Every finding on record at Village Creek Rehabilitation and Nursing Center

Based on observation, interview and record review, the facility failed to implement written policies and procedures that identify, report, and protect from further abuse of residents, for 2 of 6 residents (Resident #14 and Resident #55) reviewed for abuse. * On 03/04/26, CNA B witnessed Resident #14 yell at Resident #55 that she was a [f-ing retard]. The incident was not reported to the abuse coordinator (AC) or HHSC. No preventative measures were put in place to prevent further abuse. * On 03/20/26, CNA B and MA C both witnessed Resident #14 shove Resident #55 into trash and dirty linen barrels in her wheelchair. CNA B and MA C did not consider this to be abuse and did not report the incident to the abuse coordinator. An Immediate Jeopardy (IJ) situation was identified on 03/25/26. While the IJ was removed on 03/26/26, the facility remained out of compliance at a severity of more than minimal harm that was not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of unidentified abuse, unreported abuse, not being protected from further abuse, and a decreased quality of life. Findings included: Record review of the facility's Abuse Prohibition Policy last revised 01/01/24 indicated: INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.DEFINITIONS: Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical hmm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment.Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or depravation. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident, denying food or care, isolating a resident, etc.Abuse Prohibition Program:The facility's abuse prevention program includes the following components:-Screening-Training-Prevention-Identification-Investigation-Protection-Reporting/ Response Identification:1. Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately.3. The facility supervisory staff will monitor behavior of staff members/ residents to identify potential for abuse, neglect, and misappropriation of resident funds. Protection:1. All residents will be immediately protected from harm.4. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. Reporting/Response:1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination.2. The facility will report all allegations and substantiated occurrences of abuse,neglect or misappropriation of resident property to the state agency and to allother agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment withserious bodily injury, exploitation with serious bodily injury, and injuries ofunknown source with serious bodily injury immediately or within two hours of the allegation. Resident to Resident Incidents: The following guidelines will be implemented when resident to resident incidences occur:1. The staff observing the incident will immediately separate the residents involved.2. The charge nurse will assess the victim to determine any injury.3. Physician and family of both victim and perpetrator will be notified of incident.4. An incident report will be completed for the perpetrator and the victim.5. The Abuse Coordinator will be immediately contacted.6. The interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following:* Immediate discharge from the facility due to potential for harm to other residents.* Can the behavior be controlled by location monitoring?* Need for referral to a psychologist/psychiatrist.7. If the perpetrator is placed on location monitoring, staff will be instructed onreason for monitoring and targeted behaviors being monitored.8. If the perpetrator is on a behavioral contract, facility staff will be in servicedaccordingly, and the resident and family will be notified of consequences.9. If the perpetrator continues to exhibit inappropriate behaviors/or violates thebehaviors identified on the behavioral contract, staff will immediately notify the Administrator /DON.10. The team will conduct an emergency review to determine further course of action such as immediate discharge.11. The victim will be seen by Social Services to determine further psychologicalsupport needed as well as follow up with physician/family.12. The Ombudsman will be notified of incident /allegations as appropriate. Record review of a face sheet dated 03/24/26 indicated Resident #14 was a [AGE] year-old male admitted on [DATE]. He was his own RP. His diagnoses included paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #14 had intact cognition with a BIMS score of 15 out of 15. He had adequate hearing and clear speech. He had no behaviors during the look back period. Record review of the care plan for Resident #14 indicated:-dated 01/27/21; he had been and had the potential to be verbally aggressive and accusatory behavior towards others - staff and residents.-dated 06/14/21; he had a history of and potential for behavior problem related to my age and facility accommodates my needs by allowing me to have autonomy to make my own decisions. -dated 10/30/25; he had requested to room with a female resident. He was able to make his own decisions and consented to the move.-dated 12/11/25; he exhibited episodes of verbal aggression/irritability toward staff when care for his girlfriend/roommate was not provided immediately. During an observation and interview on 03/23/26 at 01:30 p.m. Resident #14 was in his electric wheelchair sitting outside in the smoking area. He was sitting with Resident #55. Interactions between them were appropriate with no yelling. He said he told Resident #55 to shut up and go to the room to calm down. He said it was told that he cussed at her and called her a retard but that did not happen. He said he loved her and would not do that. Record review of a face sheet dated 03/24/26 indicated Resident #55 was a [AGE] year-old female admitted on [DATE]. She was her own RP. Her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), vision loss (partial or complete loss of the ability to see), hypertension (a condition in which the force of the blood against the artery walls is too high), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #55 had intact cognition with a BIMS score of 15 out of 15. She had adequate hearing and clear speech. She had severely impaired vision. She had no behaviors during the look back period. Record review of the care plan for Resident #55 indicated:-dated 10/30/25; she requested to room with a male resident. She was able to make her own decisions and consented to the move.-dated 09/17/25; she had impaired visual function related to total Blindness.-dated 09/25/25; she had a behavior problem. The resident had history of yelling at staff. During an observation and interview on 03/23/26 at 01:30 p.m. Resident #55 was sitting in her wheelchair outside in the smoking area. She was sitting with Resident #14. Interactions between them were appropriate with no yelling. She said someone said he cussed at her, but he did not. During an observation and interview on 03/25/26 at 12:20 p.m. Resident #55 was sitting in the dining room without Resident #14. She was calm. She said Resident #14 went to the emergency room to get checked out. She said she had no issues with Resident #14 yelling and cussing at her. She said she did not feel afraid of him. She said she loved him and he took care of her since she could not see. 1. Record review of Nurse Notes for Resident #55 indicated an entry dated 03/03/26 at 09:40 a.m. [Resident #55] was sitting outside in wheelchair with other residents and boyfriend [Resident #14]. Stated to boyfriend stomach was hurting. Boyfriend yell at her. [Resident #14] was crying stated boyfriend yelled at her and belittled her in front of everybody. Stated to nurse I want to move out of that room notified social worker. Signed by LVN A. Record review of Nurse Notes for Resident #14 indicated an entry dated 03/03/26 at 09:50 a.m. [Resident #14] was sitting outside in electric wheelchair with girlfriend [Resident #55] and other residents. Yelled at girlfriend, asked [Resident #14] why yelled at girlfriend stated she said her stomach hurt and all I said was she need to tell the nurse Social worker notified of behavior. Signed by LVN A. During an interview on 03/25/26 at 09:26 a.m. LVN A said Resident #55 came to her crying and upset about Resident #14 yelling at her and belittling her in front of other residents. She said she told the SW since Resident #55 said she wanted to move out of the room. During an interview on 03/25/26 at 09:42 a.m. the SW said LVN A reported to her Resident #55 wanted to move out of the room she shared with Resident #14 because he yelled at her and belittled her. She said she went to talk with Resident #55, and she recanted what was said and said she loved him. She said when she talked with Resident #14, he said Resident #55 said her stomach hurt and he told her to tell the nurse. She said the Administrator was made aware. During an interview on 03/25/26 at 10:10 a.m. the Administrator said she was aware of the incident on 03/03/26 where Resident #55 said Resident #14 yelled at her and belittled her in front of others, but when Resident #55 was asked about it she recanted her statement. Therefore she did not think it needed to be reported. 2. Record review of a witness statement dated 03/04/26 indicated CNA B put in her witness statement she witnessed Resident #14 yell at Resident #55 that she was a [f-ing retard]. The statement was turned into the abuse coordinator. The incident was not reported to the abuse coordinator or HHSC. During an interview on 03/24/26 at 01:55 p.m. CNA B verified her witness statement that she had witnessed on 03/04/26 Resident #14 yelled at Resident #55 she was a [f-ing retard]. CNA B said she wrote it in her witness statement and thought the AC would see it. During an interview on 03/25/26 at 10:10 a.m. the Administrator said she did not see where CNA B had put in her statement about Resident #14 calling Resident #55 a [f-ing retard]. She said it would be considered as verbal abuse and would be reportable to HHSC. 3. During an interview on 03/24/26 at 01:55 p.m. CNA B said she was making rounds on 03/20/26 she had her dirty linen barrel and trash barrel in the hallway. She said MA C was passing medications, so her cart was also on the hall. She said Resident #14 and Resident #55 came out of their room with him pushing her in her wheelchair. She said Resident #14 then shoved Resident #55 into the barrels. She said she was not sure if it was abuse and did not report it to the Administrator. During an interview on 03/24/26 at 02:15 p.m. MA C said she saw Resident #14 shove Resident #55 in her wheelchair. MA C said Resident #14 told her it was her fault that Resident #55 went into the barrels. She said she told him no it was not her fault it was he who shoved Resident #55 into the barrels. She said she did not think it was a type of abuse and did not report it to the Administrator. During an interview on 03/25/26 at 10:10 a.m. the Administrator said she was not aware of the incident of Resident #14 shoving Resident #55 into the barrels until CNA B came to her and told her about 10 minutes ago. She said the incident could be considered as physical abuse and would be reportable to HHSC. The Administrator and DON were notified of the IJ on 03/25/26 at 02:07 p.m. due to the above failures. The administrator was provided with the IJ template on 03/25/26 at 02:09 p.m. The following Plan of Removal was submitted by the facility and accepted on 03/26/26 at 11:53 a.m.:[Facility Name]Plan of RemovalMarch 25, 2026 F607 Immediate Actions The facility attempted to separate the residents; however, both residents adamantly refused a room change. Due to adamant refusal to change room, 1:1 monitoring initiated for Resident #14. Monitoring done by staff until risk is fully mitigated and IDT determines supervision can be safely reduced. Care plans were reviewed and updated accordingly for Resident #55 and Resident #14 to reflect supervision needs and behavioral concerns for both residents on 3/25/2026 by MDS Coordinator. IDT provided education to both residents on 3/25/2026 regarding:Personal safety and boundaries Risks associated with unsupervised interactions Facility responsibility to intervene when safety concerns arise Outcome: Both residents verbalized understanding but continued to refuse room change; ongoing reinforcement planned A trauma-informed psychosocial assessment for Resident #55 was completed on 3/25/2026 by Social Services to evaluate for emotional distress, coercion, or unmet needsFindings: No immediate psychosocial harm identified; continued monitoring initiated Both residents were assessed for physical and psychosocial harm by nursing, with no additional injury identified on 3/25/2026 Life satisfaction rounds were completed on 3/25/2026 to ensure no other residents were negatively affected this was completed by Social Services. No negative findings with resident #14 and #55 Medical Director was notified by facility Administrator on March 25, 2026 regarding the facility alleged failure to follow abuse policies and procedures. Systemic Changes Administrator/DON were inserviced by CCS on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships Completed 3/25/2026. Competency validated via quiz. Administrator/DON inserviced staff on abuse policy and reporting procedures. To include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships Competency validated via quiz. Staff will not be allowed to work their next scheduled shift until inservice has been completed. Inservice complete 3/25/26 The above training material will be incorporated into the new hire orientation by Administrator effective March 25, 2026 and ongoing. An audit of incident reports for the last 3 months was completed by DON/Designee to ensure no other reportable incidents were identified on 3/25/2026. No negative findings identified An audit of grievances for the last 3 months was completed by Administrator to ensure no other reportable issues were identified on 3/25/2026. No negative findings identified If resident-to-resident abuse occurs and both residents refuse room change, the facility will implement immediate enhanced supervision (including 1:1 monitoring as indicated), revise care plans to reflect supervision needs, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions (behavioral, environmental, or schedule separation) to ensure resident safety. Ongoing reassessment will occur until risk is fully mitigated Monitoring and QA Administrator/DON will conduct daily review of all incidents, grievances and behavior notes x 14 days, then weekly x 4 weeks and monthly thereafter. The Administrator/DON will conduct random staff interviews (5 per week x 4 weeks) to validate understanding of abuse reporting. QAPI Committee will review weekly for 3 months for compliance, then monthly thereafter. Any identified issues will result in immediate re-education and disciplinary action if indicated. Actions for Resident Involved:The facility attempted to separate Resident #14 and #55; however, both residents adamantly refused to change rooms. Resident #14 was on 1:1 monitoring by facility staff until risk is fully mitigated and IDT determines supervision can be safely reduced. Resident #14's and #55's care plan has been updated to reflect supervision needs and behavioral concerns on 03/25/26 by MDS Coordinator. IDT provided education to both Resident #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, facility responsibilities to intervene when safety concerns arise with the outcome of both residents verbalized understanding but continued to refuse room change with ongoing reinforcement planned. Resident #55 received a trauma-informed psychosocial assessment by social services to evaluate emotional distress, coercion, or unmet needs. Findings of no immediate psychosocial harm identified; continued monitoring initiated. Residents #14 and #55 were assessed for physical and psychosocial harm by nursing staff, with no additional injury identified on 03/25/26. Life satisfaction rounds were completed on 03/25/26 to ensure no other residents were negatively affected this was completed by social services. No negative findings with Resident #14 and #55. Medical Director was notified by facility Administrator on 03/25/26 regarding the facility alleged failure to follow abuse policies and procedures. Administrator/DON was in serviced by CCS the abuse policies and reporting procedure to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on identifying abuse risk with residents and relationships completed 03/25/2026 competency validated via quiz. Administrator/DON in service staff on abuse policies and reporting procedures to include the different types of abuse, reporting abuse, and what to do in the event of an allegation of abuse and additional focus on identifying abuse risk with residents and relationships. Competency validated via quiz. Staff will not be allowed to work their next scheduled shift until end service has been completed. Service completed 03/25/26. The above abuse training materials will be incorporated into the new hire orientation but Administrator effective March 25th, 2026, and ongoing. An audit of incident reports for the last three months was completed by DON/designee to ensure no other reportable incidents were identified on 03/25/26. No negative findings identified. An audit of grievances for the last three months was completed by administrator to ensure no other reportable issues were identified on 03/25/26. No negative findings identified. If resident to resident abuse occurs in both resident refuse room change the facility will implement immediate enhanced supervision (including 1 one monitoring as indicated, revised care plan to reflect supervision needed complete IDT review assess capacity and risk, involve physician and responsible parties, and consider alternative interventions (behavioral environmental or schedule separation) to ensure residents safety. Ongoing reassessments will occur until risk is fully mitigated. Review of the IJ monitoring for the facility's plan of removal reflected the following: During an observation and interview on 03/26/26 at 1:00 p.m. LVN T was sitting outside Resident #14's door she indicated she was providing 1:1 monitoring for Resident #14. LVN T indicated she was watching and listening for any abuse between Resident #14 and #55. LVN T said they were watching a movie and that she was to make sure that Resident #14 did not physically or verbally abuse Resident #55 or any other residents. LVN T said she was documenting on a flow sheet every 15 minutes and as needed. LVN T said if an incident occurred to intervene immediately, keep resident safe and notify the Administrator immediately thereafter. Record review of Resident #14's 1:1 monitoring tracking sheet indicated facility staff began 1:1 monitoring of Resident #14 on 03/25/26 at 6:00 p.m. and was continuing to monitor the residents. Resident #14's tracking sheets included every 15-minute documentation of location and identified activities with facility staff signatures. No new incident identified. Record review of signed statements provided by Resident #14 and #55 indicated they were educated on 03/25/26 regarding personal safety and boundary risks associated with unsupervised interactions and the facilities responsibilities of intervening when safety concerns arise. Their statements acknowledge they understood the information provided and refuse to change rooms with the understanding that current and ongoing reinforcement and monitoring are planned. Record review of Residents #14's care plan indicated it was updated on 03/25/26 to include he exhibited episodes of verbal aggression/irritability towards staff when care for his girlfriend/roommate is not provided immediately and revision of interventions to include one on one monitoring. Record review of Residents #55's care plan indicated it was updated on 03/26/26 to include she had requested to room with a male resident and she was her own responsible party and was cognitively able to make her own decisions and revision of the interventions included she refused to move rooms, social worker to interview resident quarterly and as needed to discuss behaviors and potential room/roommate change, assess resident for injuries such as bruises/skin tears after any reportable incident, IDT meeting quarterly and as needed to discuss with resident any on-going concerns/issues identified, temporary separation when inappropriate interactions are identified and to have psych evaluate as needed. Record review of Resident #55's trauma-informed psychosocial assessment completed on 03/25/26 by SW indicated no immediate psychosocial harm identified related to incident. Resident #55's physical assessment dated [DATE] completed by LVN Y indicated no additional injuries identified. Record review of Resident #55's physical and psychosocial harm assessment dated [DATE] completed by LVN Y indicated no psychosocial harm or physical injury identified. Record review of Life satisfaction rounds completed on 03/25/26 by social services to ensure no other residents were negatively affected indicated no negative findings with Residents #14 and #55 Record review of a text message indicated the Medical Director was notified by the Administrator on 03/25/26 regarding the facility alleged failure to follow abuse policies and procedures. Record review of in-service dated 03/25/26 instructed by the CCS, indicated the Administrator and Director of Nursing was trained on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships. Record review of in-services dated 03/25/26 and 03/26/26 completed by the DON, indicated 70 of 72 facility staff and contract staff were trained on abuse policy and reporting procedures. To include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships. No staff will be allowed to work until this training was complete. During an interview on 03/26/26 at 6:30 p.m., the Administrator said she provided the abuse training for staff during the orientation process, and she would be utilizing the newly developed abuse policy guideline material during the orientation. She said during new orientation process staff would receive training on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on identifying abuse risk with residents in relationships. Record review of an audit of incident reports for the last 3 months completed by DON/Designee on 03/25/26 to ensure no other reportable incidents were identified for not following the abuse policy. No negative findings identified. Record review of an audit of grievances for the last 3 months was completed by Administrator on 03/25/26 to ensure no other reportable issues were identified for not following the abuse policy. No negative findings identified. During interviews conducted on 03/26/26 from 12:10 p.m. to 7:30 p.m. representing staff from various shifts (6 a.m.- 2 p.m., 2 p.m. - 10 p.m., 2 p.m.- 6 a.m.) and departments included LVN Q, VD R, MA G, ADON, CNA S, MA C, MA N, LVN T, CNA U, LVN H, LVN J, MDS RN, CNA V, SW, LVN A, LVN F, CNA M, LVN L, CNA W, AD, CNA X, LVN Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, MNT, CNA FF, CNA GG, CNA HH, CNA JJ, DDM, DM, DA KK, DA LL, DC MM, EM NN, HSK OO AND HSK PP. All staff were able to identify the different types of abuse, what to do if they witnessed resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse, and who to report any incidents of abuse. Staff were able to identify that they were to intervene immediately if abuse witnessed (both resident-to-resident even residents in relationships, and/or resident to staff). Staff were able to identify ways to prevent residents with high-risk behaviors and agitation from abuse and neglect. Example: To remove from reach of others, increase supervision. Staff knew they were to separate residents immediately, and ensure residents were safe. All staff were able to identify the responsibilities if assigned 1:1 monitoring. All staff were able to identify the responsibilities of caring for a resident with behavior and to intervene even if residents were in a relationship. All staff were able to identify the responsibilities for supervision and monitoring residents. All said they were in-serviced on 03/25/26 or prior to their shift on 03/26/26 regarding reporting alleged abuse immediately to the Administrator/AC and the allegation had to be reported to the State Agency within 2 hours of the incident. All were able to state that their abuse coordinator was the Administrator, if she were not available, they were to notify the DON. During an observation and interview on 03/26/26 at 2:00 p.m. Resident #14 and Resident #55 were in their room watching a movie and voiced no concerns. Resident #14 said staff are monitoring us closely and he would never harm his girlfriend (Resident #55). During an interview on 03/26/26 at 6:00 p.m. MA G said she was assigned to Resident #14 and indicated she was watching and listening for any abuse between Resident #14 and #55. MA G said they had been out for a smoke break and just returned to watch TV and that she was to make sure that Resident #14 did not physically or verbally abuse Resident #55 or any other residents. MA G said she was documenting on a flow sheet every 15 minutes and as needed. MA G said if an incident occurred to intervene immediately, keep residents safe and notify the Administrator immediately thereafter. During an interview on 03/26/26 at 6:10 p.m., the ADON said she received training 03/25/26 from the DON and the Administrator on Abuse policy, reporting abuse immediately, intervene and protect resident, interventions, and notify Administrator/AC immediately. If Administrator/AC not available or reachable notify DON. She said the Administrator had 2 hours from the time of the incident to report abuse allegations to the state agency. She said she trained staff on abuse, resident-to-resident altercations, intervening, separating resident, aggressors were watched while someone obtained help, and notified the administrator, staff to resident, protect resident and notify Administrator. She said the aggressor in an altercation was placed on one on one immediately protocol, psych notified, and they review and release. She said Resident #14 is on 1:1 monitoring for abuse or behaviors towards Resident #55 his girlfriend/roommate. She said Residents #14 and #55 care plan interventions were updated. She said that they were to follow the abuse policy even if the residents were in a relationship if abuse was suspected. During an interview on 03/26/2026 at 5:40 p.m., the DON said she received training 03/25/2026 from Regional Nurse/CCS on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships. She said she and the Administrator trained staff regarding the abuse policy and reporting procedure after she received her training from the Regional Nurse/CCS. She said Resident #14 was placed on 1:1 monitoring until risk is fully mitigated. She said both residents (14 and #55) have received updates on care plans, signed statements about refusing room changes and risk, psychosocial and physical assessments, and increased monitoring. She said social services completed life satisfaction rounds with no negative findings. She said she completed an audit of reportable incidents for the last 3 months regarding following the policy for reporting abuse and no negative findings identified during audit. During an interview on 03/26/2026 at 6:45 p.m., the Administrator said she received training on 03/25/2026 from Regional Nurse/CCS on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships. She said she and the DON trained staff regarding the abuse policy and reporting procedure after she received her training from the Regional Nurse/CCS. She said Resident #14 was placed on 1:1 monitoring until risk was fully mitigated. She said both Residents #14 and #55 had received updates on care plans, signed statements about refusing room changes and risk, psychosocial and physical assessments, and increased monitoring. She said social services completed life satisfaction rounds with no negative findings. She said she completed an audit of grievances for the last 3 months regarding following the policy for reporting abuse and no negative findings identified during audit. She said her ongoing monitoring would include conducting daily reviews of incidents, grievances and behavioral notes and conducting random staff interviews for abuse reporting. She said the abuse policy and reporting would be added to her QAPI review as well. The Administrator was informed that the Immediate Jeopardy was removed on 3/26/26 at 7:30 p.m. The facility remained out of compliance at a scope of pattern with the potential

