Every finding on record at The Stayton at Museum Way

Based on interview and record review the facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property for 2 of 2 residents (Resident's #1 and #2) reviewed for loss of personal property.The facility failed to ensure the admission agreement did not request or require residents to waive potential facility liability for losses of personal property.This could place residents at risk of misappropriation of their personal property.Findings included:Record review of Resident #1's 5-day MDS assessment, dated 07/16/2026, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included heart failure (when the heart cannot pump enough blood efficiently), hypertension (high blood pressure) and respiratory failure (when the lungs cannot get enough oxygen to the blood or when they cannot remove carbon dioxide from the blood). Resident #1's BIMS score was 14, indicating intact cognition. Record review of Resident #1's EHR reflected that she was discharged on 07/21/2026. Record review of Resident #1's grievance dated 07/12/2026, completed by the Administrator, reflected son reports money missing from resident wallet between Friday 07/10/26 PM and Sunday 07/12/26 AM. The amount was between $140 and $200. Further review reflected that the item had not been located, no one confessed to taking the item and it was reported to HHSC.Record review of Resident #2's admission MDS assessment, dated 07/05/2026, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure), aftercare following joint replacement surgery, and presence of left artificial knee joint (knee replacement). Resident #2's BIMS score was 15, indicating intact cognition. Record review of Resident #2's EHR reflected that she was discharged on 07/17/2026.Record review of Resident #2's grievance dated 07/17/2026, completed by the Administrator, reflected Resident called my phone and stated she discharged home today. Upon returning home stated she thought she is missing.$100 cash. Further review reflected that the item had not been located, staff interviewed did not see a purse or wallet, and incident was reported to HHSC.Interview on 07/22/2026 at 1:12 PM, the Administrator stated the incidents were reported to him, he completed grievances and investigations, and the results were inconclusive for both incidents. He stated their policy was that they were not responsible for lost items. The Administrator stated he had been there since March [2026] and this was the first time an incident like this happened. In a follow up interview on 07/22/2026 at 3:13 PM, the Administrator stated the admission agreement was from the previous company and the policy had not been changed since they had their change of ownership. He stated the facility would remove the statement that required the residents to waive their rights while they waited for the new company's admission agreement. Record review of the facility's undated Skilled Nursing admission and Care Agreement reflected the following: .B. DUTIES AND OBLIGATIONS OF THE RESIDENT Resident or Responsible Party where allowed by law agrees to: 1. Provide personal clothing, personal effects, spending money, as needed or desired by Resident. [Facility Name] shall not be responsible for any Resident's property which is lost, damaged, or stolen.

Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #5) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #5 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN. Resident #5 was ordered PRN Lorazepam (a benzodiazepine medication used primarily to treat anxiety disorders and severe agitation) on 07/19/25 without a stop date. This failure could place residents at risk of receiving unnecessary psychotropic medications. Findings included: Review of Resident #5's admission MDS Assessment, dated 07/26/25, reflected she was admitted to the facility on [DATE]. The MDS reflected she did not have a BIMS score calculated, had short and long-term memory problems, and had severely impaired cognitive skills for daily decision making. Resident #5 did not have any indications of behaviors towards others. Resident #5's active diagnoses included non-alzheimer's dementia (encompasses a variety of conditions that cause cognitive decline and memory loss beyond what is considered a normal part of aging) and anxiety disorder (a group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation). Review of Resident #5's Medication Profile, dated 10/03/25, reflected the following: Start Date: 07/19/25.Medication/Dose: Lorazepam 0.5 mg tablet.Frequency: As Needed Four Times Daily Starting 07/19/25.Class: Antianxiety Agent- Benzodiazepines. Review of Resident #5's Care Plan, effective 07/21/5, reflected the following: Problems: [Resident #5] has a diagnosis of Anxiety Disorders manifested by Verbal Distress.Interventions: Assess and record behaviors. [Resident #5] requires indefinite PRN anxiety medication for intermittent needs per hospice. Review of Resident #5's Consultation Report, dated 07/21/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Review of Resident #5's October 2025 and September 2025 MARs reflected she did not receive any tablets of her ordered PRN Lorazepam medication. Review of Resident #5's Consultation Report, dated 08/19/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Review of Resident #5's Consultation Report, dated 09/22/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Observation on 10/01/25 at 12:10 PM revealed Resident #5 was in her room in her bed and was asleep. Resident #5 did not wake up to the HHSC surveyor asking questions or knocking on the door. Interview on 10/03/25 at 9:33 AM with LVN A revealed he was Resident #5's nurse and she was on hospice services. LVN A said Resident #5 needed the PRN Lorazepam order because she can get very anxious and agitated at times. LVN A said the order should have a 14 day stop date on it. LVN A said usually when he received an order for a PRN psychotropic he would request a stop date from the provider before adding it to the resident's chart. Interview on 10/03/25 at 10:37 AM with the ADON revealed Resident #5 did have an order for PRN Lorazepam that came from her hospice company provider. The ADON said Resident #5 had intermittent episodes of anxiety and she was not sure why there was not a stop date for the order. The ADON said usually PRN psychotropic orders had a 14 day stop date associated with them that was scheduled to stop in the system. The ADON said once the order was given to the nurse adding the order to the resident's chart, they would ask the provider for the stop date at that point. Interview on 10/03/25 at 2:16 PM with the DON revealed since anti-anxiety medications worked on the spot and the facility had a doctor's indication for use she thought that meant Resident #5's PRN Lorazepam order did not require a 14 day stop date. The DON said she thought if the doctor's indication for use was indefinite, as in Resident #5's case, the 14 day stop date was not required. The DON said she misunderstood what the regulation required as far as a clinical indication past the 14 days. The DON said the purpose for the stop date was to meet the regulation in this instance regarding Resident #5. The DON said whoever audited Resident #5's chart or the nurse who entered the order should have asked the doctor for the stop date and included it. The DON said normally she also reviewed physician's orders in resident's charts as well. The DON said if the resident's order did not have a stop date they would continue to have the medication available to administer past 14 days. Review of the facility's policy, revised 07/29/25, and titled Psychotropic Medications reflected the following: .PRN orders for psychotropic medications are limited to 14 days.

Based on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #5) whose drug regimens were reviewed. The facility failed to act upon the Pharmacy Consultant's recommendations issued on 07/21/25, 08/19/25, and 09/22/25 to add a 14-day stop date for Resident #5's use of PRN Lorazepam, which is a psychotropic medication used for the treatment of anxiety disorders and severe agitation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Review of Resident #5's admission MDS Assessment, dated 07/26/25, reflected she was admitted to the facility on [DATE]. The MDS reflected she did not have a BIMS score calculated, had short and long-term memory problems, and had severely impaired cognitive skills for daily decision making. Resident #5 did not have any indications of behaviors towards others. Resident #5's active diagnoses included non-alzheimer's dementia (encompasses a variety of conditions that cause cognitive decline and memory loss beyond what is considered a normal part of aging) and anxiety disorder (a group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation). Review of Resident #5's Medication Profile, dated 10/03/25, reflected the following: Start Date: 07/19/25.Medication/Dose: Lorazepam 0.5 mg tablet.Frequency: As Needed Four Times Daily Starting 07/19/25.Class: Antianxiety Agent- Benzodiazepines. Review of Resident #5's Care Plan, effective 07/21/5, reflected the following: Problems: [Resident #5] has a diagnosis of Anxiety Disorders manifested by Verbal Distress.Interventions: Assess and record behaviors. [Resident #5] requires indefinite PRN anxiety medication for intermittent needs per hospice. Review of Resident #5's Consultation Report, dated 07/21/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Review of Resident #5's October 2025 and September 2025 MARs reflected she did not receive any tablets of her ordered PRN Lorazepam medication. Review of Resident #5's Consultation Report, dated 08/19/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Review of Resident #5's Consultation Report, dated 09/22/25 reflected the following: [Resident #5] is receiving hospice, comfort, or palliative care services.Active order for Lorazepam PRN.Recommendation:Even with hospice status, this order would require 14 day stop date. Observation on 10/01/25 at 12:10 PM revealed Resident #5 was in her room in her bed asleep. Resident #5 did not wake up to the HHSC surveyor asking questions or knocking on the door. Interview on 10/03/25 at 9:33 AM with LVN A revealed he was Resident #5's nurse. He stated Resident #5 was on hospice services. LVN A said Resident #5 needed the PRN Lorazepam order because she could get very anxious and agitated at times. LVN A said the order should have a 14-day stop date on it. LVN A said usually when he received an order for a PRN psychotropic he would request a stop date from the provider before adding it to the resident's chart. Interview on 10/03/25 at 10:37 AM with the ADON revealed Resident #5 did have an order for PRN Lorazepam that came from her hospice company provider. The ADON said Resident #5 had intermittent episodes of anxiety and she was not sure why there was not a stop date for the order. The ADON said usually PRN psychotropic orders had a 14 day stop date associated with them that was scheduled to stop in the system. The ADON said once the order was given to the nurse adding the order to the resident's chart, they would ask the provider for the stop date at that point. Interview on 10/03/25 at 2:16 PM with the DON revealed since anti-anxiety medications worked on the spot and the facility had a doctor's indication for use she thought that meant Resident #5's PRN Lorazepam order did not require a 14 day stop date. The DON said she thought if the doctor's indication for use was indefinite, as in Resident #5's case, the 14 day stop date was not required. The DON said she had been responsible for completing the pharmacy recommendations made since June 2025. The DON said she saw Resident #5's recommendations and misunderstood the regulation so she never changed her PRN Lorazepam order. The DON said the purpose of the pharmacy recommendations was another layer of review to ensure that medications were appropriate for the resident and were written correctly. The DON said if the pharmacy recommendations were not acted upon, appropriate changes may not be made based on what the recommendation was. Review of the facility's policy revised 07/29/25 and titled Monthly Medication Regimen Review reflected the following: 4. Recommendations are acted upon by the facility staff and/or the prescriber.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 1 medication cart (Hall B cart) and 1 medication room (Hall A) reviewed for pharmacy services. The facility failed to ensure expired multivitamin with zinc, with a date of 08/2025 in the Hall B nurse cart, and 2 bottles of expired multivitamin with an expiration date of 05/2025, 1 bottle of multivitamin with an expiration date of 08/2025, 3 bottles of niacin with an expiration date of 09/2025, and a box of bisacodyl suppositories with an expiration date of 06/2025 in the Hall A medication room were removed and destroyed. This failure could place residents at risk of receiving expired medications that were ineffective. Findings included: Observation on 10/02/2025 at 9:47 AM of the Hall B nurse cart with LVN A revealed one bottle of multivitamin with zinc with an expiration date of August 2025. Interview on 10/02/2025 at 10:04 AM with LVN A revealed it was his responsibility to ensure there were no expired medications on the cart. LVN A stated he should check the cart daily, but he did not check that morning. He stated that by failing to remove the expired medication, the medication could be administered, and the dose may not be therapeutic, or it could cause harm to the residents. He stated he had done training on checking carts for expired medications. Observation on 10/02/2025 at 10:15 AM of the Hall A medication room with LVN A revealed the following- Two bottles of multivitamins with an expiration date of May 2025;- One bottle of multivitamins had an expiration date of August 2025;- Three bottles of Niacin with an expiration date of September 2025; and - One box of Bisacodyl suppositories with an expiration date of June 2025. Interview on 10/02/2025 at 10:21 AM with LVN A revealed that it was all the nurses' and Central Supply's staff responsibility to check and remove expired medications from the medication room. LVN A stated that Central Supply should check and remove expired medications when restocking the over-the-counter medications in the medication room. LVN A revealed after Central Supply restocked the medication room, it was up to the nurses to ensure no medications were expired. LVN A stated by failing to remove the expired medications from the medication room, it put residents at risk of being administered the medication, and the medication might not be therapeutic. LVN A stated he had done in-services on checking the medication room and removing expired medications. Interview on 10/03/2025 at 10:53 AM with the ADON revealed that Medication Aides and Nurses should be checking the medication carts daily for any expired medications. The ADON also revealed that Central Supply stocked the cabinets in the medication rooms, and she should be checking and removing any expired medications. The ADON stated after Central Supply stocked the medication room, it was the nurses' responsibility to check the expiration date on medications. The ADON stated she has not gone behind the staff to double-check any medications. The ADON stated she was unsure if any in-services or training had been completed on checking the medication cart/room for expired medication. The ADON revealed that expired medications in the cart and medication room could be given to residents and be ineffective or cause nausea and vomiting. Interview on 10/03/2025 at 1:12 PM with Central Supply B revealed she restocked medications in the medication rooms when the supply was low. Central Supply B stated she did check the expiration dates when restocking, but she was unsure the last time the expiration dates were reviewed. She stated the expired medications must have been missed. She stated expired medications in the medication rooms could be given to the residents and make them sick. Central Supply B stated she had not done any in-services training on checking for expired medications. Interview on 10/03/2025 at 2:29 PM with the DON revealed that all the nurses and medication aides should know what medications were on their cart and what the expiration dates were. The DON stated the nurses should be checking their medications on the cart daily. The DON also revealed that Central Supply stocked the medication room and should be checking the expiration date. The DON stated the nurses should also be checking the expiration dates in the medication room when they were pulling medications. The DON stated if staff were not checking the medication room and carts for expired medications, the medications were at risk of being administered to residents and may have been ineffective. The DON revealed there has been training and in-services completed on the rights of medication administration. Review of the facility's Storage of Medications policy, revised 07/29/25, reflected the following: .2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. Drug containers with missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing. 4. The facility may not use medication that has been discontinued, outdated, or has deteriorated. In these cases, medication is returned to the dispensing pharmacy or destroyed by a pharmacist and licensed nursing staff.

Based on interviews and record reviews the facility failed to ensure residents had the right to be free from abuse and neglect for 2 (Residents #1 and #2) of 7 residents reviewed for abuse and neglect. 1. CNA A neglected Resident #1 safety and well-being when he placed a skeleton in the resident's doorway, which startled the resident and caused her to fall sustaining a skin tear and bruising on her buttocks. 2. The facility neglected to put measures in place to monitor Resident #2 after the resident injested medications, Fioricet (a barbituate used for headaches), that belonged to a family member. This resulted in the resident being unresponsive and going to the hopsital where she received IV fluids. The family member continued to visit four more times after this incident. These failures could result in residents receiving injuries. Findings included: 1. Record review of Resident #1's undated Admission Record reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bleeding ulcer requiring surgical repair, difficulty walking, muscle weakness, and unsteadiness on feet. The resident was discharged home on 11/7/24. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 13, indicating she was cognitively intact. Her Functional Status reflected she required supervision with all mobility. Record review of Resident #1's care plan, dated 08/23/24, reflected she was a moderate fall risk with interventions of assisting with mobility and assisting with toileting. Record review of a nursing note in Resident #1's EHR, dated 10/31/24, reflected: Nurse notified that resident sustained skin tear after she hit her hand on the bedside table. staff report that resident was attempting to stand without using walker, started to fall backward. she accidentally hit her wrist onto the table as she fell back into her chair. she has two skin tears to the right wrist, minimal lose [sic] of blood noted. skin approximated, first aid rendered and dressing applied. denies any pain to the wrist/hand or arm. Record review of the facility's investigation report reflected video footage revealed CNA-A could be seen with a skeleton on a stand approach Resident #1's doorway and place it in the doorway. CNA-A could then be seen entering the resident's room after a few moments. CNA-A then exited the room and continued about his duties. Interview on 01/02/25 at 1:50 PM the DON stated Resident #1 called for help and the nurse discovered her bleeding from two skin tears on her hand. The resident informed the nurse she had hit her hand on a table when she tried to get up and fell back in her wheelchair. The skin tears were treated at the facility. On 11/01/24 the resident was complaining of pain to her buttocks, and she was discovered to have bruising to her buttocks. The resident admitted she had fallen to the floor the previous night. She stated she had heard someone at her doorway, she stood up to investigate it and was startled by a skeleton in her doorway and fell backwards, landing on her bottom and hitting her hand on her bedside table. The resident stated CNA-A helped her get up and back into her wheelchair. X-rays were ordered and no injury was found. She stated CNA-A was interviewed and denied placing the skeleton in the doorway and the resident falling. She stated CNA-A was terminated for failing to follow facility policy after the video footage was reviewed, and the resident provided details about CNA A's actions. The DON stated the video footage was not available for viewing. Interview on 01/02/25 at 2:00 PM with Resident #1's family member revealed the resident had relayed to him she had heard someone at her doorway, so she got up to check, and she saw a skeleton in the doorway. The resident told the family member she was startled and fell backwards to the floor. The family member stated Resident #1 was fond of CNA-A and did not want him to get in trouble, so she did not initially tell staff what happened. The resident stated the CNA helped her get up and into her wheelchair. Attempts were made to interview CNA-A via telephone on 1/02/25 at 12:05 PM and 1:25 PM, but the attempts were unsuccessful. 2. Record review of Resident #2' s undated Admission Record, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. She had diagnoses which included a chemical imbalance in the brain, and stroke resulting in right sided paralysis and inability to speak. Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score was not calculated due to the resident's medical condition. Her Functional Status indicated she required assistance with all of her ADLs. Record review of Resident #2's care plan, dated 12/02/24, indicated she used an antidepressant and an anti-anxiety medication. She had impaired cognition related to dementia and impaired vision. Review of a nursing note in Resident #2's EHR, dated 12/08/24, reflected: The nurse was notified the staff member that resident cannot wake up, the nurse went to the resident's her [sic] room, the nurse tried to wake up the resident as well but still resident couldn't wake up, assessment done, v/s 180/104 [pulse] 68 [oxygen saturation] 97 [temperature] 97.6, the nurse called 911, pandemics [sic, paramedics] came and took the resident on the a [sic] stretcher to [hospital]. Record review of Resident #2's hospital records reflected the resident arrived unresponsive on 12/08/24 at 7:19 PM and was treated as a possible stroke. The resident's work-up was negative for a stroke, but her urine drug screen was positive for barbiturates. Nursing notes indicated the resident's family member arrived to the ER and identified a purse that had been brought with the resident as her purse. The family member notified the nurse she usually had a plastic bag with some medications in it, and the bag was missing. The family member thought the resident might have gotten into her purse and taken the medications. The medications included a barbiturate. Resident #2 was given IV fluids and had activated charcoal administered via a tube through her nose and into her stomach, because she was not alert enough to drink it, to absorb any medications in her stomach and intestines to minimize their affects. The resident was discharged back to the nursing home on 12/11/24. Record review of Resident #2's physician orders reflected no barbiturate medications. Interview on 1/02/25 at 2:46 PM the complainant stated she had been made aware by hospital staff of their concerns about the resident's condition. The hospital medical staff felt the resident would have been unable to take the medications from the family member's purse as described without assistance. Resident #2 was admitted to the hospital with a diagnosis of intentional overdose. Interview on 01/02/25 at 10:30 AM with the Pharmacist revealed after reviewing Resident #2's medication list that none of the medications Resident #2 was prescribed would show up as a barbiturate on a drug screen. Interview on 01/02/25 at 11:00 AM with Resident #2's family member revealed the family member had visited the resident on 12/07/24 and had accidentally left her purse on the resident's bed. She did not realize she had left it until she saw it in the ER with the resident. The family member stated when she looked in the purse she noticed a plastic bag that she kept some medications in was missing. The bag contained 10 ibuprofen, 5 benadryl, and 2 Fioricet (barbiturate headache medication). The family member notified the nurse and thought the resident must have got into her purse and taken the medications. Interview on 01/02/25 at 11:40 AM with RN-B revealed Resident #2 was capable of feeding herself after her food had been cut up, using her left hand, but she was not capable of moving herself, and was unable to stand. RN-B stated she did not think the resident would have been capable of getting into a purse and taking medication out of it since she had use of only her left arm and had poor eyesight. RN-B stated she had not observed any unusual interactions between Resident #2 and her family member. Interview on 01/02/25 at 11:50 AM with the OT revealed he had worked with Resident #2 and his assessment of the resident was she had no torso movement, and she did not have fine motor skills. He stated the purse would had to have been within the immediate reach of Resident #2. The skills of opening a purse, retrieving a plastic bag, opening the bag, and taking the medications were advanced skills, and the resident did not have those skills. Interview on 01/02/25 at 3:15 PM with the Social Worker revealed she had not been contacted by the hospital, but the facility staff were aware of the hospital staff's concerns. She stated the facility staff thought it was unlikely that Resident #2 had taken the medications on her own. Interview on 01/02/25 at 4:00 PM with the DON revealed she was aware of the concerns voiced by the hospital staff, but she did not think they could do anything about the family member because there was no proof she had given Resident #2 the medications. The DON stated they could not prevent the family member from visiting, or monitor the visit, but it did not matter because the family member had not visited since the resident had returned from the hospital on 12/11/24. Record review of the facility's electronic visitor log reflected the family member had visited four times between 12/11/24 and 12/30/24, and the family member's prior visits were on 12/12/24, 12/16/24, 12/23/24, and 12/28/24. Interview on 01/02/25 at 4:50 PM with the Administrator revealed he did not have a conversation with the family member specifically. He stated they did have conversations with all family members about bringing medications from home. The family members were told they needed to give the medications to the nurse and cleared before being given to the residents. Review of the facility's Abuse, Neglect, and Exploitation policy, dated 07/16/24, reflected: .Associates: .2. Associates are in-serviced on Abuse Prevention in their initial orientation and at least annually thereafter. 3. Associates suspected of abuse will be suspended pending the outcome of any investigation. Associates found guilty of abuse will be terminated Resident Rights: .2. The Right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of property.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the state survey agency but no later than 2 hours after the allegation was made for 1 of 7 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report an allegation of neglect when Resident #2 was found to have taken barbituates (Fioricet [used to treat headaches]) that belonged to a family member, which resulted in the resident being unresponsive and being sent to the hospital where she received IV fluids. This failure could place the resident at risk of continued abuse. Findings included: Record review of Resident #2's undated Admission Record, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 12/20/24. She had diagnoses which included a chemical imbalance in the brain, and stroke resulting in right sided paralysis and inability to speak. Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score was not calculated due to the resident's medical condition. Her Functional Status indicated she required assistance with all of her ADLs. Record review of Resident #2's care plan, dated 12/02/24, indicated she used an antidepressant and an anti-anxiety medication. She had impaired cognition related to dementia and impaired vision. Record review of Resident #2's physician orders reflected no barbiturate medications were prescribed. Review of a nursing note in Resident #2's EHR, dated 12/08/24, reflected: The nurse was notified the staff member that resident cannot wake up, the nurse went to the resident's her [sic] room, the nurse tried to wake up the resident as well but still resident couldn't wake up, assessment done, v/s 180/104 [pulse] 68 [oxygen saturation] 97 [temperature] 97.6, the nurse called 911, pandemics [sic, paramedics] came and took the resident on the a [sic] stretcher to [hospital]. Record review of Resident #2's hospital records reflected the resident arrived unresponsive on 12/08/24 at 7:19 PM and was treated as a possible stroke. The resident's work-up was negative for a stroke, but her urine drug screen was positive for barbiturates. Nursing notes indicated the resident's family member arrived to the ER and identified a purse that had been brought with the resident as her purse. The family member notified the nurse she usually had a plastic bag with some medications in it, and the bag was missing. The family member thought the resident might have gotten into her purse and taken the medications. The medications included a barbiturate. Resident #2 was given IV fluids and had activated charcoal administered via a tube through her nose and into her stomach, because she was not alert enough to drink it, to absorb any medications in her stomach and intestines to minimize their affects. The resident was discharged back to the nursing home on 12/11/24. Record review of Resident #2's physician orders reflected no barbiturate medications. Interview on 01/02/25 at 10:30 AM with the Pharmacist revealed after reviewing Resident #2's medication list that none of the medications Resident #2 was prescribed would show up as a barbiturate on a drug screen. Interview on 01/02/25 at 11:00 AM with Resident #2's family member revealed the family member had visited the resident on 12/07/24 and had accidentally left her purse on the resident's bed. She did not realize she had left it until she saw it in the ER with the resident. The family member stated when she looked in the purse she noticed a plastic bag that she kept some medications in was missing. The bag contained 10 ibuprofen, 5 benadryl, and 2 Fioricet (barbiturate headache medication). The family member notified the nurse and thought the resident must have got into her purse and taken the medications. Interview on 01/02/25 at 11:40 AM with RN-B revealed Resident #2 was capable of feeding herself after her food had been cut up, using her left hand, but she was not capable of moving herself, and was unable to stand. RN-B stated she did not think the resident would have been capable of getting into a purse and taking medication out of it since she had use of only her left arm and had poor eyesight. RN-B stated she had not observed any unusual interactions between Resident #2 and her family member. Interview on 01/02/25 at 11:50 AM with the OT revealed he had worked with Resident #2 and his assessment of the resident was she had no torso movement, and she did not have fine motor skills. He stated the purse would had to have been within the immediate reach of Resident #2. The skills of opening a purse, retrieving a plastic bag, opening the bag, and taking the medications were advanced skills, and the resident did not have those skills. Interview on 01/02/25 at 2:46 PM with the Hospital Case Manger revealed she had been made aware by hospital staff of their concerns about the resident's condition. Resident #2 was admitted to the hospital with a diagnosis of intentional overdose. The hospital medical staff thought the resident would not have been able to take the medications from the family member's purse as described without assistance. Interview on 01/02/25 at 3:15 PM with the Social Worker revealed she had not been contacted by the hospital, but the facility staff were aware of the hospital staff's concerns. She stated the facility staff thought it was unlikely that Resident #2 had taken the medications on her own. Interview on 01/02/25 at 4:00 PM with the DON revealed she was aware of the concerns voiced by the hospital staff, but she did not think they could do anything about the family member because there was no proof she had given Resident #2 the medications. The DON stated they could not prevent the family member from visiting, or monitor the visit, but it did not matter because the family member had not visited since the resident had returned from the hospital on 12/11/24. The DON stated the facility did not report the incident to HHSC because the hospital staff had reported it to Adult Protective Services. Record review of the facility's electronic visitor log reflected the family member had visited four times between 12/11/24 and 12/30/24, and the family member's prior visits were on 12/12/24, 12/16/24, 12/23/24, and 12/28/24. Interview on 01/02/25 at 4:50 PM with the Administrator revealed he did not notify HHSC of of the incident involving Resident #2 possibly being given by the barbiturate medication by the family member because the hospital had already reported it. Review of the facility's Abuse, Neglect, and Exploitation policy, dated 07/16/24, reflected: .Investigating and Reporting 1. If abuse or neglect is suspected, the Abuse Coordinator or a manager will be immediately notified. 2. Appropriate reporting procedures should always be followed Reporting/Response The facility must immediately report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the Healthcare Administrator, state agency, adult protective services, and all other required agencies

