevent toxicity and to ensure therapeutic levels are maintained. Notification of the MD/NP of abnormal results will be immediate. Immediately on October 12, 2021, the ADON ordered stat labs for Resident #26, Resident #14 and Resident #11 to be completed. Results will be reviewed with PA/Attending Physician upon receipt. On October 12, 2021, CCS RN and the ADON initiated in-services with the licensed nurses on lab services. The lab services in-service covered residents receiving medications that require lab monitoring must have labs monitored as ordered/appropriate to prevent toxicity and to ensure therapeutic levels are maintained. Notification of the MD/NP of abnormal results will be immediate. Nursing staff will not be allowed to work until in-servicing has been completed. On October 12, 2021, a full lab audit was conducted by RN CCS team. Any missing labs were addressed immediately by contacting the physician and obtaining orders for labs to be completed. In addition, The DON, and RN, CCS will monitor labs daily beginning on October 12, 2021, for 30 days on all residents. The DON's compliance will be monitored weekly by the RN CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. On 10/14/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The entire nursing department was interviewed (2-LVNS on the 6:00am-2:00 pm shift; 1-RN on double weekends; 3- LVNS on the 10:00 p.m.-6:00 a.m. shift; 1-RN on the 2:00 p.m.-10:00 p.m. shift; 1- LVN on the 2:00 p.m.-10:00 p.m. shift; 1- LVN the MDS nurse; 1- PRN LVN, the ADON and DON). During these interviews nurses stated that for residents on [CONDITION(S)] medications or any other medicati

Based on observation, interview and record review the facility failed to consult with the physician regarding a change in condition for 1 of 12 sampled residents (Resident #26). The facility failed to immediately consult with Resident #26's physician when she met the criteria for [CONDITION(S)] (a [CONDITION(S)] that lasts longer than 5 minutes, or more than 1 [CONDITION(S)] within a 5-minute period, without returning to a normal level of consciousness between episodes. This is a medical emergency that may lead to permanent brain damage or death) during her 50-minute period of [CONDITION(S)] activity on 8/6/21. An Immediate Jeopardy (IJ) was identified at 5:02 p.m. on 10/12/21. While the IJ was removed on 10/14/21, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate treatment, deterioration of their physical condition, and decreased quality of life Findings included: Record review of Resident #26's face sheet indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face identified the family member as Resident #26's RP Record review of the MDS dated [DATE] indicated Resident #26 usually understood others and usually made herself understood. The MDS indicated Resident #26 had moderate cognitive impairment (BIMS of 9); the MDS indicated Resident #26 had rejected care 1-3 days during the 7 day look back period. The MDS indicated Resident #26 required extensive assistance with bed mobility, dressings, eating, toilet use; and personal hygiene. The MDS indicated she was always incontinent of bowel and bladder. The MDS indicated Resident #26 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the care plan revised on 7/8/21 indicated Resident #26 had a [CONDITION(S)] disorder and was prescribed [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The care plan interventions included: document location of [CONDITION(S)] activity, type of [CONDITION(S)] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state after [CONDITION(S)] activity. The care plan interventions also included administer [CONDITION(S)] medications as ordered; obtain lab work as ordered; monitor lab work for subtherapeutic or toxic levels; report results to physician; and follow up as indicated. Record review of nursing progress note dated 8/6/21 for Resident #26 stated At about 5:45pm resident's family member came in to visit resident. About 10 mins into the visit, DON was called by the Administrator to come in resident's room. On arrival to resident's room, resident was having [CONDITION(S)] activity with rolling of her eyes and family member and administrator were by resident's bedside. DON turned off the GT feeding. Resident was in and out of [CONDITION(S)] activity, and unable to time accurately. 02NC was applied for comfort and vital signs ranges as follows: 135/84, HR 94, O2 sat 96% on 2litre, to 127/74, HR 99, 02 sat 97% on 2litre. This episode went on for about 50 mins and DON was ready to call MD/PA, or send resident to ER. Family member refused and family member stated resident will come out of it. Family member stated, resident have been having these seizures since resident was 6 years old and that resident had a stroke at the age of 3 and also resident have 1/2 brain. Family member then left the room to go get wash cloth, so the cloth will be wet with cool water to place on resident's forehead. When family member left the room, resident came out of the [CONDITION(S)]. DON asked resident if she was ok? Resident stated NO. When family member came into the room, resident immediately started having seizures again, coming in and out of the seizures. Wet cool cloth placed on resident's forehead and vital signs remain stable, no acute distress noted. Family member stayed for another 20mins and when she left, resident's [CONDITION(S)] activity stopped. Resident became more coherent, able to carry out meaningful conversation with the DON. DON report event to charge nurse, and charge nurse will continue to monitor resident. This note was written by the DON. During an interview and observation on 10/12/21 at 9:30 a.m., Resident #26 was laying in her bed. Resident #26 answered most questions with a yes or no but occasionally would speak in sentences. Resident #26 indicated she was not sure when her last [CONDITION(S)] was and indicated her seizures were scary. During an interview on 10/12/21 at 9:57 a.m., Resident #26's family member's said she was the Resident #26's Medical Power of Attorney. Resident #26 said the [CONDITION(S)] Resident #26 had on 8/6/21 was one of the worst she had seen Resident #26 have in a long time. She said Resident #26's eyes kept rolling to the back of her head and she jerked. The representative said she could not say how long the [CONDITION(S)] lasted only she seemed to come in and out of seizures and that the whole event lasted a long time. Resident #26's family member said she did tell the DON that she did not want Resident #26 transferred to the hospital on the day of [CONDITION(S)] because as long as Resident #26 did not get choked, she felt Resident #26 would be fine. During an interview on 10/12/21 at 11:28 a.m., LVN B said she worked at the facility Tuesday- Friday on the 2:00 p.m.-10:00 p.m. shift and took care of Resident #26 regularly. LVN B said she could not remember when Resident #26's last [CONDITION(S)] occurred. When asked about the [CONDITION(S)] event documented on 8/6/21, LVN B said, the DON was with the Resident. LVN B said the DON handled Resident #26 during the [CONDITION(S)], while she took care of other residents. LVN B said she did not notify the PA or physician because the DON handled it. During an interview on 10/12/21 at 11:40 a.m., The PA (physician assistant) said he was not notified Resident #26 had [CONDITION(S)] activity that lasted 50 minutes on 8/6/21 or any other time. The PA said he would have most definitely remembered being notified of such a long event. The PA said had he been notified; he would have sent Resident #26 to the emergency room as the event described met the definition of [CONDITION(S)] which was a potentially life-threatening medical emergency. The PA said any [CONDITION(S)] [MEDICATION(S)] 5-15 minutes continuously or intermittently constitutes [CONDITION(S)]. The PA said if he had been informed the Resident's family refused to have her sent to the hospital, he still could have performed medical interventions. The PA said he would have administered [MEDICATION(S)] (a benzodiazepine commonly used to treat [CONDITION(S)]) to Resident #26 to potentially stop the [CONDITION(S)]. The PA said he would have also ordered stat labs to check the levels of her [CONDITION(S)] medications to ensure they were therapeutic. The PA said residents that were stable (having no seizures with no new [CONDITION(S)] medications or changes in dosage) should have their [CONDITION(S)] medications checked at least twice a year. He said if a resident was still having seizures the medication levels should be checked quarterly. During an interview on 10/12/21 at 3:00 p.m., the Physician said he had tiered calling system so the facility would have notified this PA of the event. The physician said he was not notified Resident #26 had [CONDITION(S)] activity on 8/6/21 that lasted 50 minutes. The physician indicated he would have recalled being notified of an event that lasted 50 minutes. The Physician indicated either himself or his PA should have been notified of the [CONDITION(S)] event that lasted 50 minutes. During an interview on 10/14/21 at 10:10 a.m., the DON said she remembered Resident #26's [CONDITION(S)] on 8/6/21. The DON said someone came to get her just as she was about to leave for the day. The DON said she went to the room and found Resident #26's eyes were rolling in the back of her head and she was jerking. The DON said the Resident #26's family member was at the bedside. The DON said she started timing the [CONDITION(S)]. The DON said Resident #26 seemed to be coming in and out of seizures. The DON said she kept telling the family member the seizures were [MEDICATION(S)] too long and she was going to have to call an