Every finding on record at The Sarah Roberts French Home

Based on interviews, record review the facility failed to at the time each resident is admitted , the facility must have physician orders for the resident's immediate care for 1 of 8 (2) residents in that:Resident #2 did not have an order to be admitted to the facility.This could affect all new resident admission and could delay care.The Findings were: Record review of Resident #2's admission Record dated 11/1/2025 with diagnoses of diabetes II, anxiety disorder, hypertension, acute respiratory failure with hypoxia, cognitive communication deficit, altered mental status, and urinary tract infection. Record review of Resident #2's physician orders dated 11/1/2025 at 2:27 PM revealed on I hereby certify that this resident requires/continues to require nursing facility care for 180 days. Ordered by physician. This does not say Resident #2 will be admitted to the facility. Record review of Resident #2's nurse practitioner visit dated 11/18/2025.Record review of Resident #2's psychiatry initial evaluation dated 11/12/2025.Record review of Resident #2's chart revealed no record of a physician visit. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she had was admitted on [DATE], had moderately impaired vision, a BIMS of 7/13 (severe impairment), had behaviors, wandering, required mobilization of wheelchair, she required supervision for ADLs, she was frequently incontinent of bowel/bladder, she was administered injections/insulin medications, and she was receiving therapy services.Record review of Resident #2's Care Plan dated 11/2/2025 revealed she was diabetic, had surgery to head from a previous fall at home, ADL self-care, risk for wandering, resident prefers activities of choice, risk for falls related to weakness, resident has evidence of weakness, memory impairment, unable to manage medications and had difficulty falling asleep.Interview on 2/3/2026 at 12:25 PM with Resident #2 stated she had not been visited by a physician, since her admission.Interview on 2/5/2026 at 5:27 PM with LVN B stated she admitted Resident #2 from the hospital on [DATE]. LVN B stated Resident #2 did not have an order to admit to the facility. LVN B stated the software batch for new admission must not include the admission orders. LVN B stated DON was responsible for making sure the orders were reviewed.Interview on 2/5/2026 at 5:38 PM with DON stated after reviewing Resident #2s orders, she did not see orders for this resident. No comment. Record review of policy for Physician's progress notes (no date) revealed Regulation states that a resident must be seen by a physician on a specific timeline after admission. After admission, a resident must be seen within the first 30 days, then every 30 days thereafter to complete the first 90 days of the stay. After the 90-day time frame the resident must then be seen every 60 days. a. The physician does have the option to delegate these visits to the physician assistant (PA) or the nurse practitioner (NP). However, within the first 90 days after an admission the attending physician themselves must at least alternate visits with the PA or NP during Medicare admission.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 Residents (Resident #7) reviewed for medication administration. LVN C administered a whole pill medication to Resident #7 who required her medications to be crushed. This Failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings included: A record review of Resident #7's admission record dated 2/4/2026 revealed an admission date of 4/29/2024 with diagnoses which included Alzheimer's disease (a progressive neurodegenerative disorder and the most common cause of dementia. It affects memory, thinking, behavior, and the ability to perform daily activities), anxiety, hypertension (high blood pressure). A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female admitted for long term care related to safe assistance with activities of daily life (ADL). Resident #7 was assessed with a BIMS score of 6 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #7's care plan dated 2/4/2026 revealed, The resident has a swallowing problem related to Gerd (a chronic digestive disorder where stomach acid frequently flows back into the esophagus, irritating its lining, often causing heartburn and regurgitation, and occurs when the lower esophageal sphincter muscle weakens or relaxes abnormally) mechanical altered diet . all staff to be informed of residents special dietary and safety needs . A record review of Resident #7's imaging report dated 5/12/2025, titled Physician MBSS Consult Summary revealed, Supported in report for MBSS sic[modified barium swallow study] physician / SLP sic[speech language pathologist (a healthcare professional who diagnoses and treats communication and swallowing disorders across all ages)] and instrumental findings . Recommendations: . strategies for pills: choking risk - crush meds sic[medications] or liquid form . A record review of Resident #7's physicians orders dated 2/4/2026 revealed the physician prescribed Resident #7 was to receive pills crushed and or in liquid form, choking risk . crush meds or liquid form . A record review of Resident #7's physicians orders dated 2/4/2026 revealed on 4/23/2025, the physician prescribed Resident #7 pantoprazole 20mg, (a medication that reduces acid production in the stomach, allowing the esophagus to heal) daily in the morning. An observation on 2/4/2025 at 1:45 PM, revealed the facility's medication cart on which Resident #7's medication was stored revealed, Resident #7's pharmacy supplied medication card for pantoprazole. The card was delivered with 30 pills of pantoprazole 20mg pills and had 4 pills left. Further review revealed the pharmacist had labeled the medication with instructions do not crush. A record review of Resident #7's February 2026 medication administration record revealed Resident #7 was administered pantoprazole 20mg pill on 2/2/2026, 2/3/2026, and 2/4/2026. During an interview on 2/4/2026 at 1:35 PM LVN E demonstrated Resident #7's pantoprazole medication card as supplied by the pharmacy. LVN E stated the pantoprazole was a whole pill enteric coated and should not be crushed. LVN E stated Resident #7 had an order to crush her medications. LVN E stated the pantoprazole was scheduled to be administered at 5 am prior to her scheduled shift. During an interview on 2/4/2026 at 2:12 PM Pharmacist D stated he had access to Resident #7's medical record orders and stated Resident #7 had an order for a mechanically altered diet for mechanical crush diet texture and Resident #7 was prescribed pantoprazole delayed release medication which should not be crushed. Pharmacist D stated if the medication was crushed it would be ineffective. Pharmacist D stated the resident could receive a version of pantoprazole sprinkles which could be administered in a substance like applesauce. During an interview on 2/04/2026 at 2:44 PM LVN C stated Resident #7 was prescribed a mechanically altered diet and had her pills crushed however Resident #7 could tolerate the small pantoprazole pill and she had administered the pills whole without crushing. LVN C stated pantoprazole was an enteric coated pill which should not be crushed. During an interview on 2/4/2026 at 5:00 PM the Administrator and the DON stated the expectation was for nursing staff to administer medications as prescribed. The DON stated Resident #7 was assessed without negative outcomes and the physician was given a report and had issued no new orders. The Administrator and the DON stated the failure could potentially put residents at risk for not receiving the intended therapeutic effects of their medications. A record review of the facility's Medication Administration and General Guidelines policy dated March 2025, revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications, . Prior to administration, the medication and dosage schedule on the residence medication administration record is compared with the medication label. If the label and the medication administration record are different and the container is not flagged, indicating a change in directions, or if there is any other reason to question the dosage or directions, the physicians' orders are checked for the correct dosage schedule. Facility personnel will contact the sic[name of the pharmacy] if any discrepancies are noted.

Based on interviews, record review the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for 1 of 8 (Resident #2) residents that required physician visits in that: Resident #2 was not seen by a physician within the first 90 days after admission. This could affect all new admissions and could result in a delay in care. The findings were:Record review of Resident #2's admission Record dated 11/1/2025 reflected with diagnoses of diabetes type II, anxiety disorder, hypertension, acute respiratory failure with hypoxia, cognitive communication deficit, altered mental status, and urinary tract infection. Record review of Resident #2's physician orders dated 11/1/2025 at 2:27 PM revealed on I hereby certify that this resident requires/continues to require nursing facility care for 180 days. Ordered by physician. This does not say Resident #2 will be admitted to the facility. Record review of Resident #2's nurse practitioner visit dated 11/18/2025 reflected. Record review of Resident #2's psychiatry initial evaluation dated 11/12/2025. Record review of Resident #2's chart revealed no record of a physician visit. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she was admitted on [DATE], had moderately impaired vision, a BIMS of 7/13 (severe cognitive impairment), had behaviors, wandering, required mobilization of wheelchair, she required supervision for ADLs, she was frequently incontinent of bowel/bladder, she was administered injections/insulin medications, and she was receiving therapy services. Record review of Resident #2's Care Plan dated 11/2/2025 revealed she was diabetic, had surgery to her head from a previous fall at home, ADL self-care, risk for wandering, risk for falls related to weakness, resident has evidence of weakness, memory impairment, unable to manage medications and difficulty falling asleep. In an interview on 2/3/2026 at 12:25 PM Resident #2 stated she had not been visited by a physician, since her admission. In an interview on 2/5/2026 at 5:27 PM LVN B stated she admitted Resident #2 from the hospital on [DATE]. Record review of policy for Physician's progress notes (no date) revealed Regulation states that a resident must be seen by a physician on a specific timeline after admission. After admission, a resident must be seen within the first 30 days, then every 30 days thereafter to complete the first 90 days of the stay. After the 90-day time frame the resident must then be seen every 60 days. a. The physician does have the option to delegate these visits to the physician assistant (PA) or the nurse practitioner (NP). However, within the first 90 days after an admission the attending physician themselves must at least alternate visits with the PA or NP during Medicare admission.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and CNA B utilized proper PPE while providing care for Resident #1. This failure could place residents at risk of infection or illness. Findings included:Record review of Resident #1's face sheet, dated 11/18/2025, reflected an [AGE] year-old female admitted on [DATE]. Diagnoses included type 2 diabetes mellitus with foot ulcer (skin break down resulting from the body's inability to self-regulate glucose levels).Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS of 15, which indicated intact cognition.Record review of Resident #1's care plan report, dated 11/18/2025, revealed the following:I have actual impairment to skin integrity of the left inner thigh/groin area r/t fragile skin, incontinence of urine ***Enhanced Barrier Precautions*** for wound care. [sic]Record review of Resident #1's active physician orders did not reveal and order for EBP. In an observation on 11/18/2025 at 12:10 PM, CNA A and CNA B transferred Resident #1 using the mechanical lift device. Signage indicating Resident #1 required EBP was posted on the wall outside of the door, and a caddy containing PPE was hanging from the door. CNA A and CNA B were not wearing gowns while performing the transfer. In an interview with CNA A on 11/18/2025 at 12:10 PM, she said Resident #1 required EBP due to wounds on her buttocks. She said she did not don a gown because she assisted with a transfer, and PPE was only required when performing care such as changing a resident's soiled brief. She said not wearing proper PPE could cause an infection. In an interview with the ADON on 11/18/2025 at 1:40 PM, she said she served as the infection preventionist for the facility since July 2025. She said it was the corporate policy to not enter a physician's order for isolation precaution and to instead include any isolation required in the profile of the electronic medical record. She said the isolation precautions would populate under the special instructions of a resident's profile heading. She said the facility's policy and her expectation of staff assisting with transfers for residents on EBP they will don gowns and gloves. She said the potential harm to residents of staff not utilizing PPE was the spread of infection to staff or other residents. In an interview with the DON on 11/18/2025 at 1:50 PM, she said that staff should wear gowns and gloves while transferring residents on EBP. Record review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/2024, revealed the following:EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing Resident activity/assistance: Transfer a resident, alcohol based hand rub before and after: Yes, [NAME] gloves and gown: Yes.