Based on observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for 1 of 3 medication carts (medication cart #1) observed for medication storage. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A did not lock medication cart #1. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A left a medication cup with two pills and a resident's medication blister pack with pills on top of the medication cart unattended. These failures place residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion. Findings included: In an observation on 10/27/24 at 6:08 PM revealed medication cart #1 in Tower A unattended and not under direct observation of authorized staff. The lock was in the out position and the drawers were able to be opened and left the medications accessible. Residents' routine and PRN medication blister packs and OTC medications were organized in drawers of the medication cart. At 6:10 PM, RN A returned to the medication cart. During an observation and interview on 10/27/24 at 6:10 PM, RN A approached the medication cart where the investigator was standing and said that he was down the hall getting medications from LVN B's cart that were not available on his cart. RN A reached down and pushed the cart lock into the locked position. The click was heard when the cart locked. RN A said that he did not have a specific nurse cart. RN A said that he placed residents at risk of taking medications that may be allergic to or someone could steal medications because the cart was not locked. During an interview on 10/27/24 at 6:30 PM, the DON said that it was unacceptable to leave medication carts unlocked and unattended or not within direct line of site and arms reach for resident safety and to prevent drug diversion. The DON said that it nurses were responsible for securing medications whenever they were away from the medication cart. The DON said if residents could access the medications, swallow a medication that they are allergic to, or have an adverse reaction. The DON said she would hold a one-to-one verbal session with RN A about medication storage and drug diversion to prevent reoccurrence. The DON stated surveillance of locked medication carts are conducted regularly for quality assurance. The DON said that that facility did not have a specific policy related to Medication Storage - Storage of Medication.

Based on interview and record review, the facility failed to ensure that each resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #1) reviewed for incontinence care. The facility they failed to monitor and document signs and symptoms of bowel movements for Resident#1. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #1's admission record undated reflected the resident was an [AGE] year-old male, who initially admitted to the facility on [DATE] with a discharge date of [DATE]. Resident#1's diagnoses included hypo-osmolarity and hyponatremia, begin prostatic hyperplasia without lower urinary tract infection, pressure ulcer of sacral region stage, 3, protein calorie malnutrition, Vitamin D deficiency, reduced mobility and need for assistance with personal care. Record review of Resident#1's modified MDS dated [DATE] reflected the Resident #1 refused for toileting hygiene, shower/bathe self and lower body dressing. The MDS reflected Resident #1 was always continent of bladder. Resident#1 had a BIMS score of 07 which indicated serve cognitive impairment. Record review of Resident#1's care plan dated [DATE] reflected: Focus: The resident is incontinent of bladder. Goal: The resident will remain free from skin break down due to incontinence and brief use through the review date and interventions reflected: Brief use: The resident uses disposable briefs. Change per schedule and prn. Clean peri-area with each incontinence episode. Record review of the admission to hospital record dated [DATE] reflected Docusate Sodium 100mg, Colace (stool softener) by mouth every day as needed for constipation. MiraLAX (osmotic laxative - works with water intake in addition to dose) Take 17g by mouth every day. Record review of Resident#1's BM report 15 day look back dated [DATE] to [DATE] reflected no 1st shift (6:00 AM to 2:00 PM) shift documentation of BM movements. On 2nd shift (2:00 PM to 10:00 PM) shift missing documentation on ,d+[DATE], ,d+[DATE], ,d+[DATE],,d+[DATE]/, ,d+[DATE], ,d+[DATE],,d+[DATE]. On 2nd shift no BMs reported on ,d+[DATE], ,d+[DATE], ,d+[DATE],,d+[DATE] and ,d+[DATE]. On 3rd shift (10:00 PM to 6:00 AM) reflected: No BMs on ,d+[DATE],,d+[DATE],,d+[DATE], ,d+[DATE],,d+[DATE] and ,d+[DATE]. Record review of Resident #1's July2024, [DATE] and [DATE] MAR reflected: Resident#1 received MiraLAX oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet by mouth one time a day for constipation. Review reflected residents received medication every morning. Record review of Resident#1 Juy 2024, [DATE] and [DATE] TAR reflected: Resident#1 did not receive a dose of Docusate Sodium 100mg, Colace (stool softener) by mouth every day as needed for constipation. Record review of Resident#1 hospital records dated [DATE] at 11:24 PM reflected: a large amount of formed stool throughout the colon and rectum. This guidance are concerned for fecal impaction. ADMIT DIAGNOSIS: SEPSIS with SEPTIC SHOCK FINAL DIAGNOSIS: Fecal impaction. ER arrival vital signs: bp: ,d+[DATE], HR 92. Record review of the WMD notes dated [DATE] reflected ER physician discussed with the family about hospice, and they indicated that they were unable to get hospice at the current facility. Family requested comfort care and hospice. Resident#1 was admitted on [DATE] to inpatient Hospice. Patient gradually declined as expected. Patient passed away peacefully on [DATE]. Interview with POA on [DATE] at 9:15 AM stated the facility killed Resident#1 by not taking good care of his overall health. POA stated every facility that he had been at he was neglected by staff. The POA stated she had the death certificate stated resident died from septic shook that he had for 8 weeks. POA stated she facility doctor, nursing staff are liars and wrote false reports about providing care for Resident#1. The POA stated she did not know Resident#1 had constipation issues and the facility did not keep her informed. Interview on [DATE] at 5:00 AM LVN D stated he remembered the residents but does remember him having constipation concerns or issues. LVN D stated if a resident goes three days without having a bowel movement, he would contact the MD to put the resident on a different medication if needed. Interview on [DATE] at 5:10 AM RN F stated she did not remember Resident#1. RN F stated CNAs report to the charge nurse any constipation issue and then we call the MD to get orders adjusted. Interviews on [DATE] at 5:25 AM with CNA F and CNA G (overnight shift) stated staff did not remember Resident#1. The CNAs stated they did documentation at the end of the shift about bowel movements. The CNAs described the size, form and shape of the BMs on the Plan of Care task sheet. Interviews on [DATE] at 6:05 AM with CAN C, CNA H, CMA I and CNA J stated staff did not remember Resident#1 CNAs stated they do documentation at the end of the shift about bowel movements. CNA'S describe the size, form and shape of the BMs on the Plan of Care task sheet. CNAs stated if a resident did not have a BM in three days on any shift it would be reported to the charge nurse and MD. Interviews on [DATE] with CNA K and CNA L stated staff did not remember Resident#1 stated they do documentation at the end of the shift about bowel movements. CNA'S describe the size, form and shape of the BMs on the Plan of Care task sheet. CNAs stated if a resident did not have a BM and three days it would be reported to the MD by the charge Nurse. Interview on [DATE] at 2:25 PM the ADON stated Resident#1 would refuse medication. ADON stated she does not remember Resident#1 reporting constipation concerns. ADON stated staff worked four days on and two days off. ADON stated CNAs reported in the POC about Bowel movements for all residents. ADON stated if a resident did not have a Bowel Movement in three days it was reported to the charge nurse who notified the MD. ADON stated any change of condition or concerns with residents are reported to the on coming staff and documented in the nurse's notes. ADON stated information about Bowel movements needed to be documented to determine if the Resident needed to be on a different medication. Interview over the phone on [DATE] at 4:30 PM the MD stated he did a head-to-toe assessment on Resident#1 on and he did not see any concerns with constipation at that time. MD stated he checked the resident stomach and there was no tightness and no discomfort reported by the resident at that time. Interview on [DATE] at 6:25 PM the DON and Administrator stated residents' bowel movements were measured by small, medium, and large. The DON revealed softness and firmness was documented on the task list for CNAs to complete. The CNAs were responsible for documenting this information in the POC. DON stated all resident's bowel movements are monitored in the POC and the CNAs know to report to the charge nurse if the resident did not have a BM for three days or more. The Charge nurse would report it to the MD. The MD would put in a different order for the resident. The Administrator stated he expected the nursing staff to document the information correctly so that staff would be alerted about concerns. The Administrator and DON stated the facility did not have a policy for monitoring bowel movement.