Based on interview and record review, the facility failed to assure all nursing staff possess the competencies, and skill sets necessary to use, maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators and 4 of 4 licensed staff interviewed (LVN QQ, LVN L, LVN J and LVN H) and reviewed for nursing services.The facility failed to ensure nursing staff were competent to conduct testing of the facility's only AED according to the manufacture's guidelines.An Immediate Jeopardy (IJ) was identified on [DATE] at 4:45 p.m. While the IJ was removed on [DATE] at 5:45 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.This failure could place residents at risk for death.Findings included:During an observation on [DATE] at 2:30 p.m., the only available AED for the facility was sitting in a holder that was attached to the wall outside of the nurse's station. The AED had a black zipped case and was intermittently beeping, electrodes (a conductive materials used conductive materials used to transfer electricity to or from non-metallic components in a circuit) were not attached and the machine had a red x indicator light on.During an interview on [DATE] at 2:33 p.m., LVN QQ stated she worked the 2p-10p shift and was not responsible for checking to see if the AED was functioning properly. She said that was done on nights by LVN H and LVN J who worked opposite of each other. LVN QQ said she did not hear the AED beeping until surveyor brought it to her attention. LVN QQ looked at the AED and said the red x mark indicated the AED was off and when you turned it on it would go green. LVN QQ said the AED electrode pads were not attached to the machine and only needed to be attached if the machine was in use. LVN QQ said she had not been trained on this type of AED. LVN QQ said she had AED training [DATE], but the trainer had a different type of AED. LVN QQ said a delay in AED care for a resident could happen if the nurse was not familiar with the type of AED being used at the time during CPR. She stated not being trained to be able to understand and identify that the AED was not functioning properly, could delay CPR to the resident.During an interview on [DATE] at 2:35 p.m., LVN L stated she worked the 2p-10p shift and was not responsible for checking to see if the AED was functioning properly she said that was done on nights by LVN H and LVN J. LVN L said she had not heard the beeping noise from the AED. LVN L said she did not know why the AED had a red X mark, and the AED electrodes did not have to be attached until the AED was ready to use on a resident. LVN L said she had been trained in 2025 but couldn't remember exactly when and the trainer had used a different AED. LVN L said she was not familiar with the current AED machine, but that it would talk to her and tell her the steps to do. LVN L said not being trained in how to use and identify if the AED was ready to use could cause a delay of CPR care to the resident needing CPR emergency services.During an observation and interview on [DATE] at 2:43 p.m., the DON removed the AED from the case and said the AED was beeping. The DON verified and said the AED electrode to the pads were not attached to the machine and turned on the machine and the red X mark remained lit up the AED said change battery. The DON said that meant the battery was low, or the test went wrong and the pads did not need to be connected until it was ready to use. She said the night nurses (LVN H and LVN J) were responsible for conducting readiness checks on the AED and documenting those checks which included checking for expired AED pads and evidence of machine functioning properly like not beeping and a green check mark to indicate ready to use. The DON said her expectation was for all nurses to know how to use the AED and how to identify when it is not ready for use. The DON said she was not aware that the AED was not ready for use. The DON said CPR included the use of the AED. The DON said on September2025, the nurses were trained on the AED, but the trainer used a different AED from what the facility had on hand. She said if a resident experienced cardiac arrest during the time the AED was not functional, the facility would still be able to do CPR but not use the AED. The DON said the nurses were trained on the AED, but it was not the specific AED the facility used, and that nurses had CPR certification cards and the training included AED-use. The DON said she would create a form to include what the nurse is responsible for when checking on the AED.During an interview on [DATE] at 3:42 p.m., the Administrator said she had not noticed that the AED electrodes were not attached, machine beeping or that there was a red x mark. The Administrator said the nighttime nurses were responsible for checking the AED and documenting the results every night. When a policy was requested, the Administrator stated she believed there was a policy, but she was not sure. The Administrator said if the facility did not have a policy on the AED, they would use the manufacture's manual online to train the nurses. The Administrator said she was not aware that the nurses did not know what to check for on the AED to know it was not ready for use.During an interview on [DATE] at 3:30 p.m., LVN J said she worked the 10p-6a shift and she had not received instruction from the facility about how to check the current AED for readiness until yesterday from the DON. She said she would just check to make sure it was available part of the crash cart checklist. LVN J said she knew to check for a green check mark which meant it was fine and put a check mark on her checklist, but if the green check mark was not on and it was a red x mark, that usually meant the AED was not functional and would get with the Administrator. LVN J said she now had a form to document green check mark and AED electrodes were attached. She said not having a functioning AED or being trained on how to use the current type of facility AED, could maybe cause a delay in using the AED for CPR.During an interview on [DATE] at 4:52 p.m., LVN H stated she worked the 10p-6a shift, and she had not received instruction from the facility about how to check the current AED for readiness pads until yesterday from the DON. She said she was not aware of the AED not functioning because all she was looking for when checking the AED was if it was available. LVN H said she would just check the box on the form indicating it was available part of the crash cart checklist. She said not having a functioning AED could maybe cause a delay in using the AED for CPR, and not being trained on how to use the AED, the facility used could cause a delay in emergency AED treatment to the resident.During an interview on [DATE] at 12:40 p.m., the Medical Director said he expected the AED to be functioning, and all necessary items at all times. He said if the items were used, then it should be replaced immediately and the AED be placed back to be used again when needed. The Medical Director said if the nurses were not familiar with the current AED, then education was need because it could cause cardiac arrest or death if AED usage were delayed.Record Review of an undated resident list indicated 47 residents wished to be resuscitated in the event of cardiac arrest.Record review of the on-line owner's manual for the [AED brand name] Fully Automatic AED Plus Administrator's Guide, obtained on [DATE] at 3:30 p.m., at https://www.[NAME].com/-/media/Product-Materials/product-manuals/aed-plus-fully-automatic/01/9650-0311-01-SF_G.ashx indicated: Safety Summary: Use the Fully Automatic AED Plus unit only as described in this manual. Improper use of the device can cause death or injury.DO NOT use or place the Fully Automatic AED Plus unit in service if the unit's status indicator window (located on the left side of the handle) displays a red X. DO NOT use or place the Fully Automatic AED Plus unit in service if the unit emits a beeping tone.Keep the electrode cable connected to the Fully Automatic AED Plus unit at all times.This device should only be used by properly trained individuals.If the device is stored outside the recommended environmental conditions, the electrode pads and/or batteries may be damaged or their useful life reduced.This device is intended for use by personnel who have been trained in its operation.Record review of the facility's policy titled Automatic External Defibrillator, dated [DATE] read in part: Policy: the facility has Automatic External Defibrillator (AED) equipment available for emergency use.5. Follow manufacturer guidelines and operating procedures, including pre-programmed voices prompts for use of the AED.Maintenance. The Director of Nursing or designee will test and document the operating status of the AED in accordance with manufacturer's guidelines.The Administrator and DON were notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy was identified due to the above failures and the template was provided and POR requested via email at 4:56 p.m.The facility's plan of removal was accepted on [DATE] at 12:30 p.m., and included:Immediate Actions Taken to Remove JeopardyUpon identification of the deficient practice on [DATE], the facility immediately implemented the following corrective actions to remove the Immediate Jeopardy:The facility's AED was immediately assessed and removed from service due to malfunction (beeping alarm, red X indicator, pads not connected) on [DATE] by administrator.A fully functioning AED was obtained, inspected, and verified to be operational according to manufacturer guidelines, including:Pads properly connected No error indicators Battery verifiedThe AED function was placed in service on [DATE] at 4:45 PM. Staff Education and Competency Validation On [DATE], all licensed nurses and designated emergency response staff present in the facility were immediately re-educated by DON on [DATE] Proper use of the AED Manufacturer guidelines Identification of malfunction indicators (including red X and audible alarms} Requirement that pads remain connected at all times Staff completed return demonstration and/or verbal competency validation to ensure understanding. Any staff not present will be educated prior to next scheduled shift.All training material incorporated into new hire paperwork by Admin on [DATE]Identification of Affected ResidentsThe facility identified 47 residents with full-code status who had the potential to be affected by the deficient practice.All residents were assessed, and no adverse outcomes were identified related to this concern.Monitoring and System Changes to Prevent RecurrenceTo ensure ongoing compliance and prevent recurrence:A daily AED equipment check log was immediately implemented by DON and will be completed each shift by the Hall 100 charge nurse requiring: Visual inspection of device status Verification of pads connection. Confirmation of no alarms or error indicatorsDON/designee will be responsible for checking the completion of the log. AED checks are assigned to the licensed nurse on each shift.The DON or designee will audit compliance daily X 7 days, then weekly x 4 weeks, and monthly thereafter through QAPI.On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Verified the AED was operational according to manufacturer guidelines. Surveyor observed the AED alarm was not beeping, there was no red X indicator, but green check mark, electrodes were connected, and there was no battery error indicators. The survey team confirmed the POR by: staff interviews related to AED identification of malfunction indicators (including red X and audible alarms), electrodes remaining connected at all times, checking the AED, and documenting on new checklist form, observations of residents were conducted, review of in-services and skills check-off related to AED was completed.Review of new hire paperwork included training and checkoff for AED. Review of new checklist documentation indicated Review of 20 post-tests and 20 skills check-off sheets, dated [DATE] and [DATE], reflected licensed nurses demonstrated proper skills and demonstrated knowledge on performing AED identification of malfunction indicators, (including red X and audible alarms) and electrodes.During an interview on [DATE] at 4:30 PM, the ADM stated more than 90% of their staff had been in-serviced on safe usage of the AED and proper functioning of the AED.On [DATE] at 5:45 p.m, the administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents (Resident #5) reviewed for indwelling catheters/ quality of care. (Resident #5) 1. Resident #5 had blood present inside his suprapubic catheter (a tube inserted into the bladder to drain urine) tubing and catheter drainage bag from 03/21/2026- 03/24/2026. 2.The facility staff failed to assess, document, and report findings to the physician and Resident #5 continued with signs of a possible UTI. 3.Resident #5 did not have a suprapubic strap in place to prevent dislodgement or trauma. This failure could place residents at risk of not receiving the required level of care, trauma, or possible sepsis. Findings included: Record review of a face sheet dated 03/25/2026 indicated Resident #5 was a [AGE] year-old male admitted on initially admitted on [DATE] and readmitted [DATE]. His diagnoses included chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot supply enough oxygen to the blood, often due to underlying lung or systemic diseases), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (is a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), Colostomy (an operation that creates an opening for the large intestine through the abdomen), neuromuscular dysfunction of the bladder (occurs when nerve or spinal cord problems disrupt communication between the brain and bladder, leading to loss of bladder control and urinary complications), resistance to multiple antibiotics (known as multidrug resistance, poses a significant global health threat, making infections harder to treat and increasing the risk of severe illness and death.) bullous pemphigoid-(autoimmune response that causes blistering to skin and increases risk of kidney disease and blood-tinged urine), obstructive and reflux uropathy (blockages in the urinary track system that cause urine to remain in bladder or back flow into the kidneys causing kidney damage and blood-tinged urine), artificial opening to the urinary tract (surgical incision in the bladder for abdominal catheter placement), resistance to multiple antibiotics (known as multidrug resistance, poses a significant global health threat, making infections harder to treat and increasing the risk of severe illness and death.),Obstructive and reflex uropathy- ( can cause blood-tinged urine due to back flow of urine into the kidneys or from bladder spasms.) Record review of the quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS score of 0 out of 15 indicating his cognition was severely impaired, and he had an indwelling suprapubic catheter. Record review of a care plan revised on 09/25/2025 indicated Resident #5 had an indwelling suprapubic catheter and was at risk for frequent UTIs, dislodgement, or other complications. Goals included He will show no s/sx of Urinary infection through review date. The interventions included monitor and document intake and output as per facility policy, monitor for s/sx of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter and Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Nurse Notes from 03/02/2026-03/22/2026 for Resident #5 indicated there was no documentation related to blood being in his suprapubic catheter nor that he had pain in his groin region until the surveyor's intervention on 03/23/2026. Record review of Resident #5's order summary dated 12/20/2025 indicated there was an order that stated Check Supra Pubic leg strap for placement and change PRN every shift Record review of Resident #5's hospital after visit summary sheet dated 03/24/2026 at 6:12 a.m. indicated the reason for the visit was for Hematuria (blood in urine) and was diagnosed with urinary tract infection associated with indwelling catheter, initial encounter. He was given ceftriaxone (antibiotic) injection prescribed cephalexin (Keflex)-an antibiotic to treat his UTI. Follow up instructions listed were to follow up with MD in 2 days (around 03/26/2026). During an observation on 03/23/2026 at 9:20 a.m., Resident #5 was resting in bed. He had a catheter bag on the right side of the bed. There was dark red blood that was settled at the base of the catheter tube and bright red blood at the top. There was blood noted in his drainage bag. During an observation on 03/23/2026 at 12:49 p.m., Resident #5 had bright red blood draining from his catheter tubing and into his drainage bag. The drainage bag appeared to have been emptied since the first observation. During an interview on 03/23/2026 at 1:02 p.m. with Resident #5's family member, the family member said his urine is usually medium yellow but for the past few days the family member had noticed blood in his urine. She said his urine color is usually yellow. An interview was attempted with Resident #5 on 03/23/2026 at 1:10 p.m., Resident # 5 did not reply to the surveyor's questions. During an observation and interview on 03/23/2026 1:54 p.m. with LVN L., a clot was noted inside the drainage bag approximately the size of a [NAME] half dollar. An increase of bright red blood was noted in the drainage bag. LVN L said Resident #5 had a history of having blood in his urine. She said he had not had labs ordered since 01/14/2026. She said she had noticed scant (small) amounts of blood in his urine that morning in his tubing and drainage bag. She said the assigned CNA M reported noticing light pink blood in his catheter that morning. She said she did not document nor notify the physician because she was used to seeing blood in his urine from the past. She said she did not assess his temperature or vital signs when she noticed the scant (small) amount of blood in his suprapubic catheter tubing and drainage bag. LVN L said she had not checked Resident #5's catheter since early that morning. LVN L looked at Resident #5's suprapubic catheter with surveyor confirmed the bleeding that gotten worse. She said she should have documented his change, notified the DON, and the physician that Resident #5's condition had worsened and was not at his baseline. She said she notified the physician and he ordered for the catheter to be flushed until clear. LVN L said she completed the flush as ordered by the physician. LVN L said she had been trained on assessing, documenting, and reporting. She said she could not recall how many days he had blood in his urine for the month of March and said she did not document her findings, notify the physician nor make the DON aware. She said the potential risk was Resident #5 becoming septic. During an interview and observation on 03/23/2026 at 2:05 p.m., with CNA M, she said she cared for Resident #5 on 03/21/2026 through 03/23/2026. She said on 03/21/2026 around 12:30 p.m. she and RN O were turning Resident #5 and noticed blood in his brief. CNA M said she asked Resident #5 if he was in any pain and he said yes. She said she asked him where the pain was and he replied everywhere but specified the pain was in his groin region. She said the next day, on 03/22/2026 around noon, she had noticed blood again in his brief and reported to RN O. During an observation on 03/23/2026 at 2:05 p.m. Both CNA M and the surveyor observed a clot was noted inside the drainage bag approximately the size of a [NAME] half dollar. She said the bleeding color was a lot brighter and worse than it was on Saturday and Sunday and there were no clots in his bag those days. During an interview on 03/23/2026 at 2:30 p.m., RN O said CNA M reported to her that Resident #5 had blood in his brief and a small amount in his catheter drainage bag around noon time. She said she did not recall Resident #5 saying he was in pain. She said she noticed dark blood in his catheter drainage bag approximately 300 milliliters. She said she did not call the physician because his urine is usually dark. RN O said she changed his catheter on 03/21/2026 when she noticed the bleeding. She said she could not recall the reason why she did not make a nurse's note regarding her findings and catheter change. She said it was her responsibility to document and notify the DON and physician of the blood in Resident #5's urine. During an interview on 03/23/2026 at 2:45 p.m., the DON said in the past Resident #5 had blood in his urine, but she was not made aware he had blood in his urine that started on 03/21/2026. She said she expected staff to assess, document, and notify herself and the Physician, when blood was noted in his suprapubic catheter tubing and drainage bag, to ensure Resident #5 did not have a UTI or sepsis. She said she had educated the nursing staff on documenting infections/ possible infections. She said in the past when Resident #5 would have blood in his urine he usually had a UTI or a blockage and that the physician would order treatment when he was made aware. She said Resident #5 was sent to the hospital on [DATE] around 2:00/3:00 a.m., as requested by the physician because he continued to have bright red blood in his urine. She said he returned to the facility 03/24/2026 with a diagnosis of a UTI and received an antibiotic. During an interview on 03/23/2026 at 3:00 p.m., with the Administrator, she said she expected staff to assess, monitor, document, and notify the DON and the physician when blood was noted in Resident #5's urine immediately to avoid a delay in care. She said staff had been educated on assessing, documenting, and notifying the DON and Physician. She said it was the nurse's responsibility to call the physician and make him aware of Resident #5's change in condition. During an interview on 03/26/2026 at 12:20 p.m., with Resident #5's Physician/ Medical Director He said he had not been made aware of blood in Resident #5's urine. He said if he had been notified by the nurses that Resident #5 had blood in his urine he would have ordered a UA, CBC, CMP to ensure Resident #5 did not have a UTI or had gone septic. He said he would expect to be notified within 2 hours of the nurse's assessment to ensure he did not have a UTI or was not septic. He said the associated potential risk for infection or sepsis.Record review of the facility's policy titled Condition & MD-Family Notification revision date: August 11, 2020, indicated- Purpose:To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories:A significant change in the resident's physical, mental or psychosocial status. (See below for examples)A need to significantly alter treatment.Transfer of the resident from the facility.PROCEDUREWhen any of the above situations exists, the licensed nurse will contact the resident's family and their physician.Calls will be made to the family. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called.The physician will be contacted immediately for any emergencies irrespective of the time of day.Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. Escalation of communication process: If the primary physician cannot immediately be reached in any emergency, the Medical Director [NAME] be called. If the MedicalDirector cannot be reached; the charge nurse will make arrangements for transportation to the emergency department for further evaluation and assessment.In a non-emergency situation, the primary physician will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the Medical Director will be contacted.Each attempt will be charted as to time the call was made, who was spoken to, and what information was given to the physician.Examples of Significant Changes:A sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior. Bleeding

Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 1 of 4 meals reviewed for food and nutrition services. (Lunch meal) The facility failed to ensure the menu was followed for the lunch meal on 03/23/2026. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.The findings included:Review of the facility's weekly menu, for Week 4, dated 03/12/2026 indicated the following menu plan:03/23/2026 Monday Lunch: Smothered Chopped steak, black-eyed peas, spinach, garlic cheese biscuit, sherbert, tableside condiments, water and choice of beverage. Review of the Menu board posted outside of the dining room on 03/23/2026 at 11:28 a.m. indicated the following: lunch menu for the day: spaghetti, tossed salad, vegetable blend, garlic cheese biscuit, and sherbert. No substitute or Everyday Menu posted in the dining room. There was no weekly menu posted in the dining room.During a dining room observation on 03/23/2026 at 12:30 p.m., residents were served spaghetti noodles, with spaghetti sauce (with ground meat in the sauce), tossed salad (lettuce and tomatoes), vegetable blend (carrots, green beans), garlic biscuit, beverage (tea or lemonade) and condiments. During an interview on 3/23/2026 at 3:00 p.m., the DM indicated the lunch meal for 03/23/2026 calendar a week at a glance included Smothered Chopped steak, black-eyed peas, spinach, garlic cheese biscuit, sherbert, tableside condiments, water and choice of beverage. She stated this menu was not served because the new supplier they recently changed too had not delivered the order and the DDM told her to prepare and serve spaghetti, tossed salad, vegetable blend, garlic cheese biscuit, and sherbert. The DM stated the residents had a right to know in advance what they were receiving for meals so they could choose an alternative if they did not like what was being served. She said that the weekly menu was in a frame up on the wall in the dining room but had fallen and the glass shattered and signage not replaced. She said the new supplier does have a weekly menu at a glance, everyday menu and substitute meals. She stated the registered dietician came in on 03/23/2026 and reviewed the weekly menu and was aware of the lunch menu change for 03/23/2026 but did not update the menu provided to the surveyor. She said that she would make sure that the weekly menu, everyday menu and available substitutes are posted in the dining room and provided to residents that do not visit or eat in the dining room. She said some residents would get upset if they were not served what the menu called for because they were either looking forward to it or they would have wanted to consider their options or decrease in nutritional health.During an interview on 03/25/2026 at 4:10 p.m., with the DDM, he said that new vendor/supplier had provided a menu when they changed suppliers. He said that the new menu was scheduled to be served but the supply truck was not delivered as planned so the lunch menu for 03/23/2026 had to be changed. He said he directed the kitchen staff to prepare spaghetti noodles, spaghetti meat sauce, tossed salad, vegetable blend, and roll/biscuit instead. He said the facility started using the new supplier and menus in March of this year. He said that the facility had decided to make the supplier change due to grievances from the resident council meetings. He said the menu change was approved by the registered dietician, but the weekly menu provided to the survey team was not updated. He said the dietary team have an alternate substitute menu, and everyday available menu. He said he was not aware that the alternate substitute menu, everyday available menu and weekly menu were supposed to be posted in the dining room. He said that he provided the weekly menu to the staff to be delivered to the residents' rooms. He said residents should be offered what is on the printed weekly menu or a substitute of equal nutritional value and residents should be notified of any alterations of the daily menu. He said that he would verify that the weekly menu, everyday available menu and substitute menu was posted in the dining room and available for other residents that do not visit the dining room. During an interview on 03/25/2026 at 4:30 p.m., with the Administrator, she reported she had been working with dietary staff and got a new food/meal supplier as of March 2026 and the supply truck had been delayed this week. She said she was not aware that the dietary staff changed the lunch menu on 03/26/2026 from the scheduled menu. She reported she will ensure the menus and meal preparations are carried out following the scheduled menus and if a change is required that notifications are provided. She said that she was aware that the daily menus, everyday available menu and substitute menus were to be posted in the dining room and provided to applicable residents. She said she thought that the weekly scheduled menu was posted in the dining room but was unable to locate the signage during a tour but did locate a weekly scheduled menu at the nurses' station on the self near the resident sign out book. She said changing the menus without notifications could cause residents to not know the meal and unable to request substitute if desired which could lead to unmeet nutritional needs and a decline in nutritional health status. Record review of the facility policy, Menus dated May 2014, indicated Policy Statement It is in the center policy that menus are planned in advance to meet the nutritional needs of the resident patience in accordance with the recommended dietary allowance of the National Research council and National Academy of science menus will be developed to meet the criteria through the use of an approved menu planning guide. Action Steps. 6. The menus are served as written unless changed in response to preference unavailability of an item or a special meal. 8. Menus are posted in the nutritional service department dining room and resident patient care areas.