Based on observation, interview and record review the facility failed to, ensure that all alleged violations involving abuse, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 4 of 5 Residents (Resident #1, Resident #2, Resident #3 and Resident #4) whose records were reviewed. 1. The facility failed to report a fracture of Resident #1's coccyx/geal on 12/28/24, the date they received report from Hospice of the X-ray results. The facility made the report to HHSC on 12/30/24. 2. The facility failed to report Resident #2 sustained a gash on the back of her head requiring five (5) staples after a fall on 1/10/25. The facility reported the incident on 1/11/25. 3. The facility failed to report a Resident to Resident altercation at the time Resident #3 alleged Resident #4 hit her on the left side of her head on 4/19/25. The facility reported the allegation of abuse on 4/22/25. These deficient practices could affect any resident and place residents at risk of further abuse and neglect. The findings were: 1. Review of Resident #1's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, History of Falls and Anxiety, unspecified. Review of Resident #1's quarterly MDS, dated , 3/28/25, revealed her BIMS score was 10 of 15, reflective of moderate cognitive impairment Review of Resident #1's Care Plan, dated 3/28/25, identified Resident #1 as a high fall risk. It reflected she had fallen on 12/22/24. Review of the Provider Investigation Report, dated 12/30/24, revealed incident date was 12/22/24. There were no apparent injuries noted upon assessment on 12/22/24. Resident #1 reported pain to her neck and upper shoulders and was treated with biofreeze and Tylenol which were effective. On 12/26/24 Resident #1 complained of severe pain to the neck and upper shoulders. On 12/27/24 Hospice provided a new order for X-rays. On 12/28/24 Hospice reported X-ray results to the facility: distal coccyx/geal irregularities are visualized, likely an acute fracture. The allegation of Resident Neglect was reported to HHSC on 12/30/24. Observation and interview on 5/29/25 at 11:02 AM revealed Resident #1 was lying in bed with ¼ side rails up on both sides of the bed. Resident #1 engaged in conversation and presented as alert and oriented with some confusion and forgetfulness. Resident #1 stated she was doing well, and staff was very attentive. Resident #1 stated she did not remember the details of the fall during December of 2024. She stated she was receiving therapy, was doing much better and was very happy with rehabilitation services. Resident #1 did not express any concerns related to abuse or neglect Interview on 5/29/25 at 11:20 AM with the ADM revealed she did not work at the facility at the time of Resident #1's incident and did not know why the incident was not reported sooner. She stated staff who worked at the time no longer worked at the facility and did not have the staffs contact information. The ADM stated she understood an incident involving a major injury should be reported within 2 hours and it was not reported until 2 days after X-ray results showed a fracture. Interview with the DON and Administrator on 5/29/25 at 6:00 PM revealed the ADM stated not reporting incidents with a major injury could place the residents at risk for further abuse. 2. Review of Resident #2's face sheet, undated. revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Epileptic Seizures, Anxiety Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and left non-dominant side. Review of Resident #2's quarterly MDS, dated [DATE], revealed her BIMS score was 3 of 15, reflective of severe cognitive impairment. Resident #2 required partial to moderate assistance for most ADL's. Review of Resident #2's Provider Investigation Report, dated 1/13/25, revealed on 1/10/25 Resident #2 fell in the bathroom and hit the back of her head on the wall. It was an unassisted transfer. Resident #2 complained of right hip pain and pain to the back of head. Blood was noted on the bathroom wall and on the bathroom door. Resident #2 was sent out to a local hospital and returned to the facility on 1/12/25 with five staples on the back of her head. Further review of the Provider Investigation Report revealed Resident #2 had a history of unassisted transfers, not asking for help and falling. Review of a hospital X-Ray report for Resident #2, dated 1/11/25, revealed negative findings for a right hip fracture. Observation and interview with Resident #2 on 5/29/25 at 1:40 PM revealed she was propelling herself down the hall into the common area. Noted right arm, flaccid (limp), and had limited use of it. Resident #2 stated she did not remember falling or receiving staples on the back of her head. Resident #2 presented as alert, oriented to self and confused. When asked how she was doing she stated, fine. Interview with the DON and ADM on 5/29/25 at 6:00 PM revealed they did not work at the time of Resident #2's incident, dated 1/10/25, and did not know why it was not reported at the required timeframe. The ADM stated the incident should have been reported within 2 hours but was not reported until 1/12/25. She stated not reporting incidents with a major injury could place the residents at risk for further abuse. 3. Review of Resident #3's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis (according to MedLine it affects your brain and spinal cord). Review of Resident #3's quarterly MDS, dated [DATE], revealed her BIMS score was 13 of 15, reflective of minimal cognitive impairment. Review of Resident #3's Provider Investigation Report, dated 4/24/25, revealed Resident #3 alleged that Resident #4 hit on the side of her face during the nighttime. Resident #3 made the allegation of abuse to a staff on 4/20/25. Upon an assessment there were no noted injuries. Upon interview Resident #4 denied the allegation. Further review of the Provider Investigation Report revealed Resident #3 and Resident #4 were roommates at the time of the incident. The facility reported the allegation of abuse to HHSC on 4/22/25. Review of the facility roster, dated 5/29/25, revealed Resident #4 was no longer a resident at the facility. Observation and interview on 5/29/25 at 1:30 PM with Resident #3 revealed she was sitting in a wheelchair by the front window in the common area. Resident #3 engaged in conversation and stated Resident #4 hit her and pointed to her left shoulder. She stated it hurt when Resident #4 hit her. Resident #3 stated staff moved her to another room, and she was ok with the move. She stated she felt safe, she was good about the care she received and she did not express any concerns related to abuse and neglect. Interview with the DON and ADM on 5/29/25 at 6:00 PM revealed they were not sure the incident between Resident #3 and Resident #4 actually took place but decided to report it anyway. The ADM stated she was responsible for reporting allegations of abuse and neglect to HHSC. The DON stated she did not believe it was reportable within 2 hours because it did not result in a major injury. Upon reviewing the facility's policy the ADM stated because it was an allegation of abuse it should have been reported within 2 hours. She stated Resident #4 was discharged to another facility and was no longer a risk to Resident #3. The ADM stated it was important that all allegations of abuse were reported to ensure the safety of the residents and to prevent further abuse. Review of the facility policy, revised February 10, 2020, read The [facility] enforces that our residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, corporal punishment, involuntary seclusion, and free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. (abuse) TYPES OF INCIDENTS TO REPORT: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A Missing Resident, Misappropriation, Drug Theft, Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety. Timeframe's for each incident type: Abuse of any kind (with or without serious bodily injury); OR neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, WHEN to report the above types of incidents: IMMEDIATELY, BUT NOT LATER THAN TWO HOURS AFTER INCIDENT OCCURS OR IS SUSPECTED.

Based on interview and record review, the facility failed to provide mandatory effective training on behavioral health for 16 of 17 employees (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, DON, ADON) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, DON, ADON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Intention Control, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide C revealed a hire date of 07/19/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls, being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for CNA F revealed a hire date of 04/26/2010. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Restraints being provided annually. Record review of personnel records for [NAME] B revealed a hire date of 07/01/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for DD revealed a hire date of 04/04/2006. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for AD revealed a hire date of 05/22/1996. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls being provided annually. Record review of personnel records for LVN G revealed a hire date of 08/17/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, QAPI, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for RN H revealed a hire date of 11/22/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for LVN I revealed a hire date of 12/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health being provided annually. Record review of personnel records for LVN J revealed a hire date of 05/12/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for DON revealed a hire date of 10/05/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for ADON revealed a hire date of 07/27/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Abuse, Dementia, QAPI, Behavioral Health, HIV, Restraints being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 17 (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON) of 17 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Intention Control, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide C revealed a hire date of 07/19/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls, being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for CNA F revealed a hire date of 04/26/2010. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Restraints being provided annually. Record review of personnel records for [NAME] B revealed a hire date of 07/01/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for the DD revealed a hire date of 04/04/2006. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for the AD revealed a hire date of 05/22/1996. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls being provided annually. Record review of personnel records for LVN G revealed a hire date of 08/17/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, QAPI, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for RN H revealed a hire date of 11/22/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for LVN I revealed a hire date of 12/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health being provided annually. Record review of personnel records for LVN J revealed a hire date of 05/12/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for the Admin revealed a hire date of 04/15/2024. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI being provided upon hire. Record review of personnel records for the DON revealed a hire date of 10/05/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for the ADON revealed a hire date of 07/27/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Abuse, Dementia, QAPI, Behavioral Health, HIV, Restraints being provided annually. Interview with HR on 11/05/2024 at 3:33 PM, revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with the Admin on 11/05/2024 at 4:33 PM, revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary, based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 17 (Cook A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON) of 17 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to [NAME] A, Maintenance, Admissions, CNA E, Med Aide C, Med Aide D, CNA F, [NAME] B, DD, AD, LVN G, RN H, LVN I, LVN J, Admin, DON, ADON annually. The facility failed to ensure required trainings were provided to the Admin upon hire. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Intention Control, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide C revealed a hire date of 07/19/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls, being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for CNA F revealed a hire date of 04/26/2010. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Restraints being provided annually. Record review of personnel records for [NAME] B revealed a hire date of 07/01/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for DD revealed a hire date of 04/04/2006. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for AD revealed a hire date of 05/22/1996. Further review of a training log, provided by the HR Manager revealed no evidence of Dementia, QAPI, Behavioral Health, Falls being provided annually. Record review of personnel records for LVN G revealed a hire date of 08/17/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, QAPI, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for RN H revealed a hire date of 11/22/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for LVN I revealed a hire date of 12/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health being provided annually. Record review of personnel records for LVN J revealed a hire date of 05/12/2021. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI, Behavioral Health, HIV being provided annually. Record review of personnel records for Admin revealed a hire date of 04/15/2024. Further review of a training log, provided by the HR Manager revealed no evidence of QAPI being provided upon hire. Record review of personnel records for DON revealed a hire date of 10/05/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for ADON revealed a hire date of 07/27/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Abuse, Dementia, QAPI, Behavioral Health, HIV, Restraints being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program training for 4 of 17 employees (Cook A, Maintenance, CNA E, Med Aide D) reviewed for training, in that: The facility failed to ensure effective standards, policies, and procedures for an infection prevention and control program training was provided [NAME] A, Maintenance, CNA E, Med Aide D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Intention Control, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on ethics training for 4 of 17 employees (Cook A, CNA E, Med Aide D, DON) reviewed for training, in that: The facility failed to ensure effective ethics training was provided [NAME] A, CNA E, Med Aide D, DON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for DON revealed a hire date of 10/05/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Falls, Restraints, being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on abuse, neglect, exploitation, and misappropriation training for 5 of 17 employees (Admissions, CNA E, Med Aide D, LVN G, ADON) reviewed for training, in that: The facility failed to ensure effective abuse, neglect, exploitation, and misappropriation training was provided to Admissions, CNA E, Med Aide D, LVN G, ADON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for LVN G revealed a hire date of 08/17/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, QAPI, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for ADON revealed a hire date of 07/27/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Abuse, Dementia, QAPI, Behavioral Health, HIV, Restraints being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on rights of the resident training for 3 of 17 employees (Cook A, Admissions, DON) reviewed for training, in that: The facility failed to ensure effective rights of the resident training was provided to [NAME] A, Admissions, DON annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Admissions revealed a hire date of 05/31/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, HIV, Falls, Restraints, being provided annually. Record review of personnel records for DON revealed a hire date of 10/05/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Residents Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Falls, Restraints, being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, the facility failed to provide mandatory effective training on communications training for 8 of 17 employees (Cook A, Maintenance, CNA E, Med Aide D, CNA F, [NAME] B, LVN G, LVN I) reviewed for training, in that: The facility failed to ensure effective communication training was provided to [NAME] A, Maintenance, CNA E, Med Aide D, CNA F, [NAME] B, LVN G, LVN I annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for [NAME] A revealed a hire date of 01/04/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Residents Rights, QAPI, Intention Control, Ethic, Behavioral Health HIV, Falls, or Restraints being provided annually. Record review of personnel records for Maintenance revealed a hire date of 02/24/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Intention Control, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for CNA E revealed a hire date of 05/18/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Falls, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for Med Aide D revealed a hire date of 06/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, Dementia, QAPI, Intention Control, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for CNA F revealed a hire date of 04/26/2010. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Restraints being provided annually. Record review of personnel records for [NAME] B revealed a hire date of 07/01/2022. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health, HIV, Falls being provided annually. Record review of personnel records for LVN G revealed a hire date of 08/17/2023. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, Abuse, QAPI, Behavioral Health, HIV, Restraints, Emergency Preparedness being provided annually. Record review of personnel records for LVN I revealed a hire date of 12/02/2021. Further review of a training log, provided by the HR Manager revealed no evidence of Communication, QAPI, Behavioral Health being provided annually. Interview with HR on 11/05/2024 at 3:33 PM revealed the facility used an online system, RELIAS, to train staff on their initial and annual trainings. HR stated she is responsible to ensure staff receive their annual trainings by logging into RELIAS and assigning staff their trainings. When asked what contributed to staff not receiving their annual trainings HR stated it's been a rough year. When surveyor asked HR why it was important that staff receive their annual trainings, HR stated it was important to ensure the residents are well taken care of. Interview with Admin on 11/05/2024 at 4:33 PM revealed it is the responsibility of HR and herself to ensure staff receive initial and annual trainings. Admin stated by staff not receiving their annual trainings the residents would be at greater risk for poor treatment, abuse and neglect. Record review of facility policy In-Service Training, All Staff, dated August 2022, revealed 6. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: ( 1) activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) dementia management and resident abuse prevention. d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary ,based on the facility assessment. Based on the outcome of the facility assessment, additional training may include: a. advanced care planning; b. cultural competence; c. end of life care; d. geriatrics or gerontology; e. substance abuse; f. grief and loss; g. person-centered care; h. grief and loss; i. trauma-informed care; j. specialized rehabilitation therapy; k. substance use disorders; l. intellectual disability; and/or m. mental disorders. 8, Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on observation, interview, and record review, the facility failed to ensure that each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 meals observed, in that: Cook A did not ensure food prepared for residents receiving a mechanical soft diet was in the proper consistency for this diet. This deficient practice could affect residents who ate mechanical soft texture diets, and place them at-risk by contributing to choking, weight loss, and dissatisfaction. The findings were: Record review of the facility's list of resident's diets, dated 11/6/2024, revealed 23 of the 48 residents received mechanical soft diets. Observation on 11/05/2024 at 11:43 AM, revealed [NAME] A preparing mechanical soft porkchops. [NAME] A completed the process and placed the mechanical soft porkchops in a tray before placing it on the steamtable. Surveyor asked [NAME] A to stir mechanical soft porkchops. Four quarter sized pieces of porkchop was observed within the tray of mechanical soft porkchops. Interview with [NAME] A on 11/05/2024 at 11:47 AM, revealed he had been the cook at the facility for about two years. [NAME] A stated he received training from the dietary manager on preparing mechanical soft textures when he started at the facility. [NAME] A stated the mechanical soft texture should look like pulled pork consistency. [NAME] A stated it was important to prepare mechanical soft foods to the appropriate texture and size so that the residents can eat it. [NAME] A stated the large pieces of porkchop in the mechanical soft porkchop could cause the residents to choke. Interview with the DM on 11/05/2024 at 12:39 PM, revealed she trained the staff on therapeutic diets and altered textures. DM stated the altered textures were for the resident's safety to prevent them from choking. The DM stated the large pieces of porkchop that were left in the mechanical soft porkchops could cause the residents to choke. Record review of facility policy Therapeutic Diets, dated 2017, revealed 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: a. diabetic/calorie-controlled diet; b. low sodium diet; c. cardiac diet; and d. altered consistency diet. Policy identifying process of preparing mechanical soft diet was requested from Administrator on 11/06/2024 at 8:20 AM and was not provided prior to exit.

Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 of 8 residents (Resident #16) reviewed for advanced directives, in that: The facility failed to ensure Resident #16's RP desire to formulate an advanced directive OOH DNR was completed and part of the medical record. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident of #16's face sheet, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that dementia, type 2 diabetes mellitus (chronic health condition that affects how body turns food into energy), and chronic obstructive pulmonary disease (a group of serious lung diseases that make it hard to breathe. It's caused by damage to the lungs that narrows the airways, or bronchi, and reduces airflow). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #16's comprehensive care plan, last revised on [DATE], revealed there was no code status mentioned. Record review of Resident #16's Order Summary Report, dated [DATE], revealed no code status order. Record review of Resident #16's transfer admission records, dated [DATE], revealed Resident #16 was being transferred from another nursing facility. The record showed under advance directive: DNR. The packet contained orders from the previous nursing facility and one order showed a Do Not Resuscitate order dated [DATE] and showed active on [DATE] when the orders were printed. Record review of review of a OOH DNR form, dated [DATE], revealed only the RP's signature. No witness or doctor's signatures was on the form. Record review of a social assessment, dated [DATE], stated .G. Financial/Legal .2. Advance Directive .b. Do Not Resuscitate (DNR). The DNR was checked off. The assessment by completed by the social worker. During an interview on [DATE] at 11:27 a.m., Resident #16's RP stated he was told by the facility staff that he needed to have the OOH DNR notarized. The RP stated no one from the facility had reached out to him about completing the DNR. The RP stated he was not aware the facility could help him with completing the DNR. The RP stated all of Resident #16's family agreed with a DNR because they thought any CPR would be brutal for the resident. During an interview on [DATE] at 11:31 a.m. the SW stated he was contracted to help the facility with a few task and would periodically come to the facility. The SW stated he participated at care plan meetings and would document what the Resident or RP's desire for code status was. The SW stated other facility staff was responsible for following up with any changes needed for a resident's code status. During an interview on [DATE] at 12:43 a.m., the DON stated Resident #16 was a full code. The DON stated the social worker is a contact vendor and other facility staff would assist with DNR paperwork. The DON stated she would look into the resident's code status and get back with this surveyor. During an interview on [DATE] at 10:12 a.m., the Administrator stated the staff member who did the admission paperwork for Resident #1 was out of the facility on leave. The Administrator stated Resident #1 came from another facility with a DNR but it was not notarized. The Administrator stated on the admission paperwork no was selected for an advance directive. The Administrator was not sure who would have followed up on the DNR and stated the DON or Program Manager would know more. During a follow up interview on [DATE] at 3:27 p.m., the DON stated they were going to complete the DNR paperwork for Resident #16 and had scheduled a meeting with the RP to have it completed. The DON stated she did not know what happened when the resident was admitted from the other facility with the incomplete DNR form, but the form was not completed properly so they were going to completely redo the DNR paperwork. The DON stated the resident's whishes would not be honored if their code status was supposed to be a DNR because they would perform CPR. Record review of the facility document titled Advance Directives, dated ,d+[DATE], stated Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy . a. Advance care planning - a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated . Do Not Hospitalize (DNH)- indicates that the resident is not to be hospitalized , even if he or she has a medical condition that would usually require hospitalization . Determining Existence of Advance Directive . 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . If the Resident Has an Advance Directive 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents' medical record and pian of care . 3.The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive. b. Facility staff are not required to implement an advance directive if state law allows the provider to conscientiously object .7. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. 8. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications on 1 (central supply room) of 3 medication storage rooms and 1 (north hall crash cart) of 2 crash carts reviewed for pharmacy services. The facility failed to discard and replace expired supplies. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on [DATE] at 12:29 p.m., the central supply storage room on the north hallway contained a drawer of gastrostomy tubes (A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient. Giving food through a gastrostomy tube is a type of enteral nutrition. Also called PEG tube and percutaneous endoscopic tube.) with an expiration date of [DATE] and a bottle of iodoform packing strips (sterile, medicated gauze strips that are used to pack or drain open or infected wounds) with an expiration date of ,d+[DATE]. During an observation on [DATE] at 12:34 p.m., the north hallway crash cart contained a CPR barrier mask (a piece of personal protective equipment (PPE) that prevents the spread of bodily fluids and saliva between the rescuer and the patient during CPR) with a use by date of [DATE] and a capnography mask (used to detect the levels of CO? in the blood by measuring End-tidal Carbon Dioxide). During an interview on [DATE] at 12:35 p.m., Medical Records stated the expired supplies should be removed from the storage cart and storage room. During an interview on [DATE] at 3:08 p.m., the DON stated night shift nurses are responsible for checking the crash carts. The DON stated they should check if the supplies are on the cart and if they are expired. The DON stated the expired supplies should not be on the cart and they should be checking them. The DON said they would remove the expired supplies from the storage room because they do not use expired supplies. Record review of the facility's policy titled Storage of medications, dated ,d+[DATE], stated The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 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. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #13) reviewed for hospice services, in that: The facility failed to ensure Resident #13's most recent Physician Certification of Terminal Illness was completed and part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #13's face sheet, dated 11/06/24, revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a disease that causes plaque buildup in the arteries), acute kidney disease (a sudden reduction in kidney function that can range from mild to severe), and dementia (a decline in mental ability that affects a person's daily life). Record review of Resident #13's quarterly MDS assessment, dated 7/29/24, revealed a BIMS score of 1 which indicated severe cognitive impairment. Section O of the MDS indicated the resident received hospice care. Record review of Resident #13's care plan, revised 8/2/24, revealed Resident #13 was on hospice services for senile degeneration of brain with interventions of care for Resident #13 to be coordinated, communicated and implemented between hospice and nursing facility's staff. Record review of Resident #13's order summary, dated 11/6/24, revealed: - Admit to [Nursing Facility] with [hospice provider] effective 6/24/23 with Dr .Do Not Resuscitate dx senile degeneration of brain not elsewhere classified .with a start date of 10/13/23 and no end date. Record review of Resident #13's facility clinical record as of 11/5/24, revealed a binder with Resident #13's there was a form for the Certification of Terminal Illness dated 8/17/24 for recertification. The document was not signed by the hospice staff, attending physician, and hospice physician. During an interview on 11/5/24 at 1:53 p.m., medical records stated she took for responsibility for the hospice documents about a week ago. Medical records stated hospice probably sent the wrong document and it was not reviewed. Medical records stated she would contact hospice and get a copy of the correct form. Medical records stated the certification of terminal illness and recertification form should be a part of the hospice record to show the resident has been recertified so the facility can receive funds and provide the services to the resident. During an interview on 11/6/24 at 3:35 p.m., the DON stated medical records had been responsible for hospice records. The DON stated hospice staff brings the documents and medical records should check the records again. The DON stated the form was used to ensure the resident continues to be certified for hospice services and proof they are still eligible for hospice. Record review of the facility policy titled Hospice Program, dated 7/2017, stated, Policy Statement Hospice services are available to residents at the end of life . 12.Our facility has designated ___________ (Name) __________ (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following: d. Obtaining the following information from the hospice:(3) Physician certification and recertification of the terminal illness specific to each resident .