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 infectious diseases and infections 1 of 5 residents (Resident #2) reviewed for infection control, in that: 1. RN A failed to follow facility protocol and don a gown in addition to gloves to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions (EBP) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 2. RN A re-used the wound vac disposable components (suction device and tubing) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. These failures placed residents with wounds at an increased risk of infection, wound contamination, unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and failure of the wound to heal. Findings included: A record review of Resident #2's Admission Record printed 10/26/24 revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses of unspecified fracture of lower end of right tibia; unspecified open wound, Right knee, Sequela (a condition that results from a previous illness, injury, or medical intervention); and Infection and Inflammatory reaction due to internal right hip prosthesis, subsequent encounter (routine care during the healing or recovery phase after active treatment was received for a condition). The Admission Record reflected 13 days length of stay. A record review of the Comprehensive MDS Admit assessment dated [DATE] reflected Resident #2's BIMS score was 15, which indicated intact cognitive response. The Comprehensive MDS Admit Assessment reflected Resident #2 needed partial assistance from another person to complete ADLs. Section M - Skin conditions revealed Resident #1 was not at risk for developing pressure ulcers/injuries and surgical wound(s) were present on admission. A review of Resident #2's hospital discharge clinical records dated 10/11/24 revealed final discharge instructions that included discharge medications; diet type; Activity: Non-weightbearing to right leg; Wound/Dressing Care: do not submerge incision. Keep wound clean and dry. Perform pin site care daily. Mix 1/2 Peroxide and 1/2 Normal Saline and use gauze to clean around pin sites; Follow up with PCP in 1 week after discharge (from hospital); Follow up in 2 - 3 weeks with orthopedic surgeon; Follow up in 1 - 2 weeks with right ankle orthopedic surgeon; and Daily wet to dry dressing change right knee wound. Record review revealed a skin check on admission (10/14/24). There were no other skin checks, or a weekly skin assessment performed on Resident #2. Record review of Resident #2 progress notes dated 10/14/24 at 7:34 PM, revealed right lateral knee trauma wound 1.2 cm x 1 cm x 0.1 cm (LxWxD) 90% granulation with moderated serosanguinous drainage. Record review of Resident #2's care plan, initiated 10/16/24, reflected [Resident #2] had an alteration in musculoskeletal status r/t fracture of the right tibia and fibula, external fixator placed 10/09/24; had a chronic infection of the right hip after hip surgery; had actual impairment to skin integrity of the right knee - infection with previous surgery for incision and drainage ([I & D] a minor surgical procedure for skin and soft tissue abscesses) in May 2024, now with wound vac; and on antibiotic therapy doxycycline r/t chronic right hip arthroplasty infection. The care plan interventions included: observation, monitoring, educating, following protocol, assess, evaluation, treatment, and reporting to physician as needed. A review of Resident #2's clinical physician orders reflected: Start date 10/15/24: Daily wet to dry dressing change right knee wound one time a day for wound care [D/C date: 10/25/24] Start date 10/15/24: Do not submerge incision keep wound clean and dry. Perform pin site care daily. Mix 1/2 peroxide, 1/2 Normal Saline and use gauze to clean around pin sites. One time a day for Wound care. Start date 10/15/24: Doxycycline Hyclate Oral Tablet 100 mg. Give 100 mg by mouth two times a day for chronic infection. Start date 10/22/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. [D/C date: 10/25/24] Start date 10/26/24: Wound care right knee. Cleanse site with wound cleanser. Pat dry, apply black wound vac for dressing. Wound vac at 125 (mm/hg). Change every 3 days and PRN. One time a day every Tue, Thu, Sat. Start date 10/26/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. There were no orders noted for weekly head to toe skin assessments. Record review of Resident #2's October 2024 TAR, printed 10/26/24 at 3:59 PM, reflected RN A's user initials for pin site care, wound vac change, and mupirocin applied to right knee wound on Saturday, 10/26/24 that indicated the care was provided in the morning (Qam) as ordered. During an observation and interview on 10/26/24 at 12:02 PM, Resident #2 was sitting upright in chair with legs in a reclined position. The right lower leg had an external fixator (a metal framed medical device mounted on the exterior of the leg with pins inserted through the skin and into the bone of the leg by applying external pressure). There was a clear dressing, dated 10/25/24, on the right outer lateral knee. A suction device and tubing connected the dressing to a tubing attached to a canister a wound vac pump. Resident #2 was awake, alert, and oriented to person, place, time of day, and situation. Resident #2 said wound care was performed yesterday (10/25/24) to clean the pins (external fixator) and the wound vac was placed to the right knee wound. Resident #2 said that she did not know when the dressing would be changed again. Resident #2 said that the pins were supposed to be cleaned daily and the wound vac was supposed to be changed three times a week. During an interview on 10/26/24 at 1:25 PM, RN A said that he worked weekends only from 6AM - 10 PM. RN A was not sure about Resident #2's wound vac dressing change schedule when asked. RN A read the orders out loud, Change every 3 days and as needed. every Tue, Thu, Sat. RN A denied any other wound care needs for Resident #2. When asked what time did [RN A] plan to do the wound vac dressing change, RN A replied, maybe tomorrow. When asked to clarify the order, RN A re-read the order and said, maybe later after dinner. RN A was informed that the investigator wanted to observe (RN A) perform Resident #2's wound care, that included obtaining wound dressing supplies. RN A acknowledged understanding. During an interview and observation of wound care performed by RN A on 10/26/24 at 3:06 PM, there were wound dressing supplies neatly placed on a barrier sheet at the foot of Resident #2's bed, flushed to the right edge. RN A said that he forgot the investigator wanted to observe (RN A) collect wound dressing supplies. RN A performed hand hygiene with soap and water. RN A did not don a clean gown. RN A donned clean gloves and turned off the wound vac. RN A did not clamp the tubing between the canister and the sensor pad. There was no drainage in the tubing noted. RN A pulled at and tugged on the suction device and tubing to remove the dressing from the wound site. Resident #2 grimaced and said that it hurt when RN A pulled on the tubing. Resident #2 informed RN A that she already had pain medicine and to continue with the dressing change. After investigator intervention, RN A lifted the edges of the semi-occlusive dressing and removed the semi-occlusive dressing. The sensor pad (and tubing) and a black foam piece was attached to the. RN A did not discard the old disposable suction device and tubing. RN A placed the disposable suction device and tubing in the windowsill with the semi-occlusive dressing and piece of black foam still attached. RN A said that the DON told him to reuse the sensor pad and tubing because the facility did not have new wound vac supplies. Resident #2's right knee presented a deep red raised wound, approximately one inch (2.54 cm) long and half inch (1.27 cm) wide by visual inspection. RN A did not measure the wound to compare with previous measurements. RN A cleaned the wound with non-sterile gauze soaked with wound cleanser, patted dry with non-sterile gauze, picked up a piece of black foam from the barrier sheet on the bed, and applied to the wound. RN A did not cut the foam to the dimensions of the wound. The black foam covered the wound and overlapped onto the healthy skin around the wound. RN A did not apply barrier cream or skin prep to prevent further breakdown of skin around the wound. RN A placed a piece of adhesive dressing over the foam piece to secure in place. RN A pinched the dressing and cut a small hole. RN A picked up the old suction device and tubing from the windowsill, removed the old adhesive dressing. RN A placed the suction device and tubing over the small hole and secured in place with strips of adhesive dressing. RN A connected the tubing to the tubing attached to the old cannister. RN A turned the wound vac on. RN A told Resident #2 that there was a good seal, and the wound vac was functioning. The dressing did not appear sucked down. During an interview, RN A said that he was checked off a long time ago (greater than two years ago) for wound vac dressing change competency. RN A said a good seal meant there was no air escaping from under the dressing. RN A said reusing the disposable suction pad and tubing increased Resident #2's risk for infection. RN A said that he did not know who was responsible for ordering wound care supplies. RN A said that the DON found some foam pieces in Resident #2's drawer that were not secured in the original sealed package and told him to reuse the suction pad and tubing. During an interview on 10/26/24 at 4:09 PM, the DON said that the nurses performed wound care and were responsible for reordering wound care supplies. The DON said that skin assessments were performed weekly and opportunities for staff to discover changes in skin condition were during showers, bed baths, and when incontinent care was performed. The DON said that she totally agreed with the investigator's observation findings. The DON said that she did tell RN A to reuse the disposable wound vac suction pad and tubing. The DON said that she oversaw a NPWT competency checkoff for RN A and needed to locate the documents. The DON said that Resident #2 admitted with orders to apply wet to dry dressings to the right knee. The DON said that the wound doctor gave orders to apply the wound vac. The DON said that the WMD would determine if there the wound improved or worsened. The DON said that it was not common practice to reuse supplies at the facility. The DON said that reusing disposable supplies can increase risk for infection. The DON said that RN A was supposed to don a gown and gloves when he performed wound care as enhanced barrier precautions to prevent cross-contamination. The DON said that head to toe skin checks were performed by the nurses weekly as a skin care approach to help identify skin conditions early. The DON said that she was unsure why Resident #2 did not have a weekly skin assessment 7 days after admission, 10/21/24, or as soon as it was discovered a skin assessment was not done. The DON said that the facility did not have specific policies related to frequency of skin assessments. Interview on 10/26/24 at 4:45 PM, the DON approached the investigator and said that she spoke with the central supply staff and was informed that the wound vac supplies were ordered and stored in the ADON's office. The DON could not explain why she did not inquire with central supply about the wound vac supplies before telling RN A to reuse disposable supplies. Record review of the facility procedure Guide to Negative Pressure Wound Therapy (NPWT), dated January 2024, read in part: General Procedure o Trim the foam sponge to fit the size of the open wound and place it into the wound; the foam should not extend beyond the wound margin. Dressing Changes o Remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) and carefully remove the foam sponge. Risks and Complications Ensure proper placement of sponge and semi-occulsive adhesive cover; avoid sponge contact with healthy skin. Record review of the facility's procedure for Applying Negative Pressure Wound Therapy, Skill 8-11, dated 2011, reflected: Goal: The therapy is accomplished without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. 3. Perform hand hygiene and put on PPE, if indicated. 10. Using sterile technique, prepare a sterile field and add all the sterile supplies needed for the procedure to the field. 11. Put on a gown, mask, and eye protection. 12. Put on clean gloves. Carefully and gently remove the dressing. If there is resistance, use a silicone-based adhesive remover to help remove the drape. 14. Put on sterile gloves. Using sterile technique, irrigate the wound. 17. Wipe intact skin around the wound with a skin-protectant wipe and allow it to dry well. 19. Put on a new pair of sterile gloves, if necessary. Using sterile scissors, cut the foam to the shape and measurement of the wound. Do not cut foam over the wound. More than one piece of foam may be necessary if the first piece is cut too small. Carefully place the foam in the wound. 23. Assess the dressing to ensure seal integrity. The dressing should be collapsed, shrinking to the foam and skin. Record review of Texas Health and Human (HHS) Infection Prevention and Control Measures for Common Infections in LTC Facilities, Version 1.0, 10/07/22, Enhanced Barrier Precautions (p. 14) reflected: Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high-contact resident care activities where gown and glove use for enhanced barrier precautions (EBP) are recommended include Wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #2) of five residents reviewed for wounds. 1. RN A failed to remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) that secured the negative pressure wound therapy ([NPWT] - wound vac) suction device and tubing over the wound. RN A pulled on the suction device and tubing to remove the old dressing that caused Resident #2 pain and discomfort on 10/26/24. 2. RN A failed to follow the facility's general procedure for wound vac dressing change on 10/26/24. RN A obtained foam dressings from a drawer in Resident #2's room. The foam dressings were non-sterile due to being stored in an opened or undamaged package. RN A did not trim the foam dressing to dimensions that allowed the foam to be placed into the wound bed. RN A applied the foam dressing to the wound and overlapped onto intact skin around the wound. 3. RN A failed to follow facility protocol and don a gown in addition to gloves to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions (EBP) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 4. RN A re-used the wound vac disposable components (suction device and tubing) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 5. RN A failed to follow physician orders to apply an ointment as ordered to the surrounding skin around Resident #2's right knee wound on 10/26/24. 6.The facility failed to perform weekly skin assessments for Resident #2 on 10/21/24. These failures placed residents with wounds at an increased risk of infection, wound contamination, unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and failure of the wound to heal. Findings included: A record review of Resident #2's Admission Record printed 10/26/24 revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses of unspecified fracture of lower end of right tibia; Unspecified open wound, Right knee, Sequela (a condition that results from a previous illness, injury, or medical intervention); and Infection and Inflammatory reaction due to internal right hip prosthesis, subsequent encounter (routine care during the healing or recovery phase after active treatment was received for a condition). The Admission Record reflected 13 days length of stay. A record review of the Comprehensive MDS Admit assessment dated [DATE] reflected Resident #2's BIMS score was 15, which indicated intact cognitive response. The Comprehensive MDS Admit Assessment reflected Resident #2 needed partial assistance from another person to complete ADLs. Section M - Skin conditions revealed Resident #1 was not at risk for developing pressure ulcers/injuries and surgical wound(s) were present on admission. A review of Resident #2's hospital discharge clinical records dated 10/11/24 revealed final discharge instructions that included discharge medications; diet type; Activity: Non-weightbearing to right leg; Wound/Dressing Care: do not submerge incision. Keep wound clean and dry. Perform pin site care daily. Mix 1/2 Peroxide and 1/2 Normal Saline and use gauze to clean around pin sites; Follow up with PCP in 1 week after discharge (from hospital); Follow up in 2 - 3 weeks with orthopedic surgeon; Follow up in 1 - 2 weeks with right ankle orthopedic surgeon; and Daily wet to dry dressing change right knee wound. Record review revealed a skin check on admission (10/14/24). There were no other skin checks, or a weekly skin assessment performed on Resident #2. Record review of Resident #2 progress notes dated 10/14/24 at 7:34 PM, revealed right lateral knee trauma wound 1.2 cm x 1 cm x 0.1 cm (LxWxD) 90% granulation with moderated serosanguinous drainage. Record review of Resident #2's care plan, initiated 10/16/24, reflected [Resident #2] had an alteration in musculoskeletal status r/t fracture of the right tibia and fibula, external fixator placed 10/09/24; had a chronic infection of the right hip after hip surgery; had actual impairment to skin integrity of the right knee - infection with previous surgery for incision and drainage ([I & D] a minor surgical procedure for skin and soft tissue abscesses) in May 2024, now with wound vac; and on antibiotic therapy doxycycline r/t chronic right hip arthroplasty infection. The care plan interventions included: observation, monitoring, educating, following protocol, assess, evaluation, treatment, and reporting to physician as needed. A review of Resident #2's clinical physician orders reflected: Start date 10/15/24: Daily wet to dry dressing change right knee wound one time a day for wound care [D/C date: 10/25/24] Start date 10/15/24: Do not submerge incision keep wound clean and dry. Perform pin site care daily. Mix 1/2 peroxide, 1/2 Normal Saline and use gauze to clean around pin sites. One time a day for Wound care. Start date 10/15/24: Doxycycline Hyclate Oral Tablet 100 mg. Give 100 mg by mouth two times a day for chronic infection. Start date 10/22/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. [D/C date: 10/25/24] Start date 10/26/24: Wound care right knee. Cleanse site with wound cleanser. Pat dry, apply black wound vac for dressing. Wound vac at 125 (mm/hg). Change every 3 days and PRN. One time a day every Tue, Thu, Sat. Start date 10/26/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. There were no orders noted for weekly head to toe skin assessments. Record review of Resident #2's October 2024 TAR, printed 10/26/24 at 3:59 PM, reflected RN A's user initials for pin site care, wound vac change, and mupirocin applied to right knee wound on Saturday, 10/26/24 that indicated the care was provided in the morning (Qam) as ordered. During an observation and interview on 10/26/24 at 12:02 PM, Resident #2 was sitting upright in chair with legs in a reclined position. The right lower leg had an external fixator (a metal framed medical device mounted on the exterior of the leg with pins inserted through the skin and into the bone of the leg by applying external pressure). There was a clear dressing, dated 10/25/24, on the right outer lateral knee. A suction device and tubing connected the dressing to a tubing attached to a canister a wound vac pump. Resident #2 was awake, alert, and oriented to person, place, time of day, and situation. Resident #2 said wound care was performed yesterday (10/25/24) to clean the pins (external fixator) and the wound vac was placed to the right knee wound. Resident #2 said that she did not know when the dressing would be changed again. Resident #2 said that the pins were supposed to be cleaned daily and the wound vac was supposed to be changed three times a week. During an interview on 10/26/24 at 1:25 PM, RN A said that he worked weekends only from 6AM - 10 PM. RN A was not sure about Resident #2's wound vac dressing change schedule when asked. RN A read the orders out loud, Change every 3 days and as needed. every Tue, Thu, Sat. RN A denied any other wound care needs for Resident #2. When asked what time did [RN A] plan to do the wound vac dressing change, RN A replied, maybe tomorrow. When asked to clarify the order, RN A re-read the order and said, maybe later after dinner. RN A was informed that the investigator wanted to observe (RN A) perform Resident #2's wound care, that included obtaining wound dressing supplies. RN A acknowledged understanding. During an interview and observation of wound care performed by RN A on 10/26/24 at 3:06 PM, there were wound dressing supplies neatly placed on a barrier sheet at the foot of Resident #2's bed, flushed to the right edge. RN A said that he forgot the investigator wanted to observe (RN A) collect wound dressing supplies. RN A performed hand hygiene with soap and water. RN A did not don a clean gown. RN A donned clean gloves and turned off the wound vac. RN A did not clamp the tubing between the canister and the sensor pad. There was no drainage in the tubing noted. RN A pulled at and tugged on the suction device and tubing to remove the dressing from the wound site. Resident #2 grimaced and said that it hurt when RN A pulled on the tubing. Resident #2 informed RN A that she already had pain medicine and to continue with the dressing change. After investigator intervention, RN A lifted the edges of the semi-occlusive dressing and removed the semi-occlusive dressing. The sensor pad (and tubing) and a black foam piece was attached to the. RN A did not discard the old disposable suction device and tubing. RN A placed the disposable suction device and tubing in the windowsill with the semi-occlusive dressing and piece of black foam still attached. RN A said that the DON told him to reuse the sensor pad and tubing because the facility did not have new wound vac supplies. Resident #2's right knee presented a deep red raised wound, approximately one inch (2.54 cm) long and half inch (1.27 cm) wide by visual inspection. RN A did not measure the wound to compare with previous measurements. RN A cleaned the wound with non-sterile gauze soaked with wound cleanser, patted dry with non-sterile gauze, picked up a piece of black foam from the barrier sheet on the bed, and applied to the wound. RN A did not cut the foam to the dimensions of the wound. The black foam covered the wound and overlapped onto the healthy skin around the wound. RN A did not apply barrier cream or skin prep to prevent further breakdown of skin around the wound. RN A placed a piece of adhesive dressing over the foam piece to secure in place. RN A pinched the dressing and cut a small hole. RN A picked up the old suction device and tubing from the windowsill, removed the old adhesive dressing. RN A placed the suction device and tubing over the small hole and secured in place with strips of adhesive dressing. RN A connected the tubing to the tubing attached to the old cannister. RN A turned the wound vac on. RN A told Resident #2 that there was a good seal, and the wound vac was functioning. The dressing did not appear sucked down. During an interview, RN A said that he was checked off a long time ago (greater than two years ago) for wound vac dressing change competency. RN A said a good seal meant there was no air escaping from under the dressing. RN A said reusing the disposable suction pad and tubing increased Resident #2's risk for infection. RN A said that he did not know who was responsible for ordering wound care supplies. RN A said that the DON found some foam pieces in Resident #2's drawer that were not secured in the original sealed package and told him to reuse the suction pad and tubing. During an interview on 10/26/24 at 4:09 PM, the DON said that the nurses performed wound care and were responsible for reordering wound care supplies. The DON said that skin assessments were performed weekly and opportunities for staff to discover changes in skin condition were during showers, bed baths, and when incontinent care was performed. The DON said that she totally agreed with the investigator's observation findings. The DON said that she did tell RN A to reuse the disposable wound vac suction pad and tubing. The DON said that she oversaw a NPWT competency checkoff for RN A and needed to locate the documents. The DON said that Resident #2 admitted with orders to apply wet to dry dressings to the right knee. The DON said that the wound doctor gave orders to apply the wound vac. The DON said that the WMD would determine if there the wound improved or worsened. The DON said that it was not common practice to reuse supplies at the facility. The DON said that reusing disposable supplies can increase risk for infection. The DON said that RN A was supposed to don a gown and gloves when he performed wound care as enhanced barrier precautions to prevent cross-contamination. The DON said that head to toe skin checks were performed by the nurses weekly as a skin care approach to help identify skin conditions early. The DON said that she was unsure why Resident #2 did not have a weekly skin assessment 7 days after admission, 10/21/24, or as soon as it was discovered a skin assessment was not done. The DON said that the facility did not have specific policies related to frequency of skin assessments. Interview on 10/26/24 at 4:45 PM, the DON approached the investigator and said that she spoke with the central supply staff and was informed that the wound vac supplies were ordered and stored in the ADON's office. The DON could not explain why she did not inquire with central supply about the wound vac supplies before telling RN A to reuse disposable supplies. Record review of the facility procedure Guide to Negative Pressure Wound Therapy (NPWT), dated January 2024, read in part: General Procedure o Trim the foam sponge to fit the size of the open wound and place it into the wound; the foam should not extend beyond the wound margin. Dressing Changes o Remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) and carefully remove the foam sponge. Risks and Complications Ensure proper placement of sponge and semi-occulsive adhesive cover; avoid sponge contact with healthy skin. Record review of the facility's procedure for Applying Negative Pressure Wound Therapy, Skill 8-11, dated 2011, reflected: Goal: The therapy is accomplished without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. 3. Perform hand hygiene and put on PPE, if indicated. 10. Using sterile technique, prepare a sterile field and add all the sterile supplies needed for the procedure to the field. 11. Put on a gown, mask, and eye protection. 12. Put on clean gloves. Carefully and gently remove the dressing. If there is resistance, use a silicone-based adhesive remover to help remove the drape. 14. Put on sterile gloves. Using sterile technique, irrigate the wound. 17. Wipe intact skin around the wound with a skin-protectant wipe and allow it to dry well. 19. Put on a new pair of sterile gloves, if necessary. Using sterile scissors, cut the foam to the shape and measurement of the wound. Do not cut foam over the wound. More than one piece of foam may be necessary if the first piece is cut too small. Carefully place the foam in the wound. 23. Assess the dressing to ensure seal integrity. The dressing should be collapsed, shrinking to the foam and skin. Record review of Texas Health and Human (HHS) Infection Prevention and Control Measures for Common Infections in LTC Facilities, Version 1.0, 10/07/22, Enhanced Barrier Precautions (p. 14) reflected: Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high-contact resident care activities where gown and glove use for enhanced barrier precautions (EBP) are recommended include Wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering medications for 1 of 3 residents (Resident #3) reviewed for medication administration. RN A failed to administer medications as ordered. RN A informed Resident #3 that he mixed Miralax (brand name of an over-the-counter powder that treats occasional constipation [generic name: Polyethylene glycol (PEG) 3350]) with cranberry juice per Resident #3's request to relieve constipation. Resident #3 did not have an order for Miralax (or generic version). The facility failed to ensure RN A contacted the physician to obtain an order for a medication before administration. This failure placed residents at risk of adverse drug reactions related to drug allergies or not receiving the intended therapeutic benefit of the medication. Findings included: A record review of Resident #3's Admission Record, printed 10/27/24, revealed the resident was a [AGE] year-old female admitted on [DATE] from an acute care facility with a left fibula (calf bone) fracture. Record review on 10/27/24 revealed a Comprehensive MDS Admit Assessment was not initiated. A review of Resident #3's hospital discharge clinical records dated 10/26/24 revealed physician discharge instructions; discharge medications; diet instructions; and to schedule a follow up visit with orthopedic surgeon. Record review did not reveal a baseline care plan. A visual/bedside Kardex report, dated 10/27/24, reflected special instructions for behavior/mood and Lifestyle. There were no interventions or instructions listed. A review of Resident #3's clinical physician orders reflected: Start date 10/27/24 at 6:00 AM: Senokot S Oral Tablet 8.6-50 mg. Give 1 tablet by mouth in the morning for constipation. Hospital discharge medications reflected Senokot S Oral Tablet 8.6-50 mg. Take 1 tablet by mouth two times daily as needed for constipation. Start date 10/26/24 at 9:49 PM: Milk of Magnesia Suspension 7.75%. Give 30cc by mouth every 24 hours as needed for No BM in 3 days. If no results, call MD. Record review of Resident #3's October 2024 MAR, printed 10/27/24, reflected RN A's user initials on 10/27/24 with a comment code that medications, including over-the-counter medications, were not in administered due to not available or received by pharmacy. During an observation and interview on 10/27/24 at 1:07 PM, CNA C performed incontinent care to Resident #3. Resident #3 said that she was constipated and asked the nurse (RN A) for Miralax. Resident #3 said that RN A administered Miralax mixed in cranberry juice. Resident #3 said it had been a couple of days since her last bowel movement. During an interview on 10/27/24 at 6:10 PM, RN A said that he gave Resident #3 Miralax mixed with cranberry juice and a cup of water to help relieve constipation per her request. When inquired about Resident #3 orders, RN A said that he did not really give Resident #3 Miralax, that he just told her that he did to calm her down. RN A said that Resident #3 was upset because she had not received any medications since admission (10/26/24 around 2:00 PM). RN A could not explain why he did not review Resident #3's orders to see what medications were ordered for constipation as needed. RN A said giving a resident medication that was not ordered could cause harm if allergic to the medication. During an interview on 10/27/24 at 6:30 PM, the DON said that orders must be received from the doctor before any medication was administered. The DON said that it was a collaborative effort between the DON, ADON, and the nurse who entered the orders to ensure the order was correct and that orders were in place for every medication or treatment administered. The DON said that RN A just approached her (10 - 15 minutes prior to interview) and showed her a text to Resident #3's PCP requested an order to administer Resident #3 Miralax. The DON said that the nurse should request and obtain an order before medication was administered to a resident. The DON said a medication not ordered or reviewed by the pharmacy for interactions could be harmful to a resident. The DON said that Resident #3 was upset that she did not receive routine medications that included Alprazolam XR ([Xanax XR] a sedative that can treat anxiety and panic disorder) and oxycodone (a narcotic to treat moderate to severe pain). The DON said that the discharging facility was expected to send a 3-day supply of medications and prescriptions for controlled drugs with a resident admitted to the facility. The DON said that the facility had a locked emergency drug box that contained select medications and controlled drugs as ordered by the physician if medications were not available. The DON said that the nurses should check for availability of medications or call the doctor for alternative medications before telling a resident the medication was not available. The DON said that the facility did not have specific policies related to medication administration.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #8, Resident #21, and Resident #143) of thirteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #8, Resident #21, and Resident #143's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #8 Review of Resident #8's Face Sheet, dated 09//06/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #8 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #8's Comprehensive MDS Assessment, dated 08/16/2024, reflected that Resident #8 had a moderate impairment in cognition with a BIMS score of 08. Resident #8 required substantial assistance in toileting, shower, and dressing. Review of Resident #8's Comprehensive Care Plan, dated 08/29/2024, reflected that Resident #8 was high risk for falls related to deconditioning and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 09/04/2024 at 10:20 AM revealed Resident #8 was in his wheelchair beside his bed. Resident #8 was putting on his t-shirt and said he just had a shower. He said CNA C showered him and then made his bed. Resident #8 then said CNA C went out of the room to get a pair of new socks for him. He said CNA C haven't come back since after the shower and he was planning to call her to know where his socks were. He said he cannot call CNA C because his call light was on the floor, and it was hard for him to pick it up. It was observed that the resident's call light was on the floor behind his wheelchair. He said the CNA who made his bed did not make sure his call light was secured. Observation and interview with CNA C on 09/04/2024 at 10:43 AM revealed CNA C went inside Resident #8's room and put on the resident's socks. Resident #8 said CNA C was the aide that made his bed. After putting on the socks, CNA C then went out of the room and still did not notice that the resident's call light was on the floor. When prompted to check the resident's call light, CNA C looked up and said the call light was not on. When prompted to check on the call light's placement, CNA C went back inside the room, saw the call light on the floor, picked it up, and put it on top of the resident's bed. CNA C stated she gave the resident his shower and made his bed. She said she did not notice the call light was on the floor when she left the room. She said she should have made sure the call light was accessible to Resident #8 in case he needed something. She said the call lights were important because the resident use them to let the staff know that they needed something. Without the call light, the needs of the resident will not be known. Resident #21 Review of Resident #21's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #21 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #21's Comprehensive MDS Assessment, dated 08/09/2024, reflected that Resident #21 had a moderate cognitive impairment with a BIMS score of 11. Resident #21 required substantial assistance in toileting, shower, and dressing. Review of Resident #21's Comprehensive Care Plan, dated 07/29/2024, reflected that Resident #21 was at risk for falls related to gait balance problems and one of the interventions was to ensure/provide a safe environment. Observation and interview on 09/04/2024 at 8:54 AM revealed Resident #21 was in her wheelchair, awake. The resident's call light was observed on the floor beside the bed. She said she just came back from breakfast. She said she saw the call light on the floor when she was ushered inside the room after breakfast but the one who pushed her wheelchair did not notice the call light was on the floor. Observation and interview on 09/04/2024 at 10:28 AM revealed Resident #21 was still sitting in her wheelchair, awake. She said her call light was still on the floor. She said she frequently used it, but it should be where she could reach it in case she needed something. Observation on 09/04/2024 at 10:48 AM revealed after leaving Resident #8's room, CNA C proceeded to Resident #21's room, saw the call light on the floor, picked it up, and placed it on the bed. CNA C told Resident #21 that her call light was on the bed. Resident #143 Review of Resident #143's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #143 was diagnosed with weakness, reduced mobility, and unsteadiness on feet. Review of Resident #143's Comprehensive MDS Assessment, dated 08/27/2024, reflected Resident #143 required substantial assistance in toileting, shower, and dressing. Review of Resident #143's Comprehensive Care Plan, dated 08/28/2024, reflected that Resident #143 had an ADL self-care performance deficit related to fatigue and impaired balance and one of the interventions was to encourage the resident to use bell for assistance. Observation and interview with Resident #143 on 09/04/2024 at 8:46 AM revealed resident was in his bed, awake. It was observed that Resident #143's call light was on the floor under the bed. Resident #143 stated he was trying to look for his call light because he wanted to get up but cannot find it. He said he cannot even find the cord of his call light. He said several staff already went inside the room and did not notice his call light was on the floor. Observation and interview with RN D on 09/04/2024 at 8:55 AM, RN D stated call lights should be with the residents all the times, because they use the call lights to call for help or assistance if needed. She said the residents used the call lights to communicate to the staff that they needed something. She added that if the call lights were not with the residents, the residents might fall trying to do things by themselves or get frustrated because they could not call the staff. She said all the staff were responsible in making sure the call lights were within reach of the residents. RN D went inside Resident #143's room, picked up the call light, and handed it to Resident #143. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated call lights were important for the residents and they should be placed where the residents could access them without difficulty. The DON said the call lights were the residents' mode of communication so they could tell the staff they needed something. She said even if the residents seldom use them, the call lights should still be placed somewhere accessible. She said all the staff, from nurses, CNAs, therapy, housekeeping, and management, were responsible in ensuring that the call lights were within reach. The DON said the expectation was for the staff would be mindful that every time they leave the residents' room, the call lights were within reach. The DON said she would conduct an in-service and check-off about the call lights. She said she would personally monitor that all the residents' call lights were within reach. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated the call lights should not be on the floor or in a place not accessible to the residents because the residents needed them to call the staff. The ADON said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of the residents. The ADON said they would do an in-service about call lights being accessible to the residents. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the call lights should not be on the floor because the residents needed them to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be make sure the call lights were within reach. The Administrator said he would coordinate with the DON regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident. Record review of facility's policy Accommodations For Residents Who Cannot Use the Call light Operations and Service Standards Manual revised July 16, 2024 revealed . goal is to have a call light available and within reach of all residents.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #29, Resident #142, and Resident #144) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #29's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #142 had an order for CPAP and her nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure Resident #144's nasal cannula was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #29's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body), emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #29's Quarterly MDS Assessment, dated 08/26/2024, reflected that Resident #29 had moderate impairment in cognition with a BIMS score of 12. Resident #29's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #29's Comprehensive Care Plan, dated 08/20/2024, reflected that the resident had emphysema/COPD with chronic respiratory failure related to smoking and one of the interventions was O2 via nasal prongs at 2 L/min. Review of Resident #29's Physician Order, dated 08/19/2024, reflected O2 at 2L/Min Via (through) NC. Observation and interview with Resident #29 on 09/04/2024 at 8:41 AM revealed that Resident #29 was in her wheelchair, awake. It was observed that she had a portable oxygen tank behind her wheelchair. A nasal cannula was attached to the portable oxygen tank. It was observed that the nasal cannula was coiled on the right hand grip of the wheelchair. The nasal cannula was not bagged and there was no bag hanging at the back of the wheelchair. Resident #29 stated she was on oxygen because of her respiratory problems. Said she would use the nasal cannula on her wheelchair when she needed to go out of her room. She said she never saw a plastic bag for her nasal cannula at the back of her wheelchair and for the nasal cannula connected on the oxygen concentrator. 2. Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Comprehensive MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right-side table. A nasal pillow mask was attached to the CPAP machine. The nasal pillow mask for CPAP was not bagged. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was not bagged. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said did not know if the staff would put it on a plastic bag and said nobody told her to not just put the CPAP mask on the table. 3. Review of Resident #144's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #144 was diagnosed with chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of Resident #144's Comprehensive MDS Assessment, dated 08/26/2024, reflected that Resident #144 was cognitively intact with a BIMS score of 13. Resident #144's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #144's Comprehensive Care Plan, dated 08/23/2024, reflected that the resident had chronic respiratory failure and COPD r/t smoking and one of the interventions was O2 via nasal prongs at 4 L/min. Review of Resident #144's Physician Order, dated 08/22/2024, reflected O2 at 4 L/Min Via NC. Observation on 09/04/2024 at 10:51 AM revealed Resident #144 was in her bed, sleeping. Resident #144 was on oxygen administration at 4 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. Resident #144 also had a nasal cannula at the back of her wheelchair connected to a portable oxygen tank. The nasal cannula was coiled on the left-hand grip of the wheelchair with the prongs of the nasal cannula hanging and was touching the left rear wheel of the wheelchair. The nasal cannula was not bagged and there was no bag at the back of the wheelchair. Observation and interview with LVN A on 09/04/2024 at 11:08 AM, LVN A stated the CPAP nasal pillow, and the nasal cannula should not be exposed nor touching anything because it could cause cross contamination and infection. He said the things mentioned should be bagged when not in use. LVN A went inside Resident #144's room and confirmed the resident's nasal cannula was not bagged and was touching the rear wheel of the wheelchair. LVN A disconnected the nasal cannula attached to the oxygen tank and threw it on the trash can. He said he was going to change it and put it on a bag. LVN A then went to Resident #29's room and confirmed the nasal cannula at the back of the wheelchair was not bagged. LVN A disconnected the nasal cannula, threw it, and said he was going to change it. LVN A went to Resident #142's room and saw the nasal pillow mask for CPAP on the table. LVN A placed the nasal pillow mask for CPAP inside the plastic bag. He said he noticed the nasal pillow mask for CPAP on the table when he checked on Resident #142 but forgot to put it in the plastic bag. Observation and interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated there should be an order for CPAP because it was a treatment being done to the resident. LVN A checked Resident #142's physician order and said the resident did not have an order for CPAP. He said he saw the CPAP and the suction machine but did not check if there was an order for it. He said the physician orders were important so the staff would know the medications or treatments needed by the resident. He said without the orders, the care needed by the residents would not be addressed. He said he will put the order on the system. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated the nasal cannula and the CPAP mask should be bagged when not in use to keep it clean. She said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. The DON said the staff, including her, were responsible in monitoring if the nasal cannula and CPAP mask were bagged when not in use. She said there should be an order for the use of the CPAP. She said that through the physician orders, the staff would know what medications or treatments were needed by the residents on the daily basis. She said without the orders, the staff would not know what to do. She opened Resident #142's profile and confirmed there was no order done for the CPAP. She continued that even though the staff knew what to do and what to give, there should still be an order before executing any treatment or administering any medication. She said the expectation was for the staff to be mindful in making sure that the nasal cannula and the CPAP mask of the residents would be bagged when not in use. She said another expectation was for all the treatment and medications of the residents had orders. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula and CPAP mask. She said she would also include the breathing mask used for nebulization. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection Preventionist of the facility. She said the nasal cannula and the CPAP mask should be bagged when not in use. She said if the nasal cannula and the CPAP mask were exposed and touching surfaces that were dirty, cross contamination and possible respiratory infections could occur. She said the expectation was for the staff to bag the nasal cannula and the CPAP mask when not in use. She said she would coordinate with the DON pertaining respiratory care. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection and all the orders would be in the system. He said since he was not a clinician, he would coordinate with the DON on how to go forward about the issue of respiratory care. Policy for Respiratory Care and Oxygen Administration requested on 09/05/2024 at 12:04 PM but was not provided. The Administrator stated on an email dated 09/05/2024 at 1:32 PM that they do not have specific policies for Respiratory Care, Oxygen Therapy, and Physician Order . The email stated, In the Implementation of services and procedures each facility will utilize the appropriate resources such as [NAME] manual, CDC control and prevention . The resources mentioned were also not provided prior to exit.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 2. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 3. The Executive Chef, Cook, and Culinary Aide failed to properly wear a hair and beard covering while breakfast was being prepared and served, in the kitchen area. 4. The facility failed to clean the food storage bins in the dry food storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on [DATE] from 08:50 AM to 09:05 AM in the facility's main kitchen reflected: The Executive Chef was observed in the kitchen area during breakfast service, not wearing a beard covering. His beard was approximately ,d+[DATE] inch in length. [NAME] V was observed in the kitchen area during breakfast service, wearing a baseball cap style hat and she had a large rolled up ponytail sticking out of the back of the cap with no hairnet, and she also had about at least two inches of hair sticking out of the bottom of the cap. Culinary Aide S was observed in the kitchen area during breakfast service, wearing a chef skull cap, and he also had at least an inch of hair sticking out of the bottom of the cap. The findings in the kitchen refrigerator included the following: One large tin tray containing a tin container of shredded cheese, a tincontainer of shredded carrots, a tin container of sliced cucumbers, and a tin container containing cherry tomatoes did not have stored date. One tin tray containing 6 tin containers of butter, sour cream, shredded cheese, and bacon bits did not have stored date. One large tin tray of asparagus did not have stored date. One large tin tray of broccoli did not have stored date. One large tin tray of sliced carrots did not have stored date. One large tin tray of stringed beans did not have stored date. One opened bag of spinach was unlabeled and did not have stored date. One large bowl of soup had a hole in the clear cover, exposing it to air contaminants, and it was unlabeled and did not have stored date. One large tin tray of greens did not have stored date. One large tin tray of sauce did not have stored date. One small tin container marked salsa, did not have stored date. One small tin container of gravy was unlabeled and did not have stored date. One large tray of raw lobster tails was unlabeled and did not have stored date. One tin tray of raw shrimp was unlabeled and did not have stored date. One large bag of peperoni did not have stored date. One large bag of meat was unlabeled did not have stored date. One bag of franks was sitting in a tin tray unlabeled and did not have stored date. One large tin tray of cooked pasta was unlabeled and did not have stored date. The findings in the kitchen freezer included the following: One large bag of frozen beef patties, in a zip locked bag, unsealed and open to air contaminants. One large bag of frozen yellow fruit, in a zip locked bag, unsealed and opem to air contaminants. Two large trays of frozen croissants were uncovered and open to air contaminants. Two large trays of muffins were uncovered and open to air contaminants. The findings in the dry food storage area included the following: Two large white bins containing sugar and flour had brownish and blackish dirt stains all over the outer portion of the bins and the inside openings of the bins. One large container of beans (unknown type) was uncovered and open to air contaminants. One large bag of sliced almonds was unsealed and open to air contaminants. In an interview on [DATE] at 11:28 AM, the Executive Chef and the Director of Culinary Services was advised of the concerns observed in the kitchen area. The EC stated everyone was responsible for labeling and dating the foods in the kitchen. He stated he had a utility person that was responsible for labeling and dating the food when it arrived from the trucks, and the cooks were responsible for dating the food cooked at the end of the day, before storing it. They were shown pictures of the concerns and the EC stated he had made the corrections observed. The EC stated that everyone was responsible for checking the foods in the storage areas to ensure that it was sealed properly. The EC stated they had deep cleaned the kitchen every Sunday after brunch. The EC stated they cleaned the dry storage area, including the storage bins daily. The EC was advised of himself and the two staff members being observed not wearing the proper head and face coverings, and he stated he had corrected the issue by ensuing everyone was wearing a hairnet. The EC the concerns observed in the kitchen could contaminate foods and make the residents sick. In an interview on [DATE] at 11:28 AM, the Administrator was advised that there were concerns observed in the kitchen. He mentioned that he had spoken with the EC. He advised that the issues could cause food contamination and would be resolved. Record Review of the Facility's policy on Food Storage dated [DATE], revealed [NAME] strives to prepare, distribute, and served food under sanitary conditions. Food and supplied will be stored according to the current standards of practice. 1. Dry food storage should be maintained in a clean and dry area free of contaminants. 2. Refrigerator storage Safe practices include: d. Labeling, dating, and monitoring food. All food handling and safety must comply with the Texas Food Establishment Rules (TFER) and the CMS and Texas Health and Human Services Commission (HHSC) Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE]. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD (6) Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints. TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Subpart B - Buildings and Facilities Sec. 110.35 Sanitary operations. 5) Sanitizing agents shall be adequate and safe under conditions of use. Any facility, procedure, or machine is acceptable for cleaning and sanitizing equipment and utensils if it is established that the facility, procedure, or machine will routinely render equipment and utensils clean and provide adequate cleaning and sanitizing treatment. (e) Storage and handling of cleaned portable equipment and utensils. Cleaned and sanitized portable equipment with food-contact surfaces and utensils should be stored in a location and manner that protects food-contact surfaces from contamination.