Based on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors, for 3 of 8 residents (Residents #5, #4, and #10), reviewed for significant medication errors. * The facility did not ensure Residents #5, #4, and #10 did not receive Midodrine (medication used to raise the blood pressure) when there were parameters to hold the medication. This failure could place residents receiving medication to elevate the blood pressure at risk for stroke, hospitalization, and decreased quality of life.Findings included: 1. Record review of a face sheet dated 03/25/2026 indicated Resident #5 was a [AGE] year-old male admitted on initially admitted on [DATE] and readmitted [DATE]. His diagnoses included chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot supply enough oxygen to the blood, often due to underlying lung or systemic diseases), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), quadriplegia (is a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), Colostomy (an operation that creates an opening for the large intestine through the abdomen), neuromuscular dysfunction of the bladder (occurs when nerve or spinal cord problems disrupt communication between the brain and bladder, leading to loss of bladder control and urinary complications), resistance to multiple antibiotics (known as multidrug resistance, poses a significant global health threat, making infections harder to treat and increasing the risk of severe illness and death), atrial fibrillation (irregular heart rhythm). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #5 had Aa BIMS score of a 0 indicateding his cognition was severely impaired and had coronary artery disease (a common type of heart disease. It affects the main blood vessels that supply blood to the heart, called the coronary arteries. In coronary artery disease, there is reduced blood flow to the heart muscle. A buildup of fats, cholesterol and other substances in and on the artery walls, a condition called atherosclerosis, usually causes coronary artery disease. The buildup, called plaque, makes the arteries narrow.) Record review of Resident #5's care plan revision dated 09/25/2025 indicated Resident #5 had coronary artery disease (CAD) related to atrial fibrillation, hypercholesterolemia, HTN (hypertension). His interventions listed was administer all meds per MD orders. RX: Midodrine, give all cardiac meds as ordered by the physician. Monitor and document side effects. Report Adverse reactions to MD PRN, Monitor blood pressure. Notify physician of any abnormal readings Record review of physician orders dated 12/19/2025 thru 01/30/2026 indicated Resident #5 had an order for Midodrine 10mg three times a day related to atrial fibrillation (irregular heartbeat) hold for SBP > 110 (greater than). Record review of physician orders dated 01/30/2026 thru 02/24/2026 indicated Resident #5 had an order for Midodrine 10mg three times a day related to atrial fibrillation (irregular heartbeat) hold for SBP > 130 (greater than) and DBP >80 (greater than). Record review of physician orders dated 02/24/2026 thru current indicated Resident #5 had an order for Midodrine 10mg three times a day related to atrial fibrillation (irregular heartbeat) hold for SBP > 130 (greater than) and DBP >80 (greater than). Record review of the January 2026 MAR for Resident #5 indicated Midodrine (blood pressure medication that increases the blood pressure.) was given when it should have been held on the following dates:. -on 01/01/2026- SBP: 112; the 8:00 p.m., dose given by LVN F, -on 01/05/2026- SBP: 114; the 8:00 p.m., dose given by LVN F, -on 01/06/2026- SBP: 112; the 8:00 p.m., dose given by LVN H, -on 01/07/2026- SBP: 118; the 8:00 p.m., dose given by LVN F, -on 01/08/2026- SBP: 126; the 8:00 p.m., dose given by LVN F, on 01/09/2026- SBP: 115; the 8:00 a.m., dose given by LVN L, -on 01/09/2026- SBP: 141; the 8:00 p.m., dose given by LVN F, -on 01/10/2026- SBP: 138; the 2:00 p.m., dose given by RN O, -on 01/10/2026- SBP: 129; the 8:00 p.m., dose given by RN O, -on 01/11/2026- SBP: 137; the 8:00 a.m., dose given by RN O, -on 01/11/2026- SBP: 122; the 2:00 p.m., dose given by RN O, -on 01/12/2026- SBP: 112; the 8:00 p.m., dose given by LVN F, -on 01/13/2026- SBP: 122; the 8:00 p.m., dose given by LVN F, -on 01/16/2026- SBP: 115; the 8:00 p.m., dose given by LVN F, -on 01/20/2026- SBP: 125; the 8:00 p.m., dose given by LVN F, -on 01/22/2026- SBP: 128; the 8:00 p.m., dose given by LVN F, -on 01/23/2026- SBP: 1117; the 8:00 a.m., dose given by LVN L, -on 01/24/2026- SBP: 132; the 2:00 p.m., dose given by RN O, -on 01/24/2026- SBP: 122; the 8:00 p.m., dose given by RN O, -on 01/25/2026- SBP: 129; the 8:00 a.m., dose given by RN O, -on 01/25/2026- SBP: 136; the 2:00 p.m., dose given by RN O, -on 01/25/2026- SBP: 122; the 8:00 p.m., dose given by RN O, -on 01/26/2026- SBP: 126; the 8:00 p.m., dose given by LVN F, -on 01/27/2026- SBP: 132; the 8:00 p.m., dose given by LVN F, and -on 01/28/2026- SBP: 118; the 2:00 p.m., dose given by LVN H. Record review of the February 2026 MAR for Resident #5 indicated Midodrine was given when it should have been held. -on 02/08/2026- SBP: 133; the 8:00 p.m., dose given by RN O, -on 02/15/2026- SBP: 137; the 2:00 p.m., dose given by RN O, -on 02/17/2026- SBP: 119; the DBP: 86; the 8:00 p.m., dose given by LVN H, -on 02/25/2026- SBP: 129; the DBP:86; the 8:00 p.m., dose given by LVN J and -on 02/15/2026- SBP: 138; the 2:00 p.m., dose given by RN O. Record review of the March 2026 MAR for Resident #5 indicated Midodrine was given when it should have been held. -on 03/02/2026- SBP: 132; the 8:00 p.m., dose given by LVN P, -on 03/02/2026- SBP: 131; the 8:00 p.m., dose given by LVN P, -on 03/12/2026- SBP: 120; the DBP: 88; 8:00 p.m., dose given by LVN P, -on 03/18/2026- SBP: 130; the DBP: 82; 8:00 p.m., dose given by LVN P, -on 03/21/2026- SBP: 133; 8:00 p.m., dose given by RN O, and -on 03/21/2026- SBP: 131; 8:00 p.m., dose given by RN O. An interview was attempted 03/24/2026 at 11:15 a.m., with LVN J, a voicemail was left on her telephone. During an interview on 03/25/2026 at 11:49 a.m., with RN O, she said Midodrine is used to increase the blood pressure when it is low. She said she was aware that Midodrine had parameters and when a resident's blood pressure is outside of the ordered parameter then the blood pressure medication should be held. She said she should have held the Midodrine when Resident #5's blood pressure was out of the physician's ordered parameters. She said she was not aware that she had made the medication errors. She said the potential risk was a stroke. During an interview on 03/25/2026 at 12:45 a.m., with LVN P, she said she said she was not sure of what the medication Midodrine was used for. She said she assumed it helped with the blood pressure. She said Midodrine had a parameter for when to hold and when to give. She said she would hold the Midodrine if a resident's BP was 132/60. She said she should have held the Midodrine when his blood pressure was out of the parameters (hold for systolic blood pressure greater than 130 and hold for a diastolic blood pressure greater than 80). She stated I'll just be honest with you, I did not know what Midodrine was used for when I had administered, I thought it lowered the blood pressure she said she did not find out the use for Midodrine until two weeks ago from 03/25/2026 while working at the hospital. She stated, once I learned what the purpose of the medication Midodrine I realized I had been giving it when I should have held it. She said when she realized she had administered the Midodrine incorrectly she did not notify the DON. She said she did not report it earlier because she did not know she had made a medication error. She said once she became aware that she made a medication error, she did not report it to the DON or the physician. She said she did not know why she did not go back and report her error once she realized she made the error. She said she had read the parameters for Midodrine before she administered it. She stated I was confused on the medication and got the greater than and less signs backwards. She said she should have held the Midodrine when his bp was out of the parameter (hold for systolic blood pressure greater than 130 and hold for a diastolic blood pressure greater than 80.) She said she did not ask the DON or any other nurses for clarification on Midodrine. She said she did not know why she did not ask the DON or the other nurses for clarification on the medication. She said if the documentation reflects that she did not pay attention to the parameters for the Midodrine then that's what happened. During an interview on 03/25/2026 at 12:49 p.m., with LVN H, she said Midodrine is used to increase the blood pressure when it is low. She said she was aware that Midodrine had parameters and when a resident's blood pressure is outside of the ordered parameter then the blood pressure medication should be held. She said she should have held the Midodrine when Resident #5's blood pressure was out of the physician's ordered parameters. She said she was not aware that she had made the medication errors. She said she always reads the MAR's before administering medications. She said she could not recall the reason why she did not hold the Midodrine. She said the potential risk to Resident #5 was getting a medication he did not need. During an interview on 03/25/2026 at 1:00 p.m., with LVN F, she said Midodrine is used to increase the blood pressure when it is low. She said she was aware that Midodrine had parameters and when a residents blood pressure is outside of the ordered parameter then the blood pressure medication should be held. She said she was not aware that she had made the medication errors. She said the potential risk to Resident #5 would be his blood pressure staying elevated. During an interview on 03/25/2026 at 1:10 p.m., with LVN L, she said Midodrine is used to increase the blood pressure when it is low. She said she was aware that Midodrine had parameters and when a residents blood pressure is outside of the ordered parameter then the blood pressure medication should be held. She said she did not know why she did not hold the Midodrine. She said the potential risk to Resident #5 would be him potentially experiencing symptoms of high blood pressure. During an interview on 03/25/2026 at 1:16 p.m., with the DON, she said she did a medication audit for January 2026 and noticed the nurses had given Midodrine when it should have been held due to residents blood pressure being outside ordered parameters. She said she made the physician aware and received a new physician's order that increased the blood pressure parameters. She said she did not continue auditing monthly instead she audited every quarter. The DON said it is MA's and CNA's responsibility to ensure they administered medications according to the physician's order. She said she educated staff on ensuring they read and followed the physician's parameters. She said the associated potential risk was medication errors. During an interview on 03/25/2026 at 2:05 p.m., the Administrator said she expected staff to read and abide by the blood pressure parameters listed on the MAR. She said the associated potential risk was resident's experiencing symptoms of hypertension and medication errors. During an interview on 03/26/2026 at 12:20 p.m., the Physician/ Medical Director said, it was very important for nursing staff that administer medications follow the MAR. He said he was not aware that Resident #5 was given Midodrine several times when it should have been held. He said he expected staff to ensure they were administering medications as ordered to avoid medication errors and the potential of residents experiencing a stroke. Record review of the facilities policy titled Medication Error Reporting Protocol Identifying and Managing Medication Errors and Adverse Consequences date reviewed 3/3/2026 Indicated: Policy: Staff and Practitioners shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Protocol: 1. The staff and practitioner shall strive to minimize adverse consequence by: Following relevant clinical guidelines and manufacture's specifications for use, dose, administration, duration, and monitoring of the medications. Defining appropriate indications for use; and Deterring that the resident: 1. Has no known allergies to a medication Is not taking other medications, nutritional supplements, including herbal products, or foods that would be incompatible with the prescribed medication; and Has no condition, history, or sensitivity that would preclude use of that medication. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the DON/designee immediately. The staff shall complete the Medication Error report in its entirety, including appropriate notification of physician, etc. In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any related physician orders, and shall monitor the resident as indicated. 5. The Medical Director, DON and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility QA process.? Record review of the facilities policy titled Medication Administration Reviewed & Revised 3/5/2026 indicated: Purpose To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. General Standards 1. Only individuals licensed or legally authorized in this state may prepare, administer, and document medications. The Director of Nursing or designee supervises and oversees all personnel involved in medication administration. Staffing schedules are arranged to promote safe medication administration without unnecessary interruption. Medications are administered according to prescriber orders and within the ordered time frames. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 2. Record review of a face sheet dated 03/24/26 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypotension (a condition in which the force of the blood against the artery walls is too low). Record review of the quarterly MDS dated [DATE] indicated Resident #4 was understood by others and understood others. He had intact cognition with a BIMS of 15 out of 15. He had an active diagnosis of hypotension. Record review of the care plan for Resident #4 revised on 12/29/25 indicated a care plan dated 06/12/25 indicated he had hypotension with risk for changes in cognition and falls related to fluctuating blood pressures initiated on 06/19/23. Interventions included: - Give medications as ordered. Initiated 06/12/25; and - follow parameters set by MD for medication administration. Initiated 01/30/26 Record review of physician orders for March 2026 indicated Resident #4 had an order dated 03/25/26 for Midodrine 10mg every 8 hours related to hypotension hold for SBP greater than 130 or DBP greater than 80. Record review of the February 2026 MAR for Resident #4 indicated: - on 02/01-SBP was 136; the 09:00 a.m. dose was given; - on 02/02-SBP was 137; the 01:00 p.m. dose was given; - on 02/03-SBP was 135; the 01:00 p.m. dose was given; and - on 02/11-SBP was 142; the 01:00 p.m. dose was given. Record review of the March 2026 MAR for Resident #4 indicated: - on 03/02-SBP was 132; the 09:00 a.m. dose was given; - on 03/02-SBP was 135; the 09:00 p.m. dose was given; - on 03/05-SBP was 148; the 01:00 p.m. dose was given; - on 03/06-SBP was 132; the 09:00 a.m. dose was given; - on 03/09-SBP was 136; the 09:00 a.m. dose was given; - on 03/13-SBP was 133; the 01:00 p.m. dose was given; - on 03/16-SBP was 139; the 09:00 a.m. dose was given; - on 03/16-SBP was 138; the 01:00 p.m. dose was given; - on 03/19-SBP was 138; the 09:00 a.m. dose was given; - on 03/19-SBP was 140; the 01:00 p.m. dose was given; and - on 03/24-SBP was 140; the 09:00 a.m. dose was given. 3. Record review of a face sheet dated 03/24/26 indicated Resident #10 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypotension (a condition in which the force of the blood against the artery walls is too low). Record review of the quarterly MDS dated [DATE] indicated Resident #10 usually understood by others and usually understood others. He had severely impaired cognition with a BIMS of 04 out of 15. He had an active diagnosis of orthostatic hypotension. Record review of the care plan for Resident #10 reviewed on 02/02/26 indicated a care plan dated 06/19/23 indicated he had hypotension with risk for changes in cognition and falls related to fluctuating blood pressures initiated on 06/19/23. Interventions included: - Give medications as ordered. Initiated 06/19/23; - Monitor vital signs as needed. Notify MD of significant abnormalities. Initiated 06/19/23; and - follow parameters set by MD for medication administration. Initiated 01/30/26. Record review of physician orders for March 2026 indicated Resident #10 had an order dated 02/09/26 for Midodrine 10mg every 8 hours related to hypotension hold for SBP greater than 140 or DBP greater than 90. Record review of the February 2026 MAR for Resident #10 indicated: - on 02/21-DBP was 98; the 12:00 p.m. dose was given; - on 02/22-DBP was 92; the 12:00 p.m. dose was given; and - on 02/24-SBP was 145 and DBP was 91; the 07:00 p.m. dose was given. Record review of the March 2026 MAR for Resident #10 indicated: - on 03/10-SBP was 147; the 12:00 p.m. dose was given; - on 03/14-SBP was 147; the 12:00 p.m. dose was given; - on 03/16-SBP was 145; the 12:00 p.m. dose was given; - on 03/18-SBP was 151 and DBP was 104; the 12:00 p.m. dose was given; and - on 03/18-SBP was 154; the 07:00 p.m. dose was given.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 5 errors out of 31 opportunities, resulting in a 16.13% percent medication error involving 3 of 6 residents reviewed for medication pass. (Residents #6, #9, and #10) * LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass. * LVN A administered Metoclopramide (gastrointestinal stimulant/anti nausea) to Resident #9 on continuous enteral feeding during the medication pass. * MA C administered docusate sodium (stool softener) 100mg 1 capsule to Resident #6 when the physician order was for 2 capsule during the medication pass. * LVN G mixed GlycoLax (laxative) in water then mixed crushed gastrostomy tube medications for Resident #10 with the mixture during the medication pass. * LVN G flushed the gastrostomy tube with the GlycoLax mixture before medication administration and between medications during the medication pass. These failures could place residents at risk for inaccurate drug administration and/or drug cocktailing resulting in decline in health and decreased quality of life. Findings included:1. During an observation and interview on 03/24/2026 at 8:43 a.m. LVN A administered acetaminophen (pain reliever), metroclopramide (gastrointestinal stimulant/anti nausea), amlodipine (calcium channel blocker), aspirin (non-steroidal anti-inflammatory), carvedilol (beta blocker), furosemide (diuretic), losartan (angiotensin II receptor blocker),lactobacillus acidophilus (probiotic), multivitamin, Vitamin D3, and polyethylene glycol (laxative) via gastrostomy tube to Resident #9. LVN A did not flush the tube with water before administering the medications, did not flush the tube with water between each medication administered, and did not flush the tube with water after administering the medications. LVN A also administered Metoclopramide via gastrostomy tube. LVN A said she would not have done anything different. Record review of physician orders for March 2026 indicated Resident #9 had:- an order dated 11/10/25 for NPO, diet not applicable;- an order dated 11/10/25 for metoclopramide 10 mg via gastrostomy tube before meals and at bedtime; and- an order dated 01/22/26 flush gastrostomy tube with 70cc of water before and after medication administration and 30cc between each medication. During an interview on 03/25/26 at 09:30 a.m. LVN A said the order for metoclopramide should be clarified as to when to administer. She said she did not realize she did not flush the tube prior to and after the medication administration or between the medications. 2. During an observation and interview on 03/24/2026 at 5:05 p.m. MA C administered oral medications to Resident #6. MA C was observed obtaining 1 capseal of Docusate Sodium 100 mg and administering to Resident #6. MA C said she would not have done anything different. Record review of physician order For March 2026 indicated Resident #6 had an order dated 02/21/26 for Docusate Sodium Oral Capsule 100 mg 2 capsule by mouth two times a day. During an interview on 03/25/26 at 04:01 p.m. MA C said Resident #6 should have received 2 cap seals of Colace and not just one. She said she misread it. 3. During an observation and interview on 03/25/26 at 08:15 a.m. LVN F administered medications via gastrostomy tube to Resident #10. LVN F:- mixed 1 capful of GlycoLax (laxative) Oral Powder with 8 oz of water. - mixed 15cc of the GlycoLax mixture with each of his Lorazepam (benzodiazepine), docusate sodium (stool softener), hydrocodone-acetaminophen (pain medication), metoclopramide (gastrointestinal stimulant/anti nausea), and Vitamin C crushed medications instead of water. - flushed the gastrostomy tube prior to administering medications with 30cc of the GlycoLax mixture instead of water. - administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water. - administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water.- administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water- obtained water in a cup, administered the remaining medications with water flush between, and flushed the gastrostomy tube with 30cc of water after the medication administration. LVN F said she would not have done anything different. When surveyor asked if LVN F understood what drug cocktailing was, she said it was when medications were mixed and administered at one time. When asked if mixing the crushed medication with the GlycoLax/water mixture and flushing after each medication administration would be considered drug cocktailing, LVN F said yes it could be. Record review of physician orders for March 2026 indicated Resident #10 had:- an order dated 03/04/25 for NPO, diet not applicable; and- an order dated 02/27/26 flush gastrostomy tube with 30cc of water before and after medication administration and 10cc between each medication. Record review of an Administering Medications through an Enteral Tube policy and procedure reviewed 03/03/2026 indicated: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.General Guidelines Follow the medication administration guidelines in the policy entitled Administering Medications.1. Request liquid forms of medications from the pharmacy, if possible.2. Do not add medication directly to the enteral feeding formula.3. Administer each medication separately and flush between medications.6. Use water for diluting medications and for flushing.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure.5. Water for diluting medications;6. Water for flushing;.Steps in the Procedure.7. Stop feeding and flush tubing with at least 15 mL water(or prescribed amount).9. Dilute medication:a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute.b. Dilute crushed (powdered) medication with at least 30 ml water (or prescribed amount).c. Dilute liquid medication with 30 mL or more (depending on viscosity) purified water.10. Administer each medication separately.13. If administering more than one medication, flush with 15 mL water (or prescribed amount) between medications.14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of water (or prescribed amount). During an interview on 03/25/26 at 02:18 p.m. the DON said nurses should know how to administer medications through the gastrostomy tube correctly. She said gastrostomy tubes should be flushed with water before, after, and in between medications. She said they should not be flushed with medication in the water or mixed with water that had medication in it. She said medication should not be cocktailed because there could be a reaction of the medications mixed. She said the gastrostomy tube should always be flushed with water before medications, between medications, and after medications to ensure the tube was patent. She said MAs should administer the medications according to the physician orders. During an interview on 03/25/26 at 02:40 p.m. the Administrator said she expected the staff giving medications to know how to do it correctly and to follow the policy.

Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #9 and #10) reviewed for services provided to meet professional standards. 1. LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass.2. LVN G mixed GlycoLax (laxative) in water then mixed crushed gastrostomy tube medications for Resident #10 with the mixture on 03/25/26 during the medication pass.3. LVN G flushed the gastrostomy tube with the GlycoLax mixture instead of water before medication administration and between medications on 03/25/26 during the medication pass. These failures could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included:1. Record review of a face sheet dated 03/24/26 indicated Resident #9 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) left side, dysphagia (a condition that affects the ability to produce and understand spoken language), gastroparesis (a condition in which the muscles in the stomach don't move food as they should for it to be digested), and gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications). Record review of the quarterly MDS dated [DATE] indicated Resident #9 was rarely understood by others and sometimes understood others. She had moderately impaired cognition with a BIMS of 10 out of 15. She had a gastrostomy tube, received 51% or more calories through feeding tube, and received 501cc or more per day of fluid intake through feeding tube. Record review of the care plan for Resident #9 reviewed on 03/23/26 indicated a care plan dated 10/07/24 she required tube feeding related to dysphagia. Interventions included flush gastrostomy tube with 70cc water before and after meds and 30ccbetween each medication initiated on 03/06/2026. Record review of physician orders for March 2026 indicated Resident #9 had:- an order dated 11/10/25 for NPO, diet not applicable; and- an order dated 01/22/26 flush gastrostomy tube with 70cc of water before and after medication administration and 30cc between each medication. During an observation and interview on 03/24/2026 at 8:43 a.m. LVN A administered medications via gastrostomy tube to Resident #9. LVN A did not flush the tube with water before administering the medications, did not flush the tube with water between each medication administered, and did not flush the tube with water after administering the medications. LVN A also administered Metoclopramide via gastrostomy tube. LVN A said she would not have done anything different. During an interview on 03/25/26 at 09:30 a.m. LVN A said the order for Metoclopramide should be clarified as to when to administer. She said she did not realize she did not flush the tube prior to and after the medication administration or between the medications. 2. Record review of a face sheet dated 03/24/26 indicated Resident #10 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) left side, dysphagia (a condition that affects the ability to produce and understand spoken language), and gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications). Record review of the quarterly MDS dated [DATE] indicated Resident #10 usually understood by others and usually understood others. He had severely impaired cognition with a BIMS of 04 out of 15. He had a gastrostomy tube, received 51% or more calories through feeding tube, and received 501cc or more per day of fluid intake through feeding tube. Record review of the care plan for Resident #10 reviewed on 02/02/26 indicated a care plan dated 06/19/23 he required tube feeding related to dysphagia. Interventions included flush gastrostomy tube with 30cc water before and after meds and 10ccbetween each medication initiated on 06/19/23. Record review of physician orders for March 2026 indicated Resident #10 had:- an order dated 03/04/25 for NPO, diet not applicable; and- an order dated 02/27/26 flush gastrostomy tube with 30cc of water before and after medication administration and 10cc between each medication. During an observation and interview on 03/25/26 at 08:15 a.m. LVN F administered medications via gastrostomy tube to Resident #10. LVN F:- mixed 1 capful of GlycoLax Oral Powder with 8 oz of water. - mixed 15cc of the GlycoLax mixture with each of his 5 crushed medications instead of water. - flushed the gastrostomy tube prior to administering medications with 30cc of the GlycoLax mixture instead of water. - administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water. - administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water.- administered 1 of the medications, mixed residual medication in the cup with the GlycoLax mixture instead of water, flushing with the GlycoLax mixture between instead of water- obtained water in a cup, administered the remaining medications with water flush between, and flushed the gastrostomy tube with 30cc of water after the medication administration. LVN F said she would not have done anything different. When surveyor asked if LVN F understood what drug cocktailing was, she said it was when medications were mixed and administered at one time. When asked if mixing the crushed medication with the GlycoLax/water mixture and flushing after each medication administration would be considered drug cocktailing, LVN F said yes it could be. During an interview on 03/25/26 at 02:18 p.m. the DON said gastrostomy tubes should be flushed with water before, after, and in between medications. She said they should not be flushed with medication in the water or mixed with water that had medication in it. She said medication should not be cocktailed because there could be a reaction of the medications mixed. She said the gastrostomy tube should always be flushed with water before medications, between medications, and after medications to ensure the tube was patent. During an interview on 03/25/26 at 02:40 p.m. the Administrator said she expected the staff giving medications to know how to do it correctly and to follow the policy. Record review of an Administering Medications through an Enteral Tube policy and procedure reviewed 03/03/2026 indicated: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.General Guidelines Follow the medication administration guidelines in the policy entitled Administering Medications.1. Request liquid forms of medications from the pharmacy, if possible.2. Do not add medication directly to the enteral feeding formula.3. Administer each medication separately and flush between medications.6. Use water for diluting medications and for flushing.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure.5. Water for diluting medications;6. Water for flushing;.Steps in the Procedure.7. Stop feeding and flush tubing with at least 15 mL water (or prescribed amount).9. Dilute medication:a. Remove plunger from syringe. Add medication and appropriate amount of water to dilute.b. Dilute crushed (powdered) medication with at least 30 ml water (or prescribed amount).c. Dilute liquid medication with 30 mL or more (depending on viscosity) purified water.10. Administer each medication separately.13. If administering more than one medication, flush with 15 mL water (or prescribed amount) between medications.14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of water (or prescribed amount).

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 16 residents reviewed for notification of changes. (Resident #41). The facility failed to notify Resident #41's physician regarding the pattern of low blood pressure and of her low blood pressure medication being held for 14 out of 23 days for the month of March 2026. This failure could place residents at risk for complications due to delayed or failed physician intervention.Findings included:Record review of Resident #41's face sheet dated 03/25/2026 indicated she was a [AGE] year-old female admitted [DATE] with diagnoses of Alzheimer's disease with late onset (progressive disease that destroys memory and other important [NAME] l functions), dementia (loss of cognitive functioning), and hypertension (high blood pressure).Record review of Resident #41's quarterly MDS assessment dated [DATE] indicated a diagnosis of high blood pressure and a BIMS of 6. A BIMS score of 6 indicated she had severe cognitive impairment. Section GG0170. Mobility indicated she required substantial/ maximal assistance with activities of daily living. Record review of Resident #41's care plan dated 03/31/2026 indicated she had a diagnosis of hypertension (high blood pressure.) The goals listed were The resident will remain free of complications related to hypertension through review. Interventions listed were Avoid taking the blood pressure reading after physical activity or emotion distress. And Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Record review of Resident #41's medication administration record dated March 2026 indicated Olmesartan Medoxomil Oral Tablet 40 MG (Olmesartan Medoxomil) Give 1 tablet by mouth one time a day for hypertension HOLD FOR SBP >110 (less than 110), DBP >60 (less than 60). On the following dates, the dose of the Olmesartan Medoxomil Oral Tablet 40 MG was held when Resident #41's B/P was outside the parameters ordered by the physician: -On 03/02/2026 -SBP: 103 and DBP: 54 by MA N,-On 03/03/2026- SBP: 96 and DBP: 62 by MA N,-On 03/06/2026- SBP: 104 and DBP: 72 by MA N,-On 03/08/2026-SBP: 100 and DBP: 64 by MA N,-On 03/10/2026- SBP: 105 and DBP: 74 by MA N,-On 03/12/2026- SBP: 103 and DBP: 77 by MA N,-On 03/13/2026-SBP: 102 and DBP: 50 by MA N,-On 03/14/2026-SBP: 100 and DBP: 65 by MA K,-On 03/15/2026-SBP:102 and DBP: 73 by MA N,-On 03/16/2026-SBP:105 and DBP: 58 by MA K,-On 03/17/2026- SBP:107 and DBP: 54 by MA N,-On 03/19/2026- SBP: 100 and DBP: 62 by MA N,-On 03/20/2026- SBP:101 and DBP: 54 by MA N, and-On 03/22/2026- SBP:103 and DBP:68 by MA N. During an interview on 03/24/2026 at 12:05 p.m., MA N said she did not notify her charge nurse every time she held Resident #41's blood pressure medication. She said she could not recall the reason she did not inform her charge nurse. She said she did not notify the physician regarding the blood pressure medication being held. She said she should have when she noticed the trend. MA N said she was responsible as the assigned charge nurse so she could notify the physician that Resident #5 had his blood pressure medication held. She said the potential risk to Resident #5 was her receiving a medication she no longer needed. She said she had been trained to notify her nurse when she holds any medications. During an interview on 03/24/2026 at 12:25 p.m., MA K said she did not notify her charge nurse that she held Resident #41's blood pressure medication. She said she had been taught by the DON to notify her charge nurse, and DON if a medication had been held for a consecutive amount of days. She said she was responsible for notifying the assigned charge nurse that she held Resident #41's medication. During an interview on 03/24/2026 at 12:30 p.m., LVN L said MA K and MA N did not make her aware that Resident #41's blood pressure medication was held 14 out of 23 times because her blood pressure was outside of ordered parameters. She said it was her expectation for all MAs to make their charge nurses aware of any medications that were held so they could notify the Physician. During an interview and record review on 03/24/2026 at 12:45 p.m., the DON reviewed Resident #41's March 2026 medication administration record. The DON acknowledged that the Olmesartan Medoxomil was documented as held due to the prescribed parameters. She had been unaware of Resident #41's medications being held due to low results outside the parameters. She said best practice would be for nursing staff to notify the Physician when medications with parameters were held on consecutive occasions. The DON said the nursing staff should document in the resident's electronic record when notifying physician of medications being held and acknowledged Resident #41's electronic record gave no indication the physician had been notified of medications being held. Record review of the nurse's notes for Resident #41 dated from 03/02/2026 to 03/22/2026 indicated there was no documentation of the physician being notified that Resident #41's blood pressure medication was held. During an interview on 03/24/2026 at 2:00 p.m., the Administrator said her expectations were for the physician to be notified when a resident's medications were held, or at least every few times. The Administrator said she expected nursing staff to always follow physician orders, to notify of any changes in condition, and to document notifications.During an interview on 03/26/2026 at 12:20 p.m., Resident #41's Physician who is also the facilities Medical Director said he was not aware that Resident #41 had her blood pressure medication held 14 times as of 03/23/2026. He said he expected the MAs to report any medication they held to their charge nurse and for the charge nurse to make him aware after the 4th scheduled dose was held. He said if he had been made aware he would have reviewed her medications and discontinued the medication to prevent the potential of Resident #41 receiving a medication that was no longer needed.Record review of the facilities policy titled Condition & MD-Family Notification Revised date August 11, 2020, indicated Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories:A need to significantly alter treatment. PROCEDUREWhen any of the above situations exists, the licensed nurse will contact the resident's family and their physician.Calls will be made to the family. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called.The physician will be contacted immediately for any emergencies irrespective of the time of day.Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. Escalation of communication process: If the primary physician cannot\immediately be reached in any emergency, the Medical Director [NAME] be called. If the MedicalDirector cannot be reached; the charge nurse will make arrangements for transportation to the emergency department for further evaluation and assessment.In a non-emergency situation, the primary physician will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the Medical Director will be contacted.Each attempt will be charted as to time the call was made, who was spoken to, and what information was given to the physician.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #9) observed for dressing changes. * LVN A did not change gloves, sanitize/wash hands between glove changes, and touched clean items with dirty gloves when providing dressing change to Resident #9. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet dated 03/24/26 indicated Resident #9 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications). Record review of the quarterly MDS dated [DATE] indicated Resident #9 was rarely understood by others and sometimes understood others. She had moderately impaired cognition with a BIMS of 10 out of 15. She had a gastrostomy tube, received 51% or more calories through feeding tube, and received 501cc or more per day of fluid intake through feeding tube. Record review of the care plan for Resident #9 reviewed on 03/23/26 indicated a care plan dated 10/07/24 she required tube feeding related to dysphagia. Record review of physician orders for March 2026 indicated Resident #9 had an order dated 11/10/25 for every shift cleanse gastrostomy tube site with soap and water, pat dry, apply split gauze, and secure. During an observation and interview on 03/24/26 at 08:43 a.m. LVN A provided gastrostomy tube dressing change to Resident #9. After removing the dressing, she cleaned the area. She then without changing her gloves and performing hand hygiene obtained the clean dressing and applied it to the gastrostomy tube site. She said she would not have done anything different. During an interview on 03/25/26 at 09:30 a.m. LVN A said gloves were to be changed between dirty procedures and clean procedures. She said anytime gloves were changed hands were to be washed or use hand sanitizer prior to putting on clean gloves. She said clean items should not be touched with gloves used to clean a wound or gastrostomy tube site. She said she should have removed the gloves she used to clean Resident #9's gastrostomy tube site, sanitized her hands, and put on clean gloves before touching the dressing and applying it. She said using the same gloves could extend or worsen an infection if a resident had one. During an interview on 03/25/26 at 02:18 p.m. the DON said gloves should be changed between dirty and clean procedures. She said hand hygiene should be done between glove changes. She said clean dressings should not be touched with dirty gloves. During an interview on 03/25/26 at 02:40 p.m. the Administrator said she expected the staff providing dressing changes to know how to do it correctly and to follow the policy. Record review of a Handwashing/Hand Hygiene Residents policy dated 03/01/20 indicated: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Record review of CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 07/27/24 indicated: .When to change gloves and clean hands: * If gloves become damaged. * If gloves become soiled with blood or body fluids after a task. * If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. * If moving from one patient to another patient. * If they look dirty or have blood or body fluids on them after completing a task. * Before exiting a patient room.

Based on observation, interview, and record review, the facility failed to maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators reviewed for physical environment. 1. The facility did not maintain a working automated external defibrillator (AED - used during sudden cardiac arrest) for use in the administration of CPR. On [DATE], the AED was beeping, electrodes were not attached, and the machine had a red x indicating the AED was not in safe operating condition.2. The facility had not tested the AED according to the manufacture's guidelines from [DATE] to [DATE] (total of 23 days).These failures could place residents who had a full code status at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included:During an observation on [DATE] at 2:30 p.m., the only available AED for the facility was sitting in a holder that was attached to the wall outside of the nurse's station. The AED had a black zipped case and was intermittently beeping, electrodes were not attached and the machine had a red x indicator light on.During an observation and interview on [DATE] at 2:43 p.m., the DON removed the AED from the case and said the AED was beeping. The DON verified and said the AED electrode pads were not attached to the machine. She said the night nurses (LVN H and LVN J) were responsible for conducting readiness checks on the AED and documenting those checks which included checking for expired AED pads and evidence of machine functioning properly like not beeping and a green check mark to indicate ready to use. The DON said she was not aware that the AED was not ready for use. The DON said CPR included the use of the AED. The DON said 9/2025 the nurses were trained on the AED but the trainer used a different AED from what the facility had on had. She said if a resident experienced cardiac arrest during the time the AED was not functional, the facility would still be able to do CPR but not use the AED. The DON said the nurses were trained on AED but it was not the specific AED the facility uses and that nurses had CPR cards and training included AED. The DON stated she would get with the Administrator to either re-place the AED or figure out how to get it ready for use. DON said she would create a form to include what nurse is checking on the AED.During an interview on [DATE] at 3:42 p.m., the Administrator said she had not noticed that the AED electrodes were not attached, machine beeping or that there was a red x mark. The Administrator said the nighttime nurses were responsible for checking the AED and documenting the results every night. When a policy was requested, the Administrator stated she believed there was a policy, but she was not sure. The Administrator said if the facility did not have a policy on the AED they would use the manufacture's manual online. During an observation on [DATE] at 9:50 a.m., the AED was hanging on the wall outside of the nurse's station; the green check mark light, indicating operational readiness, was illuminated, the electrodes were attached, and the device was not beeping. During an interview on [DATE] at 3:30 p.m., LVN J said she worked the 10p-6a shift and she had not received instruction from the facility about how to check the current AED for readiness pads until yesterday from the DON. She said she would just check to make sure it was available part of the crash cart checklist. LVN J said she know to check for a green check mark which meant it was fine and put a check mark on her checklist, but if the green check mark was not on and it was a red x mark, that usually meant the AED was not functional and would get with the Administrator. LVN J said she now has a form to document green check mark and AED electrodes are attached. She said not having a functioning AED could maybe cause a delay in using the AED for CPR.During an interview on [DATE] at 4:52 p.m., LVN H she worked the 10p-6a shift and she had not received instruction from the facility about how to check the current AED for readiness pads until yesterday from the DON. She said she was not aware of the AED not functioning. LVN H said she would just check to make sure it was available part of the crash cart checklist. She said not having a functioning AED could maybe cause a delay in using the AED for CPR.Record Review of the facility form(old form) titled Crash Cart Checklist indicated a check mark in the box labeled AED#1. There was no indication a red x or green check mark, electrodes attached or beeping alert. The revised form(new form) included areas of current daily date, green check visible, no red x, pads present, battery ok, no beeping, issues and staff initials.Record Review of an undated list indicated 47 residents wished to be resuscitated in the event of cardiac arrest.Record review of on-line owner's manual for the [NAME] Fully Automatic AED Plus Administrator's Guide, obtained on [DATE] at 3:30 p.m., at https://www.[NAME].com/-/media/Product-Materials/product-manuals/aed-plus-fully-automatic/01/9650-0311-01-SF_G.ashx indicated: Safety Summary: Use the Fully Automatic AED Plus unit only as described in this manual. Improper use of the device can cause death or injury.DO NOT use or place the Fully Automatic AED Plus unit in service if the unit's status indicator window (located on the left side of the handle) displays a red X. DO NOT use or place the Fully Automatic AED Plus unit in service if the unit emits a beeping tone.Keep the electrode cable connected to the Fully Automatic AED Plus unit at all times.This device should only be used by properly trained individuals.If the device is stored outside the recommended environmental conditions, the electrode pads and/or batteries may be damaged or their useful life reduced.This device is intended for use by personnel who have been trained in its operation.Record review of the facility's policy titled Automatic External Defibrillator, dated [DATE] read in part: Policy the facility has Automatic External Defibrillator(AED) equipment available for emergency use.5. Follow manufacturer guidelines and operating procedures, including pre-programmed voices prompts for use of the AED.Maintenance. The Director of Nursing or designee will test and document the operating status of the AED in accordance with manufacturer's guidelines.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 1 of 5 residents (Residents #9) reviewed for unnecessary medications. The facility failed to hold Resident #9's Carvedilol (used to lower blood pressure) medication (for 2 administration) when the blood pressure was outside the prescribed parameters. These failures could place residents at risk for at risk for adverse reactions and decline in health condition .Findings included:Record review of Resident #9's face sheet indicated a [AGE] year-old female admitted on [DATE] with diagnosis of stroke affecting her left non-dominant side with paralysis, high blood pressure, and difficulty swallowing with a feeding tube. Record review of Resident #9's quarterly MDS assessment, dated 02/15/2026, indicated a BIMS score of 10 indicating Resident #9 was moderately impaired cognitively. Hypertension was included as one of Resident #9's diagnoses. She had difficulty swallowing with a feeding tube in place for nutrition, hydration, and medication administration. Record review of Resident #9's care plan revision date of 09/18/2025 indicated a diagnosis of hypertension. Interventions included Give medications for hypertension, monitor vital signs and notify MD of significant abnormalities, and assess for any side effects. Record review of Resident #9's physician orders indicated the following:Carvedilol Tablet 12.5 mg give 1 tablet via PEG-Tube two times a day related to hypertension hold if SBP less than 110 or heartrate less than 60 started on 11/11/2025. Record review of Resident #9's January and March 2026 MAR indicated the following:Resident #9 received Carvedilol 12.5 mg when the vital signs were outside the prescribed parameters:- 01/04/2026 at 8:00 a.m., the BP was 109/65 administered by LVN E.- 03/14/2026 at 8:00 a.m., the BP was 106/54 administered by LVN D. During observation and interview on 03/24/2026 at 10:10 a.m., indicated Resident #9 was lying in hospital bed, she was alert and no signs of distress were noted. Resident #9 did not mention any concerns regarding her Carvedilol (B/P medication) when she was asked if she had any issues regarding her medications. During an interview on 03/26/2026 at 2:15 p.m., LVN D said on 3/14/2026 at 8:00 a.m. she said that Resident #9 had several blood pressure medications and ask if she held the other B/P medications on that morning, she said if the other B/P medications were held then she must have just clicked the administered box by error and she would not have given just the one B/P medication if the B/P was below the set parameters. She said she received in-services from the facility especially regarding medication administration, unnecessary medications, medication errors and that she received in-services, and the consulting pharmacist had observed her do a medication pass. She said a negative effect if a resident received a medication that was not accurate would be a medication error and the resident could have received a dose that was not needed and caused her B/P to drop low. Attempted to contact LVN E for an interview, was unsuccessful on 3/24/2026 at 2:45 p.m. and 3/26/2026 at 2:30 p.m., left message with no return call. During an interview on 03/26/2026 at 3:00 p.m., the DON, Administrator, and Regional Nurse said the expectations were for all medications to be administered per physician orders including according to parameters. They said the Medication Aide or Nurse administering medications on the cart are responsible for following the physician orders written on the medication administration record. They said an adverse effect a resident could experience receiving a medication incorrectly would depend on the medication, but this failure could result in resident's blood pressure becoming lower. A facility policy titled Administering Medications revised dated August 2022 indicated the following. 4. Medications are administered according to prescriber orders and within the ordered timeframe.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 18 residents (Residents #56) records reviewed for resident assessments. The facility failed to ensure the discharge MDS assessment was completed and transmitted as required for Resident #56. This failure could place residents at risk of not receiving care and services as needed.Findings included: Record review of admission record for Resident #56, dated 03/26/2026, indicated Resident #56 was admitted on [DATE], was an [AGE] year-old female with diagnoses of ventricular premature depolarization (an early heartbeat originating from the heart's ventricles, causing a temporary disruption in the normal heart rhythm), dementia (loss of cognitive functioning), diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), anxiety (persistent and excessive worry that interferes with daily activities), high blood pressure, and muscle weakness. The admission record included the date of discharge was 11/22/2025. Record review of CMS system indicated Resident #56 had a resident assessment/ MDS record over 120 days old. Record review of Resident #56's discharge MDS assessment, dated 11/25/2025, indicated she was discharged on 11/22/2025 with 11/25/2025 as the completion date (Z0500B) the RN Assessment Coordinator signed assessment however the MDS was not transmitted. Record review of the electronic record for Resident #56's list of MDS assessments, dated 10/12/2025 to 11/22/2025, indicated the discharge MDS was signed and completed, but not transmitted. During an interview on 03/25/2026 at 1:00 p.m., the MDS Nurse said Resident #56's discharge assessment was completed and signed on 11/22/2025 and was batched and sent to software for submission to CMS. She said she was unsure why Resident #56's discharge was not transmitted to CMS as required. She reviewed Resident #56's discharge assessment and identified that the assessment had been labeled as do not submit to CMS in the transmitting process. She identified the error, after surveyor's intervention, and corrected the error and submitted Resident #56's discharge MDS as a modification on 3/25/2026. She said that she was responsible for verifying that the MDS was completed and accurate, including identifying which MDS was to be transmitted to CMS and changing the status. She said that was an entry error and Resident #56's discharge MDS should have been transmitted to CMS within 14 days after completion. During an interview on 03/26/2026 at 2:50 p.m., the DON said the MDS nurse was responsible for the timely completion and transmitting each MDS assessment to CMS. She said the expectations were for all MDS assessments to be completed accurately, timely, and transmitted to CMS as the MDS reflected the resident and necessary care and services provided. During an interview on 03/26/2026 at 2:55 p.m., the Administrator, and CCS said the MDS nurse was responsible for the timely completion and transmitting each MDS assessment to CMS. CCS said that the regional MDS staff monitors the facility MDS for completion and transmissions and report to each facility outstanding MDS, not sure how Resident #56's discharge MDS got missed. They said the expectations were for all MDS assessments to be completed accurately, timely, and transmitted to CMS as the MDS reflected the resident care and services provided. Record review of the facility's policy titled, MDS 5.1 Transmitting MDS Data, dated October 2025, indicated, . Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. - Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 (care plan completion date) + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B (Date RN Assessment Coordinator signed assessment as complete) + 14 days).