ambulance. The DON said the family member kept saying, 'No, she will come out of it.' The DON said she placed oxygen on Resident #26 and started monitoring her vital signs. The DON said she told the family member this could damage her brain and she was going to have to call the ambulance because the seizures were going on too long. The DON said the family member continued to refuse emergency care. The DON said the mistake she made was that she should have notified the physician herself. The DON said she told LVN B after the [CONDITION(S)] event to monitor Resident #26 and follow up. The DON said she assumed LVN B understood she meant to notify the physician. The DON said a [CONDITION(S)] [MEDICATION(S)] more than 5 minutes was a medical emergency and could cause brain damage from lack of oxygen. During an interview on 10/14/21 at 9:58 a.m., the Physician said Resident #26 [CONDITION(S)] activity having lasted 50 minutes met the criteria for [CONDITION(S)]. The physician said if he would have been notified of [CONDITION(S)] activity [MEDICATION(S)] 50 minutes and the family was refusing transport to the emergency room , he could have attempted [MEDICATION(S)] administration in attempt to stop the [CONDITION(S)] activity. During an interview on 10/14/21 at 11:44 a.m., the Administrator said she expected nurses to follow policy/procedure regarding [CONDITION(S)] management and physician notification. Record review of the facility policy and procedure titled, [CONDITION(S)] Management, revised December 2007 stated, .General Guidelines (1) a generalized tonic/clonic (grand mal) [CONDITION(S)] usually lasts 2-5 minutes and is characterized by one or more of the following (a.) crying out (b.) loss of consciousness (c.) convulsive activity .2. Seizures may occur with or without convulsions (rigidity and jerking movements) .Steps in the Procedure . (13.) If the tonic /clonic convulsions last longer than 5 minutes, or are followed by subsequent seizures, this may constitute [CONDITION(S)], which is a medical emergency. If this is suspected notify the physician. If the physician is not immediately available to discuss the situation, initiate emergency transfer . Record review of the facility's policy and procedure titled, Change of Condition and Physician/Family Notification, revised 3/25/21 stated, .Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: .a significant change in the resident's physical, mental, or psychosocial status.(see below for examples) .Examples of Significant Changes: .seizures . Record review of the John Hopkins Medicine website accessed on 10/16/21 at https://www.hopkinsmedicine.org/health/conditions-and-diseases/status-epilepticus, stated, .A [CONDITION(S)] that lasts longer than 5 minutes, or having more than 1 [CONDITION(S)] within a 5 minutes period, without returning to a normal level of consciousness between episodes is called [CONDITION(S)]. This is a medical emergency that may lead to permanent brain damage or death . This condition can occur as: (A) Convulsive [CONDITION(S)]. [CONDITION(S)] with convulsions may be more likely to lead to long-term injury. Convulsions may involve jerking motions, grunting sounds, drooling, and rapid eye movements. (B) Nonconvulsive [CONDITION(S)]. People with this type may appear confused or look like they're daydreaming. They may be unable to speak and may be behaving in an irrational way . Complications depend on the underlying cause and can range from no complications to death. If the underlying cause, such as poor [CONDITION(S)] control, can be fixed, there may no complications. If the underlying cause is a stroke or brain injury, complications may include physical disability from the cause or even death . Key points about [CONDITION(S)]: [CONDITION(S)] has many causes. Some can be prevented such as low blood glucose or alcohol and drug abuse. Individuals who have [CONDITION(S)] must take their medicine as directed. A [CONDITION(S)] that lasts more than 5 minutes, or having more than 1 within a 5 minute period is an emergency that requires immediate medical care . The Administrator was notified on 10/12/21 at 5:12 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/12/21 at 5:13 p.m. The facility's Plan of Removal was accepted on 10/13/21 at 11:08 a.m. and included: Immediately on October 12, 2021, The RN, CCS (corporate clinical specialist) in-serviced the DON and ADON on [CONDITION(S)] management and notification of Physician/NP. [CONDITION(S)] Management Inservice consisted of the review of guidelines for safely managing a resident who is having a [CONDITION(S)]. This included general guidelines and steps in the procedure. Notification of MD/NP and documentation to include any urgent issues to be reported to the physician immediately. On October 12, 2021, the RN, CCS and ADON initiated in-services with the licensed nurses on [CONDITION(S)] management and notification of Physician/NP. [CONDITION(S)] Management Inservice consisted of the review of guidelines for safely managing a resident who is having a [CONDITION(S)]. This included general guidelines and steps in the procedure. Notification of MD/NP and documentation to include any urgent issues to be reported to the physician immediately. Nursing staff will not be allowed to work until in-servicing has been completed. On October 12, 2021, an audit was conducted by the RN CCS team to identify other residents needing MD notification. This was done by reviewing the resident record for any changes in condition, review of orders, weights, vital signs and skin conditions. In order to monitor current residents for potential risk, the DON, and RN, CCS will monitor residents for physician notification, utilizing a triage log daily beginning October 12, 2021, for 30 days. The DON's compliance will be monitored weekly by the RN, CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. On 10/14/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The entire nursing department was interviewed (2-LVNS on the 6:00am-2:00 pm shift; 1-RN on double weekends; 3- LVNS on the 10:00 p.m.-6:00 a.m. shift; 1-RN on the 2:00 p.m.-10:00 p.m. shift; 1- LVN on the 2:00 p.m.-10:00 p.m. shift; 1- LVN the MDS nurse; 1- PRN LVN, the ADON and DON). During these interviews' nurses stated correctly identified appropriate safety measures to be taken in the event a resident had a [CONDITION(S)] (stay with resident, remove any hazards from the area that could cause injury, place a pillow or padded surface under the residents head, protect the airway, turn the resident on their side, loosen clothing, tilt the head forward if possible). All of the nurses said they would start timing the [CONDITION(S)] and indicated if a [CONDITION(S)] or a series of consecutive intermittent seizures lasted more than 5 minutes they would get someone to stay with the resident while they notified the physician/obtained emergency transport. The nurses also indicated they would notify the physician of any [CONDITION(S)] but would not delay notification if the [CONDITION(S)] event lasted more than 5 minutes. Record review of [CONDITION(S)] management and physician notification in-service material were reviewed, and implementation was ensured by review of the in-service sign in sheet for the DON/ADON and all nursing staff. In-service completion was corroborated with nursing interviews. Record review of MD notification audit performed by the CCS team was reviewed and all residents had been reviewed for events denoting physician notification. Record review of triage log for significant events denoting physician notification 10/12/21 and 10/13/21 was reviewed and the triage system included all residents. 2 CNAs from the 6:00 a.m. to 2:00 p.m. shift; 2 CNAs from the 2:00 p.m.-10:00 p.m. shift; and 2 CNAs from the 10:00 p.m.-6:00 a.m. shift; were all interviewed on 10/14/21 and indicated they understood signs and symptoms of seizures (which included; staring; eyes rolling to back of the head; jerking movements of the arms and legs; stiffening of the body; loss of consciousness). The CNAs said if they saw any of these symptoms, they would note the time and call for the nurse by use of call light or yelling while they stayed with the patient. On 10/14/21 at 11:30 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure basic life support was provided prior to the arrival of emergency medical personnel for 1 of 6 residents reviewed for CPR. (Resident #1) The facility did not immediately call EMS and use an AED (used to detect and correct heartbeat abnormalities during CPR) on Resident #1 as part of basic CPR when Resident #1 was found without a pulse and respirations. It was approximately 20 minutes between the time CPR was initiated and EMS was notified. The facility did not maintain a working AED and ensure staff were CPR certified. LVN B performed CPR on Resident #1 without a current CPR certification. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:13 p.m. While the IJ was removed on [DATE] at 5:04 p.m., the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with a full code status at risk of death and not having end of life wishes honored. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, was admitted [DATE], and died in the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #1 was a full code status (meaning life saving measures should be taken in the event the resident was found without respirations or a pulse). A care plan dated [DATE] indicated Resident #1 was at risk for symptoms of COVID-19 and staff should observe for and document symptoms of fever, coughing, sneezing, sore throat, and respiratory issues. The care plan indicated staff should report symptoms to the physician and observe and document psychosocial and mental status changes and report them to the physician as indicated. The care plan did not address Resident #1's full code status. A Minimum Data Set assessment dated [DATE] indicated Resident #1's cognition was severely impaired, and she made her needs known and understood others. A provider investigation report dated [DATE] indicated Resident #1 was admitted to the facility [DATE] for COVID-19 and transferred out of the COVID-19 unit on [DATE]. The report indicated on [DATE] at about 3:40 p.m., the DON was notified Resident #1 was unresponsive. The DON performed CPR on Resident #1 and 911 was called and emergency personnel took over CPR from the DON when they arrived. The report indicated emergency personnel placed AED pads on the resident and an EKG showed asystole (absence of heart contractions). The EMS medical director ordered EMS to stop CPR. The report indicated Resident #1 died [DATE] due to a gradual decline in overall health. The report indicated the facility investigation did not reveal any abuse or neglect occurred in the care of Resident #1. A nursing note dated [DATE] at 5:01 p.m., written by LVN B, indicated a CNA told the nurse to come see Resident #1 at 3:35 p.m. The resident was found unresponsive with no pulse and no respirations. At 3:40 p.m., CPR was immediately initiated by LVN B and the DON was alerted. The note indicated 911 was called and the DON took over CPR. CPR was continued by staff until EMS arrived and took over. The note indicated CPR was discontinued and the resident was pronounced deceased by EMS at 4:18 p.m. During an interview on [DATE] at 2:40 p.m., LVN B said he provided care for Resident #1 on [DATE] from 2:00 p.m. to 10:00 p.m. He said around 3:35 p.m., a CNA told him he needed to check on the resident. He said Resident #1 had no pulse and no respirations and he began CPR. He said Resident #1 was warm to touch. He said he told MA E and CNA J to get the DON. He said the DON immediately came to the room, assessed the resident, and continued CPR. LVN B said he took over CPR while the DON called 911. He said the DON called 911 within a few minutes of entering Resident #1's room. LVN B said someone got the crash cart and he used the ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing) while the DON continued to do compressions. He said they did not get the facility AED and apply it to Resident #1. He said he should have received the AED but did not think about getting it. He said it seemed like ,[DATE] minutes from the time from when he initiated CPR to the time EMS arrived. LVN B said EMS did not continue CPR on Resident #1 when they arrived. He said EMS placed the monitor on Resident #1 and it showed no pulse. He said EMS called their medical director and they pronounced Resident #1 deceased . During an interview on [DATE] at 3:14 p.m., MA E said she worked on [DATE] from 2:00 p.m. to 10:00 p.m. MA E said LVN B asked her to check on Resident #1 and she went to the room about 3:35 p.m. She said the resident's eyes were closed, her mouth was open, and her chest was not rising, so she shook the resident. She said the resident's arm was cold to touch and the resident did not respond. She said CNA J was walking by and came in the room. She said they notified LVN B and he came to the room and assessed the resident and started CPR. She said the DON immediately came to the room. She said it took EMS a while to get to the facility. A nursing note dated [DATE] at 5:54 p.m., written by the DON, indicated at about 3:40 p.m., the nurse notified the DON that Resident #1 was unresponsive. Upon the DON's arrival to the room, the nurse was performing CPR on the resident and the DON took over. The note indicated the DON checked for a pulse and there was no pulse and the resident was warm. The note indicated the DON continued CPR and the nurse took over while she called 911 at 4:00 p.m. and the code cart was brought to the scene. The note indicated the 911 crew came over and took over for the DON. The EMS crew placed the AED pads on Resident #1 and an EKG was performed and showed asystole. EMS called their medical director at 4:18 p.m. who ordered them to stop CPR. The note indicated the medical supervisor came to the scene to assess. The medical director informed nursing to proceed as usual and gave the DON the case number. The note indicated the social worker notified Resident #1's family and the funeral home. During an interview on [DATE] at 12:39 p.m., the DON said during the afternoon of [DATE], she heard a scream coming from Resident #1's room. She said when she arrived at Resident's #1's room, LVN B was performing chest compressions on Resident #1. The DON said she took over compressions and called 911 while she was performing CPR on Resident #1. She said someone brought the crash cart and they used the ambu bag. She said she and LVN B took turns performing CPR. The DON said EMS arrived within minutes of her calling 911 and EMS took over CPR. She said she did not use the AED because EMS arrived so quickly. The DON said EMS performed an EKG and it showed asystole (when no electrical activity of the heart is seen). The DON said EMS called their medical director and Resident #1 was pronounced deceased at that time. She said she could not explain why all the documentation indicated that they performed CPR for 20 minutes before EMS arrived. She said she immediately called 911 when she entered Resident #1's room and EMS arrived within minutes. An EMS run record dated [DATE] indicated the facility called 911 at 4:02 p.m. and dispatch was notified at 4:02 p.m. The record indicated EMS arrived at the facility at 4:07 p.m. The EMS run record indicated Resident #1 was in [MEDICAL CONDITION] and was lying in the bed with oxygen on. The facility nurse reported that the last known normal for Resident #1 was about 3:00 p.m. and they have been performing CPR for approximately 20 minutes. Resident #1 was pulseless and apneic (no respirations). The report indicated pads were applied to Resident #1 and asystole was noted on the monitor. The report indicated nursing facility staff were in the room upon resident contact, but EMS did not witness CPR being performed. Medical control was contacted and advised to terminate efforts at 4:18 p.m. During an interview on [DATE] at 2:08 p.m., an EMS paramedic said EMS was dispatched to the facility on [DATE] about 4:00 p.m. He said the fire department arrived at the same time as EMS. He said he walked into the resident's room and Resident #1 was lying in bed and was wearing oxygen tubing and CPR was not being performed by facility staff. The EMS paramedic said neither the fire department or EMS performed CPR on Resident #1. He said the facility staff said they performed CPR for over 20 minutes. He said he looked for a rise and fall of Resident #1's chest and there was not any. He said the only time he touched the resident was to place the pads on the resident and her skin was cool. He said the monitor showed asystole and they called the EMS medical director and were ordered to pronounce the resident deceased at that time. He said the facility did not have an AED in the room and that was atypical because using the AED was part of CPR. During an interview on [DATE] at 4:43 p.m., a fire department paramedic said the fire department was dispatched to the facility on [DATE] around 4:00 p.m. and EMS arrived at the facility about the same time. He said they were held up at the front door because the facility staff would not let them in the facility until their temperatures were checked, even though they wore full PPE. He said he was first to enter Resident #1's room. He said there was one male and two females standing in the room and the resident was lying in the bed. He said no staff was performing CPR when he came into the room. He said there was a crash cart in the room but he did not see an AED. The fire department paramedic said the staff said Resident #1 was last seen approximately 20 minutes before they found her unresponsive. He said the staff did not say if they performed CPR for 20 minutes or initiated CPR. He said Resident #1 was ice cold to touch and she was stiff when he attempted to roll her. The fire department paramedic said she had dependent lividity (pooling of blood) on her back and rigor mortis (stiffness after death) had set in on her buttocks and legs. He said based on the condition of the resident, he would say Resident #1 had been deceased for about 2.5 hours when they arrived. He said EMS hooked the resident up to their monitor and it showed asystole. He said Resident #1 had obvious clinical signs of irreversible death and at no point did they perform CPR. He said EMS staff called their medical director and the resident was pronounced deceased . A crash cart checklist dated [DATE] indicated AED #1 (COVID negative hall) and AED #2 (COVID-19 unit) were not checked from [DATE] to [DATE] and from [DATE] to [DATE]. A crash cart checklist dated [DATE] indicated AED #1 and AED #2 were not checked from [DATE] through [DATE]. A crash cart checklist dated [DATE] indicated AED #1 and AED #2 were not checked from [DATE] to [DATE], from [DATE] to [DATE], and [DATE]. During an observation on [DATE] at 12:37 p.m., a facility AED was located in a clear box mounted on a wall. There was a red X in the status indicator window. A chirping noise could be heard emitting from the AED. The DON removed the AED from the box on the wall and turned on the AED. The AED voice prompt instructed to plug in AED pads. There were no AED pads with the AED. During an observation with the administrator on [DATE] at 1:27 p.m., a facility AED in the COVID-19 positive unit was brought to the clear plastic curtain that separated the COVID-19 