Based on interviews, and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #23) of 6 residents reviewed for Care Plan reassessment and revisions. The facility failed to ensure Resident #23's care plan included the resident receiving a dietary supplement (Ensure), twice daily based on a comprehensive nutritional assessment completed by the dietician on 08/16/24. This failure could place the resident at risk for excessive weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's MDS dated [DATE] revealed, she had a Brief Interview for BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no intervention indicating the nutritional supplement of Ensure to be included in the resident's assessment. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24 and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. she stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 not having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes, but she was advised that there were no progress notes indicating the resident refusing the Ensure shake and she also did not have any orders for the Ensure Shake. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any else. She stated the resident should have had orders for the Ensure shake and she should have had it care, planned by the dietician, which she will ensure that the Dietician had completed. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Resident Care Plan dated 04/16/2024, revealed The plan of care will identify problems areas and interventions needed to meet the needs of the resident. The interdisciplinary team is responsible for updating the care plan when there is significant change in the resident's condition.

Based on interviews and record reviews the facility failed to ensure that residents received additional nutrition resources, based on comprehensive assessments reviewed for 1 (Resident #23) of 4 residents reviewed for assisted nutrition. The facility failed to ensure Resident #23 received her Ensure shake twice daily, based on a dietary comprehensive assessment completed by the Dietitian on 08/16/24. This failure placed the resident at risk of unnecessary weight loss or slowing a diagnosis that causes weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's Quarterly MDS dated [DATE] revealed, she had a BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24, which was her first weigh-in since being admitted on [DATE]. and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. She stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected, she stated she was not sure if she had completed the submission process. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes. She was advised that there were no progress notes indicating the resident refusing the Ensure shake and she was advised that the resident did not have any orders for the Ensure Shake. The DON stated she meets with her Dietician to discuss residents with weight loss concerns monthly. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any other nutritional supplement else. She stated the resident should have had orders for the Ensure shake and she should have had it care planned. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Monitoring Weight Loss dated 04/16/2024, revealed The dietician will work with the nursing staff and other members of the interdisciplinary team to determine an appropriate plan of action which will be presented to the primary physician for review.

Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #142) of seven residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #142's Comprehensive MDS Assessment accurately reflected that Resident #142 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right side table. A nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was attached to the CPAP machine. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for was still on top of the resident's side table. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said the staff were reminding her the benefits of using the CPAP. In an interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated the residents should be properly assessed everyday so that the staff could provide the best care possible. He said assessment was done during, admission, when there was a fall, or there was a change in condition. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. She said the care plan of the residents would be based on the assessment of the resident. She said if a resident was using a CPAP, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. She said if the residents were not properly assessed, the proper care and needs would not be met. The DON checked the resident's profile and confirmed that Resident #142 was triggered for care plan. The DON said the expectation was that the residents were properly assessed not only during admission but every day to see if there were changes in condition, any refusal of care, or a resident acting different than usual. She said she would collaborate with the MDS Nurse to audit the MDS Assessments and make the appropriate changes. She said she would do an in-service about accurate assessment and to document the assessment. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated if a resident was using a CPAP, it should be reflected on the system to make sure the effectiveness of the resident's use of the CPAP. She added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the current condition of the resident should be reflected in the system to address the current needs of the resident. He said she would coordinate with the DON to evaluate the situation. Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible for doing the MDS Assessment. She said the CPAP would be triggered once it was on the physician order. The MDS Nurse logged on to her computer, checked the resident's profile, and confirmed that Resident #142 was not triggered for CPAP in the MDS assessment. She then checked the physician order and saw the physician order for CPAP that was just transcribed by LVN A on 09/06/2024 at 8:46 AM. She said since the CPAP already had a physician order, she would trigger it on the MDS. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in synched to provide a clear overview of the resident's current condition. She said she would make an audit to make sure the MDS would reflect the current condition of the residents. Record review of facility policy, New Admission Assessment Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Each new resident should be assessed in a timely manner.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #142) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #142 was care planned for CPAP. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea. Review of Resident #142's Quarterly MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that Resident #142 had a CPAP machine with a nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was on top of the resident's right-side table. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed the resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was still on top of the table. Resident #142 said she used the CPAP at night, and it helped her sleep better. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's problem lists, goals, and intervention. She said the care plan should be resident-centered and should show what specific care the resident needed. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the MDS Nurse to audit the care plans of the resident. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. She said without the care plan, the staff would not be synched on the care of the residents and their needs would not be addressed. She said the expectation was all the issue of the residents were care planned. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. He said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. He said he would coordinate with the DON to make sure all the residents were care planned. Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible in making the care plan. She said since the CPAP was not triggered in the MDS, Resident #142 did not have a care plan. She said after triggering it in the MDS, she would do the care plan to reflect the goals and the interventions. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff might overlook the interventions needed by the residents. Record review of facility's policy, Resident Plan Of Care Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard . develop a plan of care for each resident . Utilizing the assessment . team will develop a plan of care for each resident . 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident.

Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity and cared for in an environment that enhanced his or her quality of life for 2 (Resident #19 and #24) of 3 residents reviewed for dignity. The facility failed to treat Resident #19 and #24 with dignity and enhance their quality of life when the residents were not provided a privacy bag for their catheter bag (drainage bag outside of the body that collects urine). This failure placed residents at risk of not having their right to dignity maintained. Findings included: Review of Resident #19's face sheet, dated 08/16/24, reflected that Resident #19 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #19 was diagnosed with flaccid neurogenic bladder (the bladder did not function properly because of muscle and nerve damage). Review of Resident #19's Comprehensive Care Plan, dated 08/19/24, reflected Resident #19 had an indwelling catheter related to neurogenic bladder (bladder does not function properly because of nerve damage) and one of the interventions was catheter care each shift. Review of Resident #19's MDS Quarterly Assessment, dated 08/23/24, reflected Resident #19 had moderate cognitive impairment with a BIMS score of 08. The MDS Assessment indicated Resident #19 had an indwelling catheter. Review of Resident #19's Physician's Orders, dated 05/07/22, reflected a 22 French (French: unit used to indicate the size of the catheter) suprapubic catheter (device inserted into bladder to drain urine) for neurogenic bladder. Change monthly on the 7th and ending on the 8th of every month for neurogenic bladder. Observation on 09/04/24 at 09:55 AM revealed Resident #19 lying in bed. Resident #19's catheter bag was hanging on the side of the bed that faced the door. This was visible when standing in the resident's doorway. It was not touching the floor. The catheter bag was not in a privacy bag and the contents were visible. Observation on 09/05/24 at 11:07 AM revealed Resident #19 lying in bed. Resident #19's catheter bag was hanging on the side of his bed that faced the door. The catheter bag still did not have a privacy bag and contents were seen from the doorway of the resident's room. Resident #24 Review of Resident #24's face sheet, dated 08/15/24, reflected Resident #24 was a [AGE] year-old male admitted on [DATE]. Resident #24 was diagnosed with obstructive uropathy (blockage of urine flow). Review of Resident #24's Comprehensive Care Plan, dated 08/16/24, reflected Resident #24 had an indwelling catheter related to obstructive uropathy (blockage of urine flow) and one of the interventions was position catheter bag and tubing below the level of the bladder and away from entrance room door. Put bag in privacy cover. Review of Resident #24's MDS Comprehensive Assessment, dated 08/23/24, reflected Resident #24 had intact cognition with a BIMS score of 14. The MDS Comprehensive Assessment indicated Resident #24 had an indwelling catheter. Review of Resident #24's Physician's Orders, dated 08/15/24, reflected a 16 French (French: unit used to indicate the size of the catheter) suprapubic catheter (device inserted into bladder to drain urine). Change catheter drainage bag and tubing every 14 days and as needed. Observation on 09/04/24 at 10:22 AM revealed Resident #24 was sitting in the recliner in his room. Resident #24's catheter bag was hanging on the side of the bed that did not face the doorway. It was not touching the floor. The catheter bag was not seen from the doorway but was visible when standing in front of the resident. The catheter bag was not in a privacy bag and the contents were seen. Observation on 09/05/24 at 11:00 AM revealed Resident #24's catheter bag was still not in a privacy bag. Resident #24 was sitting in his recliner. The catheter bag was not visible from the doorway, but the contents of the bag were seen when standing in front of the resident. During an interview with CNA D on 09/05/24 at 11:22 AM, she stated that every resident with a catheter bag was supposed to have it covered with a privacy bag, even when the resident was in his or her room. During an interview with the Nurse Manager on 09/05/24 at 11:30 AM, she stated the resident's catheter bag should have been covered when in public view and using a privacy bag was a discreet way to do that. The Nurse Manager stated she did not know the facility policy for covering a catheter bag when the resident was in his or her room. During an interview with the ADON on 09/05/24 at 11:36 AM, she stated she did not know the facility policy, but that the catheter bag was normally in a privacy bag. The ADON stated she previously worked in hospitals and we didn't use privacy bags there. During an interview with LVN A on 09/05/24 at 01:15 PM, he stated all residents' catheter bag should be covered whether the resident was outside or inside the room. LVN A stated that was for the resident's dignity and so other people did not see what was in the catheter bag. LVN A said that the best practice was for the catheter bag to be in a privacy bag. During an interview with RN D 09/06/24 at 09:14 AM, she stated it was standard to have the resident's catheter bag in a privacy bag whether the resident was in or out of their room. Review of the facility policy Resident Rights, revised 04/16/2024, reflected Residents have the right to be treated with respect and dignity.

Based observations, interviews, 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 two (Resident #7 and Resident #145) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #145. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #7's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with reduced mobility and need for assistance with personal care. Review of Resident #7's Quarterly MDS Assessment, dated 06/11/2024, reflected that Resident #7 was cognitively intact with a BIMS score of 14. Resident #7's Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #7's Comprehensive Care Plan, dated 07/17/2024, reflected that Resident #7 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/04/24 at 11:18 AM revealed CNA C was about to transfer Resident #7 to her recliner using a sit-to-stand lift (a mechanical device designed to assist individuals in moving from a sitting position to a standing position and vice versa). CNA C entered the room with the sit-to-stand. CNA C put on a pair of gloves, she did not do hand hygiene before putting on the pair of gloves. CNA C assisted the resident into a sitting position at the side of the bed. CNA C then placed the protective strap around the resident's chest and hooked it on the sit-to-stand lift. CNA C raised Resident #7 into a standing position. Before transferring the resident to the recliner, CNA C pushed the sit-to-stand lift to the bathroom because the resident said she wanted to relieve herself. Before lowering the resident down to the toilet seat, CNA C pulled the resident's brief down and then lowered the resident onto the toilet seat. While the resident was relieving herself, the brief fell on the floor. CNA C took off the brief, threw it on the trash can, and then tied the plastic bag where she threw the brief. CNA C took off her gloves and put on a new pair of gloves, she did not sanitize her hands before putting on the new pair of gloves. CNA C then took a new brief from the sink that was just behind her, opened it, and placed it on the side of the sink. When the resident said that she was done, CNA C raised the resident up, pulled some wipes, and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the opened brief that she placed at the side of the sink that was behind her and put it on the resident. CNA C did not change her gloves after cleaning the resident's bottom. After putting on the brief, CNA C rolled the sit-to-stand lift and lowered the resident to her recliner. CNA C took off her gloves, threw it, and left the room. She did not wash her hands after incontinent care and the transfer. In an interview with CNA C on 09/05/2024 at 1:13 PM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. She said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs. She said she should have done hand hygiene and changed her gloves after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief. She said she was in a hurry and forgot to change her gloves before getting the new brief. 2. Review of Resident #145's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #145 was diagnosed with weakness and malaise (a general feeling of discomfort, illness, or uneasiness). Review of Resident #145's Comprehensive MDS Assessment, dated 08/20/2024, reflected Resident #145 had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Review of Resident #145's Comprehensive Care Plan, dated 08/21/2024, reflected Resident #145 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/05/2024 at 12:43 PM revealed CNA B was called by Resident #145's family member because the resident wanted to go to the bathroom. Resident #145 was already inside the bathroom and was waiting for CNA B. CNA B put on pair of gloves and assisted the resident to stand up from the wheelchair. CNA B did not do hand hygiene before putting on the gloves. CNA B instructed the resident to pivot, lowered the resident's pull-up, and then assisted the resident to sit down on the toilet seat. The pull-up was observed to be soiled. When the resident was done relieving herself, she told CNA B that she was done. CNA B assisted the resident to stand up, pulled some wipes, and cleaned the resident's bottom from middle to back. CNA B instructed the resident to sit down again so she could change the soiled pull-up. CNA B took off the resident's shoes followed by the resident's pants. CNA B then pulled the soiled pull-up and threw it on the trash can. CNA B then reached out to the sink and took a new pull-up from the side of the sink. She did not change her gloves after cleaning the resident's bottom, taking off the resident's shoes and soiled pull-up. CNA B then put on the new pull-up, followed by the resident's pants, and then the resident's shoes. In an interview with CNA B on 09/05/2024 at 12:56 PM, CNA B stated she should do hand hygiene before doing any care for a resident. She confirmed that she did not wash her hands nor sanitized her hands before putting on her gloves. She said, during incontinent care, the gloves should have been changed after touching the shoes and the soiled pull-up. She added that after touching anything that was dirty or soiled and before touching the clean items, hand hygiene should be done. She said hand hygiene should also be done in between changing of gloves. She said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. In an interview with LVN A 09/05/2024 at 1:47 PM, LVN A stated hand hygiene was the basic component in the prevention of cross contamination and development of infection. LVN said hand hygiene should be a part of the staff's routine, especially those that were providing direct care. He said staff should do hand hygiene before and after any care. He continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. He said hands should also be sanitized in between changing of gloves. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated that hand hygiene was the most effective way to prevent cross contamination and infection. She said, first, it should be done before and after every care. She continued that secondly, the gloves should be changed after touching any soiled items. She said for this case, the gloves should have been changed after touching the shoes and the soiled brief and pull-up. She said lastly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. She said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, and to do hand hygiene when changing the gloves. She said he will do an in-service and check-off about infection control and would monitor the issue personally. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection preventionist of the facility. She said hand hygiene was included in all the procedures of any care. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said not doing hand hygiene could cause of cross contamination and probable infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and when transitioning from a dirty area to a clean area. The ADON said they would do in-service about infection control. In an interview with the Administrator on 09/06/2024 at 8:39 AM the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, and not sanitizing the hands in between changing of gloves could contribute to cross contamination and probable infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he would collaborate with the DON to in-service the staff about infection control. Review of facility policy, Hand Hygiene Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection . can use alcohol-based hand sanitizer . hand hygiene should be performed . before and after client contact . after removing gloves . after touching contaminated items. Policy for Incontinent Care requested on 09/05/2024 at 12:04 PM and on 09/06/2024 at 10:22 PM but was not provided prior to exit.

Based on observation, interview and record review, the facility's Administrator and the Assistant Executive Director failed to use the facility's resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #1) of four residents reviewed for abuse and neglect. The Assistant Executive Director and the Administrator failed to implement the facility's Abuse and Neglect Policy when the AED failed to immediately report to the Administrator and the State survey and certification agency an allegation of abuse, neglect and/or mistreatment, failed to conduct a thorough investigation, and failed to protect the residents of the facility from further potential harm. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's 41 residents by placing them at risk for abuse and/or mistreatment by staff members. Findings included: Resident #1's closed clinical record reflected on the Face Sheet, dated [DATE], that the resident admitted on [DATE], and was [AGE] years of age at the time of the incidents. Interdisciplinary notes reflected that on [DATE], he was readmitted from a local hospital with [DIAGNOSES REDACTED]. The notes, dated [DATE] at 01:57 AM reflected he readmitted on Hospice services. The notes reflected that on [DATE], he expired of natural causes. Resident #1's MDS assessment dated [DATE] (prior to his change of condition and hospice services), reflected he required extensive assistance with ADLs (Activities of Daily Living) and he was cognitively intact. He had no history of behaviors. Resident #1's Coordination of Care Agreement, dated [DATE], confirmed hospice services were initiated on [DATE]. The admitted [DIAGNOSES REDACTED]. Resident #1's Interdisciplinary notes, dated [DATE], reflected he was placed on one-on-one (one staff was to be with the resident 24 hours a day, seven days a week) continuous care that day ([DATE]) due to becoming combative and refusing care. Further review of Resident #1's Interdisciplinary Notes revealed an entry by LVN B, dated [DATE] at 21:20 (9:20 PM), reflected Resident #1 requested to drink water. H-LVN A gave him a glass and water and he broke the glass and began attempting to hurt H-LVN A and facility staff. It noted while staff attempted to remove the broken glass, Resident #1 became combative, bit H-LVN A and she "slapped" him to let go of her arm. It noted he received an injection of [MEDICATION NAME]. It noted LVN-C and Resident #1's family were notified. During an interview with LVN B on [DATE] at 11:40 AM, she stated that on the evening of [DATE], Resident #1 broke a glass over his side rail, and he was using the broken glass to try to cut the staff that were in the room. She stated she was holding one of Resident #1's hands and H-LVN A was holding the other. LVN B stated she and H-LVN A were trying to get the broken glass from him and out of his bed. She stated with the assistance of H-LVN A, CNA D, CNA E and CNA M, they turned him on his side facing H-LVN A. She said Resident #1 bit LVN A on the arm. LVN B did not know which arm Resident #1 bit. She stated H-LVN A slapped Resident #1 in the face in order to get him to stop biting her. She stated LVN A then called out for help. During a subsequent interview with LVN B on [DATE] at 10:30 AM, she stated she heard LVN A yell, "You are hurting me." LVN B stated then she heard a "pop." Review of a written statement completed by LVN B on [DATE], provided additional information. She noted CNA E, who was also in the room at the time of the incident, came to her after the incident and reported that H-LVN A had slapped Resident #1 (during the incident). During an interview on with CNA E on [DATE] at 1:05 PM, she confirmed she was present during the incident of Resident #1 having broken glass in his hand. She stated that she did not see Resident #1 bite LVN A. CNA E stated Resident #1 was trying to bite, pinch and throw punches at the staff. She stated she did not see Resident #1 bite H-LVN A. She stated she heard a what sounded like a slap. She stated after the incident, she asked LVN B if she (LVN B) saw or heard H-LVN A slap Resident #1. She stated LVN B had told her, "Yes," that sometimes you have to do what you have to do (referring to LVN A slapping Resident #1) to get him to quit biting. She stated that LVN B was her charge nurse and she felt that by speaking about the incident with LVN B, it was the same as reporting the incident to her supervisor. CNA E added that she did not know if H-LVN A slapping Resident #1 was considered abuse. Review of a written statement completed by CNA E, dated [DATE], reiterated the above information and added that she (CNA E) and H-LVN A tried to get the broken glass from him. She held his right arm, and H-LVN A had his left arm, which was holding the broken glass. She heard a slap and then heard H-LVN A say, "I should not have done that." During an interview with LVN C on [DATE] at 12:10 PM, she stated she was the on-call supervisor on the evening of [DATE]. She stated LVN B called her and reported the incident that occurred with Resident #1. She said she called the hospice company and told them not to send LVN A back to the facility. LVN C said she called the AED and reported the incident involving Resident #1 and LVN A to her. During a subsequent interview with LVN C on [DATE] at 3:40 PM, she provided the following additional information: She said LVN B told her Resident #1 had done something to H-LVN A and she (H-LVN A) slapped him. LVN C stated she told LVN B to assess Resident #1, to escort LVN A out of the building and have someone sit with Resident #1 until a (replacement) nurse came to the facility. She said she then called the AED to let her know what happened. She said the AED told her she (the AED) would take care of it. During a confidential interview, it was said he/she visited the facility around mid-night and H-LVN A was still on duty. It was said he/she heard H-LVN A yell at Resident #1 to "Shut up." It was said, he/she told facility staff they did not want H-LVN A caring for Resident #1. During a subsequent confidential interview, it was said they were at the facility around 11:15 PM on [DATE] and could hear Resident #1 yelling for God to take him and then LVN A say, "Do you really think anybody can hear you? ...Do you think anybody is coming to help you?" It was said they believed Resident #1 was in pain and told H-LVN A he needed medication. It was said, H-LVN A told them Resident #1 would just spit out the medication. It was said they then asked that they obtain an order for [REDACTED]. During a subsequent interview with LVN C on [DATE] at 9:25 AM, she was asked why H-LVN A had been allowed to remain in the facility after the incident that occurred she said when she gave instructions to LVN B to have LVN A escorted out of the building, as far as she knew, her instructions were followed. Review of a written statement completed by LVN C, dated [DATE], noted that after the incident, at 8:30 PM, she received a phone call from LVN B telling her Resident #1 had broken a glass and tried to cut her and LVN A when they were trying to take the glass away. LVN B told her LVN A slapped Resident #1 because he was squeezing her hand. LVN C's statement reflected LVN C told LVN B to send LVN A home immediately and call the hospice agency for a replacement. She further wrote she also called the Assistant Executive Director (AED) to inform her of the incident. On [DATE], there was an added notation, which reflected the AED told her the hospice agency would be filing the abuse incident with the state. LVN C wrote she asked the AED if she needed to write a statement, and the AED told her, "No, the hospice company was taking care of it and we do not need to do anything else." Review of Resident #1's Interdisciplinary Notes reflected the nursing entries for [DATE] at 6:34 AM, were completed by LVN F. Interview with LVN F on [DATE] at 2:45 PM revealed when he reported to work on the evening of [DATE], he got report from LVN B about Resident #1's combative behavior earlier in the evening. LVN F stated that H-LVN A was still at Resident #1's bedside when his shift ended at 6:00 AM on [DATE]. Review of the timesheet provided by the hospice agency for LVN A revealed she was in the facility from 10:00 PM on [DATE] to 8:00 AM on [DATE]. During an interview with the Administrator on [DATE] at 12:20 PM, she stated she began employment on [DATE] with the facility. She stated she was still in her orientation period and the AED told her she was handling the incident involving LVN A and Resident #1. She said she told the AED since the incident involved their resident, they needed to do the investigation. She stated she now realizes she should have been more adamant the facility conduct an investigation. During an interview with AED on [DATE] at 2:16 PM, she stated LVN C called her on [DATE] around 10:00 PM and told her Resident #1 was having behaviors. She stated she told LVN C to provide comfort measures and she (the AED) would check on Resident #1 in the next morning. She stated she did not know LVN A was not escorted out of the building until she spoke with Resident #1's family member on [DATE]. Interview on [DATE] at 11:30 AM with the facility's only ADON (Interim DON) revealed she was out of town from [DATE] through [DATE]. She stated she was not informed of the incident until the surveyor entered the facility on [DATE]. The facility was provided with a written statement from LVN A via the hospice agency, which was signed and dated [DATE]. It reflected Resident #1 asked for a drink of water and LVN A gave him water in a glass goblet. Resident #1 threw the water on LVN A and then began trying to break the glass. "He then hit it against the half-bed rail where upon it shattered. Pieces landed on the bed and on the floor, I (LVN A) immediately went to the door and call (sic) for help. Several aides and the facility's LVN came to help me. ...After removing the larger pieces (of glass) from the bed we had to change the sheets, all the while the patient (Resident #1) was still very agitated and fighting. ...I was holding (Resident #1's) upper torso with my right arm across the front of him when he bit my right arm very hard. The sudden pain startled and surprised me so much that unintentionally popped him lightly on the face with my left hand... It was an unintended action that was done unconsciously on my part. For that I am sorry and apologize...." Attempts were made to contact LVN A, which were unsuccessful. Following surveyor intervention, the facility conducted an investigation. The Facility's Provider Investigation Report, dated [DATE], reflected, "(Resident #1) was allegedly slapped by (LVN A) after he bit her on the arm. ...Description of Assessment (Resident #1) was assessed by (LVN B). No injury noted. ...Provider Response (LVN B) called (the hospice agency) and requested another nurse to be sent out to care for (Resident #1). Facility staff were instructed to minimize stimulation in resident's room and only enter one at a time to prevent agitation. ...Investigation Summary (Resident #1) was slapped by (LVN A) per her own witness statement. (Resident #1) did not sustain any injuries from the incident. The facility informed (the hospice agency) that (LVN A) was no longer permitted to care for residents at the facility. ...Provider Action Taken Post-Investigation Administrative staff in-serviced by corporate executive director on reporting abuse and neglect. All staff in-serviced on Abuse and Neglect and Managing Challenging Behaviors. Notified (the hospice agency) that (LVN A) is no longer allowed to care for residents who reside at the facility." A written statement from LVN B dated [DATE] reflected on [DATE], Resident #1 was very combative and tried to hurt staff. LVN B's written statement reflected at some point, the resident hit a CNA (name not given) and tried to twist another staff's hand (name not given). Her statement reflected when she got to Resident #1's room, LVN A was holding/securing the resident's hand, because he was holding a broken glass and had broken glass all over his body and in his bed. LVN B wrote Resident #1 was turned to his left side. LVN A was on his left side holding the resident. LVN B wrote, at that time, the resident got hold of LVN A's arm and started to bite it. LVN B heard LVN A yell, "He's biting my arm. Let go of my arm." She then heard a "pop," but was focused on picking up the broken glass. She did not see LVN A slap Resident #1. After the "pop," the resident let go of LVN A's arm. She wrote that CNA E was also in the room, came to her and told her LVN A had slapped the resident. Review of the facility's Provider Investigation Report dated [DATE] revealed an Interview with LVN C, which reflected she received a phone call from LVN B, who told her Resident #1 had broken a glass and was trying to cut staff. LVN A slapped Resident #1 because the resident had a tight grip on her and he would not let go. LVN C's interview reflected she told LVN B to call the hospice company and send out a new nurse, preferably a male. LVN C said she then called the AED to inform her of the situation. Interview on [DATE] at 4:20 PM with CNA G revealed she worked the 10 PM to 6 AM shift. She stated when she reported to work on the evening of [DATE], she could hear Resident #1 screaming for help. She said she went into his room and saw LVN A sitting at bedside. She said she saw a television remote lying on the floor beside the bed and bent down to get it when LVN A told her, "Leave it alone and don't get near him." CNA G stated LVN A went on to describe the incident that occurred earlier in the evening when Resident #1 pulled her hair and bit her. CNA G stated LVN A told her she "had" to hit Resident #1. CNA G stated Resident #1 seemed confused. Resident #1 then said, "Get her out of here. She's trying to kill me." CNA G stated she did not report what LVN A said to her or what Resident #1 said to her (CNA G). CNA G said at 4:00 AM that morning she went in to assist another CNA with changing Resident #1, and LVN A was still there at bedside. The facility's current Abuse Policy, released on [DATE], reflected, "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse included The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." "...Immediate action will be taken to protect the resident from retaliation and harm." An IJ was identified on [DATE] at 5:40 PM and the ED, AED, Administrator and ADON were notified. A Plan of Removal for the IJ was requested at that time. Interview with the Executive Director on [DATE] at 9:30 AM revealed the AED and LVN B were suspended. The facility's Plan of Removal, dated [DATE] and accepted on [DATE], reflected the following: In-service counseling will be done on each community employee to include ongoing monitoring. Disciplinary Plan for Associates involved in abuse allegation: LVN B: Investigation underway, however it appears termination will occur no later than [DATE]. This nurse is a PRN staff member and has not been nor will be back in the building to provide care. CNA D: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA K: no disciplinary action, however she will be included in the facility in-service training. CNA E: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA E's one-on-one training was completed on [DATE] at 10:00 PM by the Corporate DON and the EDHS. Details of action taken for each employee who had knowledge of incident of alleged abuse: 1. The following management staff were in-serviced on [DATE] by the EDHS: a. AED b. ADON c. Administrator d. ED 2. The AED is currently away from the building until investigation is complete. 3. The plan is to re-orient all on-call managers regarding responsibility to follow-up and ensure resident safety when situations like this occur by [DATE]. a. Responsible Party: the DON b. Follow-up: Competency Evals to be administered by Corporate DON no later than [DATE]. 4. Management staff will be trained on proper investigations and reporting process by [DATE]. 5. Face-to-face monthly in-services (See Attachment C for all-staff Schedule) Annual In-service Calendar and materials covering all 12 required in-services to be maintained and monitored by the HR Director and the ADON. Responsible Parties: Director of HR and the ADON to ensure nurse check-offs and compliance with all regulations. Corporate DON will review to ensure completion Monthly staff tests of competencies Responsible Party: Administrator Follow-up: Corporate DON will review to ensure accuracy and completion. Immediate Quality of Life interviews with alert and oriented residents. This will begin on [DATE] and be completed by [DATE]. Responsible party: Social Worker Follow-up: Administrator will review upon completion and recommend any necessary follow-up actions. 6) The Medical Director was notified of the IJ on [DATE] at 12:15 PM. 7) Newly hired employees ( including Administrator and DON) will have weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 8) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: RN N, LVN B, LVN J, CNA D, CNA E, CNA I, CNA K, CNA L and CNA M were interviewed and said they were in-serviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. They verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse. They stated they felt comfortable reporting abuse or neglect and did not fear retaliation. The SW conducted quality of life rounds with the three remaining hospice residents and their families. The IJ was removed on [DATE]. The ED was notified on [DATE] at 10:00 AM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The facility's CMS 672, Resident Census and Conditions of Residents, dated [DATE] reflected a census of 41 residents.