Based on observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 7 residents (Resident #1) reviewed for reporting. The facility failed to ensure LVN A reported injury of unknown origin found on Resident #1 to the Administrator on 06/20/2025. This failure could place residents at risk for injuries of unknown origin not being reported.Findings included: Record review of Resident #1's face sheet, dated 10/20/2025, indicated Resident #1 was a [AGE] year-old male with an initial admission date of 03/30/2023 and re- admitted on [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. His diagnoses included Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), seizure disorder (abnormal electrical activity in the brain leading to recurrent seizures.), autistic disorder (challenges in social communication and interaction, along with restricted and repetitive behaviors), cerebral palsy (a condition that affects movement and posture). In section B- (hearing, speech, vision) indicated Resident #1 was sometimes understood by others and at times could make himself understood to others. In section GG- (Functional abilities) indicated Resident #1 required setup assistance for chair to bed transfers and needed maximal assistance for dressing, and personal hygiene. Record review of Resident #1's nurses note, dated 6/20/2025 at 9:28 p.m., written by LVN A indicated, RP reported bruising to right upper arm. Healing bruise noted to right inner upper arm. Resident #1 unable to voice what happened. Will continue to monitor. Record review of grievance logs, dated 06/2025 and 07/2025, indicated there was no grievance report for Resident #1 regarding bruises underneath his right arm. Record review of incident reports, dated 06/2025 and 07/2025, indicated there was no incident report for Resident #1 regarding bruises underneath his right arm. During an interview and observation with Resident #1 on 10/30/2025 at 10:27 a.m., indicated Resident #1 was in his shared room with his dad playing with bedsheets. The surveyor attempted to have a conversation with Resident #1, he was unable to say his name, date, or how bruised he was. Resident #1 has a BIMS score of 03 indicating Resident #1 had severe cognitive impairment. During an interview and observation with Resident #1's RP, on 10/30/2025 at 10:30 a.m., indicated Resident #1 approximately had four half penny sized yellow-colored faded bruises underneath the upper part of his right arm (in the armpit region). He said he noticed the bruising under Resident #1's right arm in the armpit region on 06 /20/2025. Resident #1's RP said he did not know how the resident got the bruises and could not tell him what caused the bruises. Resident #1's RP said he immediately went to LVN A and reported the bruises. During an observation Resident #1's RP showed surveyor a picture of the faded bruising he found on Resident #1, with approximately four half penny sized yellow-colored faded bruises underneath the upper part of his right arm (in the armpit region). During an interview on 10/30/2025 at 11:15 a.m., the ADON said she had never received any reports from any staff member regarding Resident #1's bruising under his right arm. The ADON said she educated staff on reporting any marks or bruising of unknown origin. She said the Administrator should have been immediately contacted when the nurse received the bruising report from Resident #1's RP. She said the DON and ADON conducted in-services on when and how to report bruising of unknown origin. During an interview with LVN A on 10/30/2025 at 12:05 p.m. LVN A said Resident #1's RP reported to her Resident #1 had bruising to his right arm. LVN A said she assessed Resident #1 and saw he was not in distress nor acting outside of his normal behavior. LVN A said she asked Resident #1 how he was bruised. She said Resident #1 was unable to answer. LVN A said she made a nurse's note about the bruising. She said she did not report it to the ADON, DON, nor the Administrator because she did not know how the bruising occurred. LVN A said she had been trained on reporting bruises of unknown origin by the ADON. LVN A said she should have reported it to either the ADON, DON, or the Administrator immediately. She said not reporting potentially placed residents at risk for their bruises of unknown origin not getting investigated. An interview with the Administrator on 10/30/2025 at 12:46 p.m. indicated the Administrator said she was not made aware of bruising underneath Resident #1's right arm. She said Resident #1's RP did not report it to her. The administrator said it was her first time hearing Resident #1 had any kind of bruising. The Administrator said all staff had been in- serviced on reporting bruises of unknown origin. She said her expectation is for staff to report any kind of bruising of unknown origin immediately to her and the DON. The potential risk to the resident's if not done would be the facility would not be able to start an investigation. During an interview on 10/30/2025 at 12:50 p.m., the DON said no staff member nor Resident #1's RP reported to her Resident #1 had any kind of bruising. The DON said all staff had been in- serviced on reporting bruises of unknown origin. She said her expectation was for staff to report all bruises of unknown origin immediately to her and the Administrator. She said if bruising of unknown origin was not immediately reported to the Administrator (Abuse coordinator) could result in an ineffective investigation. An observation on 10/29/2025 at 10:00 a.m. indicated the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway. Record review of the facility's current Abuse Prohibition policy, dated 06/02/2025, indicated, INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Abuse Prohibition Program: The facility's abuse prevention program included the following components: Screening Training Prevention Identification Investigation Protection Reporting/ Response Reporting/Response:Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator. Identification:4. All incidences of unknown origin will be investigated.

Based on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to medication carts for 1 of 2 Nurse medication carts (Hall 100 Nurse Cart) reviewed for medication storage. LVN E failed to ensure the Hall 100 Nurse medication cart was kept locked and under direct observation where residents and unauthorized staff could not access it when left at the main nurse's station for six minutes.This failure could place residents at risk of unauthorized persons, as well as residents, at risk of gaining access to unlocked medications that were not prescribed to them.Findings included:Observation on 10/29/25 from 5:20 p.m. to 5:26 p.m., indicated the Hall 100 Nurse medication cart was noted to be unsecured and unsupervised at the main nurse station. The Hall 100 Nurse medication cart was front facing with the drawers facing the hallway with the lock mechanism out (indicating it was unlocked). At 5:27 p.m. the state surveyor notified LVN E, who was coming out of a closed door halfway down 100 hall and approximately 100 feet away from the unlocked 100 hall nurse medication cart. Further observation of 100 hall nurse cart with LVN E, indicated inside the medication cart Drawer #1 were accu-check strips and glucometers, OTC (over the counter) aspirin, vitamins, minerals and eye drops. Drawer #2 had a locked compartment with several controlled substances, and multiple resident's individual medication bubble-blister packets.During an interview on 10/29/25 at 5:30 p.m. LVN E said she was in charge of the cart. LVN E turned around, went to the cart and said she was sorry for leaving the cart open and she was the person responsible for administering medications on the 100 hall and used the cart. LVN E said she was in a room talking with a resident with the room door closed and the cart was out of her line of site. LVN E said she forgot to lock the cart before she stepped away from it. LVN E said the cart should not be unlocked and unattended because anyone walking by could get into the medications and risk medication theft or diversion. LVN E said she was in-serviced this year to keep the medication cart locked at all times when not in use. During an interview on 10/30/25 at 12:45 p.m., the DON said she expected the nurses to follow the facility values, policy and procedure related to medication pass and drug safety. She said the medication carts should be locked if staff walked away from it or turned their back to it. The DON stated she was responsible for making sure the nurses locked the carts because of risk for misappropriation of property. The DON said she made random rounds daily and checked to make sure nurses locked their medication carts. She said she had in-serviced nursing staff to keep the medication cart locked at all times. She stated nurses were trained during orientation, annually and as needed, on medication administration and securing meds.During an interview on 10/30/25 at 1:00 p.m., the Administrator said the expectation was that staff would follow medication safety policy and procedures to lock and secure the medication carts when not in use. She said all nursing staff were responsible for securing medications when not in use. She said the potential risk of unsecured medication cart was medication safety.Record review of the facility's Storage of Medication policy and procedure, dated 6/24/25, indicated , Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments.3. The nursing staff is responsible for maintaining storage and preparation areas.8. Compartments (including, but not limited to , drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. 12. Only persons authorized to prepare and administer medications have access to locked medications.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents.The facility failed to provide adequate supervision with Resident #1 on 08/11/2025 while completing perineal care in bed. CNA A provided perineal care and Resident #1 rolled off the bed to the floor. Resident #1 initially complained of pain in his right arm after this fall. Resident #1 was sent to the hospital for further evaluation on 08/11/2025.The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began.These failures placed residents at risk for hospitalization, harm and serious injury. Findings included: Record review of Residents #1's face sheet reflected a [AGE] year-old male with an admission date of 5/05/2025. Resident #1's diagnoses included morbid obesity, need for assistance with personal care, and lack of coordination. Record review of Resident #1's Optional State Assessment MDS, dated [DATE], indicated Resident #1 had a BIMS score of 12 (moderate cognitive impairment). It indicated under functional status; his bed mobility was a number 3 (2 + persons physical assist). Record review of Resident #1's Care Plan Report dated 04/07/2025 indicated, The resident is at risk for falls. This care plan did not specify how many staff were to assist the resident. Record review of Resident #1's order summary, dated 11/19/2025, indicated a pressure redistribution mattress to bed every shift with a start date of 12/17/2024. Record review of the Provider Investigation report, dated 08/15/2025, indicated on 08/11/2025 the resident was receiving care from the CNA, who reported that peri-care had been nearly completed, and a clean brief was being applied when the resident unexpectedly rolled out of bed. The CNA immediately called for assistance. The charge nurse responded promptly. The resident was found lying on his abdomen, face forward on the floor. A head-to-toe assessment was conducted, and vital signs were obtained. No visible skin abnormalities were noted, and vital signs were within normal limits. With the assistance of two staff members and a (name of brand) lift, the resident was safely transferred back to bed. At that time, the resident voiced pain in his right arm. A PRN dose of Tylenol was administered for discomfort. The physician was notified of the fall. Orders were received for X-rays of the skull, right knee, bilateral (both sides) tibia/fibula (lower legs), bilateral shoulders and arms, right ribs, and both feet. The resident's [family member] was contacted by both the charge nurse and the DON. The [family member] consented for the resident to remain in the facility for X-ray imaging. X-ray results were received, showing acute fractures of the right 5th and 6th ribs. The [family member] was notified of the results and requested the resident be sent to the hospital for further evaluation. The resident was transferred to (hospital name) in (name of city), TX. Approximately six hours later, the resident returned to the facility. Hospital documentation indicated no fractures but confirmed osteoporosis. Both the physician and the resident's [family member] were updated accordingly. Record review of the mobile x-ray radiology interpretation, dated 08/11/2025, indicated .the acute right 5th and 6th rib fracture is present. No other fractures were mentioned in this report. Record review of hospital record diagnostic imaging report, dated 08/11/2025, did not state whether there were rib fractures or not. It stated the resident was there for bilateral knee pain and pain after fall.and pain after trauma. The x-rays provided stated no acute findings for chest, spine, head, and knees. Record review of the Medical Director's statement dated 11/20/2025 revealed he reviewed the hospital x-rays and there were no findings of rib fractures. In an interview on 11/19/2025 at 9:54 AM and 11/21/2025 at 9:13 AM with CNA A, it was revealed he changed Resident #1 by himself, and he rolled off the bed. He is a big boy and does not normally inch to either side. He stated he gained no injuries, that I know of. He stated, I heard he was really sore the next day. CNA A stated he was suspended immediately after the fall. He stated at the time the Kardex (electronic health record section that includes how residents are assisted) had Resident #1 as one assist for bed mobility. After the fall, everyone was re-trained, and it was changed to 2-assist. He stated anyone that provided direct care to residents should verify how residents were assisted in the Kardex. He stated the DON and the Administrator provided training to the staff. CNA A stated if the protocol was not followed for assisting a resident, it could cause an injury to the resident or to the staff member that was providing assistance. In an interview on 11/19/2025 at 10:40 AM and 11/21/2025 at 9:08 AM with LVN B, it was revealed she did not think Resident #1 had injuries after that fall. LVN B stated nurses and CNAs were to look up in the electronic health record how residents should be assisted. LVN B stated the resident could fall and get hurt or the staff member assisting could get hurt. She stated, It is very dangerous. In an interview on 11/19/2025 at 1:18 PM with the Administrator and the DON revealed CNA A was suspended immediately. The Administrator stated he was retrained before he returned to work. The Administrator stated before the fall, Resident #1 was one assist in the Kardex. After the fall, they did a complete audit of their Kardex, Care Plans, and MDS assessments, and found they did not all match. The Kardex had one-assist, and the care plan and MDS had two-assist for Resident #1. They have fixed the discrepancy in the three areas. The DON and the Administrator both stated they were told there were no rib fractures in the report given by the hospital. In an interview on 11/19/2025 at 2:32 PM with Resident #1 revealed he was in a lot of pain after his fall. He stated, his chest and knees hurt. He stated he did not have rib fractures, and he had not had any incidents since that fall. In an interview on 11/21/2025 at 9:32 AM with the DON revealed CNA's and nurses assisted residents for bed mobility. She stated the DON and physical therapy provided in-services over transferring and bed mobility to staff. The expectation was for staff to use proper equipment, right number of staff, and ensure safety. The DON stated, the Kardex should be viewed by staff to determine a resident's level of assistance. She stated not providing the correct assistance could cause injury to self or patient. In an interview on 11/21/2025 at 10:34 AM with the Administrator, it revealed the Kardex was the main place for staff to look for the required assistance for each resident. She stated the CNA or anyone providing direct care was responsible for looking at the Kardex. She stated the DON and the ADON were responsible for training staff about transfer and bed mobility. LVN C was responsible for ensuring all three areas matched in the electronic health record. She stated LVN C was very new and needed to be educated in this area. She stated LVN C knows now that all three records need to be checked to ensure they have the same information. The Administrator stated the resident being transferred incorrectly or incorrect bed mobility being done could put the resident at harm and potential for falls. In an interview on 11/21/25 at 11:18 AM with LVN C, it was revealed she was a new care plan nurse and was still learning. She stated the Kardex, MDS, and the Care plan did not match up. She has since been re-trained. The possible outcome for a resident that was not transferred properly could be a fall or injury to the resident. Record review of the facility's Safe Handling and Moving Protocol policy, dated 07/18/2018, indicated .ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident.expectations of assessment and communication.in order to ensure accurate level of assistance is communicated the charge nurse will notify current floor staff providing care;.via Electronic Health Record ADL and care guide set up.precautions and considerations.bariatric needs (obesity). The Administrator was notified on 11/19/25 at 2:00 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 08/11/2025. The facility took the following actions to correct the non-compliance on 08/11/2025: Record review of a document titled Ad Hoc QAPI dated as signed off on 08/11/2025 revealed these interventions were put in place before this surveyor's entrance on 11/18/2025. Issues: Resident #1 fell from bed while peri care was being provided by CNA. No injuries noted per hospital evaluation. Immediate actions:- Resident #1 received full head-to-toe assessment.- Resident #1 interviewed regarding fall.- The facility obtained statements from the AP and was suspended pending an investigation.- X-ray ordered per MD.- Family and MD notified.- Risk Management completed.- Immediate In-services initiated:-Neglect-Safe Peri Care and bed mobility for high-risk residents-Kardex Utilization- Comprehension quizzes completed after the in-services.- Life satisfaction rounds- Peer reviews and witness statements gathered.- Police were notified.- Ombudsman notified.- The residents care plan and Kardex were updated immediately to specify 2-person assist for peri care and bed mobility.- Facility wide care plan and Kardex audit were completed for required transfer assistance.- Ongoing monitoring was initiated for 7 days, followed by weekly checks for four weeks. - Spot checks were completed and corrective actions taken, if needed Record review of in-service trainings titled, Abuse, Neglect, and Resident Rights, Training on Neglect and Prevention Response, Safe Peri-Care and Bed Mobility for High-Risk Residents, and Abuse, Neglect, and Drill Evaluation were all completed with signatures on 08/11/2025. All trainings included CNA A's signature. Interviews conducted all shifts beginning on 11/19/2025 at 9:42 AM through 11/21/2025 at 11:30 AM with the following staff CNA A, LVN B, LVN C, LVN D, CNA E, CNA F, MA G, CNA H, LVN I, LVN J, CNA K, CNA L, the Administrator, and the DON indicated they knew where to find how residents were to be transferred or level of bed mobility. The staff were able to verbalize understanding and information provided in the in-service/training. Record review of the facility folder that included all of the Facility Provider Report documentation included statements by resident and staff, x-ray results, risk management documentation, comprehension quizzes, all completed in-services, life satisfaction rounds, documentation of police and ombudsman notification, and complete audit documentation of Kardex, care plan, and the MDS assessments. Record reviews of random sample residents (Resident #1, Resident #2, Resident #3, and Resident #4) found no inconsistencies between the MDS, the Care Plan, and Kardex between 11/18/2025 through 11/21/2025. An observation of perineal care and bed mobility was completed on 11/19/2025 at 1:34 PM by CNA K and LVN J, no noncompliance found during this observation. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry area observed for infection control. The facility failed to ensure that dirty and clean linen had a separation of the airflow in the laundry. These failures could place the residents at risk of cross-contamination and the development of infection. Findings included: During an observation on 01/15/25 at 8:39 a.m., the laundry area had a shear curtain between the clean and dirty linen. The air flow was not prevented from dirty to clean linen by the thin sheer curtain 2 foot by 4 feet and left opening on the bottom of the doorway an approximate 3-foot area not covered at all. During an interview on 01/15/25 at 8:45 a.m., the Laundry Supervisor said had requested for rubber curtain flaps back in November 2024 from the maintenance department. She said she was responsible for the laundry. She said the rubber flaps could prevent cross contamination. During an interview 0n 01/15/25 at 11:00 a.m., the Administrator said she was not aware of the laundry needing rubber curtain flaps. She said the rubber curtain flaps were here and had been put up after surveyor intervention. Record review of the Laundry Operations dated 06/2016 indicated . The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen.