positive unit and negative halls. There was a red X in the status indicator window. During an observation and interview on [DATE] at 2:16 p.m., the DON called the phone number on the AED. The AED representative said the AED would show a red X in the status indicator window unless the AED pads were connected to the AED. He said the AED would not operate unless the AED pads were connected. The DON was unable to locate the pads in the pockets of the AED case. She checked the AED on the COVID-19 unit and it did not have pads connected or with the AED. The DON brought pads for the AED and said she found them at the nursing station. The DON plugged the cord of the AED pads into the AED and the red X changed to a green check. The DON turned on the AED and the voice prompts indicated the AED was ready for use. The AED's operator's guide dated 2015 indicated .do not use or place the AED Plus unit in service if the unit's status indicator window (located on the left side of the handle) displays a red X .Do not use or place the AED Plus unit in service if the unit emits a beeping tone . During an interview on [DATE] at 2:25 p.m., the DON said it was the responsibility of the 10 p.m. to 6 a.m. nurses to complete the daily crash cart and AED checklist. During an interview on [DATE] at 3:45 p.m., LVN C said he worked 10 p.m. to 6 a.m. He said checking the crash cart and AED every night was not his responsibility. He said the nurse that worked on another hall was responsible for checking the crash cart and AED. During an interview on [DATE] at 3:40 p.m., LVN K said he worked 10 p.m. to 6 a.m. He said he was not aware that it was his responsibility to complete the daily crash cart checklist. He said he was oriented by a PRN (as needed) nurse and was not told anything about the crash cart or AED. He said he received no training on the AED or crash cart. During an interview on [DATE] at 1:28 p.m., LVN L said she worked PRN (as needed) 10 p.m. to 6 a.m. She said she was trained on checking the crash cart and AED on the night shift. She said she only checked to ensure the AED was in the clear box on the wall and did not check to ensure it was ready to use. A CPR certification card for LVN B (who initiated CPR for Resident #1 on [DATE]) indicated it expired on [DATE]. During an interview on [DATE] at 3:11 p.m., LVN B said he knew his CPR certification was about to expire but did not realize it was expired. He said he did not receive AED training upon hire. During an interview on [DATE] at 12:39 p.m., the administrator said Resident #1 had a decline after she moved off the COVID-19 unit. She said the nursing documentation had incorrect times regarding the length of time staff performed CPR on Resident #1 before EMS arrived. The administrator said the facility had been without human resources staffing for months and human resources was responsible for ensuring staff employee files were compliant. A list provided by the facility on [DATE] indicated 17 residents wished to be resuscitated in the event of [MEDICAL CONDITION]. An AED policy dated [DATE] indicated .use of the device for defibrillation is indicated on victims of [MEDICAL CONDITION] with apparent lack of circulation as indicated by unconsciousness, absence of breathing, and absence of pulse and other signs of circulation .licensed nurses will receive basic life support level cardiopulmonary resuscitation training upon hire, if not currently certified, or as required for recertification. Licensed nurses will be trained to provide defibrillation with the AED using manufacturer's training materials upon hire and annually thereafter .The DON or designee will test and document the operating status of the AED accordance with manufacturer's guidelines . The facility's CPR policy dated [DATE] indicated .in the event of cardiopulmonary arrest of a resident without Do Not Resuscitate (DNR) status, life support measures will be initiated according to either the American Heart Association/American Red cross guidelines or per State guidelines. According to the 2001 American Heart Association, Basic Life Support for Healthcare Providers, prompt initiation of CPR remains the standard of care expect when rigor mortis, lividity, tissue decomposition or obvious fatal trauma are present. Rescuers who initiate BLS should continue until one of the following occurs: restoration of effective spontaneous circulation and ventilation; transfer of care to emergency medical responders or other trained personnel who continue BLS or initiate advanced life support; transfer of care to a physician who determines that resuscitation should be discontinued; inability to continue resuscitation because of exhaustion, because environmental hazards endanger the rescuer, or because continued resuscitation would jeopardize the lives of others; recognition of reliable criteria for determination of death; or presentation of a valid no-CPR order to the rescuers. Any clinical employee trained in BLS may initiate CPR. The Emergency Medical System will be activated immediately. Advanced Life Support functions will be instituted by paramedics with the EMS system .This facility is not currently equipped with defibrillator or cardiac drugs to conduct ACLS measures .Documentation: time arrest called, date and location-information must be complete on every record .Ventilation: note time started and stopped, types of ventilation and by whom. Chart time started and stopped and each person involved .Time, pulse, pupils, skin-the resident's condition at intervals should be recorded with regard to blood pressure, pulse, pupils, and skin. Time EMS called, arrived, and departed with the resident . According to the American Heart Association retrieved on ,[DATE] from https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf, .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with an automated external defibrillator (AED), can more than double a victim's chance of survival.3 In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [MEDICAL CONDITION]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,[DATE]% . The administrator and DON were notified [DATE] at 5:13 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on [DATE] at 5:23 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:37 p.m. and included: Immediately, on [DATE], (the corporate RN) and (the company DON) in serviced (the facility DON) on 1. Change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. 2. AED policy and procedure to include when to use the AED, how to use the AED, and daily/monthly checks of the AED. 3. CPR policy and procedure to include notification of 911. Competency was established by check offs for the AED. Training and competencies for (the facility DON) were completed on [DATE]. On [DATE] (the facility DON) and (the company DON) initiated in-services with the licensed nurses on 1. Change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. 2. AED policy and procedure to include when to use the AED, how to use the AED, and daily/monthly checks of the AED. 3. CPR policy and procedure to include notification of 911. Competency will be established by check offs for the AED. Completion date for the licensed nurses in-services and competency evaluation is [DATE]. Nursing staff will not be allowed to work until in-servicing has been completed. CPR training for all staff was initiated on [DATE] by (the CPR instructor). CPR training will be completed on [DATE]. Staff will not be allowed to work until in-servicing has been completed. The above training material will be incorporated into the new hire nursing orientation by {the facility DON) effective [DATE]th and ongoing. On [DATE] an audit was conducted by (the corporate RN, the company DON, and facility DON) to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. In order to monitor current residents for potential risk, (the facility DON and the corporate RN) will monitor residents with change of condition daily beginning [DATE] for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. (The facility DON's) compliance will be monitored weekly by (the corporate RN) for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. In order to monitor AED, Director of Nursing/Designee will review daily AED check off form and AED machine daily beginning [DATE] for 30 days. Thereafter, QA will monitor quarterly up to a year for compliance. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 12:31 p.m., the administrator said in-servicing was initiated with staff on [DATE] and no staff would be allowed to return to duty until they were in-serviced. The administrator said they had a CPR certified instructor in the facility on [DATE] and [DATE] and all staff received CPR certification. During an interview on [DATE] at 12:36 p.m., the DON of a sister facility said she in-serviced the DON on changes of condition. She said the in-servicing included the change of condition policy, comprehensive assessments, and notification of family and physician. She said the DON was in-serviced on the CPR and AED policy, notification of 911, when and how to use the AED, and daily/monthly AED check offs. She said the DON showed competency with the use of the AED. The DON of the sister facility said the DON understood all of the in-servicing and she had no concerns regarding the DON. She said after the DON was in-serviced, they in-serviced the staff together. She said staff were in-serviced on changes of condition, comprehensive assessments, notification of physician and family, CPR and AED, calling 911, when and how to use the AED, and daily/monthly AED check offs. She said all licensed nurses were checked off for AED competency. She said all staff were CPR certified. She said the new hire nursing orientation was updated to included trainings on AED and CPR certification. During an interview on [DATE] at 12:49 p.m., the DON said she was in-serviced on changes of condition including the policy, comprehensive assessments, and notification of family and physician. She said she was in-serviced on the CPR and AED policy, notification of 911, when and how to use the AED, and daily/monthly AED check offs. She said she completed AED competency check-offs for all licensed nurses. She said after she completed in-servicing, she and the DON of the sister facility in-serviced staff. She said staff were in-serviced on changes of condition, comprehensive assessments, notification of physician and family, CPR and AED, calling 911, when and how to use the AED, and daily/monthly AED check offs. She said all licensed nurses were checked off for AED competency. She said all staff were CPR certified. Seven nurses (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., 10 p.m. to 6 a.m., 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m.) said they were in-serviced on changes of condition, CPR, and the AED. They were able to identify examples of changes of condition. They said they would immediately assess a resident if they noticed a change of condition or if staff notified them of a change of condition. They said if a resident presented with changes of condition, they would assess the resident and call the NP and responsible party. They said they would document any changes of condition in the resident's clinical record and interventions that were put into place. They said they were in-serviced on the location of the AED, how to make sure the AED had a green check was ready for use, when to use the AED, and how to use the AED. They said they were checked off to ensure they knew how to correctly use the AED. They said they were in-serviced on daily and monthly check offs of the AED and crash cart. They said a CPR instructor came to the facility and they completed CPR certification. Three CNAs, 1 MA, 1 housekeeper, and 1 dietary staff said they received CPR certification and were checked off to ensure they knew how to correctly use the AED. They said they were in-serviced on changes of condition and were able to identify examples of changes of condition. They said they would report any changes of condition to the resident's charge nurse. Change of condition assessments dated [DATE] for 43 residents were reviewed. There was no evidence of changes of condition in the residents. Change of condition assessments were completed by resident observation, staff interviews, and resident record review. Change of condition assessments were completed on [DATE]. AED staff competencies were reviewed and indicated staff could correctly confirm the AED was ready to use (green check), knew an AED was used when a resident was pulseless and unresponsive, knew when to call 911, knew correct placement AED pads, knew how to turn on the AED, understood the AED voice prompts, and understood the daily/monthly AED checks. AED competencies were completed on [DATE]. A daily and AED checklist was reviewed and included daily checks to verify the green checkmark was present indicating the AED was ready for use. The monthly checks included a visual inspection to ensure the AED was clean and undamaged with no cracks or loose parts. The monthly checklist included verification that [MEDICATION NAME] were connected to the AED and sealed in their package and not expired, turn the AED on and off to verify the green checkmark, ensure batteries have not expired, and check for adequate supplies. CPR certifications for staff were reviewed and indicated staff successfully completed basic life support training that included CPR and AED. CPR certifications were completed on [DATE]. On [DATE] at 5:04 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care based on the comprehensive assessment and in accordance with standards of practice was provided for 1 of 6 residents reviewed for change of condition. (Resident #1) The facility did not properly assess or recognize when Resident #1 experienced a significant change of condition. Resident #1 was found snoring loudly, unable to be awakened, take medications, and eat. Resident #1 had a change of condition for more than 9 hours before she died in the facility. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk deteriorating health, serious illness and death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted [DATE], and died in the facility on [DATE]. Her [DIAGNOSES REDACTED]. The face sheet indicated Resident #1 was a full code status. Physician orders [REDACTED].#1 was ordered daily blood sugar checks before each meal and at bedtime. Resident #1 was ordered [MEDICATION NAME] 30 units twice a day and regular human insulin per sliding scale. A care plan dated [DATE] indicated Resident #1 was at risk for symptoms of COVID-19 and staff should observe for and document symptoms of fever, coughing, sneezing, sore throat, and respiratory issues. The care plan indicated staff should report symptoms to the physician and observe and document psychosocial and mental status changes and report as indicated. An MDS assessment dated [DATE] for Resident #1 indicated her cognition was severely impaired, she was able to make her needs known, and she understood others. She required extensive 2-person assistance with ADLs and was incontinent of bowel and bladder. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] During an interview on [DATE] at 3:41 p.m., LVN C said he worked [DATE] from 10:00 p.m. until [DATE] at 6:00 a.m. He said during the morning of [DATE], he went into Resident #1's room between 5:00 a.m. and 6:00 a.m. to administer [MEDICATION NAME]. He said Resident #1 was lying in her bed with her eyes closed. He said she was not snoring. He said Resident #1 did not usually breath loud when she was sleeping. He said he woke Resident #1 up and told her it was time to take her medication. He said Resident #1 said ok. He said he raised the head of the bed and gave Resident #1 her medication, assisted her with drinking some water, and laid the head of the bed back down. LVN C said Resident #1 responded as she normally did, and he did not notice a change in her condition. He said that was the last time he saw Resident #1 before he ended his shift. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A TAR dated [DATE] indicated on [DATE] at 6:00 a.m., Resident #1's blood sugar was 146. The TAR did not include documentation that Resident #1's scheduled 11:30 a.m. blood sugar was completed and there was no recorded blood sugar outcome. A nursing note dated [DATE] at 1:14 p.m., written by LVN A, indicated Resident #1 had not opened her eyes since the start of this shift but could be heard snoring hard from the hallway. The note indicated the resident's vital signs included a blood pressure of ,[DATE] (a normal blood pressure is ,[DATE]), a pulse of 58 (a normal pulse is ,[DATE] beats per minute) a temperature of 97.3, and an oxygen saturation of ,[DATE]% (a normal oxygen saturation is ,[DATE] percent). The note indicated the NP was notified of the resident's vital signs and the NP advised to start the resident on oxygen at ,[DATE] liters a minute and monitor. The note indicated 5 minutes into monitoring the resident's oxygen saturation went up to ,[DATE]% and no signs of distress were noted. During an interview on [DATE] at 11:17 a.m., LVN A said he worked with Resident #1 on [DATE] from 6:00 a.m. to 2:00 p.m. He said he worked with the resident a few days after she was moved from the COVID-19 positive unit. He said he first saw Resident #1 on [DATE] around 6:30 a.m. and she was snoring loud enough he heard her from the hallway. He said he was not able to awaken Resident #1 and she did not open her eyes. LVN A said Resident #1 grunted when she was moved. He said that was abnormal for Resident #1 because she usually woke easily and would speak to him. He said Resident #1 normally did not snore loudly and he never heard her snore as loud as that day. LVN A said he checked Resident #1's blood sugar around 6:30 a.m. and she did not need sliding scale coverage. He said he could not remember if he administered her 7:00 a.m. scheduled 30 units of [MEDICATION NAME]. He said Resident #1 did not eat breakfast. He said he notified the DON of Resident #1's status around 10:30 a.m. after he assessed the resident. He said Resident #1's vitals were stable but her O2 was low. He said he listened to her lungs and they were clear. LVN A said he checked Resident #1's blood sugar but could not remember what it was. He said he notified the NP after he assessed Resident #1 that Resident #1 was difficult to wake up, did not eat breakfast, and did not take her morning medications. He said the NP ordered oxygen by nasal cannula for Resident #1. LVN A said after applying oxygen her O2 came up to 97% and she was no longer grunting. He said he did not call the NP back and did not send her to the hospital because when her O2 came up, she was stable. He said he checked her blood sugar at 11:30 a.m. but could not remember what it was. He said he checked on her throughout his shift and assessed her vital signs and listened to her lungs a total of 3 times. He said he did not perform a neurological check because Resident #1 could not open her eyes. LVN A said Resident #1 was sleeping every time he saw her, was not able to eat, and not able to take her oral medications. LVN A said he did not notify Resident #1's family of her change. He said he notified the oncoming nurse to keep an eye on Resident #1 because she had not eaten, not taken her medications, or awakened during the shift. During an interview on [DATE] at 1:28 p.m., the