Based on interview and record review, it was determined the facility failed to implement the facility's written policies and procedures that prohibit abuse, neglect and/or mistreatment of [REDACTED].#1) of four residents reviewed for abuse. LVN A slapped Resident #1 as a response to his biting her, which was witnessed and/or heard by three staff. LVN A was not removed from providing care to Resident #1 or removed from the facility, which resulted in LVN A continuing to abuse Resident #1. The facility failed to report an allegation of abuse, neglect, and/or mistreatment immediately to the Administrator or the Stage agency or thoroughly investigate and/or implement interventions to prevent this incident from reoccurring until surveyor intervention. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 PM While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's 41 residents by placing them at risk for abuse and/or mistreatment by staff members. Findings included: The facility's current Abuse Policy, released on [DATE], reflected, "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse included The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." "...Immediate action will be taken to protect the resident from retaliation and harm." Resident #1's closed clinical record reflected on the Face Sheet, dated [DATE], that the resident admitted on [DATE], and was [AGE] years of age at the time of the incidents. Interdisciplinary notes reflected that on [DATE], he was readmitted from a local hospital with [DIAGNOSES REDACTED]. The notes, dated [DATE] at 01:57 AM reflected he readmitted on Hospice services. The notes reflected that on [DATE], he expired of natural causes. Resident #1's MDS assessment dated [DATE] (prior to his change of condition and hospice services), reflected he required extensive assistance with ADLs (Activities of Daily Living) and he was cognitively intact. He had no history of behaviors. Resident #1's Coordination of Care Agreement, dated [DATE], confirmed hospice services were initiated on [DATE]. The admitted [DIAGNOSES REDACTED]. Resident #1's Interdisciplinary notes, dated [DATE], reflected he was placed on one-on-one (one staff was to be with the resident 24 hours a day, seven days a week) continuous care that day ([DATE]) due to becoming combative and refusing care. Further review of Resident #1's Interdisciplinary Notes revealed an entry by LVN B, dated [DATE] at 21:20 (9:20 PM), reflected Resident #1 requested to drink water. H-LVN A gave him a glass and water and he broke the glass and began attempting to hurt H-LVN A and facility staff. It noted while staff attempted to remove the broken glass, Resident #1 became combative, bit H-LVN A and she "slapped" him to let go of her arm. It noted he received an injection of [MEDICATION NAME]. It noted LVN-C and Resident #1's family were notified. During an interview with LVN B on [DATE] at 11:40 AM, she stated that on the evening of [DATE], Resident #1 broke a glass over his side rail, and he was using the broken glass to try to cut the staff that were in the room. She stated she was holding one of Resident #1's hands and H-LVN A was holding the other. LVN B stated she and H-LVN A were trying to get the broken glass from him and out of his bed. She stated with the assistance of H-LVN A, CNA D, CNA E and CNA M, they turned him on his side facing H-LVN A. She said Resident #1 bit LVN A on the arm. LVN B did not know which arm Resident #1 bit. She stated H-LVN A slapped Resident #1 in the face in order to get him to stop biting her. She stated LVN A then called out for help. During a subsequent interview with LVN B on [DATE] at 10:30 AM, she stated she heard LVN A yell, "You are hurting me." LVN B stated then she heard a "pop." Review of a written statement completed by LVN B on [DATE], provided additional information. She noted CNA E, who was also in the room at the time of the incident, came to her after the incident and reported that H-LVN A had slapped Resident #1 (during the incident). During an interview on with CNA E on [DATE] at 1:05 PM, she confirmed she was present during the incident of Resident #1 having broken glass in his hand. She stated that she did not see Resident #1 bite LVN A. CNA E stated Resident #1 was trying to bite, pinch and throw punches at the staff. She stated she did not see Resident #1 bite H-LVN A. She stated she heard a what sounded like a slap. She stated after the incident, she asked LVN B if she (LVN B) saw or heard H-LVN A slap Resident #1. She stated LVN B had told her, "Yes," that sometimes you have to do what you have to do (referring to LVN A slapping Resident #1) to get him to quit biting. She stated that LVN B was her charge nurse and she felt that by speaking about the incident with LVN B, it was the same as reporting the incident to her supervisor. CNA E added that she did not know if H-LVN A slapping Resident #1 was considered abuse. Review of a written statement completed by CNA E, dated [DATE], reiterated the above information and added that she (CNA E) and H-LVN A tried to get the broken glass from him. She held his right arm, and H-LVN A had his left arm, which was holding the broken glass. She heard a slap and then heard H-LVN A say, "I should not have done that." During an interview with LVN C on [DATE] at 12:10 PM, she stated she was the on-call supervisor on the evening of [DATE]. She stated LVN B called her and reported the incident that occurred with Resident #1. She said she called the hospice company and told them not to send LVN A back to the facility. LVN C said she called the AED and reported the incident involving Resident #1 and LVN A to her. During a subsequent interview with LVN C on [DATE] at 3:40 PM, she provided the following additional information: She said LVN B told her Resident #1 had done something to H-LVN A and she (H-LVN A) slapped him. LVN C stated she told LVN B to assess Resident #1, to escort LVN A out of the building and have someone sit with Resident #1 until a (replacement) nurse came to the facility. She said she then called the AED to let her know what happened. She said the AED told her she (the AED) would take care of it. During a confidential interview, it was said he/she visited the facility around mid-night and H-LVN A was still on duty. It was said he/she heard H-LVN A yell at Resident #1 to "Shut up." It was said, he/she told facility staff they did not want H-LVN A caring for Resident #1. During a subsequent confidential interview, it was said they were at the facility around 11:15 PM on [DATE] and could hear Resident #1 yelling for God to take him and then LVN A say, "Do you really think anybody can hear you? ...Do you think anybody is coming to help you?" It was said they believed Resident #1 was in pain and told H-LVN A he needed medication. It was said, H-LVN A told them Resident #1 would just spit out the medication. It was said they then asked that they obtain an order for [REDACTED]. During a subsequent interview with LVN C on [DATE] at 9:25 AM, she was asked why H-LVN A had been allowed to remain in the facility after the incident that occurred she said when she gave instructions to LVN B to have LVN A escorted out of the building, as far as she knew, her instructions were followed. Review of a written statement completed by LVN C, dated [DATE], noted that after the incident, at 8:30 PM, she received a phone call from LVN B telling her Resident #1 had broken a glass and tried to cut her and LVN A when they were trying to take the glass away. LVN B told her LVN A slapped Resident #1 because he was squeezing her hand. LVN C's statement reflected LVN C told LVN B to send LVN A home immediately and call the hospice agency for a replacement. She further wrote she also called the Assistant Executive Director (AED) to inform her of the incident. On [DATE], there was an added notation, which reflected the AED told her the hospice agency would be filing the abuse incident with the state. LVN C wrote she asked the AED if she needed to write a statement, and the AED told her, "No, the hospice company was taking care of it and we do not need to do anything else." Review of Resident #1's Interdisciplinary Notes reflected the nursing entries for [DATE] at 6:34 AM, were completed by LVN F. Interview with LVN F on [DATE] at 2:45 PM revealed when he reported to work on the evening of [DATE], he got report from LVN B about Resident #1's combative behavior earlier in the evening. LVN F stated that H-LVN A was still at Resident #1's bedside when his shift ended at 6:00 AM on [DATE]. Review of the timesheet provided by the hospice agency for LVN A revealed she was in the facility from 10:00 PM on [DATE] to 8:00 AM on [DATE]. During an interview with the Administrator on [DATE] at 12:20 PM, she stated she began employment on [DATE] with the facility. She stated she was still in her orientation period and the AED told her she was handling the incident involving LVN A and Resident #1. She said she told the AED since the incident involved their resident, they needed to do the investigation. She stated she now realizes she should have been more adamant the facility conduct an investigation. During an interview with AED on [DATE] at 2:16 PM, she stated LVN C called her on [DATE] around 10:00 PM and told her Resident #1 was having behaviors. She stated she told LVN C to provide comfort measures and she (the AED) would check on Resident #1 in the next morning. She stated she did not know LVN A was not escorted out of the building until she spoke with Resident #1's family member on [DATE]. Interview on [DATE] at 11:30 AM with the facility's only ADON (Interim DON) revealed she was out of town from [DATE] through [DATE]. She stated she was not informed of the incident until the surveyor entered the facility on [DATE]. The facility was provided with a written statement from LVN A via the hospice agency, which was signed and dated [DATE]. It reflected Resident #1 asked for a drink of water and LVN A gave him water in a glass goblet. Resident #1 threw the water on LVN A and then began trying to break the glass. "He then hit it against the half-bed rail where upon it shattered. Pieces landed on the bed and on the floor, I (LVN A) immediately went to the door and call (sic) for help. Several aides and the facility's LVN came to help me. ...After removing the larger pieces (of glass) from the bed we had to change the sheets, all the while the patient (Resident #1) was still very agitated and fighting. ...I was holding (Resident #1's) upper torso with my right arm across the front of him when he bit my right arm very hard. The sudden pain startled and surprised me so much that unintentionally popped him lightly on the face with my left hand... It was an unintended action that was done unconsciously on my part. For that I am sorry and apologize...." Attempts were made to contact LVN A, which were unsuccessful. Following surveyor intervention, the facility conducted an investigation. The Facility's Provider Investigation Report, dated [DATE], reflected, "(Resident #1) was allegedly slapped by (LVN A) after he bit her on the arm. ...Description of Assessment (Resident #1) was assessed by (LVN B). No injury noted. ...Provider Response (LVN B) called (the hospice agency) and requested another nurse to be sent out to care for (Resident #1). Facility staff were instructed to minimize stimulation in resident's room and only enter one at a time to prevent agitation. ...Investigation Summary (Resident #1) was slapped by (LVN A) per her own witness statement. (Resident #1) did not sustain any injuries from the incident. The facility informed (the hospice agency) that (LVN A) was no longer permitted to care for residents at the facility. ...Provider Action Taken Post-Investigation Administrative staff in-serviced by corporate executive director on reporting abuse and neglect. All staff in-serviced on Abuse and Neglect and Managing Challenging Behaviors. Notified (the hospice agency) that (LVN A) is no longer allowed to care for residents who reside at the facility." A written statement from LVN B dated [DATE] reflected on [DATE], Resident #1 was very combative and tried to hurt staff. LVN B's written statement reflected at some point, the resident hit a CNA (name not given) and tried to twist another staff's hand (name not given). Her statement reflected when she got to Resident #1's room, LVN A was holding/securing the resident's hand, because he was holding a broken glass and had broken glass all over his body and in his bed. LVN B wrote Resident #1 was turned to his left side. LVN A was on his left side holding the resident. LVN B wrote, at that time, the resident got hold of LVN A's arm and started to bite it. LVN B heard LVN A yell, "He's biting my arm. Let go of my arm." She then heard a "pop," but was focused on picking up the broken glass. She did not see LVN A slap Resident #1. After the "pop," the resident let go of LVN A's arm. She wrote that CNA E was also in the room, came to her and told her LVN A had slapped the resident. Review of the facility's Provider Investigation Report dated [DATE] revealed an Interview with LVN C, which reflected she received a phone call from LVN B, who told her Resident #1 had broken a glass and was trying to cut staff. LVN A slapped Resident #1 because the resident had a tight grip on her and he would not let go. LVN C's interview reflected she told LVN B to call the hospice company and send out a new nurse, preferably a male. LVN C said she then called the AED to inform her of the situation. Interview on [DATE] at 4:20 PM with CNA G revealed she worked the 10 PM to 6 AM shift. She stated when she reported to work on the evening of [DATE], she could hear Resident #1 screaming for help. She said she went into his room and saw LVN A sitting at bedside. She said she saw a television remote lying on the floor beside the bed and bent down to get it when LVN A told her, "Leave it alone and don't get near him." CNA G stated LVN A went on to describe the incident that occurred earlier in the evening when Resident #1 pulled her hair and bit her. CNA G stated LVN A told her she "had" to hit Resident #1. CNA G stated Resident #1 seemed confused. Resident #1 then said, "Get her out of here. She's trying to kill me." CNA G stated she did not report what LVN A said to her or what Resident #1 said to her (CNA G). CNA G said at 4:00 AM that morning she went in to assist another CNA with changing Resident #1, and LVN A was still there at bedside. An IJ was identified on [DATE] at 5:40 PM and the ED, AED, Administrator and ADON were notified. A Plan of Removal for the IJ was requested at that time. Interview with the Executive Director on [DATE] at 9:30 AM revealed the AED and LVN B were suspended. The facility's Plan of Removal, dated [DATE] and accepted on [DATE], reflected the following: In-service counseling will be done on each community employee to include ongoing monitoring. Disciplinary Plan for Associates involved in abuse allegation: LVN B: Investigation underway, however it appears termination will occur no later than [DATE]. This nurse is a PRN staff member and has not been nor will be back in the building to provide care. CNA D: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA K: no disciplinary action, however she will be included in the facility in-service training. CNA E: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA E's one-on-one training was completed on [DATE] at 10:00 PM by the Corporate DON and the EDHS. Details of action taken for each employee who had knowledge of incident of alleged abuse: 1. The following management staff were in-serviced on [DATE] by the EDHS: a. AED b. ADON c. Administrator d. ED 2. The AED is currently away from the building until investigation is complete. 3. The plan is to re-orient all on-call managers regarding responsibility to follow-up and ensure resident safety when situations like this occur by [DATE]. a. Responsible Party: the DON b. Follow-up: Competency Evals to be administered by Corporate DON no later than [DATE]. 4. Management staff will be trained on proper investigations and reporting process by [DATE]. 5. Face-to-face monthly in-services (See Attachment C for all-staff Schedule) Annual In-service Calendar and materials covering all 12 required in-services to be maintained and monitored by the HR Director and the ADON. Responsible Parties: Director of HR and the ADON to ensure nurse check-offs and compliance with all regulations. Corporate DON will review to ensure completion Monthly staff tests of competencies Responsible Party: Administrator Follow-up: Corporate DON will review to ensure accuracy and completion. Immediate Quality of Life interviews with alert and oriented residents. This will begin on [DATE] and be completed by [DATE]. Responsible party: Social Worker Follow-up: Administrator will review upon completion and recommend any necessary follow-up actions. 6) The Medical Director was notified of the IJ on [DATE] at 12:15 PM. 7) Newly hired employees ( including Administrator and DON) will have weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 8) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: RN N, LVN B, LVN J, CNA D, CNA E, CNA I, CNA K, CNA L and CNA M were interviewed and said they were in-serviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. They verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse. They stated they felt comfortable reporting abuse or neglect and did not fear retaliation. The SW conducted quality of life rounds with the three remaining hospice residents and their families. The IJ was removed on [DATE]. The ED was notified on [DATE] at 10:00 AM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The facility's CMS 672, Resident Census and Conditions of Residents, dated [DATE] reflected a census of 41 residents.