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary Staff A and Dietary Staff B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food. Findings included: During an observation and interview on 01/13/25 at 7:55 a.m., while preparing meal for residents in the dining room Dietary Staff A's hair was not totally contained in a hair restraint, at the back of the neckline. The hair restraint did not cover approximately 3 inches of the lower neckline. The Dietary Manager said the dietary staff's hair should have been completely contained. She informed Dietary Staff A her hair needed to be adjusted in a hair restraint after surveyor intervention. During an observation on 01/13/25 at 10:30 a.m., Dietary Staff A's hair remained outside of hair restraint at the neckline. Dietary Staff A was preparing tray carts for noon meal. During an observation and interview on 01/13/25 at 11:20 a.m., Dietary Staff A's hair was not completely contained in a hair restraint at the neckline. The hair restraint did not completely cover approximately 2 inches of the lower neckline. Lunch trays were being prepared for residents' meal. Dietary Staff A said she had been employed at facility approximately one month and had been trained on hair hygiene. During an observation and interview on 01/14/25 at 7:45 a.m. and 8:15 a.m., Dietary Staff B's hair was outside of the hair restraint with approximately 3-inch sprigs of hair eluding from the ears to neckline area. This occurred while preparation for breakfast meal was occurring in food service area. Dietary Staff B said she had been trained on hair restraint hygiene. The Dietary Manager acknowledged stated Dietary Staff B's hair had not totally been contained in a hair restraint and should have been. During an interview on 01/14/25 at 8:25 a.m., the Dietary Manager said her expectations were for all dietary employees to have their hair completely contained in hair restraints while involved with food preparation and serving from the kitchen. She said unsecured hair could play a role in hair landing in food while being prepared. During an interview on 01/15/25 at 11:15 a.m., the Administrator said her expectations were for dietary employees to have their hair completely contained in hair restraints while preparing food and meals for residents. She said hair that was not restrained could land in the food and was unsanitary. A facility policy dated October 2023 titled Staff Attire indicated All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 2 of 4 linen/storage rooms (Hall 2 and Hall 3), 2 of 4 hall's ceiling vents (Hall 3 and Hall 4), and 1 of 1 nurses' station ceiling area reviewed for physical environment. The facility failed to maintain the ceiling in the Hall 2's linen/storage room. The facility failed to maintain the ceiling in Hall 3's linen/storage room and prevent odor. The facility failed to maintain the ceiling above 1 of 1 nurse's station free of stains. The facility failed to maintain the vent and ceiling around the vents on Hall 3. The facility failed to maintain the vents and ceiling around the vents on Hall 4. (2 of 3 vents) These failures could place residents, staff, and visitors at risk of being in unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility. Findings included: During observations on 01/13/25 from 8:15 a.m. to 9:35 a.m., the following were observed: -The white ceiling above the 1 of 1 nurse's station had an area 2 feet by 2 feet of brown and yellowish stains around the vent and another area had an approximately 4-inch circle in the ceiling with an open area in the sheet rock. -On Hall 4, two of 3 vents were discolored around the vents in the ceiling. The vents had a grayish substance which extended on the ceiling 2-3 inches. During observations on 01/13/25 from 9:50 a.m. to 11:00 a.m., the following were observed: -Hall 3's linen storage room was not being used but there was a section of the ceiling that had been removed approximately 4 by 6 foot leaving the attic exposed. The section of the ceiling 3 by 6 foot which remained was covered with grayish black spots and the linen room had a musty smell. The top shelf was covered with a thick black substance which extended up the corner of the shelf. -Hall 2's linen/supply closet had a hole approximately 4 inches and water damage noted on the ceiling. During an interview on 01/13/25 at 1:00 p.m., the Maintenance Supervisor said the water damage happened back in October and November 2024, from the AC duct work sweating. He said the facility received bids but had not decided on the plans for fixing the duct and the sheet rock repairs needed. He said the repairs needed to be done to make the building look better. During an interview and observation on 1/15/25 at 11:45 a.m., the Administer observed the areas, and she took pictures indicating she would get with the regional corporate maintenance and see what their plans were. She said they had received bids in November 2024 work on the water damage. She said the bids were sent to the corporate office. The Administrator said her expectation was for the building to be maintained and would provide the survey team with the policy about maintaining the environment. During an exit interview on 1/15/25 at 1:30 p.m., the Administrator said she was unable to find a policy on maintaining the environment.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 2 of 20 residents (Resident #2 and #13) reviewed for environment. The facility failed to maintain a sanitary and comfortable homelike environment for Resident #2 and Resident #13's rooms. This failure could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment. Findings included: 1. Record review of Resident #2's face sheet dated 01/15/25 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses of bi-polar (disorder associated with episodes of mood swings), anxiety (mental health disorder with feelings of worry and fear) and depression (common mental disorder with loss of pleasure). Record review of the MDS significant change assessment dated [DATE] indicated Resident #2 BIMS (cognitive screening measure assessment) score was 13, which indicated he was cognitively intact. During an observation on 01/13/25 at 9:20 a.m., the Resident #2's room had discoloration (grayish to black spots) that extended out and around the light switch on the wall and electrical receptacle on the wall above the built in dresser drawers. There were 2 areas grayish black spots along left side of the door frames which were 1 by 6 inches of the room. During an interview on 1/15/25 at 9:30 a.m., Resident #2 said that the black and gray spots on the walls been there since he moved in. He said he would like the areas to be painted. 2. Record review of Resident#13's face sheet dated 01/15/25, indicated Resident #13 was a [AGE] year-old male admitted to the facility on [DATE]. Resident#13 was diagnosed with major depressive disorder (mental illness with persistently depressed mood) and chronic obstructive pulmonary disease (lung diseases that block airflow and make it hard to breath). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #13 was cognitively intact with a BIMS score of 14. During an observation on 01/14/25 at 9:40 a.m., Resident #13 had discoloration (grayish to black spots) that extended out and around the light switch on the wall and electrical receptacle on the wall above the built in dresser drawers. There were 2 areas grayish black spots along left side of the door frames which were 1 by 6 inches of the room. During an interview on 1/14/25 at 9:45 a.m., Resident #13 said his room had black and gray spots on the walls for months. He said an unnamed housekeeper would wipe around the door frame with a bleach rag. He stated, the mildew just comes back, and it needs to be fixed the right way. During an interview and observation on 1/15/25 at 11:45 a.m., the Administrator observed the areas, and she took pictures indicating she would get with the regional corporate maintenance and see what their plans were. She said they had received bids in November 2024 work on the water damage. She said the bids were sent to the corporate office. She said the areas in the resident's rooms would need to be fixed also and said she was unsure why that happened. The Administrator said her expectation was for the building to be maintained and would provide the survey team with the policy about maintaining the environment. During exit on 1/15/25 at 1:30 p.m., the Administrator said she was unable to find a policy on maintaining the environment.

Based on interviews and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 16 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from sexual abuse on 08/28/24 and 09/02/24. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 11/19/24 indicated he was a [AGE] year-old male admitted on [DATE]. His diagnoses included unspecified intracranial injury without loss of consciousness (brain injury), major depressive disorder (mental disorder), and other sequelae of non-traumatic intracerebral hemorrhage (causes of stroke). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he had unclear speech, was rarely/never understood, usually understood others, had severely impaired cognitive skills, and utilized a wheelchair for mobility. Record review of Resident #1's electronic care plan dated 08/23/24 did not address sexually inappropriate behaviors. Record review of Resident #1's incident report dated 08/28/24 indicated Resident #1 was noted leaning against another resident (Resident #2) with his face at breast level flicking Resident #2's breast. Resident #1 was removed from the TV room and taken to his room. MD and RP notified. DON B documented If resident is brought to common areas, resident is to be kept away from other female residents. Record review of Resident #1's incident report dated 09/02/24 indicated Resident #1 had his hand down a female resident's pants/briefs. DON B documented Resident #1 was removed from the area and taken to his room and placed on 1 to 1. The MD, RP, and police were notified. Resident #1 had his fingers in Resident #2's brief with pinky and palm visible outside of brief. Police notified the administrator that Resident #1 had a warrant out for his arrest. Record review of the facility investigation dated 09/04/24 indicated after police notification on 09/02/24 and prior to his discharge on 09/04/24, Resident #1 was arraigned by a judge in the facility for an outstanding warrant in another county for continuous sexual abuse of a child under [AGE] years. Record review of Resident #1's progress note dated 09/04/24 at 1:00 p.m. and completed by LVN P indicated Resident #1 discharged home with Family Member R. Record review of Resident #2's face sheet dated 08/28/24 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral palsy (movement disorder), anxiety disorder (feelings of fear, dread, or uneasiness), conversion disorder with seizures or convulsions (mental health issue disrupts how the brain works), epilepsy (seizure disorder), and microcephaly (small head). Record review of Resident #2's progress note dated 08/28/24 at 2:03 p.m. completed by previous DON B indicated another resident was noted flicking Resident #2's breast in the TV room. Resident #2 was removed from the TV room, a skin assessment was completed, no psychosocial harm to resident. MD was notified and responsible party was called. Record review of Resident #2's care plan dated 08/28/24 indicated there was a report of alleged inappropriate flicking of her breast by a male resident while she was watching TV, in the TV room. Interventions included staff were to monitor and ensure accused perpetrator was not in the area of Resident #2. Record review of Resident #2's progress note dated 09/02/24 at 7:35 p.m. completed by LVN S indicated Resident #2 was in her wheelchair at the nursing station with another resident's hand inside Resident #2's pants/brief. Resident #2 was taken with LVN S to be monitored. Resident #2 was assessed head to toe. ADON, DON B, RP were notified. Telemed visit completed by NP DD. Record review of Resident #2's care plan dated 09/02/24 indicated staff observed a male resident with his hand inside the top of Resident #2's pants while she was seated in her wheelchair. Interventions included monitoring for psychological distress. Record review of Resident #2's progress note dated 09/02/24 at 9:17 p.m. completed by NP DD indicated Resident #2 was awake and alert and non-verbal at baseline. Resident #2 was assessed head to toe and no visible injures or distress noted. Nursing to continue to monitor Resident #2 for any changes or signs of distress. Record review of Resident #2's progress note dated 09/03/24 at 4:30 a.m. completed by LVN EE indicated Resident #2 continued to yell in room. Resident #2 was assisted up to her wheelchair and moved to nursing station with her tablet for activities. Resident #2 was closely monitored by staff. Record review of Resident #2's progress note dated 09/03/24 at 8:33 a.m. completed by DON B indicated she spoke to NP DD regarding Resident #2. Resident #2 continued to holler out but resident was at her baseline. NP DD said to continue to monitor and notify MD of any changes. Record review of Resident #2's progress note dated 09/05/24 at 1:00 a.m. completed by LVN EE indicated Resident #2 continued to scream and yell and was one on one with the nurse. Notified physician. Received one time dose of Lorazepam and new referral for psych consult. Record review of Resident #2's social service note dated 09/05/24 at 2:30 p.m. completed by the Administrator indicated a psych services referral was made. Social worker will continue Resident #2's status. Record review of Resident #2's psych evaluation dated 09/08/24 at 2:46 p.m. completed by LVN I indicated the resident was assessed by psych services and there were no new orders. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she was rarely/never understood, usually understood others, had severe cognitive impairment, utilized a wheelchair for mobility, and was dependent on all ADLS. During an interview on 11/19/24 at 11:45 a.m., previous Administrator C said he was standing at the nurse's station with the maintenance staff on 08/28/24 (after the lunch meal). He said he observed that Resident #1 and Resident #2 were in the TV room common area. He said Resident #1's head was near Resident #2's breast, between the breast and armpit area. He said Resident #1 was flicking with his fingers between the breast and armpit area. He said Resident #1 was removed from the common area. He said the residents were assessed and there were no injuries. He said a care plan should have been developed and implemented on 08/28/24 to prevent further inappropriate sexual behaviors from Resident #1 and to protect Resident #2. He said a second incident occurred on 09/02/24 when Resident #1 was found with his fingers inside Resident #2's pants. He said Resident #1 had been brought from his room to the TV room common area and was watching TV. He said Resident #2 was near the nurse station. He said LVN I left the nurse's station to care for another resident. He said ADON J returned to the nurse's station area and observed Resident #1 had his fingers inside of Resident #2's pants. Previous Administrator C said Resident #1 and Resident #2 were immediately separated. He said Resident #1 was placed on 1 to 1. He said the residents were assessed and there were no injuries. He said the police were notified. He said the police requested the residents' face sheets. He said he received a call within 10 minutes of providing the face sheets to the police and was informed that the police had been looking for Resident #1, for the previous 6 months, as Resident #1 had an outstanding warrant for continuous sexual abuse of a child under the age of 14. He said Resident #1 remained on 1-1 supervision until he was arraigned by a judge (while at the facility). He said Resident #1 was discharged on [DATE] with Family Member R. During an interview on 11/19/24 at 12:36 p.m., ADON J said Resident #1 was not supposed to be around Resident #2. She said she could not recall if he was not supposed to be around all females. She said she could not recall any specific training regarding Resident #1's supervision or monitoring his behavior. She said she was working on 09/02/24. She said Resident #1 repeatedly left his bed and put himself on his floor. She said staff assisted him in his wheelchair and he was brought to the TV room common area. She said Resident #1 was adjacent to the nurse's station. She said she left the nurse's station to continue her duties and when she returned to the nurse's station area, she observed Resident #1 with his fingers inside Resident #2's pants. She said the residents were immediately separated. She said Resident #1 was resistant to moving his hand out of Resident #2's pants. She said she had to physically move his hand and arm away from Resident #2. She said Resident #1 was immediately placed on 1-1 supervision until he was discharged on [DATE]. She said she did not know how Resident #1 was left unsupervised. She said there were no current residents in the facility with identified sexually inappropriate behaviors. During an interview on 11/19/24 at 12:52 p.m., CNA D said that after the incident on 08/28/24, the staff were instructed to keep Resident #1 away from female residents. She said the facility's abuse prohibition policy was reviewed and it included that if you see anything report it and separate residents immediately if the abuse was resident on resident. During an interview on 11/19/24 at 12:56 p.m., MA E said that after the incident with Resident #1 and Resident #2 on 08/28/24, staff were instructed to keep Resident #1 away from Resident #2. During an interview on 11/19/24 at 1:04 p.m., RN F said after the first incident on 08/28/24, staff were told to keep Resident #1 away from Resident #2. During an interview on 11/19/24 at 1:10 p.m., MA G said after the first incident on 08/28/24, staff were instructed to report any type of abuse witnessed and to keep Resident #1 away from Resident #2. During an interview on 11/19/24 at 1:14 p.m., Activity Director H said after the first incident on 08/28/24, staff were to report any type of abuse seen and to keep Resident #1 away from Resident #2. During an interview on 11/19/24 at 1:21 p.m., previous MDS LVN K said she thought she updated Resident #2's care plan after the first and second incidents of sexually inappropriate behavior. She said she did not know why the care plans and interventions were not updated. She said there was a risk of further incidents of inappropriate sexual behaviors if the care plans and interventions were not updated immediately. During an interview on 11/19/24 at 2:48 p.m., RDO L said staff failure to follow the facility's abuse prevention policy could place residents at risk of abuse. She said previous Administrator C and previous DON B were in-serviced on 09/02/24 on types of abuse, investigation, interventions for mitigation, inappropriate resident to resident contact to include how to intervene, and 1 to 1 supervision of alleged perpetrator. She said facility staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. She said Resident #1 should have been placed on 1 to 1 supervision after the first incident of inappropriate sexual behavior on 08/28/24. During an interview on 11/20/24 at 11:54 a.m., previous Administrator C said he was aware the nurses and aides supervised Resident #2 when he was in the common areas. However, there was no formal monitoring system or interventions in place for supervision. He said staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. During an interview on 11/20/24 at 2:30 p.m., CNA M said on 09/02/24 he assisted Resident #1 to his wheelchair and brought him to the TV room. He said Resident #2 was not at the nurse's station when he brought Resident #1 to the TV room. He said he went on his break and when he returned from his break, he was made aware of Resident #1's fingers being inside of Resident #2's pants. He said Resident #1 was mobile with his wheelchair. He said he was aware of the previous incident of Resident #1's sexually inappropriate behavior on 08/28/24. He said he was trained to ensure Resident #1 was kept away from female residents. He had not been trained in monitoring behaviors after an inappropriate behavior was identified. During an interview on 11/21/24 at 9:05 a.m., previous DON B said Resident #1 was supposed to be set away from any other female residents. She said she was not aware Resident #1 was mobile with his wheelchair. She said if she were aware Resident #1 was mobile with his wheelchair, he would have been on 1-1 from the date of the first incident on 08/28/24. She said there were IDT meetings and care plan conferences after the incidents on 08/28/24 and 09/02/24 at risk of harm if there were insufficient interventions in place to protect Resident #2 and other female residents from Resident #1. During an interview on 11/21/24 at 11:15 a.m., the Administrator said residents were at risk of abuse when the facility's Abuse Prohibition Policy was not implemented. She said Resident #1 should have been on 1 to 1 staffing and his behavior monitored following the first incident of inappropriate sexual behavior on 08/28/24. She said Resident #1's care plan should have been reviewed, updated, and interventions implemented to prevent further inappropriate sexual behaviors and abuse. She said there were no current residents in the facility with identified sexually inappropriate behaviors. During an interview on 11/21/24 at 1:25 p.m., LVN I said he was aware of the first incident on 08/28/24 regarding Resident #1's inappropriate sexual behavior toward Resident #2. He said he was in-serviced to keep Resident #1 away from the female residents. He had not been trained in monitoring behaviors after an inappropriate behavior was identified. He said on 09/02/24, Resident #1 was in the TV room common area. He said Resident #2 was adjacent to the nurse's station. He said he saw another resident walking on a hall that should not have been walking and he went to assist the resident to bed. He said by the time he returned to the nurse station there was a lot of commotion, and he was made aware of Resident #1's fingers being inside of Resident #2's pants. He said he was not aware Resident #1 could move his wheelchair fast enough to make it over to Resident #2. Record review of the facility's Abuse Prohibition Policy revised 11/07/23 indicated each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. 5. Resident identified as exhibiting abusive behaviors will be reviewed and have their treatment plans modified as appropriate. Protection: 1. All residents will be immediately protected from harm. 4. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. Resident to Resident incidents: The following guidelines will be implemented when resident to resident incidences occur: 1. The staff observing the incident will immediately separate the residents involved. 2. The charge nurse will assess the victim to determine any injury. 3. Physician and family of both victim and perpetrator will be notified of the incident. The abuse coordinator will be immediately contacted. 6. The interdisciplinary team will make the determination what course of action needs to be taken with the perpetrator such as, but not limited to the following: *Immediate discharge from the facility due to potential of harm to other residents. *Can the behavior be controlled by location monitoring? The facility and physician of the perpetrator will be notified of the next steps. 7. If the perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. 8. If the perpetrator is on a behavioral contract, facility staff will be in-serviced accordingly, and the resident and family will be notified of the consequences. 9. If the perpetrator continues to exhibit inappropriate behaviors/or violates the behaviors identified on the behavioral contract, staff will immediately notify the Administrator/DON. 10. The team will conduct an emergency review to determine further course of action such as immediate discharge. 11. The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family. 13. If the incident involves sexual behavior, the following will occur: *Determine if both the victim and perpetrator are able to make decisions. *Determine if sexual contact was consensual. *If the contact was not consensual, follow steps 1-12. 1. Sexual abuse is non-consensual sexual contact of any type with a resident Sexual abuse includes, but is not limited to: a. unwanted intimate touching of any kind especially of breasts or perineal (genital) area; . Record review of the facility's Resident Rights policy dated 04/2017 indicated . Residents shall: . g. Be free from mental, emotional, and physical abuse and neglect, from chemical or physical restraints, and from financial exploitation and misappropriation of property; . During interviews on 11/19/24, 11/20/24, and 11/21/24 with staff who represented all shifts, (the current Administrator, 1 ADON, 2 RNs, 5 LVNs, 8 CNAs, 4 medication aides, 1 maintenance supervisor, 1 activity director, and 1 human resource officer) were able to give examples of abuse and neglect, would report immediately to the abuse coordinator or designee, were aware there was no current resident in the facility identified with inappropriate sexual behaviors, and were aware of the facility's 1 to 1 monitoring protocol for alleged perpetrators. Record review of the facility's in-service records dated 08/28/24 indicated Resident #1 was to be kept away from female residents. Record review of an in-service dated 09/02/24 indicated previous Administrator C and previous DON B were in-serviced on types of abuse, investigation, interventions for mitigation, inappropriate resident to resident contact to include how to intervene, and 1 to 1 supervision of alleged perpetrator. Record review of in-service dated 09/02/24, 09/08/24 and 09/13/24 indicated 43 out of 53 staff indicated staff were retrained and tested on abuse and neglect prevention and reporting, inappropriate resident to resident contact, how to intervene, and 1 to 1 supervision of alleged perpetrators. The remaining staff would be trained prior to working any shift. The facility incorporated the same training into new hire orientation as of 09/02/24. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. 36214