NP said she saw Resident #1 through telehealth visits because she originally admitted to the COVID-19 unit. She said she received 2 calls about Resident #1 on [DATE]. She said LVN A called her in the morning and said they had a hard time waking up Resident #1 and the resident did not eat breakfast. She said LVN A told her Resident #1 was sleeping more lately and her O2 was low. The NP said she told LVN A to put oxygen on the resident and to keep a close eye on her. She said she told LVN A to notify her if the resident did not improve. She said LVN A did not tell her that they were unable to wake up Resident #1 or that she was unable to take her medications. She said she was not notified Resident #1 did not eat lunch. She said if she was provided with all the information, she may have ordered other interventions, or ordered the resident to be sent to the hospital. She said the next call she got from the facility was from the DON and they were performing CPR on the resident. During an interview on [DATE] at 12:39 p.m., the DON said on [DATE] around 10:00 a.m., LVN A notified her Resident #1 could not be woken up, did not take her medications, and did not eat breakfast. She said she was in Resident #1's room when LVN A assessed Resident #1 and listened to the resident's lungs. She said Resident #1 was unable to open her eyes. She said she and LVN A opened the resident's eyes and they were fixed. She said Resident #1's oxygen saturation was low and LVN A notified the NP and received an order for [REDACTED].#1's vital signs were stable. She said it was normal for COVID-19 residents to be difficult to wake up and it was common for residents to have a change of condition when they came off the COVID-19 unit. During an interview on [DATE] at 1:44 p.m., MA D said she worked with Resident #1 on [DATE] and [DATE]. She said on [DATE], Resident #1 was awake, alert, and could answer questions. MA D said Resident #1 took her oral medications with no issues on [DATE]. She said on [DATE], she first went into Resident #1's room at 8:30 a.m. with the resident's medications and the resident was snoring loud enough she heard her from the hall. MA D said she called the resident's name and shook the resident but Resident #1 did not wake up and did not respond to her. MA D said she left the room and came back to Resident #1's room about 20 minutes later. She said Resident #1 was in the same condition. She said she went back to Resident #1's room one more time during her shift between 12:00 p.m. and 1:00 p.m. and Resident #1 was still snoring and unable to awake up. MA D said she reported Resident #1's change to LVN A each time she checked the resident. During an interview on [DATE] at 11:59 a.m., CNA F said Resident #1 required extensive 2-person assistance with ADLs but was able to make her needs known. She said Resident #1 required feeding assistance with meals. She said on [DATE] she worked 6:00 a.m. to 2:00 p.m. and Resident #1 was not herself. She said when she checked on Resident #1 during her first round, the resident was snoring loud and she did not normally snore. CNA F said she continued to check on Resident #1 during her shift and she was unable to wake the resident up. She said Resident #1 was usually awake and alert. She said the Resident #1 did not eat breakfast or lunch because she was sleeping. She said Resident #1 usually ate her meals. CNA F said Resident #1 did not respond to her during her shift. She said they provided incontinent care to Resident #1 and the resident did not wake up. She said she reported Resident #1's change to LVN A. She said she checked on Resident #1 several times during her shift and she was snoring each time she checked on her. During an interview on [DATE] at 12:52 p.m., CNA G said Resident #1 was normally alert and could answer questions. She said Resident #1 required staff assistance with feeding and ADLs. She said on [DATE], Resident #1 would not wake up and was snoring loudly. CNA G said Resident #1 did not respond when she tried to wake her and did not eat breakfast or lunch. She said Resident #1 did not open her eyes throughout her shift and was snoring when she checked on her. During an interview on [DATE] at 3:14 p.m., MA E said she worked on [DATE] from 2:00 p.m. to 10:00 p.m. MA E said LVN B asked her to check on Resident #1 and she went to the room about 3:35 p.m. She said the resident's eyes were closed, her mouth was open, and her chest was not rising so she shook the resident. She said the resident's arm was cold to touch and the resident did not respond. She said CNA J was walking by and came in the room. She said they notified LVN B and he came to the room and assessed the resident and started CPR. She said the DON came to the room. MA E said she thought it took EMS a while to get to the facility. During an interview on [DATE] at 1:59 p.m., CNA J said she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She said that was the first day she worked with Resident #1. She said she entered Resident #1's room with MA E to check on her but she was not sure of the time. She said Resident #1's eyes were closed, and she was not sure if the resident was breathing. She said they called for LVN B and he immediately came to the room. CNA J said the DON also came in the room and they were performing CPR on Resident #1. She said LVN B, the DON, and she were in the room when EMS arrived, and the DON was performing CPR. A nursing note dated [DATE] at 5:01 p.m., written by LVN B, indicated at 3:35 p.m. the nurse was informed by a CNA to come see the resident. Resident #1 was found unresponsive with no pulse and no respirations. At 3:40 p.m., CPR was immediately initiated, and the DON was alerted. 911 was called and the DON took over CPR. CPR was continued by staff until EMS arrived and took over. CPR was discontinued, and the resident was pronounced deceased by EMS at 4:18 p.m. During an interview on [DATE] at 2:40 p.m., LVN B said he provided care for Resident #1 on [DATE] from 2:00 p.m. to 10:00 p.m. He said around 3:35 p.m., a CNA told him he needed to check on the resident. He said Resident #1 had no pulse and no respirations and he began CPR. He said Resident #1 was warm to touch. He said he told MA E and CNA J to get the DON. He said the DON immediately came to the room, assessed the resident, and continued CPR. LVN B said he took over CPR while the DON called 911. He said the DON called 911 within a few minutes of entering Resident #1's room. LVN B said someone got the crash cart and he used the ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing) while the DON continued to do compressions. He said they did not get the facility AED and apply it to Resident #1. He said he should have retrieved the AED but did not think about getting it. He said it seemed like ,[DATE] minutes from the time from when he initiated CPR to the time EMS arrived. LVN B said EMS did not continue CPR on Resident #1 when they arrived. He said EMS placed the monitor on Resident #1 and it showed no pulse. He said EMS called their medical director and they pronounced Resident #1 deceased . A nursing note dated [DATE] at 5:54 p.m., written by the DON, indicated at about 3:40 p.m. the nurse notified the DON Resident #1 was unresponsive. The note indicated the nurse was performing CPR on the resident and the DON took over. The note indicated the DON checked the resident's pulse and there was no pulse and the resident was warm. The DON continued CPR and the nurse took over while the DON called 911 at 4:00 p.m. and code cart was brought to the scene. The note indicated the 911 crew took over for the DON and placed the AED pads on Resident #1. An EKG was performed and showed asystole (no ventricular heart contractions). EMS called their medical director at 4:18 p.m. who ordered them to stop CPR. The note indicated the medical supervisor came to the scene to assess. The note indicated the medical director informed nursing to proceed as usual and gave the DON the case number. The social worker notified Resident #1's family and the funeral home. During an interview on [DATE] at 12:39 p.m., the DON said she was very busy on [DATE] and did not check on Resident #1 after seeing her in the morning with LVN A. She said later that afternoon, she heard a scream coming from Resident #1's room and she went to Resident's #1's room where she saw LVN B performing chest compressions on Resident #1. She said she took over compressions and she called 911 while she (the DON) was performing CPR on Resident #1. She said EMS performed an EKG and it showed asystole. She said EMS called their medical director and Resident #1 was pronounced deceased at that time. An EMS run record dated [DATE] indicated the facility called 911 at 4:02 p.m. and dispatch was notified at 4:02 p.m. EMS arrived at the facility at 4:07 p.m. The EMS run record indicated Resident #1 was in [MEDICAL CONDITION]. The run record indicated EMS arrived to find Resident #1 lying in bed with oxygen on. The facility nurse reported that the last known normal for Resident #1 was about 3:00 p.m. and they have been performing CPR for approximately 20 minutes. Resident #1 was pulseless and apneic. Pads were applied to Resident #1 and asystole was noted on the monitor. Nursing facility staff were in the room upon resident contact, but EMS did not witness CPR being performed. Medical control was contacted and advised to terminate efforts at 4:18 p.m. During an interview on [DATE] at 12:39 p.m., the administrator said Resident #1 had a decline after she moved off the COVID-19 unit. She said the nursing documentation had incorrect times regarding the length of time staff performed CPR on Resident #1. A change of condition policy dated [DATE] indicated