Based on interview and record review, it was determined the facility failed to implement its policies and procedures that prohibit abuse, neglect and/or mistreatment for one (Resident #1) of four residents reviewed for abuse. Hospice LVN A slapped hospice Resident #1 as a response to his biting her, which was witnessed and/or heard by three staff. LVN A was not removed from providing care to Resident #1 or removed from the facility, which resulted in LVN A continuing to abuse Resident #1. The facility failed to report an allegation of abuse, neglect, and/or mistreatment immediately to the Administrator or the Stage agency or thoroughly investigate and/or implement interventions to prevent this incident from reoccurring until surveyor intervention. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 PM While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's 41 residents by placing them at risk for abuse and/or mistreatment by staff members. Findings included: Resident #1's closed clinical record reflected on the Face Sheet, dated [DATE], that the resident admitted on [DATE], and was [AGE] years of age at the time of the incidents. Interdisciplinary notes reflected that on [DATE], he was readmitted from a local hospital with [DIAGNOSES REDACTED]. The notes, dated [DATE] at 01:57 AM reflected he readmitted on Hospice services. The notes reflected that on [DATE], he expired of natural causes. Resident #1's MDS assessment dated [DATE] (prior to his change of condition and hospice services), reflected he required extensive assistance with ADLs (Activities of Daily Living) and he was cognitively intact. He had no history of behaviors. Resident #1's Coordination of Care Agreement, dated [DATE], confirmed hospice services were initiated on [DATE]. The admitted [DIAGNOSES REDACTED]. Resident #1's Interdisciplinary notes, dated [DATE], reflected he was placed on one-on-one (one staff was to be with the resident 24 hours a day, seven days a week) continuous care that day ([DATE]) due to becoming combative and refusing care. Further review of Resident #1's Interdisciplinary Notes revealed an entry by LVN B, dated [DATE] at 21:20 (9:20 PM), reflected Resident #1 requested to drink water. H-LVN A gave him a glass and water and he broke the glass and began attempting to hurt H-LVN A and facility staff. It noted while staff attempted to remove the broken glass, Resident #1 became combative, bit H-LVN A and she "slapped" him to let go of her arm. It noted he received an injection of [MEDICATION NAME]. It noted LVN-C and Resident #1's family were notified. During an interview with LVN B on [DATE] at 11:40 AM, she stated that on the evening of [DATE], Resident #1 broke a glass over his side rail, and he was using the broken glass to try to cut the staff that were in the room. She stated she was holding one of Resident #1's hands and H-LVN A was holding the other. LVN B stated she and H-LVN A were trying to get the broken glass from him and out of his bed. She stated with the assistance of H-LVN A, CNA D, CNA E and CNA M, they turned him on his side facing H-LVN A. She said Resident #1 bit LVN A on the arm. LVN B did not know which arm Resident #1 bit. She stated H-LVN A slapped Resident #1 in the face in order to get him to stop biting her. She stated LVN A then called out for help. During a subsequent interview with LVN B on [DATE] at 10:30 AM, she stated she heard LVN A yell, "You are hurting me." LVN B stated then she heard a "pop." Review of a written statement completed by LVN B on [DATE], provided additional information. She noted CNA E, who was also in the room at the time of the incident, came to her after the incident and reported that H-LVN A had slapped Resident #1 (during the incident). During an interview on with CNA E on [DATE] at 1:05 PM, she confirmed she was present during the incident of Resident #1 having broken glass in his hand. She stated that she did not see Resident #1 bite LVN A. CNA E stated Resident #1 was trying to bite, pinch and throw punches at the staff. She stated she did not see Resident #1 bite H-LVN A. She stated she heard a what sounded like a slap. She stated after the incident, she asked LVN B if she (LVN B) saw or heard H-LVN A slap Resident #1. She stated LVN B had told her, "Yes," that sometimes you have to do what you have to do (referring to LVN A slapping Resident #1) to get him to quit biting. She stated that LVN B was her charge nurse and she felt that by speaking about the incident with LVN B, it was the same as reporting the incident to her supervisor. CNA E added that she did not know if H-LVN A slapping Resident #1 was considered abuse. Review of a written statement completed by CNA E, dated [DATE], reiterated the above information and added that she (CNA E) and H-LVN A tried to get the broken glass from him. She held his right arm, and H-LVN A had his left arm, which was holding the broken glass. She heard a slap and then heard H-LVN A say, "I should not have done that." During an interview with LVN C on [DATE] at 12:10 PM, she stated she was the on-call supervisor on the evening of [DATE]. She stated LVN B called her and reported the incident that occurred with Resident #1. She said she called the hospice company and told them not to send LVN A back to the facility. LVN C said she called the AED and reported the incident involving Resident #1 and LVN A to her. During a subsequent interview with LVN C on [DATE] at 3:40 PM, she provided the following additional information: She said LVN B told her Resident #1 had done something to H-LVN A and she (H-LVN A) slapped him. LVN C stated she told LVN B to assess Resident #1, to escort LVN A out of the building and have someone sit with Resident #1 until a (replacement) nurse came to the facility. She said she then called the AED to let her know what happened. She said the AED told her she (the AED) would take care of it. During a confidential interview, it was said he/she visited the facility around mid-night and H-LVN A was still on duty. It was said he/she heard H-LVN A yell at Resident #1 to "Shut up." It was said, he/she told facility staff they did not want H-LVN A caring for Resident #1. During a subsequent confidential interview, it was said they were at the facility around 11:15 PM on [DATE] and could hear Resident #1 yelling for God to take him and then LVN A say, "Do you really think anybody can hear you? ...Do you think anybody is coming to help you?" It was said they believed Resident #1 was in pain and told H-LVN A he needed medication. It was said, H-LVN A told them Resident #1 would just spit out the medication. It was said they then asked that they obtain an order for [REDACTED]. During a subsequent interview with LVN C on [DATE] at 9:25 AM, she was asked why H-LVN A had been allowed to remain in the facility after the incident that occurred she said when she gave instructions to LVN B to have LVN A escorted out of the building, as far as she knew, her instructions were followed. Review of a written statement completed by LVN C, dated [DATE], noted that after the incident, at 8:30 PM, she received a phone call from LVN B telling her Resident #1 had broken a glass and tried to cut her and LVN A when they were trying to take the glass away. LVN B told her LVN A slapped Resident #1 because he was squeezing her hand. LVN C's statement reflected LVN C told LVN B to send LVN A home immediately and call the hospice agency for a replacement. She further wrote she also called the Assistant Executive Director (AED) to inform her of the incident. On [DATE], there was an added notation, which reflected the AED told her the hospice agency would be filing the abuse incident with the state. LVN C wrote she asked the AED if she needed to write a statement, and the AED told her, "No, the hospice company was taking care of it and we do not need to do anything else." Review of Resident #1's Interdisciplinary Notes reflected the nursing entries for [DATE] at 6:34 AM, were completed by LVN F. Interview with LVN F on [DATE] at 2:45 PM revealed when he reported to work on the evening of [DATE], he got report from LVN B about Resident #1's combative behavior earlier in the evening. LVN F stated that H-LVN A was still at Resident #1's bedside when his shift ended at 6:00 AM on [DATE]. Review of the timesheet provided by the hospice agency for LVN A revealed she was in the facility from 10:00 PM on [DATE] to 8:00 AM on [DATE]. During an interview with the Administrator on [DATE] at 12:20 PM, she stated she began employment on [DATE] with the facility. She stated she was still in her orientation period and the AED told her she was handling the incident involving LVN A and Resident #1. She said she told the AED since the incident involved their resident, they needed to do the investigation. She stated she now realizes she should have been more adamant the facility conduct an investigation. During an interview with AED on [DATE] at 2:16 PM, she stated LVN C called her on [DATE] around 10:00 PM and told her Resident #1 was having behaviors. She stated she told LVN C to provide comfort measures and she (the AED) would check on Resident #1 in the next morning. She stated she did not know LVN A was not escorted out of the building until she spoke with Resident #1's family member on [DATE]. Interview on [DATE] at 11:30 AM with the facility's only ADON (Interim DON) revealed she was out of town from [DATE] through [DATE]. She stated she was not informed of the incident until the surveyor entered the facility on [DATE]. The facility was provided with a written statement from LVN A via the hospice agency, which was signed and dated [DATE]. It reflected Resident #1 asked for a drink of water and LVN A gave him water in a glass goblet. Resident #1 threw the water on LVN A and then began trying to break the glass. "He then hit it against the half-bed rail where upon it shattered. Pieces landed on the bed and on the floor, I (LVN A) immediately went to the door and call (sic) for help. Several aides and the facility's LVN came to help me. ...After removing the larger pieces (of glass) from the bed we had to change the sheets, all the while the patient (Resident #1) was still very agitated and fighting. ...I was holding (Resident #1's) upper torso with my right arm across the front of him when he bit my right arm very hard. The sudden pain startled and surprised me so much that unintentionally popped him lightly on the face with my left hand... It was an unintended action that was done unconsciously on my part. For that I am sorry and apologize...." Attempts were made to contact LVN A, which were unsuccessful. Following surveyor intervention, the facility conducted an investigation. The Facility's Provider Investigation Report, dated [DATE], reflected, "(Resident #1) was allegedly slapped by (LVN A) after he bit her on the arm. ...Description of Assessment (Resident #1) was assessed by (LVN B). No injury noted. ...Provider Response (LVN B) called (the hospice agency) and requested another nurse to be sent out to care for (Resident #1). Facility staff were instructed to minimize stimulation in resident's room and only enter one at a time to prevent agitation. ...Investigation Summary (Resident #1) was slapped by (LVN A) per her own witness statement. (Resident #1) did not sustain any injuries from the incident. The facility informed (the hospice agency) that (LVN A) was no longer permitted to care for residents at the facility. ...Provider Action Taken Post-Investigation Administrative staff in-serviced by corporate executive director on reporting abuse and neglect. All staff in-serviced on Abuse and Neglect and Managing Challenging Behaviors. Notified (the hospice agency) that (LVN A) is no longer allowed to care for residents who reside at the facility." A written statement from LVN B dated [DATE] reflected on [DATE], Resident #1 was very combative and tried to hurt staff. LVN B's written statement reflected at some point, the resident hit a CNA (name not given) and tried to twist another staff's hand (name not given). Her statement reflected when she got to Resident #1's room, LVN A was holding/securing the resident's hand, because he was holding a broken glass and had broken glass all over his body and in his bed. LVN B wrote Resident #1 was turned to his left side. LVN A was on his left side holding the resident. LVN B wrote, at that time, the resident got hold of LVN A's arm and started to bite it. LVN B heard LVN A yell, "He's biting my arm. Let go of my arm." She then heard a "pop," but was focused on picking up the broken glass. She did not see LVN A slap Resident #1. After the "pop," the resident let go of LVN A's arm. She wrote that CNA E was also in the room, came to her and told her LVN A had slapped the resident. Review of the facility's Provider Investigation Report dated [DATE] revealed an Interview with LVN C, which reflected she received a phone call from LVN B, who told her Resident #1 had broken a glass and was trying to cut staff. LVN A slapped Resident #1 because the resident had a tight grip on her and he would not let go. LVN C's interview reflected she told LVN B to call the hospice company and send out a new nurse, preferably a male. LVN C said she then called the AED to inform her of the situation. Interview on [DATE] at 4:20 PM with CNA G revealed she worked the 10 PM to 6 AM shift. She stated when she reported to work on the evening of [DATE], she could hear Resident #1 screaming for help. She said she went into his room and saw LVN A sitting at bedside. She said she saw a television remote lying on the floor beside the bed and bent down to get it when LVN A told her, "Leave it alone and don't get near him." CNA G stated LVN A went on to describe the incident that occurred earlier in the evening when Resident #1 pulled her hair and bit her. CNA G stated LVN A told her she "had" to hit Resident #1. CNA G stated Resident #1 seemed confused. Resident #1 then said, "Get her out of here. She's trying to kill me." CNA G stated she did not report what LVN A said to her or what Resident #1 said to her (CNA G). CNA G said at 4:00 AM that morning she went in to assist another CNA with changing Resident #1, and LVN A was still there at bedside. The facility's current Abuse Policy, released on [DATE], reflected, "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse included The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." "...Immediate action will be taken to protect the resident from retaliation and harm." An IJ was identified on [DATE] at 5:40 PM and the ED, AED, Administrator and ADON were notified. A Plan of Removal for the IJ was requested at that time. Interview with the Executive Director on [DATE] at 9:30 AM revealed the AED and LVN B were suspended. The facility's Plan of Removal, dated [DATE] and accepted on [DATE], reflected the following: In-service counseling will be done on each community employee to include ongoing monitoring. Disciplinary Plan for Associates involved in abuse allegation: LVN B: Investigation underway, however it appears termination will occur no later than [DATE]. This nurse is a PRN staff member and has not been nor will be back in the building to provide care. CNA D: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA K: no disciplinary action, however she will be included in the facility in-service training. CNA E: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA E's one-on-one training was completed on [DATE] at 10:00 PM by the Corporate DON and the EDHS. Details of action taken for each employee who had knowledge of incident of alleged abuse: 1. The following management staff were in-serviced on [DATE] by the EDHS: a. AED b. ADON c. Administrator d. ED 2. The AED is currently away from the building until investigation is complete. 3. The plan is to re-orient all on-call managers regarding responsibility to follow-up and ensure resident safety when situations like this occur by [DATE]. a. Responsible Party: the DON b. Follow-up: Competency Evals to be administered by Corporate DON no later than [DATE]. 4. Management staff will be trained on proper investigations and reporting process by [DATE]. 5. Face-to-face monthly in-services (See Attachment C for all-staff Schedule) Annual In-service Calendar and materials covering all 12 required in-services to be maintained and monitored by the HR Director and the ADON. Responsible Parties: Director of HR and the ADON to ensure nurse check-offs and compliance with all regulations. Corporate DON will review to ensure completion Monthly staff tests of competencies Responsible Party: Administrator Follow-up: Corporate DON will review to ensure accuracy and completion. Immediate Quality of Life interviews with alert and oriented residents. This will begin on [DATE] and be completed by [DATE]. Responsible party: Social Worker Follow-up: Administrator will review upon completion and recommend any necessary follow-up actions. 6) The Medical Director was notified of the IJ on [DATE] at 12:15 PM. 7) Newly hired employees ( including Administrator and DON) will have weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 8) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: RN N, LVN B, LVN J, CNA D, CNA E, CNA I, CNA K, CNA L and CNA M were interviewed and said they were in-serviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. They verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse. They stated they felt comfortable reporting abuse or neglect and did not fear retaliation. The SW conducted quality of life rounds with the three remaining hospice residents and their families. The IJ was removed on [DATE]. The ED was notified on [DATE] at 10:00 AM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The facility's CMS 672, Resident Census and Conditions of Residents, dated [DATE] reflected a census of 41 residents.

Based on interview and record review, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, and/or mistreatment were immediately reported to the Administrator and the State survey and certification agency, have evidence the alleged violations were thoroughly investigated and protected residents from further abuse, neglect and/or mistreatment after the alleged incident occurred for one (Resident #1) of four residents reviewed for abuse. 1. An allegation of abuse, neglect and/or mistreatment was not immediately reported to the Administrator or the State survey and certification agency. 2. An investigation into an allegation of abuse, neglect and/or mistreatment from [DATE] was not started until surveyor intervention on [DATE]. 3. The facility residents and Resident #1 were not protected from further abuse, neglect and/or mistreatment following the alleged incident of abuse, neglect and/or mistreatment against Resident #1. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's 41 residents by placing them at risk for abuse, neglect and/or mistreatment. Findings included: Resident #1's closed clinical record reflected on the Face Sheet, dated [DATE], that the resident admitted on [DATE], and was [AGE] years of age at the time of the incidents. Interdisciplinary notes reflected that on [DATE], he was readmitted from a local hospital with [DIAGNOSES REDACTED]. The notes, dated [DATE] at 01:57 AM reflected he readmitted on Hospice services. The notes reflected that on [DATE], he expired of natural causes. Resident #1's MDS assessment dated [DATE] (prior to his change of condition and hospice services), reflected he required extensive assistance with ADLs (Activities of Daily Living) and he was cognitively intact. He had no history of behaviors. Resident #1's Coordination of Care Agreement, dated [DATE], confirmed hospice services were initiated on [DATE]. The admitted [DIAGNOSES REDACTED]. Resident #1's Interdisciplinary notes, dated [DATE], reflected he was placed on one-on-one (one staff was to be with the resident 24 hours a day, seven days a week) continuous care that day ([DATE]) due to becoming combative and refusing care. Further review of Resident #1's Interdisciplinary Notes revealed an entry by LVN B, dated [DATE] at 21:20 (9:20 PM), reflected Resident #1 requested to drink water. H-LVN A gave him a glass and water and he broke the glass and began attempting to hurt H-LVN A and facility staff. It noted while staff attempted to remove the broken glass, Resident #1 became combative, bit H-LVN A and she "slapped" him to let go of her arm. It noted he received an injection of [MEDICATION NAME]. It noted LVN-C and Resident #1's family were notified. During an interview with LVN B on [DATE] at 11:40 AM, she stated that on the evening of [DATE], Resident #1 broke a glass over his side rail, and he was using the broken glass to try to cut the staff that were in the room. She stated she was holding one of Resident #1's hands and H-LVN A was holding the other. LVN B stated she and H-LVN A were trying to get the broken glass from him and out of his bed. She stated with the assistance of H-LVN A, CNA D, CNA E and CNA M, they turned him on his side facing H-LVN A. She said Resident #1 bit LVN A on the arm. LVN B did not know which arm Resident #1 bit. She stated H-LVN A slapped Resident #1 in the face in order to get him to stop biting her. She stated LVN A then called out for help. During a subsequent interview with LVN B on [DATE] at 10:30 AM, she stated she heard LVN A yell, "You are hurting me." LVN B stated then she heard a "pop." Review of a written statement completed by LVN B on [DATE], provided additional information. She noted CNA E, who was also in the room at the time of the incident, came to her after the incident and reported that H-LVN A had slapped Resident #1 (during the incident). During an interview on with CNA E on [DATE] at 1:05 PM, she confirmed she was present during the incident of Resident #1 having broken glass in his hand. She stated that she did not see Resident #1 bite LVN A. CNA E stated Resident #1 was trying to bite, pinch and throw punches at the staff. She stated she did not see Resident #1 bite H-LVN A. She stated she heard a what sounded like a slap. She stated after the incident, she asked LVN B if she (LVN B) saw or heard H-LVN A slap Resident #1. She stated LVN B had told her, "Yes," that sometimes you have to do what you have to do (referring to LVN A slapping Resident #1) to get him to quit biting. She stated that LVN B was her charge nurse and she felt that by speaking about the incident with LVN B, it was the same as reporting the incident to her supervisor. CNA E added that she did not know if H-LVN A slapping Resident #1 was considered abuse. Review of a written statement completed by CNA E, dated [DATE], reiterated the above information and added that she (CNA E) and H-LVN A tried to get the broken glass from him. She held his right arm, and H-LVN A had his left arm, which was holding the broken glass. She heard a slap and then heard H-LVN A say, "I should not have done that." During an interview with LVN C on [DATE] at 12:10 PM, she stated she was the on-call supervisor on the evening of [DATE]. She stated LVN B called her and reported the incident that occurred with Resident #1. She said she called the hospice company and told them not to send LVN A back to the facility. LVN C said she called the AED and reported the incident involving Resident #1 and LVN A to her. During a subsequent interview with LVN C on [DATE] at 3:40 PM, she provided the following additional information: She said LVN B told her Resident #1 had done something to H-LVN A and she (H-LVN A) slapped him. LVN C stated she told LVN B to assess Resident #1, to escort LVN A out of the building and have someone sit with Resident #1 until a (replacement) nurse came to the facility. She said she then called the AED to let her know what happened. She said the AED told her she (the AED) would take care of it. During a confidential interview, it was said he/she visited the facility around mid-night and H-LVN A was still on duty. It was said he/she heard H-LVN A yell at Resident #1 to "Shut up." It was said, he/she told facility staff they did not want H-LVN A caring for Resident #1. During a subsequent confidential interview, it was said they were at the facility around 11:15 PM on [DATE] and could hear Resident #1 yelling for God to take him and then LVN A say, "Do you really think anybody can hear you? ...Do you think anybody is coming to help you?" It was said they believed Resident #1 was in pain and told H-LVN A he needed medication. It was said, H-LVN A told them Resident #1 would just spit out the medication. It was said they then asked that they obtain an order for [REDACTED]. During a subsequent interview with LVN C on [DATE] at 9:25 AM, she was asked why H-LVN A had been allowed to remain in the facility after the incident that occurred she said when she gave instructions to LVN B to have LVN A escorted out of the building, as far as she knew, her instructions were followed. Review of a written statement completed by LVN C, dated [DATE], noted that after the incident, at 8:30 PM, she received a phone call from LVN B telling her Resident #1 had broken a glass and tried to cut her and LVN A when they were trying to take the glass away. LVN B told her LVN A slapped Resident #1 because he was squeezing her hand. LVN C's statement reflected LVN C told LVN B to send LVN A home immediately and call the hospice agency for a replacement. She further wrote she also called the Assistant Executive Director (AED) to inform her of the incident. On [DATE], there was an added notation, which reflected the AED told her the hospice agency would be filing the abuse incident with the state. LVN C wrote she asked the AED if she needed to write a statement, and the AED told her, "No, the hospice company was taking care of it and we do not need to do anything else." Review of Resident #1's Interdisciplinary Notes reflected the nursing entries for [DATE] at 6:34 AM, were completed by LVN F. Interview with LVN F on [DATE] at 2:45 PM revealed when he reported to work on the evening of [DATE], he got report from LVN B about Resident #1's combative behavior earlier in the evening. LVN F stated that H-LVN A was still at Resident #1's bedside when his shift ended at 6:00 AM on [DATE]. Review of the timesheet provided by the hospice agency for LVN A revealed she was in the facility from 10:00 PM on [DATE] to 8:00 AM on [DATE]. During an interview with the Administrator on [DATE] at 12:20 PM, she stated she began employment on [DATE] with the facility. She stated she was still in her orientation period and the AED told her she was handling the incident involving LVN A and Resident #1. She said she told the AED since the incident involved their resident, they needed to do the investigation. She stated she now realizes she should have been more adamant the facility conduct an investigation. During an interview with AED on [DATE] at 2:16 PM, she stated LVN C called her on [DATE] around 10:00 PM and told her Resident #1 was having behaviors. She stated she told LVN C to provide comfort measures and she (the AED) would check on Resident #1 in the next morning. She stated she did not know LVN A was not escorted out of the building until she spoke with Resident #1's family member on [DATE]. Interview on [DATE] at 11:30 AM with the facility's only ADON (Interim DON) revealed she was out of town from [DATE] through [DATE]. She stated she was not informed of the incident until the surveyor entered the facility on [DATE]. The facility was provided with a written statement from LVN A via the hospice agency, which was signed and dated [DATE]. It reflected Resident #1 asked for a drink of water and LVN A gave him water in a glass goblet. Resident #1 threw the water on LVN A and then began trying to break the glass. "He then hit it against the half-bed rail where upon it shattered. Pieces landed on the bed and on the floor, I (LVN A) immediately went to the door and call (sic) for help. Several aides and the facility's LVN came to help me. ...After removing the larger pieces (of glass) from the bed we had to change the sheets, all the while the patient (Resident #1) was still very agitated and fighting. ...I was holding (Resident #1's) upper torso with my right arm across the front of him when he bit my right arm very hard. The sudden pain startled and surprised me so much that unintentionally popped him lightly on the face with my left hand... It was an unintended action that was done unconsciously on my part. For that I am sorry and apologize...." Attempts were made to contact LVN A, which were unsuccessful. Following surveyor intervention, the facility conducted an investigation. The Facility's Provider Investigation Report, dated [DATE], reflected, "(Resident #1) was allegedly slapped by (LVN A) after he bit her on the arm. ...Description of Assessment (Resident #1) was assessed by (LVN B). No injury noted. ...Provider Response (LVN B) called (the hospice agency) and requested another nurse to be sent out to care for (Resident #1). Facility staff were instructed to minimize stimulation in resident's room and only enter one at a time to prevent agitation. ...Investigation Summary (Resident #1) was slapped by (LVN A) per her own witness statement. (Resident #1) did not sustain any injuries from the incident. The facility informed (the hospice agency) that (LVN A) was no longer permitted to care for residents at the facility. ...Provider Action Taken Post-Investigation Administrative staff in-serviced by corporate executive director on reporting abuse and neglect. All staff in-serviced on Abuse and Neglect and Managing Challenging Behaviors. Notified (the hospice agency) that (LVN A) is no longer allowed to care for residents who reside at the facility." A written statement from LVN B dated [DATE] reflected on [DATE], Resident #1 was very combative and tried to hurt staff. LVN B's written statement reflected at some point, the resident hit a CNA (name not given) and tried to twist another staff's hand (name not given). Her statement reflected when she got to Resident #1's room, LVN A was holding/securing the resident's hand, because he was holding a broken glass and had broken glass all over his body and in his bed. LVN B wrote Resident #1 was turned to his left side. LVN A was on his left side holding the resident. LVN B wrote, at that time, the resident got hold of LVN A's arm and started to bite it. LVN B heard LVN A yell, "He's biting my arm. Let go of my arm." She then heard a "pop," but was focused on picking up the broken glass. She did not see LVN A slap Resident #1. After the "pop," the resident let go of LVN A's arm. She wrote that CNA E was also in the room, came to her and told her LVN A had slapped the resident. Review of the facility's Provider Investigation Report dated [DATE] revealed an Interview with LVN C, which reflected she received a phone call from LVN B, who told her Resident #1 had broken a glass and was trying to cut staff. LVN A slapped Resident #1 because the resident had a tight grip on her and he would not let go. LVN C's interview reflected she told LVN B to call the hospice company and send out a new nurse, preferably a male. LVN C said she then called the AED to inform her of the situation. Interview on [DATE] at 4:20 PM with CNA G revealed she worked the 10 PM to 6 AM shift. She stated when she reported to work on the evening of [DATE], she could hear Resident #1 screaming for help. She said she went into his room and saw LVN A sitting at bedside. She said she saw a television remote lying on the floor beside the bed and bent down to get it when LVN A told her, "Leave it alone and don't get near him." CNA G stated LVN A went on to describe the incident that occurred earlier in the evening when Resident #1 pulled her hair and bit her. CNA G stated LVN A told her she "had" to hit Resident #1. CNA G stated Resident #1 seemed confused. Resident #1 then said, "Get her out of here. She's trying to kill me." CNA G stated she did not report what LVN A said to her or what Resident #1 said to her (CNA G). CNA G said at 4:00 AM that morning she went in to assist another CNA with changing Resident #1, and LVN A was still there at bedside. The facility's current Abuse Policy, released on [DATE], reflected, "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse included The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." "...Immediate action will be taken to protect the resident from retaliation and harm." An IJ was identified on [DATE] at 5:40 PM and the ED, AED, Administrator and ADON were notified. A Plan of Removal for the IJ was requested at that time. Interview with the Executive Director on [DATE] at 9:30 AM revealed the AED and LVN B were suspended. The facility's Plan of Removal, dated [DATE] and accepted on [DATE], reflected the following: In-service counseling will be done on each community employee to include ongoing monitoring. Disciplinary Plan for Associates involved in abuse allegation: LVN B: Investigation underway, however it appears termination will occur no later than [DATE]. This nurse is a PRN staff member and has not been nor will be back in the building to provide care. CNA D: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA K: no disciplinary action, however she will be included in the facility in-service training. CNA E: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA E's one-on-one training was completed on [DATE] at 10:00 PM by the Corporate DON and the EDHS. Details of action taken for each employee who had knowledge of incident of alleged abuse: 1. The following management staff were in-serviced on [DATE] by the EDHS: a. AED b. ADON c. Administrator d. ED 2. The AED is currently away from the building until investigation is complete. 3. The plan is to re-orient all on-call managers regarding responsibility to follow-up and ensure resident safety when situations like this occur by [DATE]. a. Responsible Party: the DON b. Follow-up: Competency Evals to be administered by Corporate DON no later than [DATE]. 4. Management staff will be trained on proper investigations and reporting process by [DATE]. 5. Face-to-face monthly in-services (See Attachment C for all-staff Schedule) Annual In-service Calendar and materials covering all 12 required in-services to be maintained and monitored by the HR Director and the ADON. Responsible Parties: Director of HR and the ADON to ensure nurse check-offs and compliance with all regulations. Corporate DON will review to ensure completion Monthly staff tests of competencies Responsible Party: Administrator Follow-up: Corporate DON will review to ensure accuracy and completion. Immediate Quality of Life interviews with alert and oriented residents. This will begin on [DATE] and be completed by [DATE]. Responsible party: Social Worker Follow-up: Administrator will review upon completion and recommend any necessary follow-up actions. 6) The Medical Director was notified of the IJ on [DATE] at 12:15 PM. 7) Newly hired employees ( including Administrator and DON) will have weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 8) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: RN N, LVN B, LVN J, CNA D, CNA E, CNA I, CNA K, CNA L and CNA M were interviewed and said they were in-serviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. They verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse. They stated they felt comfortable reporting abuse or neglect and did not fear retaliation. The SW conducted quality of life rounds with the three remaining hospice residents and their families. The IJ was removed on [DATE]. The ED was notified on [DATE] at 10:00 AM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The facility's CMS 672, Resident Census and Conditions of Residents, dated [DATE] reflected a census of 41 residents.