Based on interviews and record review, the facility failed to develop and implement the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 2 of 16 residents (Resident #1 and Resident 3) reviewed for care plans. 1. The facility failed to develop and implement interventions in the care plan to prevent Resident #1's sexual abuse of Resident #2. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because resident care plans were not reviewed and revised. 2. The facility failed to develop and implement Resident #3's care plan and interventions to prevent Resident #3's verbal and emotional abuse of Resident #4. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 11/19/24 indicated he was a [AGE] year-old male admitted on [DATE]. His diagnoses included unspecified intracranial injury without loss of consciousness (brain injury), major depressive disorder (mental disorder), and other sequalae of non-traumatic intracerebral hemorrhage (causes of stroke). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he had unclear speech, was rarely/never understood, usually understood others, had severely impaired cognitive skills, and utilized a wheelchair for mobility. Record review of Resident #1's electronic care plan dated 08/23/24 did not address sexually inappropriate behaviors. Record review of Resident #1's incident report dated 08/28/24 indicated Resident #1 was noted leaning against another resident (Resident #2) with his face at breast level flicking Resident #2's breast. Resident #1 was removed from the TV room and taken to his room. MD and RP notified. DON B documented If resident is brought to common areas, resident is to be kept away from other female residents. Record review of Resident #1's incident report dated 09/02/24 indicated Resident #1 had his hand down a female resident's pants/briefs. DON B documented Resident #1 was removed from the area and taken to his room and placed on 1 to 1. The MD, RP and police were notified. Resident #1 had his fingers in Resident #2's brief with pinky and palm visible outside of brief. Police notified administrator Resident #1 had a warrant out for his arrest. Record review of the facility investigation dated 09/04/24 indicated after police notification on 09/02/24 and prior to his discharge on 09/04/24, Resident #1 was arraigned by a judge in the facility for an outstanding warrant in another county for continuous sexual abuse of a child under [AGE] years. Record review of Resident #1's progress note dated 09/04/24 at 1:00 p.m. and completed by LVN P indicated Resident #1 discharged home with his family member. 2. Record review of Resident #2's face sheet dated 08/28/24 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral palsy (movement disorder), anxiety disorder (feelings of fear, dread, or uneasiness), conversion disorder with seizures or convulsions (mental health issue disrupts how the brain works), epilepsy (seizure disorder), and microcephaly (small head). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she was rarely/never understood, usually understood others, had severe cognitive impairment, utilized a wheelchair for mobility, and was dependent for all ADLS. Record review of Resident #2's care plan dated 08/28/24 indicated there was a report of alleged inappropriate flicking of her breast by a male resident while she was watching TV in the TV room. Interventions included staff were to monitor and ensure accused perpetrator was not in the area of Resident #2. Record review of Resident #2's care plan dated 09/02/24 indicated staff observed a male resident with his hand inside the top of Resident #2's pants while she was seated in her wheelchair. Interventions included monitoring for psychological distress. 3. Record review of Resident #3's face sheet dated 11/20/24 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included persistent mood affective disorder (low mood lasting for years), major depressive disorder (persistently depressed mood), anxiety disorder, and unspecified intellectual disabilities. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood, she understood others, was cognitively intact (BIMS score 15), and required minimal assist for some ADLS. Record review of Resident #3's electronic care plan dated 09/25/24 did not include verbal and emotional abuse of Resident #4. 4. Record review of Resident #4's face sheet dated 11/20/24 indicated he was a [AGE] year-old male admitted on [DATE] and his diagnoses included schizophrenia (mental disorder), unspecified psychosis (disconnection from reality), major depressive disorder, anxiety disorder, and unspecified intellectual disabilities. Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, was cognitively intact (BIMS score of 13), and required supervision for some ADLS. Record review of Resident #4's care plan dated 10/25/23 indicated he was spiritually married to Resident #3 and they had a set of babies, and he was at risk for psychosocial issues related to his knowledge the babies were not real, and his wife believed they were real. Interventions included talking about feelings related to current personal situation, continue to go to (named provider) and speak with a counselor), and encourage Resident #4 to speak with Resident #3 about his feelings. Record review of Resident #4's care plan dated 04/01/24 indicated he was at risk for depression related to accusations and emotional manipulation. On 03/29/24, (named provider) reported Resident #4 was in emotional distress from Resident #3. Interventions included discussing concerns, fears, issues, and encouraging Resident #4 to express feelings. Record review of the facility investigation dated 04/11/24 indicated Resident #4's psych counselor alleged Resident #4 reported that Resident #3 made emotionally abusive comments towards Resident #4. Resident #3 was removed from their room. Resident #3 denied the allegations. Resident #3 and Resident #4 were in-serviced regarding emotional/verbal abuse, emotional abuse vs normal conflict, isolating others, and threatening behavior. Staff were in-serviced on abuse/neglect, emotional abuse, customer service, and resident rights. Safe surveys were completed with no concerns found. Resident #3 and Resident #4 were interviewed and said the allegations were a misunderstanding and the residents wanted to return to live in the same room. The facility continued to monitor Resident #3 and Resident #4's relationship. There were no addtional concerns noted as of 11/21/24. During an interview on 11/19/24 at 11:15 a.m., Resident #4 said he never wanted to be separated from Resident #3. He said he never felt he was abused. He said he felt safe living in the same room with Resident #3 and he wanted to move back in with Resident #3. He said they were married and he loved Resident #3. He said he received information on abuse and continued to attend day services of his choice. During an interview on 11/19/24 at 11:45 a.m., previous Administrator C said he was standing at the nurse's station with the maintenance staff on 08/28/24 (after the lunch meal). He said he observed that Resident #1 and Resident #2 were in the TV room common area. He said Resident #1's head was near Resident #2's breast, between the breast and armpit area. He said Resident #1 was flicking with his fingers between the breast and armpit area. He said Resident #1 was removed from the common area. He said the residents were assessed and there were no injuries. He said a care plan should have been developed and implemented on 08/28/24 to prevent further inappropriate sexual behaviors from Resident #1 and to protect Resident #2. He said a second incident occurred on 09/02/24 when Resident #1 was found with his fingers inside Resident #2's pants. He said Resident #1 had been brought from his room to the TV room common area and was watching TV. He said Resident #2 was near the nurse station. He said LVN I left the nurse's station to care for another resident. He said ADON J returned to the nurse's station area and observed Resident #1 had his fingers inside of Resident #2's pants. Previous Administrator C said Resident #1 and Resident #2 were immediately separated. He said Resident #1 was placed on 1 to 1. He said the residents were assessed and there were no injuries. He said the police were notified. He said the police requested the residents' face sheets. He said he received a call within 10 minutes of providing the face sheets to the police and was informed that the police had been looking for Resident #1, for the previous 6 months, as Resident #1 had an outstanding warrant for continuous sexual abuse of a child under the age of 14. He said Resident #1 remained on 1-1 supervision until he was arraigned by a judge (while at the facility). He said Resident #1 was discharged on [DATE] with Family Member R. He said he was informed by CM N of Resident #3's alleged verbal and emotional abuse of Resident #4. He said there was a care plan conference and Resident #3's care plan was supposed to be reviewed and updated to include the allegation of alleged verbal and emotional abuse. He said the previous MDS LVN K was responsible for updating resident care plans. He said he was not aware Resident #3's care plan was not updated. During an interview on 11/19/24 at 12:36 p.m., ADON J said Resident #1 was not supposed to be around Resident #2. She said she could not recall if he was not supposed to be around all females. She said she could not recall any specific training regarding Resident #1's supervision or monitoring his behavior. She said she was working on 09/02/24. She said Resident #1 repeatedly left his bed and put himself on his floor. She said staff assisted him in his wheelchair and he was brought to the TV room common area. She said Resident #1 was adjacent to the nurse's station. She said she left the nurse's station to continue her duties and when she returned to the nurse's station area, she observed Resident #1 with his fingers inside Resident #2's pants. She said the residents were immediately separated. She said Resident #1 was resistant to moving his hand out of Resident #2's pants. She said she had to physically move his hand and arm away from Resident #2. She said Resident #1 was immediately placed on 1-1 supervision until he was discharged on [DATE]. She said she did not know how Resident #1 was left unsupervised. She said there were no current residents in the facility with identified sexually inappropriate behaviors. During an interview on 11/19/24 at 1:21 p.m., previous MDS LVN K said she thought she updated Resident #2's care plan after the first and second incidents of sexually inappropriate behavior. She said she did not know why the care plans and interventions were not updated. She said there was a risk of further incidents of inappropriate sexual behaviors if the care plans and interventions were not updated immediately. She said she did not know why Resident #3's care plan was not updated after it was alleged, she verbally and emotionally abused Resident #4. She said she thought she updated the care plan and put interventions in place as required after the care conferences. During an interview on 11/20/24 at 11:54 am., CM O said Resident #3 was verbally assaultive toward Resident #4. She said Resident #4 said Resident #3 was making him stay home to take care of the baby dolls with her. She said Resident #4 indicated Resident #3 threatened Resident #4 with divorce and would throw her wedding rings at him. She said there was a care plan conference and Resident #3 understood what she was doing was not right. She said Resident #3 never said he was abused. During an interview on 11/20/24 at 2:30 p.m., CNA M said on 09/02/24 he assisted Resident #1 to his wheelchair and brought him to the TV room. He said Resident #2 was not at the nurse's station when he brought Resident #1 to the TV room. He said he went on his break and when he returned from his break, he was made aware of Resident #1's fingers being inside of Resident #2's pants. He said Resident #1 was mobile with his wheelchair. He said he was aware of the previous incident of Resident #1's sexually inappropriate behavior on 08/28/24. He said he was trained to ensure Resident #1 was kept way from female residents. He had not been trained in monitoring behaviors after an inappropriate behavior was identified. During an interview on 11/21/24 at 9:05 a.m., previous DON B said Resident #1 was supposed to be set away from any other female residents. She said she was not aware Resident #1 was mobile with his wheelchair. She said if she were aware Resident #1 was mobile with his wheelchair, he would have been on 1-1 from the date of the first incident on 08/28/24. She said there were IDT meetings and care plan conferences after the incident on 08/28/24 and 09/02/24 and the previous MDS LVN K was responsible for updating the resident care plans. She said she did not know why Resident #1's care plan was not updated. She said the corporate MDS supervisor was responsible for ensuring the care plans were updated as required. She said other residents were at risk of harm if there were insufficient interventions in place to protect Resident #2 and other female residents from Resident #1. She said Resident #4's care plan should have been reviewed, updated, and interventions implemented to prevent further verbal and emotional abuse of Resident #3. During an interview on 11/21/24 at 11:32 a.m., RDO L said any of the nurse staff could update resident care plans. She said previous Administrator C and previous DON B were responsible for ensuring resident care plans and interventions were updated. If care plans were not updated as required, residents were at risk of not receiving care and services required. During an interview on 11/20/24 at 11:54 a.m., previous Administrator C said Resident #1's care plan should have been updated to keep him away from all female residents. He said Resident #3's care plan should have been reviewed, updated, and interventions implemented to prevent further verbal and emotional abuse of Resident #4. During an interview on 11/21/24 at 11:15 a.m., the Administrator said Resident #1's care plan should have been reviewed, updated, and interventions implemented to prevent further inappropriate sexual behaviors and abuse. She said Resident #3's care plan should have been reviewed, updated, and interventions implemented to prevent further verbal and emotional abuse of Resident #4. During an interview on 11/21/24 at 1:25 p.m., LVN I said he was aware of the first incident on 08/28/24 regarding Resident #1's inappropriate sexual behavior toward Resident #2. He said he was in-serviced to keep Resident #1 away from the female residents. He had not been trained in monitoring behaviors after an inappropriate behavior was identified. He said on 09/02/24, Resident #1 was in the TV room common area. He said Resident #2 was adjacent to the nurse's station. He said he saw another resident walking on a hall that should not have been walking and he went to assist the resident to bed. He said by the time he returned to the nurse station there was a lot of commotion, and he was made aware of Resident #1's fingers being inside of Resident #2's pants. He said he was not aware Resident #1 could move his wheelchair fast enough to make it over to Resident #2. Record review of the facility's Comprehensive Person-Centered Care Plan policy dated 10/2022 indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.8. Incorporate identified problem areas; . An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because resident care plans were not reviewed and revised. 36214

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 4 residents reviewed for accidents. (Resident #1 and Resident #42) The facility did not develop interventions to prevent Resident #1 from leaving the facility without staff knowledge after she had an increase in wandering behaviors and an attempt to leave the facility. Resident #1 left the faciity on [DATE] sometime after midnight during the 10 p.m. to 6 a.m. shift. Resident #1 was found in the parking lot at a store next door to the facility. The resident sustained [REDACTED]. The facility did not secure the hazardous room door to prevent Resident #42 from entering a hazardous area. An Immediate Jeopardy (IJ) situation was identified on 11/06/19 at 2:36 a.m. While the IJ was removed on 11/06/19 at 5:42 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who are an elopement risk or have wandering behaviors at risk of severe injury or death. Findings included: 1. Physician orders [REDACTED].#1 admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan problem with onset date of 11/2/15 indicated Resident #1 was at risk for wandering related to a [DIAGNOSES REDACTED]. The goals of being safe and secure in the facility and not receiving a preventable injury as a result from wandering was achieved 11/20/17 and her Wanderguard bracelet (a device used to help prevent elopement by activating an alarm when the resident gets close to an exit) was discontinued. The most recent MDS assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and required limited assistance with ADLs. The MDS indicated the resident did not have wandering behaviors during the 7 day look back period. The MDS indicated the resident was ambulatory and used a wheel chair for mobility. An elopement/wandering risk assessment dated [DATE] indicated Resident #1 was not at risk for elopement. A progress note dated 9/25/19 at 3:28 a.m. indicated Resident #1 was agitated and confused. Continues to get out of bed without oxygen stating she needs to go home and demands to be left alone. Resident is looking for her blue truck to drive home, denies living in (facility name). Not oriented to place, person, date, time, or situation. Refusing to wear oxygen. A progress note dated 9/25/19 at 7:05 a.m. indicated (Resident #1) in room walking around. Resident appears confused stated, 'did my kids get on the bus, I'm looking for them' Reassured resident that kids are okay. A care plan for Resident #1 updated on 09/30/19, prior to her elopement and fall, indicated the resident had a history of [REDACTED]. The goal for Resident #1 was not to experience any injuries related to falls. Interventions listed included monitor for changes in condition that may warrant increased supervision / assistance and notify physician. A progress note dated 10/1/19 at 6:38 a.m. indicated Resident #1 increasingly more confused, becoming agitated when try to redirect. Resident refusing to keep oxygen via nasal cannula on, OOB (out of bed) walking down halls without walker or wheelchair multiple times. Continues looking for small children and stating her kids are here to see her and demanding they be allowed to visit with her, will not return to room until nurse finds her sons. There was no update to the care plan to indicate the need for increased supervision due to increase of wandering behaviors. A care plan problem with onset date of 11/2/19 indicated Resident #1 was at risk for falls related to cognitive impairment, impaired posture, and walking hunched forward. Interventions included to monitor for changes in the resident's condition that may warrant increased supervision/assistance and notify the physician. An incident report dated 10/21/19 during the 10:00 p.m. to 6:00 a.m. shift indicated Resident #1 was wandering and fell outside in parking lot. The resident was assessed, and blood was cleaned from the resident's face. Resident #1 complained of pain to her face, head, neck, and shoulders. The report noted the resident was confused and required constant redirection. The report indicated wandering at night is not a new onset behavior, resident needs a wanderguard even though she does sit outside adlib during day and evening (and with other residents) to enjoy the fresh air and to smoke at times. Staff stated that she always sit outside on benches and does not leave the facility property. During an interview on 11/6/19 at 5:55 a.m., LVN A said during the night of 10/21/19, Resident #1 walked repeatedly to the nurse station looking for her children. LVN A said the resident tried to get out the front doors, but was stopped by a CNA and another nurse. She said the resident was combative with staff and did not want to come back in. LVN A said they sat the resident at the nurse's station. LVN A said she began making her rounds and when she got back to the nurse station, Resident #1 was not there. She asked LVN B (the nurse for Resident #1) where the resident was. LVN A said LVN B and CNA C went outside to look for her. LVN A said she thought they found her next door in the (store name) parking lot. She said the resident was wandering in the facility more often at night in the last month looking for her children. LVN A said Resident #1 was in a wheel chair at the nurse station after she had tried to leave the facility. During an interview on 11/1/19 at 6:56 a.m., CNA D said she usually worked the 2:00 p.m. - 10:00 p.m. shift. She said Resident #1 would go out to the smoking area and sit, but never tried to leave. The CNA said on 10/21/19 at 3:11 a.m., she went on her break and Resident #1 was sitting on the bench outside. When CNA D returned, LVN B and CNA C were outside looking for Resident #1. Resident #1 was found next door in the (store name) parking lot. During a phone interview on 11/5/19 at 2:35 p.m., CNA C said Resident #1 left the building probably between 2-3:00 a.m. She said the resident had attempted to leave the building earlier that night and was looking for her children most of the night. The resident went out, unsupervised, to the bench in the smoking area. CNA C said she tried to redirect Resident #1 to her room, and the resident fought her, hit her, and called her inappropriate names. She said the resident was usually easy to redirect to her room, but not that night. CNA C said she sat Resident #1 at the nursing station because Resident #1 would not return to her room. CNA C said she asked LVN B to watch Resident #1 so the CNA could make her rounds. She said a short time later, Resident #59 told CNA C that Resident #1 was outside on the bench and the resident said she told LVN B that Resident #1 was outside. CNA C said when she completed the rounds, she asked LVN B where Resident #1 was. The nurse told CNA C the resident was outside on the bench. CNA C and LVN B went outside to look for the resident. CNA C said she saw Resident #1 sitting up on the curb of the parking lot next door at a store, with her back to the facility. CNA C said the resident had to go down a ditch and up the other side into the parking lot. When CNA C reached Resident #1, she was unable to get up without the assistance of the CNA and was crying help me, help me, help me. The CNA said the resident had blood all on her face. The resident said her face, neck and back hurt. CNA C said this was the first time the resident had tried to leave the building prior to that night. During an interview on 11/6/19 at 6:08 a.m., Resident #59 said on 10/21/19, she saw Resident #1 near the nurse station flipping through a calendar. She said Resident #1 told her she was waiting for her daughter to pick her up. Resident #59 said she followed Resident #1 outside and tried to get the resident to go back in the building. Resident #59 said she went inside and told LVN B she needed to go get Resident #1 from outside because she was afraid she would wander off. She said the nurse never got up to go check. Resident #59 was going to her room when she saw CNA C in the hall. Resident #59 said she told CNA C what she told the nurse. During an interview on 11/6/19 at 7:54 a.m., LVN B said on the night of 10/21/19, around 3:00 a.m., Resident #1 was looking for her children. She said the resident would go to her room for 20-30 minutes and then get back up looking for her children. She said Resident #1 went to the lobby door one time to exit, and CNA C attempted to bring her back, and that was when she tried to fight CNA C. LVN B said they did not attempt to keep Resident #1 near the nursing station because there was not someone there all the time, as they were taking care of other residents. LVN B said around 3:00 a.m. on 10/22/19, CNA C was making rounds and noticed Resident #1 was not in her room. LVN B denied hearing Resident #59 tell her the resident was outside. She said it was the first time Resident #1 had tried to exit on the 10:00 p.m. - 6:00 a.m. shift. Radiology reports from a local hospital dated 10/21/19 indicated Resident #1 had a CT scan of her C-spine and it indicated age indeterminate type II odontoid fracture, could be acute. This is minimally displaced, without significant canal encroachment at the current time. The CT scan of the face indicated Nasal bone fractures, likely acute. (fractured nose) 2. Physician orders [REDACTED].#42, admitted [DATE], was [AGE] years old with a [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #42 was severely cognitively impaired and had limited range of motion to upper and lower extremities. She required limited assistance with mobility. During an observation and interview on 11/4/19 at 8:20 a.m., Resident #42 was attempting to go into a room with door signs indicating Hazardous Area and Keep door shut. The resident was in her wheel chair pushing the door open with her foot. The door was open approximately 12 inches. There was no staff at the nurse station. A housekeeper was down the hall approximately 25-30 feet away. Surveyor signaled the housekeeper to help the resident. Housekeeper [NAME] said the door should have been locked and closed. During an interview on 11/4/19 at 8:22 a.m., the ADON said Resident #42 should not be going in the hazardous room. The ADON said the door should have been locked. During an observation on 11/6/19 at 11:05 a.m., the door marked Hazardous Area did not latch when closed last and the room was not secured. The room had a panel approximately 2 feet high with multiple electrical outlets, phone lines, and cable lines. The floor had boxes of used parts and the main breaker box was behind the door, which could not be locked. During an interview on 11/6/19 at 11:10 a.m., the regional director of plant operations said the door marked Hazardous Area was not latching correctly. During further interview at 3:00 p.m. he said the breaker panel could not be locked in case the fire department needed access. The administrator and regional vice president (RVP) were notified on 11/6/19 at 2:36 p.m. an IJ situation was identified due to the above failures. The facility's Plan of Removal was accepted on 11/6/19 at 5:42 p.m. and included: 1. All resident wanderer assessments were audited for completion. Audit was completed by DON 10/23/19. No resident elopement assessment was found to be missing. The DON/ADON/designee updated all wander assessments and there were no changes from the results of the previous elopement risk assessments. No other residents were identified as needing a wanderguard. Updates were completed by 11/1/19. The resident was assessed on 10/23/19 and was determined to need a wanderguard and the wander guard is currently in place. Resident's care plan updated by case mix nurse to reflect the resident's change in supervision. 2. The door to the phone system closet was repaired on 11/6/19. It is currently properly shutting and no residents have access to this room. All doors throughout the facility have been checked to ensure that no doors that should close automatically is not out of order. No issues were identified. In-service initiated with staff on the importance of monitoring doors to ensure that doors are functioning properly. The facility will check doors weekly to ensure that these doors remain operational. On 11/6/19 the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: *Resident #1's wandering/elopement assessment was updated and a Wanderguard was placed on the resident. *An in-service dated 10/22/19 indicated staff were in-serviced on what to do if a resident is exhibiting exit seeking behaviors. Resident should be placed on franklin monitoring (checking on the resident every 15-30 minutes) and/or one on one monitoring. Wanderguard also may be put in place with consent of the physician and RP (responsible party); never leave an exit seeking resident unattended. *An in-service dated 10/22/19 indicated staff were in-serviced on dealing with unmanageable residents. *An in-service dated 10/22/19 indicated staff were in-serviced on change in condition. *During an interview on 11/6/19 at 11:55 a.m., the administrator said staff had been educated on elopement, change in condition, and incident reporting. All residents were assessed to ensure elopement assessments were up to date. All residents are being re-assessed to ensure there has been no change in their elopement risk. She said there had been no changes. *During interviews on 11/6/19 5 CNAs (all 3 shifts) 1 RN (6-2 shift), and 4 charge nurses (all 3 shifts), said they had been in-serviced on elopement procedures. Residents with new exit seeking behaviors would not be left alone. They were aware a wanderguard bracelet was in the medication room. *During an interview on 11/7/19 at 10:00 a.m., the administrator said the staff had been educated on procedures if a door does not shut properly to a hazardous area, they will stay at the door and have someone notify maintenance and the administrator. *During interviews on 11/7/19 at 10:19 a.m. thorough 12:45 p.m., the administrator, BOM, HR, SW, activity director, medical records, maintenance personnel, DON/RN, 1 staff RN, 7 charge nurses (all 3 shifts), 5 MAs, 20 CNAs (all 3 shifts), and 3 housekeeping staff said they had been in-serviced on hazardous areas and doors which should remain secured. They said if they noticed a door not shutting properly to a hazardous area, they will stay at the door and have someone notify maintenance and the administrator. *An in-service dated 11/6/19 indicated staff were in-serviced on locked doors and doors required to be locked. On 11/7/19 at 1:08 p.m., the administrator and RVP were informed the IJ was removed; however, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 11/7/19 at 1:08 p.m., the facility was asked for additional information at exit related to the findings and no additional information was provided.