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 8 residents (Resident #32) whose records were reviewed for abuse and neglect: The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #32 suffered a nose fracture and was not able to say what happened. These deficient practices could affect residents by contributing to further abuse and neglect. The findings were: Record review of Resident #32's Admission record revealed an [AGE] year-old female admitted [DATE] with Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, and the ability to perform daily tasks) and white matter disease (is a general term for damage to the white matter in the brain, which can lead to a range of neurological symptoms). Record review of Resident #32's quarterly MDS, dated [DATE], revealed the resident had moderately impaired cognition for daily decision making. Record review of Resident #32's care plan, last updated 6/26/24, revealed she had an actual fall with fracture to nose, related to poor balance, poor safety awareness, and generalized weakness with interventions to monitor/ document/ report as needed x 72hrs to MD for s/s of pain, change in mental status, bruising, new onset of confusion, sleepiness, inability to maintain posture, agitation, pharmacy consult to evaluate medications, provide activities that promote exercise and strength building when possible, PT consult for strength and mobility, therapy to screen for services. Continue with all current interventions in place, and monitor vital signs as ordered or every shift. Record review of incident report, dated 6/26/24, revealed Resident #32 had an unwitnessed fall. The incident description showed the nursing description: notified by staff resident on the floor. This nurse observed resident on tour, face down with blood on the floor under face. [NAME] by former facility nurse. The Resident description: already stated she does not know what happened, she was getting up to go to the bathroom. Swelling and bruising noted at bridge of nose and forehead in between eyes. The incident was not witnessed. Under mental status it showed the resident was oriented two person, to place, the time, and disoriented/confused at times. Predisposing situation factors were improper footwear. Record review of a Nursing note, dated 6/26/24, stated Returned from ER with DX: Nasal Fracture and UTI. Prescription filled by family member, cefdinir 300mg 1 cap PO Every 12 hours X 10days . During an interview on 11/4/24 at 1:16 p.m., Resident #32 stated she had never fallen at the facility. Resident #32 stated she had only broken her nose when she was a little girl. Resident #32 stated she had never had an injury since she had been at the facility. The resident struggled to answer questions and smiled and stated she could not think. During an interview on 11/06/24 at 10:03 a.m., the Administrator stated when deciding if they should report an incident, they look at injuries of unknown origin, any fractures, what the resident tells them, and were staff involved. The Administrator stated the DON does the self-reports to HHSC for the facility. The Administrator stated she thought Resident #32 was able to tell the DON what happened, so they did not report it. The Administrator stated they thought Resident #32 was getting up to go to the bathroom when she fell and did not think it was abuse or neglect so they did not report it to HHSC. During an interview on 11/6/24 at 3:16 p.m., the DON stated she was responsible for completing fall incident reports. The DON stated Resident #32 tended to walk quickly and stumble. The DON stated Resident #32 can be confused at times. The DON stated the fall was unwitnessed, but she recalled Resident #32 told her she fell when she got up to go use the bathroom. The DON stated she is not sure why she forgot to document what the resident told her. The DON stated she did not consider this a reportable incident because they knew what happened when they found her on the floor. The DON stated the fall was unwitnessed and the resident did break her nose, but she only needed ice as needed and antibiotics for treatments. The DON stated Resident #32 was not able to describe how she fell ; she was only able to say she was getting up to go to the bathroom. The DON stated she did not know how the resident fell . The DON stated the incident fall report was her investigation. Record review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation, revised 12/12/2020, stated Our Home meets the requirements as set forth in NFRLMC, Subchapter G, Freedom from Abuse, Neglect, and Exploitation . TYPES OF INCIDENTS TO REPORT: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A Missing Resident, Misappropriation, Drug Theft, Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety. Time frames for each incident type: Abuse of any kind (with or without serious bodily injury); OR neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that results in serious bodily injury. WHEN to report the above types of incidents: IMMEDIATELY, BUT NOT LATER THAN TWO HOURS AFTER INCIDENT OCCURS OR IS SUSPECTED. S483.ll{b) F 608-Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse (See section 2011{19}{A) of the Act) . HHSC rules define abuse as: . Injuries of unknown source: Note: an injury should be classified as an injury of unknown source when both of the following conditions are met: D The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one point in time or the incidence of injuries over time. If a resident cannot explain his or her injury and another person did not observe the incident that resulted in the injury, but the injury does not meet the criteria listed above, the NF is not required to report it. For example, a resident has a minor skinned knee, but she can't remember if and when she fell . Example of an injury of unknown source that must he reported: A resident has bruising on their left cheek bone area that was determined to be non-serious. No one witnessed the source of the injury. Although the injury was determined to be non-serious, the injury is suspicious because of the location of the injury.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #16) reviewed for comprehensive care plans: The facility failed to ensure Resident #16's care plan contained a code status. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident of #16's face sheet, dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that dementia, type 2 diabetes mellitus (chronic health condition that affects how body turns food into energy), and chronic obstructive pulmonary disease (a group of serious lung diseases that make it hard to breathe. It's caused by damage to the lungs that narrows the airways, or bronchi, and reduces airflow). The advance directive section listed the resident as full code. Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #16's comprehensive care plan, last revised on [DATE], revealed there was no code status mentioned. Record review of Resident #16's Order Summary Report, dated [DATE], revealed no code status order. Record review of Resident #16's transfer admission records, dated [DATE], revealed Resident #16 was being transferred from another nursing facility. The record showed under advance directive: DNR. The packet contained orders from the previous nursing facility and one order showed a Do Not Resuscitate order dated [DATE] and showed active on [DATE] when the orders were printed. Record review of review of an OOH DNR form, dated [DATE], revealed only the RP''s signature. No witness or doctor''s signatures were on the form. Record review of a social assessment, dated [DATE], stated .G. Financial/Legal .2. Advance Directive .b. Do Not Resuscitate (DNR). The DNR was checked off. The assessment by completed by the social worker. During an interview on [DATE] at 11:27 a.m., Resident #16's RP stated he was told by the facility staff that he needed to have the OOH DNR notarized. The RP stated no one from the facility had reached out to him about completing the DNR. The RP stated he was not aware the facility could help him with completing the DNR. The RP stated all of Resident #16's family agreed with a DNR because they thought any CPR would be brutal for the resident. During an interview on [DATE] at 11:31 a.m., the SW stated he was contracted to help the facility with a few task and would periodically come to the facility. The SW stated he participated at care plan meetings and would document what the Rresident or RP''s desire for code status was. The SW stated other facility staff was responsible for following up with any changes needed for a resident''s code status. During a follow up interview on [DATE] at 3:27 p.m., the DON stated they were going to complete the DNR paperwork for Resident #16 and had scheduled a meeting with the RP to have it completed but the resident was full code until then. The DON stated the current staff that completed care plans worked at the facility on Tuesdays and Thursdays. The DON stated the MDS nurse would always inquire what the resident or RP wanted to continue with the code status or change it. The DON stated she was surprised the code status was not listed on the care plan because she always hears the MDS nurse discuss it at every meeting. The DON stated the care plan is the residents plan of care and for code status would tell the staff what we are supposed to do if the resident needed CPR. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], stated Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; .

Based on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 4 residents reviewed for call lights (Resident #s 1 and 2). The facility failed to ensure Residents #s 1 and 2's call light was accessible and in reach. Resident #1's call light button was observed hanging behind her mattress on the floor. Resident #2's call light button was hanging over the side of her bed and touching the floor. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. Findings included: Resident #1 Record review of Resident #1's electronic faces sheet revealed Resident #1 was [AGE] years old and was admitted on [DATE]. Resident #1's diagnoses included the following: History of Falling, Repeated Falls, Lack of Coordination, Major Depression, and Anxiety Disorder. Record review of Resident #1's MDS (Quarterly 10/5/2023) revealed a BIMS of 99 (interview not completed). Additionally, both the Mood Evaluation and ADLs Tab were disabled. Record review of Resident #1's Care Plan (7/22/2023) stated, (Resident #1) is High risk for falls r/t dementia, Alzheimer's with poor safety awareness. And had 3 falls during the month of August 2022. Interventions included: (Resident #1) needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in a low position at night; Slide rails as ordered, handrails on walls, personal items within reach. (Resident #1's) call light is within reach and encourage (Resident #1) to use it for assistance as needed. (Resident #1) needs prompt response to all requests for assistance. Observation on 11/30/2023 at 11:06 AM. Resident #1 was observed sleeping in her bed. During this observation, Resident #1's call light button was observed hanging behind her mattress on the floor. During an interview at this time, Charge Nurse, LVN A, confirmed Resident #1 would be unable to reach the call light button given her limited mobility. LVN A mentioned Resident #1 required a lot of monitoring and supervision given her fall history and level of confusion. LVN A indicated she was unsure if Resident #1 was alert enough to understand how to utilize her call light button. A photograph of the call light button positioning was taken at this time. Interview on 11/30/2023 at 12:15 PM the Administrator and DON were informed of this observation and confirmed them to be true after being shown the photographs of the misplaced call light buttons and agreed both resident's would have a hard time calling for assistance. Resident #2 Record review of Resident #2's electronic face sheet revealed Resident #2 was [AGE] years old and was admitted on [DATE]. Resident #2's diagnoses included the following: Repeated Falls, convulsions, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), overactive bladder, anxiety disorder Record revie of Resident #2's MDS (Quarterly 10/6/2023) revealed a BIMS of 99 (interview not completed). Additionally, both the Mood Evaluation and ADLs Tab were disabled. Record review of Resident #2's Care Plan stated, Risk for Falls. Interventions included, Be sure (Resident #2's) call light is within reach and encourage (Resident #2) to use it for assistance as needed. (Resident #2) needs prompt response to all requests for assistance. Observation and interview on 11/30/2023 at 11:16 AM, Resident #2 was observed lying on her right side in her bed while staring at the floor. Further observation revealed Resident #2's call light button was hanging over the side of her bed and touching the floor. During an interview at this time, LVN A indicated Resident #2's call light button was in a position beyond Resident #2's ability to reach while attempting to readjust it. LVN A stated, we have to keep an eye on (Resident #2) because she has been caught walking to the restroom on her own. LVN A indicated she was unsure if Resident #2 was alert enough to understand how to utilize her call light button. Interview on 11/30/2023 at 12:15 PM the Administrator and DON were informed of this observation. Record review of facility policy, titled, Call Systems, Residents, dated September 2022), stated, 1. 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 observation, record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/19/23. During or after the discharge, Resident #1 broke her leg and was hospitalized . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. While the IJ was removed on 9/24/23 at 7:06 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were discharged safely. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were: Record review of Resident #1's demographics page, dated 9/20/23, revealed CO F was Resident #1's POA and Emergency Contact #2 and CO E was Resident #1's Emergency Contact #1. Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does not produce enough hormones], essential (primary) hypertension, and unspecified vision loss. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the following Item: - G0110. Activities of Daily Living (ADL) Assistance A. Bed Mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The answer for this item was, Two+ persons physical assist. - G0110. Activities of Daily Living (ADL) Assistance B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance C. Walk in room - how resident walks between locations in his/her room. The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance G. Dressing - how resident puts on/fastens and takes off all items of clothing, including donning [putting on]/removing a prosthesis or TED hose [specialized stockings that prevent blood clots and swelling in the legs.] Dressing includes putting on and changing pajamas and housedresses. The answer for this item was One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance H. Eating - how resident eats and drinks, regardless of skill . Includes intake of nourishment by other means (e.g. tube feeding, total parenteral nutrition [when nutrients are given through the veins], IV fluids administered for nutrition or hydration.) The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes . The answer for this item was, Two+ persons physical assist. - G0110. Activities of Daily Living (ADL) Assistance J. Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands . The answer for this item was, One person physical assist. - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer for this item was No. Record review of Resident #1's BIMS assessment, dated 8/17/23, revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. Record review of a document titled, NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 8/16/23, revealed Resident #1 was given a 30-day discharge notice on 8/16/23 with a discharge date of 9/16/23. The reasons for discharge were list as: Resident refuses MD in facility . Refuses services to include mistreatment of staff to include profanity and belittling staff . Resident has failed . to pay or refused to pay for stay at the Facility AND the resident has not submitted the necessary paperwork for third party payment . If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal . The facility will not discharge/transfer you while the appeal of your discharge/transfer is pending if you exercise your right to appeal unless the failure to discharge/transfer you would endanger your health and safety or that of other residents/other individuals in the Facility. On the signature line was no signature from Resident #1, CO E, or CO F on this discharge notice. Instead, there were the words, Copy handed to [CO E], written by DON J. Record review of a facility document titled, Appendix B. Patient/Family Behavior Contract, dated 8/16/23, revealed the following: Behavior Expectations: 1. Will not belittle staff while discharge is pending [DATE]. 2. Will not use profanity while discharge is pending [DATE]. Will allow [the facility's physician group] to provide care while discharge is pending [DATE]. There was a section below this that read: I have read and understood the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in immediate termination of the relationship between me and the provider/organization. This section had a portion for the resident or responsible party to initial and there was no initial present. At the bottom of this same document there was no signature from Resident #1, CO E, or CO F. There was a signature from the Administrator and DON J as well as the words Family refuses to sign 8/16/23. Next to these words were the Administrator's initials. Record review of a document titled, Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge, dated 9/15/23, revealed CO F signed for an appeal of Resident #1's discharge on [DATE], before the projected discharge date on Resident #1's 30 day discharge. Record review of a group text message between the Administrator, DON I, and the Director of Activities and Life Enrichment, dated 9/18/23 at 8:53 p.m., revealed the following message from the Administrator to this group: I spoke with [ADON L.] Apparently last week [Resident #1] was so rude to [a CNA] that nurses had to intervene and nurses had to provide care . [ADON L] wants us to evict [Resident #1] based on violating the behavior policy . 1. If we go to appeals court, we have no way to win. They do not evict for behavior. 2. We evict for violation of behavior contract we may get a tag for dumping. DON I responded to the Administrator's message with the following: I agree that abuse at work is hard and if there is any path to cultivating a safe and peaceful work environment, we should take it. I vote for an eviction and amendment to prevent future abuse from residents. Record review of a text message between the Administrator and the Ombudsman, dated 9/19/23 at 2:41 p.m., revealed the following message from the Administrator to the ombudsman: I'm sorry we evicted [Resident #1] based on the abusive behavior to the staff and took her to [CO E's] house. Record review of Resident #1's nursing progress notes from 8/15/23 to 9/19/23 revealed the following: - Nursing progress note, dated 9/19/23 at 2:20 p.m. and written by ADON L: Pt was discharged to her home with [CO E]. Pt was discharged with all medications and instructions/directions for administration. Glucometer [a machine to check blood sugars], strips, and syringes also provided. Pt provided with wheelchair and her personal walker for short distances as sheis [sic] ambulatory. There were no progress notes indicating Resident #1 had an injury. There were no progress notes that indicated coordination of post-discharge care was done with Resident #1, CO E, or CO F prior to Resident #1's discharge on [DATE]. There was no documentation indicating successful coordination other service providers such as home health or provider services. Record review of Resident #1's physician orders, obtained on 9/20/23, revealed Resident #1 had the following orders started on the following dates: - Aspirin EC Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day every Mon for blood thinner. Started on 9/11/23. - Furosemide Oral Tablet 20 MG (Furosemide) [a medication used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease ] Give 1 tablet by mouth one time a day. Started on 9/6/23. - Levothyroxine Sodium [a thyroid hormone] Tablet 75 MCG Give 1 tablet by mouth in the morning. Started on 7/24/23. - [Brand Name] Check [blood sugar check] at HS at bedtime. Started on 1/8/23. - Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) [a type of injectable, long-acting medication that helps control high blood sugar levels throughout the day] Inject 10 unit subcutaneously in the afternoon. Started on 3/10/23. - Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously in the morning. Started on 6/13/23. - HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) [a type of injectable, fast-acting medication that helps control high blood sugar levels] Inject as per sliding scale: if 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units CALL MD IF >450. Started on 6/1/23. Record review of all of the facility's electronic incident reports revealed no incident of injury involving Resident #1. Record review of the Administrator's statement titled, Ms. [Resident #1], not dated, revealed the following: On the day of eviction, we waited until [Resident #1] had been toileted . We made sure she was clean and dressed and told her maintenance needed in the room, making sure there was no conflict getting her out of her room. We had someone by the door and the bus outside the lift down to make sure it was a quick exit out of the building to reduce conflict. I had staff keep a sheet ready in case she became physically violent, do not grab her wrists or arms because that is how someone gets hurt. Just use the sheet to swaddle her like a baby. We exited the building and went straight to the bus as quickly as possible with no incident. The bus right was 9 min. long . I prepared staff not to respond to [Resident #1] when she was yelling at them and to let only one person, [ADON L], speak because [ADON L] needed to keep the resident calm and did not need too many people at once getting involved. The ADON and Maintenance sat in the back with [Resident #1' to make sure everything stayed calm and safe We had our admissions person call [CO E] first to make sure [CO E] was home and sent her [the admission staff] to the house ahead of us to be certain . Other than [Resident #1] yelling on the 9 min drive, the trip was without incident. We arrived at the home, got [Resident #1] off the bus with no incident and took her to the door. [CO E] refused to unlock the screen door to let us take [Resident #1] inside and said she was calling 911. [Resident #1] put herself out of the wheelchair . Then I instructed all my staff to leave . Leaving [Resident #1] on the porch was without incident other than [CO E] yelling at us. During an interview on 9/20/23 at 11:50 a.m., CO F stated on 9/19/23 at around 2:45 p.m., he received a call from CO E, who stated Resident #1 was just dropped off at her [CO E's] house. CO F stated I guess Resident #1 fell off those steps, so not only did this facility not let [CO E] know they were going to drop [Resident #1] off . When [CO E] opened the door, she saw [the Admissions Staff], [the Administrator], and [Resident #1], and 3 employees. And [CO E] got upset and [CO E] was going to call the police. And then that's when [Resident #1] fell off the [concrete porch] stairs and she hurt her back. I don't know if they [the staff and CO E] weren't paying attention or if [Resident #1] lost her balance. [CO E] stated she had EMS out there and I think the fire department . So [Resident #1's] injuries could have been avoided if [the staff] didn't drop her off. CO F stated neither he nor CO E were informed that Resident #1 was going to be discharged on 9/19/23. CO F stated Resident #1 was placed in the facility because Resident #1 lost her eyesight and had diabetes. CO F stated Resident #1 needed assistance with orientation for eating and required assistance with walking. CO F stated Resident #1 cannot cook. CO F stated no assistance can be provided to Resident #1 at CO E's house because CO E cannot provide assistance to Resident #1. CO F stated, that's why [Resident #1 is] in [the facility.] During an interview on 9/20/23 at 3:39 p.m., Agency LVN K stated she worked with Resident #1 and worked on 9/19/23. Agency LVN K stated she did not know anything about Resident #1's discharge on [DATE] because Resident #1's discharge occurred before her shift from 2:00 pm to 10:00 p.m. Agency LVN K stated Resident #1 was blind and needed assistance with transfers and needed assistance with walking to and from the bathroom to her [Resident #1's] bed. During an interview on 9/20/23 at 4:52 p.m., when asked how did the discharge planning process start and how did the discharge planning progress, ADON L stated, I don't have too much input. I haven't been phased that much in decision-making or keeping up with the status as of yet. The ADON stated the Administrator and other staff members, like the Admissions Staff, were also involved in the discharge, but the Administrator spearheads the admissions and discharges. When asked how the facility involved a resident in the discharge, ADON L stated, families will be contacted and asked to come in and have a meeting and at the meeting is where the discussion will happen, how to better meet [the resident's] needs . It's important to have the family or the loved one involved. So we try to get as much input as possible. When asked what the facility's policies stated about facility-initiated discharges, ADON L stated, I'm not able to tell you off the top off my head. ADON L stated Resident #1 was diabetic, blind, petite, and wanted things done in a particular fashion. ADON L stated, When asked if Resident #1 required 24-hour care, ADON L stated, my personal opinion, I believe [Resident #1] can live at home. I know she can't self-administer insulin due to her eyesight, but I don't think she needs 24-hour care. During an observation and interview on 9/21/23 at 8:10 a.m., Resident #1 was observed lying in bed in a local hospital. Resident #1 stated she had difficulty walking and she needed someone with her to help her bathe and help her administer insulin. Resident #1 stated, I can't do my insulin. I'm too afraid to put it into the vein. Resident #1 stated she did not have assistance in CO E's house. Resident #1 stated CO E stated CO E also had poor vision and could not administer her [Resident #1's] insulin. Resident #1 stated she and CO E cannot cook. Resident #1 stated she did not have a home health agency or a provider. Resident #1 stated, I didn't know I was going to be discharged . I'm still shaking from it. It was awful. Resident #1 stated on 9/19/23 at around 2:00 p.m., CNA A told her someone was coming to work in her room so they had to get her out. Resident #1 stated, and before I knew it [CNA A] was taking me out of the room in a rush. I thought it was weird they were going to do the bathroom and the light. They put me in a wheelchair and rushed me out . I got to [CO E's] house . they pushed me up on the wheelchair on that porch . Somewhere my foot got stuck [during the transport.] My foot was fractured . [CO E] called 911 because I felt I was in pain. During an interview on 9/21/23 at 9:45 a.m., Representative M stated medical records of the local hospital were outsourced and any records this surveyor requested will be sent within 3-5 business days. No records were released to this surveyor at the time of this interview. During an interview on 9/21/23 at 9:53 a.m., Representative G stated Resident #1 was admitted to the hospital due to a fall at [CO E's] house after Resident #1's dismissal from the nursing home. Representative