Based on interview and record review, the facility failed to ensure each resident had the right to be free from verbal and physical abuse for one (Resident #1) of four residents reviewed for abuse. H-LVN A slapped hospice Resident #1 in response to him biting her. Facility staff failed to intercede and allowed H-LVN A to continue working with Resident #1. As a result, a second incident of abuse occurred. That same night, H-LVN A told Resident #1 to "shut up," and made a comment to include "...do you think anybody can hear you? ...Do you think anybody is coming to help you?" An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect the facility's 41 residents by placing them at risk for abuse and/or mistreatment by staff members or agency staff. Findings included: Resident #1's closed clinical record reflected on the Face Sheet, dated [DATE], that the resident admitted on [DATE], and was a [AGE] years of age at the time of the incidents. Interdisciplinary notes reflected that on [DATE], he was readmitted from a local hospital with [DIAGNOSES REDACTED]. The notes, dated [DATE] at 1:57 AM, reflected he readmitted on Hospice services. The notes reflected that on [DATE], he expired of natural causes. Resident #1's MDS assessment, dated [DATE] (prior to his change of condition and hospice services), reflected he required extensive assistance with ADLs (Activities of Daily Living) and he was cognitively intact. He had no history of behaviors. Resident #1's Coordination of Care Agreement, dated [DATE], confirmed hospice services were initiated on [DATE]. The admitted [DIAGNOSES REDACTED]. Resident #1's Interdisciplinary notes, dated [DATE], reflected he was placed on one-on-one (one staff was to be with the resident 24 hours a day, seven days a week) continuous care that day ([DATE]) due to becoming combative and refusing care. Further review of Resident #1's Interdisciplinary Notes revealed an entry by LVN B, dated [DATE] at 21:20 (9:20 PM), reflected Resident #1 requested to drink water. H-LVN A gave him a glass and water and he broke the glass and began attempting to hurt H-LVN A and facility staff. It noted while staff attempted to remove the broken glass, Resident #1 became combative, bit H-LVN A and she "slapped" him to let go of her arm. It noted he received an injection of [MEDICATION NAME] (an antipsychotic). It noted LVN C and Resident #1's family were notified. During an interview with LVN B on [DATE] at 11:40 AM, she stated that on the evening of [DATE], Resident #1 broke a glass over his side rail, and he was using the broken glass to try to cut the staff that were in the room. She stated she was holding one of Resident #1's hands and H-LVN A was holding the other. LVN B stated she and H-LVN A were trying to get the broken glass from him and out of his bed. She stated with the assistance of H-LVN A, CNA D, CNA E and CNA M, they turned him on his side facing H-LVN A. She said Resident #1 bit LVN A on the arm. LVN B did not know which arm Resident #1 bit. She stated H-LVN A slapped Resident #1 in the face in order to get him to stop biting her. She stated H-LVN A then called out for help. During a subsequent interview with LVN B on [DATE] at 10:30 AM, she stated she heard H-LVN A yell, "You are hurting me." LVN B stated then she heard a "pop." Review of a written statement completed by LVN B on [DATE], provided additional information. She noted CNA E, who was also in the room at the time of the incident, came to her after the incident and reported that H-LVN A had slapped Resident #1 (during the incident). During an interview on with CNA E on [DATE] at 1:05 PM, she confirmed she was present during the incident of Resident #1 having broken glass in his hand. She stated that she did not see Resident #1 bite H-LVN A. CNA E stated Resident #1 was trying to bite, pinch and throw punches at the staff. She stated she did not see Resident #1 bite H-LVN A. She stated she heard a what sounded like a slap. She stated after the incident, she asked LVN B if she (LVN B) saw or heard H-LVN A slap Resident #1. She stated LVN B had told her, "Yes," that sometimes you have to do what you have to do (referring to H-LVN A slapping Resident #1) to get him to quit biting. She stated that LVN B was her charge nurse and she felt that by speaking about the incident with LVN B, it was the same as reporting the incident to her supervisor. CNA E added that she did not know if H-LVN A slapping Resident #1 was considered abuse. Review of a written statement completed by CNA E, dated [DATE], reiterated the above information and added that she (CNA E) and H-LVN A tried to get the broken glass from him. She held his right arm, and H-LVN A had his left arm, which was holding the broken glass. She heard a slap and then heard H-LVN A say, "I should not have done that." During an interview with LVN C on [DATE] at 12:10 PM, she stated she was the on-call supervisor on the evening of [DATE]. She stated LVN B called her and reported the incident that occurred with Resident #1. She said she called the hospice company and told them not to send H-LVN A back to the facility. LVN C said she called the AED and reported the incident involving Resident #1 and H-LVN A to her. During a subsequent interview with LVN C on [DATE] at 3:40 PM, she provided the following additional information: She said LVN B told her Resident #1 had done something to H-LVN A and she (H-LVN A) slapped him. LVN C stated she told LVN B to assess Resident #1, to escort H-LVN A out of the building and have someone sit with Resident #1 until a (replacement) nurse came to the facility. She said she then called the AED to let her know what happened. She said the AED told her she (the AED) would take care of it. During a confidential interview, it was said he/she visited the facility around mid-night and H-LVN A was still on duty. It was said he/she heard H-LVN A yell at Resident #1 to "Shut up." It was said, he/she told facility staff they did not want H-LVN A caring for Resident #1. During a subsequent confidential interview, it was said they were at the facility around 11:15 PM on [DATE], and could hear Resident #1 yelling for God to take him and then H-LVN A say, "Do you really think anybody can hear you? ...Do you think anybody is coming to help you?" It was said they believed Resident #1 was in pain and told H-LVN A he needed medication. It was said, H-LVN A told them Resident #1 would just spit out the medication. It was said they then asked that they obtain an order for [REDACTED]. During a subsequent interview with LVN C on [DATE] at 9:25 AM, she was asked why H-LVN A had been allowed to remain in the facility after the incident that occurred she said when she gave instructions to LVN B to have H-LVN A escorted out of the building, as far as she knew, her instructions were followed. Review of a written statement completed by LVN C, dated [DATE], noted that after the incident, at 8:30 PM, she received a telephone call from LVN B telling her Resident #1 had broken a glass and tried to cut her and H-LVN A when they were trying to take the glass away. LVN B told her H-LVN A slapped Resident #1 because he was squeezing her hand. LVN C's statement reflected LVN C told LVN B to send H-LVN A home immediately and call the hospice agency for a replacement. She further wrote she also called the Assistant Executive Director (AED) to inform her of the incident. On [DATE], there was an added notation, which reflected the AED told her the hospice agency would be filing the abuse incident with the state. LVN C wrote she asked the AED if she needed to write a statement, and the AED told her, "No, the hospice company was taking care of it and we do not need to do anything else." Review of Resident #1's Interdisciplinary Notes reflected the nursing entries for [DATE] at 6:34 AM, were completed by LVN F. Interview with LVN F on [DATE] at 2:45 PM revealed when he reported to work on the evening of [DATE], he got report from LVN B about Resident #1's combative behavior earlier in the evening. LVN F stated that H-LVN A was still at Resident #1's bedside when his shift ended at 6:00 AM on [DATE]. Review of the timesheet provided by the hospice agency for H-LVN A revealed she was in the facility from 10:00 PM on [DATE] to 8:00 AM on [DATE]. During an interview with the Administrator on [DATE] at 12:20 PM, she stated she began employment on [DATE] with the facility. She stated she was still in her orientation period and the AED told her she was handling the incident involving H-LVN A and Resident #1. She said she told the AED since the incident involved their resident, they needed to do the investigation. She stated she now realizes she should have been more adamant the facility conduct an investigation. During an interview with AED on [DATE] at 2:16 PM, she stated LVN C called her on [DATE] around 10:00 PM and told her Resident #1 was having behaviors. She stated she told LVN C to provide comfort measures and she (the AED) would check on Resident #1 in the next morning. She stated she did not know H-LVN A was not escorted out of the building until she spoke with Resident #1's family member on [DATE]. Interview on [DATE] at 11:30 AM with the facility's only ADON (Interim DON) revealed she was out of town from [DATE] through [DATE]. She stated she was not informed of the incident until the surveyor entered the facility on [DATE]. The facility was provided with a written statement from H-LVN A via the hospice agency, which was signed and dated [DATE]. It reflected Resident #1 asked for a drink of water and H-LVN A gave him water in a glass goblet. Resident #1 threw the water on H-LVN A and then began trying to break the glass. "He then hit it against the half-bed rail where upon it shattered. Pieces landed on the bed and on the floor, I (H-LVN A) immediately went to the door and call (sic) for help. Several aides and the facility's LVN came to help me. ...After removing the larger pieces (of glass) from the bed we had to change the sheets, all the while the patient (Resident #1) was still very agitated and fighting. ...I was holding (Resident #1's) upper torso with my right arm across the front of him when he bit my right arm very hard. The sudden pain startled and surprised me so much that unintentionally popped him lightly on the face with my left hand... It was an unintended action that was done unconsciously on my part. For that I am sorry and apologize...." Attempts were made to contact H-LVN A, which were unsuccessful. Following surveyor intervention, the facility conducted an investigation. The Facility's Provider Investigation Report, dated [DATE], reflected: "(Resident #1) was allegedly slapped by (H-LVN A) after he bit her on the arm. ...Description of Assessment (Resident #1) was assessed by (LVN B). No injury noted. ...Provider Response (LVN B) called (the hospice agency) and requested another nurse to be sent out to care for (Resident #1). Facility staff were instructed to minimize stimulation in resident's room and only enter one at a time to prevent agitation. ...Investigation Summary (Resident #1) was slapped by (H-LVN A) per her own witness statement. (Resident #1) did not sustain any injuries from the incident. The facility informed (the hospice agency) that (H-LVN A) was no longer permitted to care for residents at the facility. ...Provider Action Taken Post-Investigation Administrative staff in-serviced by corporate executive director on reporting abuse and neglect. All staff in-serviced on Abuse and Neglect and Managing Challenging Behaviors. Notified (the hospice agency) that (H-LVN A) is no longer allowed to care for residents who reside at the facility." A written statement from LVN B dated [DATE] reflected on [DATE], Resident #1 was very combative and tried to hurt staff. LVN B's written statement reflected at some point, the resident hit a CNA (name not given) and tried to twist another staff's hand (name not given). Her statement reflected when she got to Resident #1's room, H-LVN A was holding/securing the resident's hand, because he was holding a broken glass and had broken glass all over his body and in his bed. LVN B wrote Resident #1 was turned to his left side. H-LVN A was on his left side holding the resident. LVN B wrote, at that time, the resident got hold of H-LVN A's arm and started to bite it. LVN B heard H-LVN A yell, "He's biting my arm. Let go of my arm." She then heard a "pop," but was focused on picking up the broken glass. She did not see H-LVN A slap Resident #1. After the "pop," the resident let go of H-LVN A's arm. She wrote that CNA E was also in the room, came to her and told her H-LVN A had slapped the resident. Review of the facility's Provider Investigation Report dated [DATE] revealed an Interview with LVN C, which reflected she received a telephone call from LVN B, who told her Resident #1 had broken a glass and was trying to cut staff. H-LVN A slapped Resident #1 because the resident had a tight grip on her and he would not let go. LVN C's interview reflected she told LVN B to call the hospice company and send out a new nurse, preferably a male. LVN C said she then called the AED to inform her of the situation. Interview on [DATE] at 4:20 PM with CNA G revealed she worked the 10:00 PM to 6:00 AM shift. She stated when she reported to work on the evening of [DATE], she could hear Resident #1 screaming for help. She said she went into his room and saw H-LVN A sitting at bedside. She said she saw a television remote lying on the floor beside the bed and bent down to get it when H-LVN A told her, "Leave it alone and don't get near him." CNA G stated H-LVN A went on to describe the incident that occurred earlier in the evening when Resident #1 pulled her hair and bit her. CNA G stated H-LVN A told her she "had" to hit Resident #1. CNA G stated Resident #1 seemed confused. Resident #1 then said, "Get her out of here. She's trying to kill me." CNA G stated she did not report what H-LVN A said to her or what Resident #1 said to her (CNA G). CNA G said at 4:00 AM that morning she went in to assist another CNA with changing Resident #1, and H-LVN A was still there at the resident's bedside. The facility's current Abuse Policy, released on [DATE], reflected: "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse included The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." "...Immediate action will be taken to protect the resident from retaliation and harm." An IJ was identified on [DATE] at 5:40 PM, and the ED, AED, Administrator and ADON were notified. A Plan of Removal for the IJ was requested at that time. Interview with the Executive Director on [DATE] at 9:30 AM revealed the AED and LVN B were suspended. The facility's Plan of Removal, dated [DATE] and accepted on [DATE], reflected the following: In-service counseling will be done on each community employee to include ongoing monitoring. Disciplinary Plan for Associates involved in abuse allegation: LVN B: Investigation underway, however it appears termination will occur no later than [DATE]. This nurse is a PRN staff member and has not been nor will be back in the building to provide care. CNA D: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA K: no disciplinary action, however she will be included in the facility in-service training. CNA E: Investigation underway, we anticipate a first and final written warning regarding abuse/neglect and inappropriate handling of residents. One-on-one training will occur regarding abuse/neglect and proper handling of residents by the Corporate DON. CNA E's one-on-one training was completed on [DATE] at 10:00 PM by the Corporate DON and the EDHS. Details of action taken for each employee who had knowledge of incident of alleged abuse: 1. The following management staff were in-serviced on [DATE] by the EDHS: a. AED b. ADON c. Administrator d. ED 2. The AED is currently away from the building until investigation is complete. 3. The plan is to re-orient all on-call managers regarding responsibility to follow-up and ensure resident safety when situations like this occur by [DATE]. a. Responsible Party: the DON b. Follow-up: Competency Evals to be administered by Corporate DON no later than [DATE]. 4. Management staff will be trained on proper investigations and reporting process by [DATE]. 5. Face-to-face monthly in-services (See Attachment C for all-staff Schedule) Annual In-service Calendar and materials covering all 12 required in-services to be maintained and monitored by the HR Director and the ADON. Responsible Parties: Director of HR and the ADON to ensure nurse check-offs and compliance with all regulations. Corporate DON will review to ensure completion Monthly staff tests of competencies Responsible Party: Administrator Follow-up: Corporate DON will review to ensure accuracy and completion. Immediate Quality of Life interviews with alert and oriented residents. This will begin on [DATE] and be completed by [DATE]. Responsible party: Social Worker Follow-up: Administrator will review upon completion and recommend any necessary follow-up actions. 6) The Medical Director was notified of the IJ on [DATE] at 12:15 PM. 7) Newly hired employees (including Administrator and DON) will have weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 8) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: RN N, LVN B, LVN J, CNA D, CNA E, CNA I, CNA K, CNA L and CNA M were interviewed and said they were in-serviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. They verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse. They stated they felt comfortable reporting abuse or neglect and did not fear retaliation. The SW conducted quality of life rounds with the three remaining hospice residents and their families. The IJ was removed on [DATE]. The ED was notified on [DATE] at 10:00 AM the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. The facility's CMS 672, Resident Census and Conditions of Residents, dated [DATE] reflected a census of 41 residents.