a significant change of condition included .a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior .the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached .the physician will be contacted immediately for any emergencies irregardless of the time of day .If the physician cannot be reached, the DON or charge nurse can make arrangement for transportation to the emergency department . An in-service dated [DATE] presented by the DON indicated nurses were in-serviced on changes in condition. The in-service indicated when a nurse notices a change in condition they should assess the resident, notify the NP or physician, hospice if indicated, and document mental status changes, vital signs, refusal of medications/meals, and assess skin. The administrator and DON were notified on [DATE] at 5:13 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on [DATE] at 5:23 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:37 p.m. and included: .Immediately, on [DATE], (the corporate RN) and (the company DON) in serviced (the facility DON) on 1. Change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. On [DATE] (the facility DON) and (the company DON) initiated in-services with the licensed nurses on 1. Change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Nursing staff will not be allowed to work until in-servicing has been completed . On [DATE] an audit was conducted by (the corporate RN, the company DON, and the facility DON) to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. In order to monitor current residents for potential risk, (the facility DON and the corporate RN) will monitor residents with change of condition daily beginning [DATE] for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. (The facility DON's) compliance will be monitored weekly by (the corporate RN) for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee . On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 12:31 p.m., the administrator said in-servicing was initiated with staff on [DATE] and no staff would be allowed to return to duty until they were in-serviced. During an interview on [DATE] at 12:36 p.m., the DON of a sister facility said she in-serviced the DON on changes of condition. She said the in-servicing included the change of condition policy, comprehensive assessments, and notification of family and physician. She said after the DON was in-serviced, they in-serviced the staff together. She said staff were in-serviced on changes of condition, comprehensive assessments, and notification of physician and family. During an interview on [DATE] at 12:49 p.m., the DON said she was in-serviced on changes of condition including the policy, comprehensive assessments, and notification of family and physician. She said after she completed in-servicing, she and the DON of the sister facility in-serviced staff. She said staff were in-serviced on changes of condition, comprehensive assessments, notification of physician and family. Seven nurses (6 a.m. to 2 p.m., 2 p.m. to 10 p.m., 10 p.m. to 6 a.m., 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m.) said they were in-serviced on changes of condition. They were able to identify examples of changes of condition. They said they would immediately assess a resident if they noticed a change of condition or if staff notified them of a change of condition. They said if a resident presented with changes of condition, they would assess the resident and call the NP and responsible party. They said they would document any changes of condition in the resident's clinical record and interventions that were put into place. Three CNAs, 1 MA, 1 housekeeper, and 1 dietary staff said they were in-serviced on changes of condition and were able to identify examples of changes of condition. They said they would report any changes of condition to the resident's charge nurse. Change of condition assessments dated [DATE] for 43 residents were reviewed. There was no evidence of changes of condition in the residents. Change of condition assessments were completed by resident observation, staff interviews, and resident record review. Change of condition assessments were completed on [DATE]. On [DATE] at 5:04 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #7) of 13 residents reviewed received adequate supervision and assistive devices to prevent accidents. 1) Resident #7 was not transferred by mechanical lift as indicated in her care plan. This resulted in Resident #7 sustaining a fall and an acute right lower leg fracture. 2) The facility's supervisory staff, the ADON, failed to intervene when staff (CNAs A and B) failed to transfer Resident #7 according to her assessment and care plan interventions. 3) The facility failed to assess Resident #7's degree of mobility and physical impairment to determine the proper and safest method of transfer when Resident #7 expressed her desire to become more independent with her transfer activities. These failures resulted in an acute fracture for Resident #7 and could affect the other 38 residents, who were totally dependent or required staff assistance for transfers. Findings included: 1) The Quarterly MDS assessment, dated 10/19/2011, reflected Resident #7's [DIAGNOSES REDACTED]. The assessment reflected Resident #7 scored a 14 on the Brief Interview of Mental Status, which indicated she was cognitively intact. The assessment reflected the resident required extensive physical assistance (resident involved in activity, staff provide weight bearing support) with two or more staff for transfers, bed mobility, dressing, toilet use, bathing, and hygiene. The assessment also reflected Resident #7 had not walked, turned around, moved from a seated to standing position, or moved on and off a toilet, and was not steady and only able to stabilize with human assistance when transferring from bed to chair. The assessment reflected Resident #7 was 63 inches in height and weighed 384 pounds. The Face Sheet, dated 04/20/2012, reflected Resident #7 was admitted to the facility on [DATE]. During the Initial Tour on 04/17/2012 at 9:56 AM, while accompanied by the facility's only ADON, Resident #7 was observed in bed resting. At this time, the ADON stated Resident #7 was alert and oriented, had terminal cancer, and had fractured her ankle two to three months previously when her ankle rotated during a transfer. The ADON stated Resident #7 was only transferred by mechanical lift. On 04/17/2012 at 12:31 PM, Resident #7 was interviewed and stated a few months back, staff transferred her from her wheelchair to the sofa in the television room. Resident #7 stated she fell and landed with her right leg underneath her. Resident #7 stated right before she stood, the ADON said to the CNAs to use a gait belt. Resident #7 stated she sustained a fractured leg as a result of the fall. Resident #7's Care Plans, dated 07/20/2011 and updated 10/20/2011, reflected the resident had the following problem: "I am unable to transfer independently, I require a hoyer lift with two staff to safely transfer me." The care plan's identified approaches for this problem included the following: "I require two person extensive assistance with hoyer lift for all transfers." An Incident and Accident Report, dated 12/27/2011, reflected Resident #7 requested to be assisted to a standing position and after taking two steps, "started sitting down and was lowered to floor. Rt (right) leg was under her." The report reflected Resident #7 complained of right leg pain and there were three witnesses at the time of the fall, the ADON, and CNAs A and B. Documented in the steps taken to prevent recurrence section of the report, was written "Hoyer lift only." In the section for [DIAGNOSES REDACTED]." The report reflected it was completed by the ADON. A Radiology Report, dated 12/27/2011, reflected Resident #7 sustained an acute right lower fibular shaft fracture with mild displacement. Review of Resident #7's Fall Risk Assessments, dated 10/17/2011 and 12/27/2011 (day of the fall), reflected Resident #7 was coded with a score of "2" for gait and balance activities. According to the risk assessment legend, this score indicated Resident #7 was not able to perform these functions as directed. The facility's Investigation Follow-up to the 12/27/2011 incident, dated 12/29/2011, reflected it was completed by the DON. The summary of the investigation reflected the following: Resident #7 requested assistance to stand, so she could transfer to the couch. A walker was provided and placed in front of her. With staff standing on each side of her and behind her, Resident #7 was assisted to a standing position. Resident #7 took two to three steps, began to collapse to a seated position and staff eased her to the floor. A Hoyer lift was used to lift Resident #7 from the floor and returned her to a wheelchair. Resident #7 was then wheeled back to her room and a Hoyer lift was used to transfer her to bed. An X-ray was obtained and a fracture to the right lower extremity was noted. "Res dx of morbid obesity contributes to unable to bear own weight. Res wt in excess of 300 lbs. Res previously able to ambulate short distances." 