G stated Resident #1 had a fracture to her left distal fibular [her left ankle] and had to wear a boot at this time. During an interview on 9/21/23 at 10:47 a.m., LVN B stated Resident #1 was blind, was not able to get up by herself, required stand-by assistance when walking, required set-up assistance to eat, and required stand-by supervision during baths. LVN B stated she did not think Resident #1 would be able to administer insulin herself. LVN B stated Resident #1 tended to take a lot of time to do activities of daily living such as bathing and washing her hands. LVN B stated it would typically take 20-25 minutes. LVN B stated, it takes up too much time as far as doing that.They said she's refused stuff as far as not letting her blood sugar checked. LVN B stated she worked on 9/19/23 and towards the end of her shift (at around 2:00 p.m.) ADON L told her [LVN B] that she [ADON L] needed Resident #1's medication. LVN B stated from ADON L was in charge of Resident #1's discharge. During an interview on 9/21/23 at 11:13 a.m. HA C stated she took care of Resident #1. HA C stated, Usually I helped [Resident #1] because she was blind. I helped her to the restroom. I assisted her. I helped her put her shoes on. I helped dress her. HA C stated she worked on 9/19/23, but did not know anything about Resident #1's discharge that day. In a follow-up interview on 9/21/23 at 12:09 p.m., when asked if Resident #1 met criteria for long-term care, ADON L stated, Yes, [Resident #1] could not administer her own insulin. ADON L stated, a lot of assistance was mostly like a stand-by assist. Because [Resident #1] is ambulatory, she does her own personal hygiene like brushing her teeth and oral care . Most of it was stand-by and set-up for her meals. She didn't need assistance with eating, but you had to tell her where it [the food] was. ADON L stated Resident #1 would refuse blood sugar checks and insulin, would make accusations, and was verbally abusive. ADON L stated Resident was discharged because of her behaviors. ADON L stated the administrator initiated Resident #1's discharge on Monday, 9/18/23. ADON L stated, I think there were some complaints that may have happened on the weekend or Monday. ADON L stated she believed DON J and the Ombudsman attempted to find alternative placements, but the family ultimately refused to transfer. ADON L stated Resident #1 wanted to stay in the facility. ADON L stated on Tuesday, 9/19/23, the Administrator told her [ADON L] Resident #1 was being discharged . ADON L stated at around 2:00 p.m. she then went to gather Resident #1's medications and prepare documentation for the discharge. ADON L stated, I said [to Resident #1], we're going to go over your medication with you because you're discharged . And [Resident #1] said 'hmph, I'd like to see that.' ADON L stated while she was attempting to explain the paperwork, [Resident #1] was yelling, I don't care, I don't care! ADON L stated she did not know if any services were coordinated with Resident #1 or CO E. ADON L stated shortly after 2:00 p.m., Resident #1 was placed in a wheelchair, taken to the van and then driven to CO E's house. ADON L stated she, the Administrator, the Director of Activities and Life Enrichment, the Admissions Staff, and the Maintenance Technician went with Resident #1 during the journey. ADON L stated upon arrival, CO E closed the door and would not allow the staff to enter the home. ADON L stated, [CO E] says 'I'm going to close the door and I'm going to call the cops.' ADON L stated Resident #1 transferred herself to the steps of the concrete porch and sat there. ADON L stated she did not see Resident #1 fall from the porch. ADON L stated CO E did not open the door and she, along with the rest of the facility staff, left. Continuing ADON L's follow-up interview on 9/21/23 at 12:09 p.m., when asked how she ensured Resident #1's discharge was safe, ADON L stated, I went over [Resident #1's] meds with her. I didn't get a chance to go inside [CO E's home] to see what [Resident #1] needed. When asked what sort of things should be done before a resident was discharged , ADON L stated, I'd like to be able to do an on-site visit if [Resident #1] needs a refrigerator for her medication or special equipment or if there's a trip hazard or just safety for the resident. I'd like to be part of that. This was a very different discharge. My involvement was very limited. When asked how CO E's home was going to meet Resident #1's needs, ADON L stated, I'm not aware of who else was in the home. I know there were others living in the home because there were vehicles parked on the lawn. But I wouldn't have-I would hate to answer or assume-I don't want to make any assumptions because my involvement with the decisions of the date and time and the process, it was very limited. I wasn't involved with preparing the discharge for [Resident #1]. When asked if there was anything she would have changed about Resident #1's discharge, ADON L stated, I would have appreciated a more 24-hour notice so I could make sure that I could speak with the family member and I could coordinate with the doctor in case [Resident #1] needed something further outside of [the facility.] When asked if she would have sent Resident #1 to another place, ADON L stated, Me, personally, I think home with home health is probably best for her or activities with an adult day care would probably be best for her. When asked if she felt Resident #1's discharge location was safe, ADON L stated, [CO E's house] didn't look dilapidated. It looked like a nice home. The environment in the home didn't give me that it wasn't appropriate for [Resident #1]. The yard was neatly kept and the house looked clear. ADON L stated since Resident #1 was discharged , she had not received any new education regarding discharge. During an interview on 9/21/23 at 2:06 p.m., CNA A stated he told Resident #1 her room needed maintenance in order to get Resident #1 out of the room. CNA A stated, Because she would have taken a long time to get ready. During an interview on 9/21/23 at 3:19 p.m., Physician D stated Resident #1 was his patient. Physician D stated he did not know anything about Resident #1's discharge and only heard about it on the day of this interview, 9/21/23. Physician D stated he was not aware of any home health services or provider services for Resident #1. When asked if he felt a home was a safe discharge location for Resident #1, Physician D stated, Her home, yeah. [Resident #1] came from home and, you know, she was refusing care. During a joint interview with the Maintenance Supervisor and the Maintenance Technician on 9/21/23 at 3:44 p.m., the Maintenance Supervisor stated he and the Maintenance Technician assisted in transporting Resident #1 to CO E's house on 9/19/23. The Maintenance Supervisor stated he was informed by the Administrator to assist in discharging Resident #1 around 11:30 a.m. to 12:00 p.m. The Maintenance Technician stated, At first, [Resident #1] didn't know what was going on. And then [ADON L] told her and [Resident #1] said, 'oh, you are?' And then [Resident #1] realized what was going on and at first [Resident #1] didn't believe it. [Resident #1] said, 'you're not taking me to [CO E.]' The Maintenance Technician stated Resident #1 was yelling and screaming on the bus when Resident #1 did not know what was happening. Both the Maintenance Supervisor and the Maintenance Technician denied Resident #1 fell on the porch during the discharge. During an interview on 9/21/23 at 4:40 p.m., CO E stated on 9/19/23 she received a call from the Admissions Staff and the Admissions Staff stated she wanted to give CO E a social security form for Resident #1. CO E stated when she [CO E] came to the door she saw the Admissions Staff member standing on her porch with Resident #1's medications and then the facility's van arrived to her house with Resident #1. CO E stated, I wasn't warned. I wasn't even told they were going to bring her. What I was waiting for was for [the Admissions Staff] to drop off the social security paper and there weren't even papers. It was the records from [the facility.] CO E stated when she saw the Administrator arrive she shut the door and called the police. CO E stated, [Resident #1] said they [the staff] were in a hurry and they messed up her ankle. And [Resident #1] has a boot because the [hospital] doctor said [Resident #1] didn't require surgery. So [Resident #1] has to wear the boot. [Resident #1' said, [CO E] they were in a hurry and they didn't even care how they were handling me. And I don't know if she fell also. I don't know. I didn't see her [fall]. I just saw her when they were getting her to the porch. CO E stated Resident #1 was placed in the facility because no one in Resident #1's family could take care of Resident #1. CO E stated, [Resident #1's] diabetes is not easy. [Resident #1] needs her insulin . sometimes her sugars are very high and sometimes when [Resident #1] wakes up her sugars are very low . And she's completely blind. She can't see at all, so she cannot cook, can't drive, can't even go to the doctor's appointment. She needs help bathing also, and getting her to the restroom. She needs a lot of care. CO E stated Resident #1 could not administer her own insulin. CO E stated no assistance can be provided to Resident #1 at CO E's home. During an interview on 9/22/23 at 8:47 a.m., the Administrator stated, Typically I wouldn't play a role in discharge, other than I sign off [on a form] saying I know they [the resident] went out. When asked how she provided oversight to the discharge process, the Administrator stated, I rely on the Director of Nursing and they tell me what they're doing or why. And we go over the ADTs at the morning meeting and then I sign off on the paperwork saying yes, that's what happened. And that I know where they're going. When asked how the discharge planning started and how did the discharge planning process, the Administrator stated, In general, the discharge would depend on where [the resident is] being discharged to, whether it's a hospital or a skilled facility or a home . I'm not really part of that. The Administrator stated if a resident was going to be discharged home, they would work with the family and speak with the family about the ramifications of not being in a nursing home. The Administrator stated, the general idea is notify the family and the resident and prepare for safe discharge. They [the family and the resident] have the right to appeal, unless there's documented evidence that the resident's return would endanger the health and safety of the other residents. The Administrator stated a resident was able to be discharged anytime the family wants them [the resident] to leave. Anytime they [the resident] needs skilled care because we can't provide care for them or meet their needs. The Administrator stated, I've never done an eviction, so I've never done an appeals hearing. When asked how she ensured a resident's discharge was safe, the Administrator stated, we go over it [the discharge] in the morning meeting. The [DON] tells me what's happening and I sign off on the paperwork. Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated they determined the facility could care for Resident #1 based on Resident #1's medical necessity, financial eligibility, and because there were no records of any behavior such as physical violence, smoking status, or elopement risk . Medically, yes, [Resident #1] met the standard for nursing home care based on her records. When asked what services the facility was providing Resident #1, the Administrator stated, There are two things: visual impairment and diabetes-insulin . And basically [Resident #1] gets one pill a day and it's really the diabetes that she can't manage it . If she had family support, then that wouldn't have been a problem. It's just checking your blood sugar and giving an injection but [Resident #1] had no family that would help her. No family would take her in. Prior to that [Resident #1's admission] she lived with [a family member], but then [the family member] dropped her off and took off . [CO F] works all the time and he doesn't want to be involved in this . [CO E] says, 'I'm too old to take care of her.] And none of them wanted her to live with them and allow community services to come in and help [Resident #1] with her medications. The Administrator stated there were attempts to transfer Resident #1 to other facilities, but ultimately the family refused the transfer. The Administrator stated Resident #1 was discharged because Resident #1 was abusive to the staff . it had reached a place where staff were quitting, crying. When asked who initiated Resident #1's discharge, the Administrator stated, As a group we talked about what to do and [DON I] had to say well, that's what we wanted to do. The Administrator stated on 9/18/23, she was informed by the Ombudsman that Resident #1 appealed her discharge. The Administrator stated the decision to discharge Resident #1 was made on the evening of 9/18/23. Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated on 9/19/23, she instructed the Admissions Staff to arrive at CO E's house to verify CO E was home, take photographs of the home so the other facility staff can identify CO E's home, and attempt to gain entry into the house in order to assist the other staff members in entering the home when the other staff members arrived. The Administrator stated, meanwhile, ADON L got Resident #1's medications ready and obtain an extra glucometer for Resident #1. The Administrator stated she instructed CNA A told Resident #1 her room required maintenance in order to get Resident #1 out of the room. The Administrator stated she instructed the Director of Activities and Life Enrichment to bring the facility's van around and Resident #1 was loaded into the van in a wheelchair. The Administrator stated one of the staff members had a blanket to swaddle Resident #1 if Resident #1 became physically violent. The Administrator stated she instructed the Maintenance Director to also follow behind the facility van and also had the Maintenance Technician inside the facility van with Resident #1 so both the Maintenance Director and the Maintenance Technician can assist with transporting Resident #1 into CO E's home. The Administrator stated ADON L was also on the journey to CO E's house in order to talk to Resident #1 and keep Resident #1 calm. The Administrator stated, [ADON L] told [Resident #1], 'we're going to be at [CO E's] house in a few minutes. And [Resident #1] said, '[TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 5 residents (Resident #1) reviewed for discharges, in that: The facility failed to have a valid reason to discharge Resident #1 and failed to permit Resident #1 to remain in the facility while her discharge appeal was pending. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. While the IJ was removed on 9/24/23 at 7:06 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were discharged safely. This failure could result in residents being discharged without appropriate reasons and could place a medically compromised resident at risk of a decline due to changing clinical environments and care continuity. The findings were: Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does not produce enough hormones], essential (primary) hypertension, and unspecified vision loss. Record review of Resident #1's admission documents, dated 12/13/22 revealed no mention of a behavioral contract. Record review of Resident #1's care plan, dated 1/19/23, revealed the following focus area: Resident uses profanity towards staff during care or when staff is rounding every 2 hours. Resident yells at staff. This focus area has the following interventions: - Ask yes/no questions in order to determine the resident's needs. - Engage the resident in simple, structured activities that avoid overly demanding tasks. Determine activities of interest and adapt these to current attention/cognitive level. Record review of Resident #1's quarterly MDS, dated [DATE], Section Q revealed the following items: - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer to this item was No. - Q0500. Return to Community. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond): Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The answer to this item was Unknown or uncertain. Record review of the all of the facility's electronic incident reports revealed no incident of any physical abuse involving Resident #1. Record review of a document titled, NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 8/16/23, revealed Resident #1 was given a 30-day discharge notice on 8/16/23 with a discharge date of 9/16/23. The reasons for discharge were list as: Resident refuses MD in facility . Refuses services to include mistreatment of staff to include profanity and belittling staff . Resident has failed . to pay or refused to pay for stay at the Facility AND the resident has not submitted the necessary paperwork for third party payment . If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal . The facility will not discharge/transfer you while the appeal of your discharge/transfer is pending if you exercise your right to appeal unless the failure to discharge/transfer you would endanger your health and safety or that of other residents/other individuals in the Facility. On the signature line was no signature from Resident #1, CO E, or CO F on this discharge notice. Instead, there were the words, Copy handed to [CO E], written by DON J. Record review of a facility document titled, Appendix B. Patient/Family Behavior Contract, dated 8/16/23, revealed the following: Behavior Expectations: 1. Will not belittle staff while discharge is pending [DATE]. 2. Will not use profanity while discharge is pending [DATE]. Will allow [the facility's physician group] to provide care while discharge is pending [DATE]. There was a section below this that read: I have read and understood the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in immediate termination of the relationship between me and the provider/organization. This section had a portion for the resident or responsible party to initial and there was no initial present. At the bottom of this same document there was no signature from Resident #1, CO E, or CO F. There was a signature from the Administrator and DON J as well as the words, Family refuses to sign 8/16/23. Next to these words were the Administrator's initials. Record review of Resident #1's BIMS assessment, dated 8/17/23, revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. Record review of a document titled, Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge, dated 9/15/23, revealed CO F signed for an appeal of Resident #1's discharge on [DATE], before the projected discharge date on Resident #1's 30 day discharge. Record review of a group text message between the Administrator, DON I, and the Director of Activities and Life Enrichment, dated 9/18/23 at 8:53 p.m., revealed the following message from the Administrator to this group: I spoke with [ADON L.] Apparently last week [Resident #1] was so rude to [a CNA] that nurses had to intervene and nurses had to provide care . [ADON L] wants us to evict [Resident #1] based on violating the behavior policy . 1. If we go to appeals court, we have no way to win. They do not evict for behavior. 2. We evict for violation of behavior contract we may get a tag for dumping. DON I responded to the Administrator's message with the following: I agree that abuse at work is hard and if there is any path to cultivating a safe and peaceful work environment, we should take it. I vote for an eviction and amendment to prevent future abuse from residents. Record review of Resident #1's nursing progress notes from 8/15/23 to 9/19/23, obtained 9/21/23, revealed the following: - Nursing progress note, dated 9/19/23 at 2:20 p.m. and written by ADON L: Pt was discharged to her home with [CO E]. Pt was discharged with all medications and instructions/directions for administration. Glucometer [a machine to check blood sugars], strips, and syringes also provided. Pt provided with wheelchair and her personal walker for short distances as sheis [sic] ambulatory. Further record review of the progress notes from 8/15/23 to 9/19/23 revealed was no documentation indicating Resident #1 was physically or verbally aggressive to staff members or other residents. However, there was documentation Resident #1 occasionally refused blood sugar checks. Record review of a text message between the Administrator and the Ombudsman, dated 9/19/23 at 2:41 p.m., revealed the following message from the Administrator to the Ombudsman: I'm sorry we evicted [Resident #1] based on the abusive behavior to the staff and took her to [CO E's] house. Record review of the Administrator's statement titled, Ms. [Resident #1], not dated, revealed the following: [Resident #1] has been unkind and demanding from the beginning . She purposefully slowed all the staff down . she demanded her meals be a certain way, and then change the way repeatedly . She demanded showers lasting 45min - 1hr; bathroom time 30 min - 45 min. Many times managers or nurses would have to jump in and help to free up staff. She demeaned, belittled, verbally attacked front line staff (CNAs) calling them names, questioning their intelligence, their skills, etc. She was especially vicious to African American staff. Many times management had staff in their offices crying, threatening to quit, begging to be reassigned . [Resident #1] refused to allow us to file for Social Security, which means no payment for [the facility], no Medicaid. So we have been providing free care. We have tried to educate, plead, involve the family, and finally 2 months ago [Resident #1] agreed . When I returned from [a local] Conference, I found another staff had left [Resident #1's] room crying and the ADON had to intervene and nurses had to provide care. I evicted her on the basis of the behavior contract. During an interview on 9/20/23 at 11:16 a.m., the Ombudsman stated on 8/16/23 she attended a care plan meeting wherein the facility presented Resident #1 and [CO E] with a behavioral contract which detailed that if Resident #1 continued to verbally abuse staff, then Resident #1 would be discharged . The Ombudsman stated after the facility presented the behavioral contract, the facility then issued a 30-day discharge. The Ombudsman stated, from what I can tell it wasn't curse words. It was just her questioning the validity of the staff. They were having an issue with [Resident #1] seeing anyone [a physician] in the facility and that she wouldn't choose her own doctor. They were also saying that [Resident #1's] medication was going to run out . I filed the appeal [for Resident #1] this past Friday [9/15/23], I called this past Monday [9/18/23] and told [the Administrator] the appeal had been filed. The Ombudsman stated since the meeting on 8/16/23, Resident #1 agreed to see the facility's physician. During an interview on 9/20/23 at 3:39 p.m., Agency LVN K stated she worked with Resident #1 and worked on 9/19/23. Agency LVN K stated she did not know anything about Resident #1's discharge on [DATE] because Resident #1's discharge occurred before her shift from 2:00 pm to 10:00 p.m. Agency LVN K stated Resident #1 was blind and needed assistance with transfers and needed assistance with walking to and from the bathroom to her [Resident #1's] bed. When asked if Resident #1 was ever aggressive, Agency LVN K stated Resident #1 was never physically aggressive to her [Agency LVN K], but was verbally aggressive to CNAs. Agency LVN K stated Resident #1 would often yell when Resident #1 felt things were not done fast enough and would often swear at CNAs or talk down to the CNAs. During an interview on 9/20/23 at 4:52 p.m., ADON L stated she had only been with this facility for about one month. ADON L stated, my understanding of a discharge is that you're going to get some discharge orders and understand if the patient is going to the hospital or another facility or home and try to set up a smooth discharge so it's a safe transfer to wherever the patient is electing to discharge by helping them set up any follow-up appointments if they need to or DMEs if they need that or hospice. It just depends on what the discharge entails. When asked how did the discharge planning process start and how did the discharge planning progress, ADON L stated, I don't have too much input [in the discharge planning process.] I haven't been phased that much in decision-making or keeping up with the status as of yet. The ADON stated the Administrator and other staff members, like the Admissions Staff, were also involved in the discharge, but the Administrator spearheads the admissions and discharges. When asked how the facility involved a resident in the discharge, ADON L stated, families will be contacted and asked to come in and have a meeting and at the meeting is where the discussion will happen, how to better meet [the resident's] needs . It's important to have the family or the love one involved. So we try to get as much input as possible. When asked what the facility's policies stated about facility-initiated discharges, ADON L stated, I'm not able to tell you off the top off my head. ADON L stated Resident #1 was diabetic, blind, petite, and wanted things done in a particular fashion. ADON L stated, [Resident #1] kind of demands more of your time. You're unable to provide care to other residents because for something as small as [Resident #1 wanting] to wash [her] hands . It's hard to anticipate what she wants . And if you don't get it right, she'll insult you. During an observation and interview on 9/21/23 at 8:10 a.m., Resident #1 was observed lying in bed in a local hospital. Resident #1 stated she wanted to stay in the facility. Resident #1 stated, I didn't know I was going to be discharged . I'm still shaking from it. It was awful. Resident #1 stated around 2:00 p.m., CNA A told her someone was coming to work in her room so they had to get her out. Resident #1 stated, and before I knew it [CNA A] was taking me out of the room in a rush . They put me in a wheelchair and rushed me out I got to [CO E's] house . they pushed me up on the wheelchair on that porch. When asked about her behaviors, Resident #1 stated, [The Administrator] said I was cruel to the nurses.Maybe I shouted one time. Resident #1 stated she was not physically aggressive to other residents or staff. When asked what was explained to her [Resident #1] about her behavior contract, Resident #1 stated, I don't know. When asked what the facility told her about any consequences of the behavior contract, Resident #1 stated, Just that I would be discharged . Resident #1 stated, [The Ombudsman] was helping me with an appeal . I remember 9/15/23 was the discharge date . And [CO E] said she called [the Ombudsman] to file an appeal. That was 9/11/23. I wasn't expecting them to discharge me. Resident #1 stated she never refused to see the facility's physicians and stated she saw Physician D on 9/15/23. During an interview on 9/21/23 at 10:47 a.m., LVN B stated Resident #1 tended to take a lot of time to do activities of daily living such as bathing and washing her hands. LVN B stated it would typically take 20-25 minutes. LVN B stated, it takes up too much time as far as doing that.They said she's refused stuff as far as not letting her blood sugar checked. When asked if Resident #1's needs were beyond what she could provide, LVN B stated, no, it just takes time. LVN B stated Resident #1 was not verbally aggressive with her, but was aware Resident #1 was verbally aggressive with some CNAs. LVN B stated, I don't know if she was physically aggressive. I just know she was just verbally inappropriate. I've heard she's racist . As far as being mean, she could be sarcastic with words, like call people stupid. LVN B stated she did not feel unsafe working with Resident #1. When asked if she knew if any of her co-workers felt unsafe working with Resident #1, LVN B stated, I