2) The ADON was interviewed on 04/17/2012 at 2:21 PM and stated Resident #7 wanted to transfer from her wheelchair to the sofa on 12/27/2011. The ADON stated Resident #7 had been able to stand with a walker in front of her, take a few steps, pivot and sit down. The ADON stated, "I was always on the aides to use a gait belt with her when they got her to stand because they got so used to her standing without one." The ADON stated that day (12/27/2011), "I told them (CNAs A and B) to get a gait belt. They did not. During the transfer, her leg buckled and she went to the floor. Now she only wants to get up occasionally and we have to use the mechanical lift." The ADON continued stating a gait belt should always be placed on a resident when assisting them to transfer. She stated, at the time Resident #7 fell , they did not have bariatric gait belts, but that was not an excuse. She stated they could have used a regular gait belt and placed it higher on her body. The ADON stated when Resident #7 stood up, she took a few steps then went down with her leg up under her. CNA A was interviewed on 04/18/2012 at 9:16 AM and stated she was one of the aides assisting Resident #7 when she fell on [DATE]. CNA A stated CNA B asked her for help getting Resident #7 to the couch in the television room. CNA A stated Resident #7's walker was retrieved from her room and brought to the television room. CNA A stated Resident #7 would sit in her wheelchair and rock, with her hands on her wheelchair arms, then stand up. She stated once she stood up, she would grab on to the walker. CNA A stated on that day, the resident went down and yelled, "My leg! My leg!" CNA A stated the resident's right leg was underneath the resident. She stated the ADON was there and repositioned the resident. CNA A did not recall the ADON saying to use a gait belt, and CNA A stated a gait belt had never been used before. CNA B was interviewed on 04/18/2012 at 9:45 AM and stated she was one of the aides assisting Resident #7 when she fell on [DATE]. CNA B stated the ADON asked her to assist Resident #7 from her wheelchair to the couch. CNA B stated she asked CNA A for help. CNA B stated the three of them, the ADON, CNA A and CNA B, assisted the resident. CNA B stated she did not recall the ADON saying to use a gait belt. CNA B stated a gait belt was not used. During the transfer, Resident #7 went down on the couch and slid to the floor. CNA B stated Resident #7's leg was underneath her and she yelled, "My leg!" CNA B stated Resident #7 required a mechanical lift when moving from the bed to the wheelchair, and that was how she was used to transferring Resident #7. CNA B stated she had never transferred Resident #7 the way she was transferred the day of the fall, but she had seen the hospice aide and others transfer her that way. On 04/18/2012 at 11:20 AM, COTA C was interviewed and stated she recalled the day Resident #7 fell . COTA C stated staff stopped her and asked for her help. She stated Resident #7 had just fallen and was on the floor in the television room. COTA C stated she used her gait belt to help move and reposition Resident #7 onto a mechanical lift sling, so she could be lifted into her wheelchair. COTA C stated she knew Resident #7 required a mechanical lift for transfers, and she had never seen the resident transfer from the chair to a sofa by standing with a walker. When asked if she thought that method was appropriate, COTA C stated if she had been caring for Resident #7 and knew she required a mechanical lift to transfer her from bed to wheelchair, she would have used the mechanical lift to move her from the wheelchair to the sofa. COTA C stated, "If she is not safe to transfer from bed to wheelchair then she is not safe for wheelchair to sofa." During the same interview, COTA C also stated that while she helped staff reposition Resident #7 onto the sling, Resident #7 kept saying she did not know what went wrong, because she had transferred that way several times. COTA C stated Resident #7 did not have a gait belt applied, because she had to use her gait belt to reposition Resident #7 onto the mechanical lift sling. COTA C stated it was always important to use a gait belt for the safety of the resident and staff. An interview was conducted with LVN F on 04/18/2012 at 3:05 PM. LVN F stated she was Resident #7's charge nurse during the 2:00 PM to 10:00 PM shift on 12/27/2011. LVN F stated Resident #7 had fallen during the previous shift. LVN F stated Resident #7 was not transferred much during her shift, but she "definitely" needed a Hoyer lift for transfers from the bed to the wheelchair or even to a sofa. LVN F stated a mechanical lift was needed for safety purposes and due to Resident #7's size. During a meeting with the Administrator and the DON on 04/18/2012 at 4:20 PM, they were asked why Resident #7 was not transferred in accordance with her care plan. The DON stated Resident #7 wanted to be more mobile. She stated the resident could ambulate some with a walker, but she needed to be transferred from bed to wheelchair by a mechanical lift. The DON was asked if an assessment was conducted prior to changing the way staff transferred Resident #7, given the care plan reflected Resident #7 required a Hoyer lift for all transfers. The DON stated she had no documentation to that effect. She stated she would check with the Therapy Department to see if they did an assessment. The MDS Coordinator was interviewed on 04/19/2012 at 11:29 AM. When asked how she determined the accurate coding for the MDS transfer status, the MDS Coordinator stated she read the documentation on the aides flow sheet regarding how they transferred a resident. The MDS Coordinator stated she also interviewed staff, but could not recall staff telling her Resident #7 could take steps. The MDS Coordinator stated she never observed Resident #7 stand with a walker and take steps. The MDS Coordinator stated it was important to accurately code the transfer ability, because that was what "drove" the care plan. LVN G was interviewed on 04/19/2012 at 12:11 PM. She stated she was a charge nurse during the 6:00 AM to 2:00 PM shift for the 100 Hall, where Resident #7 resided. LVN G stated she was familiar with Resident #7 and was aware that Resident #7 required a mechanical lift to be transferred from the bed to the wheelchair. LVN G stated she had seen Resident #7 transferred before without a lift. LVN G stated aides would assist Resident #7 to stand and pivot to change surfaces. LVN G stated the aides would use a gait belt to help steady Resident #7. CNA H was interviewed on 04/19/2012 at 12:44 PM. CNA H stated she worked on the 100 Hall during the 6:00 AM to 2:00 PM shift and was familiar with Resident #7. CNA H stated staff transferred Resident #7 with a mechanical lift from the bed to the wheelchair. CNA H stated, sometimes if the resident wanted to move from her wheelchair to another seat, staff would help her stand and pivot. CNA H stated Resident #7 would take a few steps. During the interview, CNA H was asked what the care plan for Resident #7 reflected regarding transfer activities. CNA H stated, "It said she needed a Hoyer lift, but she wanted to be more mobile and we let her stand, turn, and sit." When asked if she conferred with a nurse before transferring Resident #7 in that manner, CNA H stated, "I think I told one of the nurses, but I can't remember who because I've had a lot of nurses." In an interview on 04/20/2012 at 12:11 PM, Resident #7 stated a couple of months after her admission (07/20/2011), she wanted to be more independent in her activities of daily living. Resident #7 stated she requested to stand and transfer, and was doing this occasionally. Resident #7 stated she could not recall anyone, including a nurse or therapist, assessing her regarding her ability to transfer prior to standing and pivoting to change surfaces. Resident #7 stated staff would use the gait belt off and on, but they did not the day she fell and fractured her leg. Resident #7 stated she heard her ankle pop, "no sooner after it went up under me." On 04/20/2012 at 3:41 PM, the ADON was interviewed again and asked why she did not stop the transfer and apply a gait belt. The ADON stated Resident #7 stopped her and asked to be transferred. The ADON stated she told one of the aides about Resident #7's request, and instructed her to go and get Resident #7's walker from her room. The ADON stated she then left the area and when she passed by again, CNAs A and B were in the process of the transfer. She stated, "I asked them where the gait belt was but by that time (Resident #7) was in the process of standing up. I went up and stood behind the wheelchair." As of exit on 04/20/2012 at 6:00 PM, no documentation of any assessment for Resident #7 was provided by facility staff to reflect an assessment was conducted to determine the safest way to transfer the resident given her request to become more independent. 3) The facility's current Safe Handling and Moving Protocol, dated May 2010, reflected the following: "The Q.A. Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting transferring, repositioning or movement of a resident... 2. Expectation of Assessment and Communication: a. The licensed nurse will, upon resident admission, monthly summary or incident/accident related to transfers will determine the level of assistance required to safely transfer the resident, while minimizing the risk to resident and staff... e. The nursing staff will communicate immediately to nursing administration or rehab designee, any concerns that arise from the current assigned level of assistance. The licensed nurse/ therapist will re-assess the resident's abilities and determine appropriate level of assistance required to minimize risk of injury to resident and staff... Transfer Technique Training: Precautions: Residents with cardiac/respiratory limitations... Impaired Balance... Bariatric needs (Obesity)... General considerations:... Utilize gait belt during all weight bearing transfer activity." 4) The Resident Census and Conditions of Residents form, CMS 672, dated and signed by the MDS Coordinator on 04/17/2012, reflected six residents were totally dependent on staff for transfers and 33 residents required the assistance of one or two staff for transfers.