don't think physically, but sometimes I think the fear is that they [the co-workers] might lose their job. LVN B stated she worked on 9/19/23 and towards the end of her shift (at around 2:00 p.m.) ADON L told her [LVN B] that she [ADON L] needed Resident #1's medication because Resident #1 was going home. LVN B stated from ADON L was in charge of Resident #1's discharge. During an interview on 9/21/23 at 11:13 a.m. HA C stated she took care of Resident #1. HA C stated Resident #1 likes to have things a certain way . She was very snappy. She does have her moments where she got mad at us for certain stuff, but it was normal resident stuff. And not being on time for her insulin one was one of them. When asked if she ever felt unsafe with Resident #1, HA C stated, No, she just uses her words a little bit much. When asked if she knew if any of her other co-workers felt unsafe with Resident #1, HA C stated, No. HA C stated she worked on 9/19/23, but did not know anything about Resident #1's discharge that day. During an interview on 9/21/23 at 11:40 p.m., CNA A stated, [Resident #1] was very demanding woman. She'll talk to you, but she'll talk down to you because she doesn't figure you're on the same level as her. CNA A stated the other CNAs reported Resident #1 was mean. CNA A stated, her yelling, and her particularness and it makes you feel bad, especially if you're new or an agency [staff]. CNA A stated he never felt unsafe working with Resident #1. In a follow-up interview on 9/21/23 at 12:09 p.m., ADON L stated Resident #1 would refuse blood sugar checks and insulin, would make accusations, and was verbally abusive. ADON L stated she never witnessed the behavior herself. ADON L stated, it was not anything beyond what the staff could provide, it was just the time it took to complete the task. ADON L stated Resident #1 was discharged because of her behaviors. ADON L stated on 8/16/23, Resident #1 was placed on a behavior contract. ADON L stated, The meeting was for the notice of proposed transfer or discharge due to her behaviors. For this situation, [Resident #1] had 3 stipulations. Her expectations were to not belittle staff while discharging on 9/16/23, will not use profanity, and will allow [the local physician group] to provide care until discharging . The failure to meet the expectation would be termination of the relationship between the patient and the provider. ADON L stated Resident #1 did begin to see the facility's physician group. ADON L stated she could not find a facility policy on behavioral contracts. ADON L stated she was not sure if the Ombudsman appealed Resident #1's discharge. ADON L stated if a resident's discharge was being appealed, she would wait to discharge until the hearing. ADON L stated the administrator initiated Resident #1's discharge on Monday, 9/18/23. ADON L stated, I think there were some complaints that may have happened on the weekend or Monday. ADON L stated Resident #1 wanted to stay in the facility. ADON L stated on Tuesday, 9/19/23, the Administrator told her [ADON L] Resident #1 was being discharged . ADON L stated at around 2:00 p.m. she then went to gather Resident #1's medications and prepare documentation for the discharge. ADON L stated shortly after 2:00 p.m., Resident #1 was placed in a wheelchair, taken to the facility van, and then driven to CO E's house. ADON L stated she was one of the staff members who were with Resident #1 during the journey. ADON L stated upon arrival, CO E closed the door and would not allow the staff to enter the home. ADON L stated CO E stated she [CO E] was going to call the police. ADON L stated Resident #1 transferred herself to the steps of the concrete porch and sat there. ADON L stated CO E did not open the door and she, along with the rest of the facility staff, left. During an interview and record review on 9/22/23 at 8:47 a.m., the Administrator provided her statement which was titled, Ms. [Resident #1]. The Administrator stated, Typically, I wouldn't play a role in the discharge, other than I sign off saying I know they went out. The Administrator stated if a resident was going to be discharged home, they would work with the family and speak with the family about the ramifications of not being in a nursing home. When asked when a resident was able to be discharged , the Administrator stated, Anytime the family wants them [the resident] to leave. Anytime they [the resident] needs skilled care because we can't provide care for them or meet their needs. For the appeals process, if they're [the resident is] not financially meeting their obligation, I think there's an avenue for that. When asked to explain the appeals process, the Administrator stated, years ago, we had a resident that we loved but the family was terribly frightening. And I talked to the president of the [facility's] board and he sent me to a lawyer in [another city] and she [the lawyer] said that you can give a 30-day eviction notice and they [the resident] can appeal, but the only way an appeal committee would hold it up is if they're [the resident is] not paying their bill. Failing to meet financial obligation. But I've never done an eviction, so I've never done an appeals hearing. When asked if a resident was able to appeal the discharge on ce a 30-day discharge notice was issued, the Administrator stated, Yes, absolutely. When asked what the facility's policy stated on facility-initiated discharges, the Administrator began to read the following from the facility's policy: transfer or discharge in which the resident objects to . is not in alignment for a resident's stated goals or preferences. A resident's declination of treatment is not grounds for discharge unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The Administrator stated, We've never done that [a behavior contract] before and we have no policy on it. [DON J] had experience with that from a previous facility, so she was in charge of the behavior contract. We relied on [DON J's] experience from previous facilities. And [the Medical Records Staff] and [ADON L's] experience from other facilities, so I relied on the nurse . I'm sure they're [the behavioral contracts] are issued to put a family into notice that the behavior cannot continue. That we need those behaviors corrected in order to be here [in the facility.] Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated Resident #1 wanted to stay in the facility. When asked why Resident #1 was discharged , the Administrator stated Resident #1 was abusive to the staff. The Administrator stated Resident #1 made staff cry and threaten to quit. The Administrator stated during the care plan meeting on 8/16/23, they presented the behavior contract to Resident #1 and the family. The Administrator stated the consequence of the behavioral contract was immediate discharge if Resident #1 did three things: belittling of staff, using profanity, and now allow [the local physician group] to provide care. The Administrator stated the facility had assisted Resident #1 to apply for Medicaid. The Administrator stated DON I initiated the discharge. The Administrator stated on 9/18/23 the Ombudsman told her Resident #1's family had signed the appeal to the discharge. The Administrator stated the decision to discharge Resident #1 was made on the evening of 9/18/23 because Resident #1 did not adhere to her behavioral contract. The Administrator stated, it was so bad what [Resident #1] did to the staff and [Resident #1 was] calling them 'sasquatch' and 'stupid' and she would slow her words down and say, 'this is what I want, can you understand my words now?' So I gave up waiting on the appeals process because it was so egregious . she was escalating, being so mean to the CNAs that the nurses had to step in and provide care. The Administrator stated they placed Resident #1 in a wheelchair, placed her in the facility van, and then took Resident #1 to CO E's house. The Administrator stated because CO E did not open the door for the facility staff, they could not enter the home. The Administrator stated Resident #1 transferred herself from the wheelchair to the concrete porch and the facility left Resident #1 on CO E's porch. During an interview and record review on 9/22/23 at 3:40 p.m., DON I stated she had only worked in the facility for 12 days. DON I stated she was not involved with Resident #1's discharge and did not know Resident #1's discharge goals. DON I stated she was not aware of a plan to discharge Resident #1 on 9/19/23. DON I's message to the Administrator on the evening of 9/18/23 at 8:53 p.m. was reviewed with DON I. DON I stated she recalled the statement she made in response to the Administrator's message on 9/18/23. DON I stated her response to the Administrator's message was meant to be a generic response. DON I stated If someone was saying they were being abused, in very generic terms, that is not acceptable. During an interview on 9/23/23 at 3:11 p.m., DON J stated she worked at the facility from 1/20/23 until about July or August 2023. DON J stated she recalled Resident #1 and stated Resident #1 was supposed to be a long-term resident. DON J stated by the time she left, the facility was still looking for another facility for Resident #1. When asked if she would have dropped off Resident #1 on CO E's porch with her [Resident #1's] medications and paperwork and without setting up any services, DON J stated, Absolutely not. I've learned over the years that there's appropriate ways to do that . When asked how she would use Resident #1's behavior contract to initiated the discharge, DON J stated, I would reach out to the doctor and I'd tell him, 'This is what we have in place. How do we go about discharging the resident appropriately?' We would have obtained an order. We would have called [CO E.] We would have made a care plan meeting and we would have call the family and the Ombudsman. So that way the family can be aware that she [Resident #1] broke [the behavioral contract] and we need options today. We need to figure out what we're going to do today. Record review of a facility policy titled, Discharging a Resident without a Physician's Approval, dated October 2012, revealed the following: A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. Record review of a facility policy titled, Transfer or Discharge, Facility Initiated, dated October 2022, revealed the following: 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; b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs services provided by this facility; c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. the health of individuals in the facility would otherwise be endangered; e. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility . f. the facility ceases to operate. A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others . Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals . If a resident exercises his or her right to appeal a transfer or discharge he or she will not be transferred or discharge while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The Administrator, ADON L, and LVN O were notified of an IJ on 9/22/23 at 5:15 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 9/24/23 at 2:21 p.m. and included the following: [The facility] will conduct an in-service training to ensure the staff are trained regarding resident discharges by using [online training] Planning Your Resident Discharge. [Facility] staff are requested to complete this training by 9/23/23; Any staff not available today will be required to do their training when they come back and before they take the floor for their shift. ADMIN will ensure this is done. The facility ensure that staff receive the in-service training by requiring the staff to submit their Certificate of Completion immediately to the ADMIN. Moving forward, future residents who receive a Discharge Notice will have the discharge process and appeals process reviewed and signed by the Admin to ensure the resident's discharge is safe and the appeal process is honored. The mechanism to ensure that all appropriate facility staff are aware of a resident's discharge status begins in the morning meetings. Every morning meeting any potential ADTs are discussed and evaluated for safety and proper process. Moving forward, Admin will ensure all elements of safe discharge as delineated in the training are met. The below list includes all nurses and nurse management staff employed by [the facility] as well as all Directors and PRN staff employed by [the facility]. All agency nurses moving forward and starting immediately today 9/24/23 will be required to complete the training before picking up a shift. The surveyor verification of the Plan of Removal on 9/24/23 was as follows: On 9/24/23 interviews were conducted with 18 staff members (including LVNs and RNs from all 3 shifts, Agency Nurses, and administrative staff) were interviewed. All staff members confirmed they received the education on resident discharges and were able to verbalize examples of how to ensure a safe discharge (i.e. education, return demonstration, and post-discharge follow-up calls.) During an interview on 9/24/23 at 4:25 p.m., the Administrator confirmed she received the training on discharge. Administrator confirmed that potential discharges will be discussed and if the discharge plan does not have all the elements noted in the discharge training, then the resident will not be discharged . Record review of the facility's education document titled, Planning Your Resident discharge, revealed this education included why discharge planning is important, how to prepare a resident for discharge, the importance of involving the resident and family in the discharge planning, and who was involved in the discharge planning. Record review of educational certificates of completion revealed a total of 20 employees and 4 agency nurses have completed the discharge training. On 9/24/23 at 7:06 p.m., RN N, the Administrator, and the interim DON were notified the IJ was removed. However, the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.