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for 5 of 15 residents reviewed for falls (Resident #s 2, 10, 12, 43 and 70) and for 5 of 8 residents reviewed for personal safety devices. (Residents #s 15, 17, 56, 54 and 66) *Resident #43's bed wheel locks were broken and she sustained a fall resulting in a right hip fracture when she attempted to get into bed. Prior to that injury, she had reported her bed wheel locks were broken, but the facility had not repaired her bed. *Resident #70's bed wheel locks were broken and she sustained two falls during attempts to get into bed, one while transferring alone and the other while transferring with the PT. The facility did not repair the bed after either fall. *Resident #s 2, 10 and 12's bed wheel locks were broken and the residents expressed fear and concern regarding their safety. This failure contributed to Resident #43's fall, fractured hip and hip replacement surgery and placed 33 residents with beds with non-locking wheels at risk for serious injuries. An immediate jeopardy was identified on 09/14/11. While the IJ was removed on 09/15/11, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. Non-Immediate Jeopardy * Resident #56 fell from her wheelchair and the personal safety device did not alarm. The device had a missing battery. * Resident #66's personal safety device had a low battery and staff did not know who was responsible for checking the batteries. * Resident #54's bed pressure alarm did not sound when the resident was assisted out of bed. * Resident #17's chair pressure alarm did not sound when the resident was assisted to stand. * Resident #15's chair alarm was not secured to the resident. This failure could place 8 residents with personal safety devices at risk of injuries. Findings included: 1.) Resident #43's physician orders [REDACTED]. A quarterly MDS for Resident #43 dated 07/07/11 indicated her cognition was intact and she was independent in all ADLs including ambulation. An incident report noted Resident #43 fell [DATE] at 12:10 a.m. The report noted, "ADON down hall answering another resident call light noticed resident coming from bathroom trying to get into bed; bed moved resident fell on the floor. Resident complained of right hip pain and was transferred to the hospital for evaluation." Interventions included keeping the room free from clutter, the lights on, and for the resident to use the call light for assistance. A hospital consultation report for Resident #43 dated 8/20/11 read, "Present Illness: This is a [AGE] year old female resident of (a local) Nursing Home. She states she was trying to get into her bed this morning when the wheels slipped and she fell hitting her right hip. She complained of right hip pain and did hit her head but had no loss of consciousness. She is usually ambulatory with a walker. Proceed with fixation of her right hip." An incident report for Resident #43 dated 8/20/11 was signed by the former ADON and former administrator acknowledging the incident. A physician telephone order dated 08/26/11 noted Resident #43 was readmitted from the hospital with a [DIAGNOSES REDACTED]. An incident report for Resident #43 dated 08/20/11 was signed by the former ADON and former administrator acknowledging the incident. During an observation and interview on 09/14/11 at 9:00 a.m., Resident #43 was lying in bed and said she fell and broke her right hip on 08/20/22. She said the bed rolled away from her when she sat down and she fell because "the wheels would not lock." She said she was still in the same bed and it "was dangerous." She said she had asked the facility to fix the bed prior to her fall, but no one had repaired it. During an observation and interview on 09/14/11 at 9:30 a.m., CNA M attempted to lock the wheels on Resident #43's bed and was unsuccessful. She stated "a lot of the beds do not lock." During an observation on 09/14/11 at 9:40 a.m., CNA N attempted to lock the wheels on Resident #43's bed and was unsuccessful. During an interview on 09/14/11 at 10:10 a.m., Housekeeper O said most of the beds have wheels that did not lock. She could easily move beds to clean under them and did not have to unlock or lock them. During an interview on 09/14/11 at 10:14 a.m., CNA P said some of the beds had wheels that did not lock. During an observation and interview on 09/14/11 at 11:40 a.m., LVN R attempted to lock the wheels on Resident #43's bed and was unsuccessful. She said there was a potential for the resident to have another fall since the bed wheels would not lock. A significant change MDS for Resident #43 dated 09/13/11 noted she was totally dependent for transfers and locomotion off the unit and needed extensive assistance for bed mobility, locomotion on the unit, dressing, and toilet use. During an interview on 09/14/11 at 2:20 p.m., the PT for Resident #43 said her ADL capabilities had declined, since her fall. Resident #43's care plan dated 09/13/11 for falls did not address bed safety. 2.) Resident #70's closed record included physician orders [REDACTED]. An incident report for Resident #70 dated 06/21/11 at 3:25 p.m. noted a written statement from the PT that read, "While helping the patient to sit down back to bed, it slid backwards and patient's knees gave up and I was able to assist patient down to floor while holding the gait belt." No interventions or follow up were documented for that incident. An incident and accident report for Resident #70 dated 06/24/11 at 6:10 p.m. read, "Resident was found sitting on the floor beside bed A in front of bedside table and stated bed moved when she tried to sit down and she missed it; denies hitting head." The report indicated she was alert and oriented. The intervention was to monitor every 15 minutes. There were no interventions addressing bed repair. An incident report for Resident #70 dated 6/24/11 was signed by the former DON acknowledging the incident. Resident #70's care plan for falls dated 08/17/11 did not address bed safety. During an observation on 09/15/11 at 8:55 a.m., the surveyor attempted to lock the wheels on Resident #70's previous bed. The wheels would not lock. 3.) Resident #12's September 2011 consolidated physician orders [REDACTED]. Resident #12's care plan for falls dated 08/08/11 indicated she had a history of [REDACTED]. A 30 day MDS for Resident #12 dated 08/27/11 indicated her cognition was intact. Resident #12's fall risk assessment dated [DATE] noted she was at high risk for falls. During an observation and interview on 09/14/11 at 1:59 p.m., Resident #12 stated, "It scares the hell out of me" because the bed wheels will not lock. Resident #12 stated, "When they lay me down, my bed slides and so does my roommate's." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. 4.) Resident #2's September 2011 consolidated physician orders [REDACTED]. Resident #2's 30 day MDS dated [DATE] indicated her cognition was intact. During an observation and interview on 09/14/11 at 1:46 p.m., Resident #2 stated, "I'm afraid I may fall out of the bed if I slide over because the brakes don't work. I'll break my hip. There was a lady that fell out of bed and broke her hip. My bed just goes where it wants to." Resident #2 said the broken brakes had been reported to the maintenance man, LVN X, a therapist, and the business office manager. Resident #2 said the maintenance man had been told several times. Resident B said he "promises each day he will do it, but he does nothing." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. During an interview on 09/15/11 at 8:48 a.m., the maintenance supervisor said he had fixed the brakes on Resident #2's bed, but had not received any complaints from other residents about the brakes not working on their beds. During an interview on 09/15/11 at 10:26 a.m., the business office manager denied any resident had reported problems with the brakes on their beds. 5.) Resident #10's September 2011 consolidated physician orders [REDACTED]. Resident #10's care plan for falls dated 06/27/11 indicated she had a history of [REDACTED]. Resident #10's fall risk assessment dated [DATE] noted she was at high risk for falls. Resident #10's 60 day MDS dated [DATE] indicated her cognition was intact. During an interview on 09/14/11 at 1:56 p.m., Resident #10 stated, "They just blow it off" when it was reported the brakes on the bed did not lock. Resident #10 stated, "When I get on the bed, it slides over." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. 6.) During an observation of Hall 400 on 09/14/11 at 1:40 p.m. with CNA N, the following beds had wheels that did not lock: * 401 bed A and B (bed A unoccupied) * 402 bed B (unoccupied) * 406 bed A (unoccupied) * 408 bed A * 410 bed A and B (bed B unoccupied) * 412 bed A and B * 414 bed A and B * 416 bed A and B (bed A unoccupied) * 415 bed A * 409 bed A (unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 300 on 09/14/11 at 1:45 p.m., the following beds had wheels that did not lock: * 303 bed B * 304 bed A and B * 305 bed A and B (bed A unoccupied) * 307 bed A and B (bed A unoccupied) * 309 bed A * 313 bed A and B (bed A unoccupied) * 315 bed A and B (bed A unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 100 on 09/14/11 at 1:46 p.m., the following beds had wheels that did not lock: * 101 bed A and B * 103 bed A * 105 bed B * 106 bed A and B * 107 bed B * 109 bed A and B * 110 bed B * 111 bed A and B (bed B unoccupied) * 112 bed A and B (both beds unoccupied) * 114 bed A and B (bed A unoccupied) * 113 bed A * 116 bed A (unoccupied) * 115 bed A (unoccupied) * 118 bed A and B * 108 bed A (unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 200 on 0 9/14/11 at 3:00 p.m., the wheels on the unoccupied bed in Room 207A would not lock. In-service records for dated April 2011 through September 2011 indicated no training that pertained to bed safety. During interviews on 09/14/11, the following staff said they had not received training at the facility regarding bed safety with fall prevention: at 9:30 a.m., CNA M, at 9:40 a.m., CNA N, at 10:14 a.m., CNA P, and at 10:15 a.m., CNA Q. On 9/14/11 at 3:20 p.m., the survey team determined the failure to ensure a safe environment related to bed wheels that did not lock constituted an Immediate Jeopardy. On 9/14/11 at 3:20 p.m., the survey team notified administrator and the regional nurse consultant of the Immediate Jeopardy. On 09/14/11 at 7:15 p.m., the facility's Plan of Removal was accepted and included the following: "1. All nonfunctioning beds will be removed and replaced with a bed that is in good repair. Resident's room rounds will be completed by 18:45 on 09/14/11 by Administrator /Administrative staff. 2. All resident's who have been identified for increased fall risk will have care plans to include checking for bed safety. 3. Staff checked bed immediately of Residents who were identified as increased risk completed task at 6:15 p.m. on 09/14/11. 4. The Administrator/Designee will monitor logs on a weekly basis and as needed. 5. The Maintenance Director will be responsible for ensuring issues in maintenance log are followed up on in a timely manner. 6. When an incident report is completed, the Director of Nursing/Designee will review for completion and content to ensure compliance. DON/Designee will review the who, what, when, where, and why of the incidents. This information will be analyzed to determine if incident is reportable and if we followed all policy and procedures. Staff will notify responsible party and physician. 7. The Maintenance Director will complete weekly/month reports to include all mobility aids/bed to ensure they are in good repair, and functioning properly and without safety hazards. 8. Administrator/Designee will interview residents and if they express any fears, they will reassure them that all safety concerns will be addressed by Administrator/Designee. 9. All bed/chair alarms will be checked to ensure batteries are fully functional to increase resident's safety. Residents with essential equipment/alarms will be checked by the Administrative Staff/Designee and will be completed by 8:30 p.m. on 09/14/11. 10. All residents who have bed/chair alarms will have care plans to include checking to ensure batteries are properly functioning. 11. Administrative staff/Designee checked bed alarms immediately of residents who were identified. Task was completed at 8:15 p.m. on 09/14/11. 12. The DON/Designee will monitor logs on a weekly basis and as needed. 13. The DON/Designee will be responsible for ensuring issues with essential equipment such as bed/chair alarms are followed up on in timely manner. 14. When an incident report is completed, the Director of Nursing/Designee will review of completion and content to ensure compliance. DON/Designee will review the who, what, when, where, and why of the incidents. This information will be analyzed to determine if incident is reportable and all policy and procedure have been followed. DON/Designee will notify responsible party and physician with any findings. 15. The DON/Designee will review documentation on weekly and as needed basis to include bed/chair alarms are in good repair, functioning properly, and without safety hazards. 16. DON/Designee will interview residents and if they express any fears, they will reassure them that all safety concerns will be addressed by Administrator/Designee. 17. Any negative findings will be discussed by QA Committee." During an interview on 09/14/11 at 8:30 p.m., the administrator said the audit of all beds to ensure resident safety and proper functioning of bed wheel locks indicated there were 58 beds with wheels that would not lock. The facility removed the wheels from the beds and received new beds on 09/15/11. The survey team determined the facility implemented its plan of removal. Beds were checked and found to not roll. The facility provided resident care plans that had been updated. The facility interviewed residents and ensured their safety concerns were addressed. The facility provided the surveyors with the itnerviews. Monitoring logs were presented to ensure beds were in good repair; sufficiently to remove the Immediate Jeopardy and the Immediate Jeopardy no longer existed on 09/15/11 at 9:30 a.m. On 09/15/11 at 9:30 a.m., administrator and regional nurse consultant was informed the Immediate Jeopardy was lifted. The facility remained out of compliance because of the facility's need to monitor and evaluate whether the systems put in place were effective. The noncompliance continued at a pattern of actual harm. Non-Immediate Jeopardy 7.) Resident #56's September 2011 consolidated physician orders [REDACTED]. The orders included a chair alarm to be used due to falls. Resident #56's care plan dated 08/13/11 indicated the resident had a history of [REDACTED]. The 60 Day Medicare MDS dated [DATE] indicated Resident #56 had experienced falls. A fall risk assessment dated [DATE] indicated Resident #56 was at high risk for falls. During an observation and interview on 09/14/11 at 5:09 p.m., Resident #56 was lying on the floor in the dining room area. Her wheelchair was adjacent to her and there was a white pressure pad in the seat of the wheelchair. MA S said the resident was propelling herself down the hall to the dining room when her feet got stuck under the chair and she tumbled onto the floor. She said the pressure chair alarm did not go off. During an observation and interview on 09/14/11 at 5:23 p.m., Resident #56 was in her room with RN T and LVN U. The resident's pressure alarm mat remained in the seat of the wheelchair and the attached power box was hanging off the arm. The cover was missing from the battery compartment, and only two batteries were present. There were slots for three batteries. RN T said the alarm would not work because a battery was missing. During an interview on 09/14/11 at 5:40 p.m., LVN U said she had been employed for approximately three and a half months and did not monitor the alarms on a routine basis. She glanced at the alarms when working with the residents and did not document monitoring alarms. She said Resident #56 always picked at the power box on the alarm and took the batteries out. She said the cover to the battery compartment had been missing for as long as she worked there. The manufacturer instructions for the pad chair alarm, revised 10/24/08, noted, " ...place resident so that resident ' s buttocks are in center of bed or chair pad. When resident is placed on pad, alarm will automatically be set to alarm if patient attempts to get out of bed or chair." 8.) Resident #66's September 2011 consolidated physician orders [REDACTED]. The orders included, " May have bed alarm due to fall history. " Resident #66's admission care plan dated 08/01/11 indicated a risk for falls and injuries and approaches included the use of a bed and/or wheelchair alarm. A care plan for Resident #66 dated 09/14/11 addressed a history of falls and approaches included a bed alarm while in bed to alert staff of attempts to get out of bed. Resident #66's fall risk assessment dated [DATE] indicated she was at high risk for falls. During an interview on 09/14/11 at 5:50 p.m., RN F said when the alarm device was blinking, that meant the battery was getting low. She said Resident #66's alarm was blinking at that time and she had reported that to maintenance supervisor at approximately 4:30 p.m. She said she monitored alarm devices as she worked with residents, but she did not routinely monitor the alarms nor document monitoring. During an observation on 09/14/11 at 5:59 p.m., Resident #66 was lying in her bed with a bed alarm device present and the power box light was blinking. During an interview on 09/14/11 at 6:02 p.m., the maintenance supervisor said he did not monitor the functionality of the bed and chair alarms; it was a nursing responsibility. He said he replaced batteries in the devices when nursing staff requested. He said he had not received a request for battery replacement for Resident #66 that day or recently. During an interview on 09/14/11 at 6:12 p.m., CNA V said Resident #66's alarm device had been blinking for awhile and he reported it to the charge nurse 10 days ago. 9.) Resident #54's September 2011 consolidated physician orders [REDACTED]. The orders included, "May have bed alarm to alert staff when resident is in an unsafe position." A face sheet dated 03/23/11 indicated an original admission date of [DATE]. Resident #54's care plan dated 09/13/11 indicated a history of falls and approaches included a bed alarm while in bed to alert staff of attempts to get out of bed. Resident #54's quarterly MDS dated [DATE] indicated she had experienced falls. Resident #54's fall risk assessment dated [DATE] indicated she was at high risk for falls. During an observation on 09/15/11 at 11:12 a.m., Resident #54 was sitting on her bed. CNA W assisted the resident up, and the bed alarm did not sound. CNA W began hitting the mattress with her hand, and after four hard strikes, the alarm sounded. The sound was barely audible and was muffled. CNA W found the device under the pillow and pulled it out, and the sound was louder. The battery cover was missing and the batteries were exposed. CNA W had to hit the button numerous times to get the device to stop sounding. During an interview on 09/14/11 at 5:40 p.m., LVN U, one of two charge nurses, said Resident #56 was her only resident that had an alarm. During an interview on 09/14/11 at 5:50 p.m., RN F, the other charge nurse, said she had three residents with alarms. A list of physician orders [REDACTED]. The two charge nurses were unaware of all the residents that had alarms. The administrator was asked for a policy and procedure for monitoring bed and chair alarm use and functionality on 09/14/11 at 6:06 p.m. No policy was provided. 10.) Resident #17's September 2011 consolidated physician orders [REDACTED]. Resident #17's care plan for falls dated 06/08/11 indicated he had an unsteady gait and history of falls. Resident #17's significant change MDS dated [DATE] noted his cognition was severely impaired and he required limited assistance with transfers. During an observation on 09/14/11 at 6:17 p.m., Resident #17 was sitting in a wheelchair in the dining room. A pressure alarm mat was in the seat of the chair and an attached power box was hanging off the arm of the wheelchair. When RN F and the activity director assisted the resident to stand, the alarm did not sound. During an interview on 09/14/11 at 7:10 p.m., RN F said she did not know why the device did not sound. The manufacturer instructions for the pad alarm revised 10/24/08 noted, "...place resident so that resident's buttocks are in center of bed or chair pad. When resident is placed on pad alarm will automatically be set to alarm if patient attempts to get out of bed or chair..." 11.) Resident #15's September 2011 consolidated physician orders [REDACTED]. Resident #15's fall risk assessment dated [DATE] indicated she was at high risk for falls. Resident #15's quarterly MDS dated [DATE] noted her cognition was severely impaired and she required extensive assistance with transfers. During an observation and interview on 09/14/11 at 6:07 p.m., Resident #15 was sitting in a wheelchair in the dining room. A chair alarm device was on the back of the wheelchair, but the clip was not attached to the resident. RN F stated, "Now it is" then clipped the device to the resident. The manufacturer instructions for the chair alarm revised 5/13/10 noted, "...attach cord to resident's clothing with locking clip so that the clip is not accessible to the resident. Be sure to gather adequate clothing material in clip before closing for best results..." A list provided 09/22/11 indicated 33 occupied resident beds with broken wheel locks. A list of physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure essential equipment was in safe operating condition for 5 of 15 residents reviewed for falls (Resident #s 2, 10, 12, 43 and 70) and for 4 of 8 residents reviewed for personal safety devices. (Residents #s 17, 56, 54 and 66) *Resident #43's bed wheel locks were broken and she sustained a fall resulting in a right [MEDICAL CONDITION] when she attempted to get into bed. Prior to that injury, she had reported her bed wheel locks were broken, but the facility had not repaired her bed. *Resident #70's bed wheel locks were broken and she sustained two falls during attempts to get into bed, one while transferring alone and the other while transferring with the PT. The facility did not repair the bed after either fall. *Resident #s 2, 10 and 12's bed wheel locks were broken and the residents expressed fear and concern regarding their safety. This failure contributed to Resident #43's fall, [MEDICAL CONDITION] and hip replacement surgery and placed 33 residents with beds with non-locking wheels at risk for serious injuries. An immediate jeopardy was identified on 09/14/11. While the IJ was removed on 09/15/11, the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. Non-Immediate Jeopardy * Resident #56 fell from her wheelchair and the personal safety device did not alarm. The device had a missing battery. * Resident #66's personal safety device had a low battery and staff did not know who was responsible for checking the batteries. * Resident #54's bed pressure alarm did not sound when the resident was assisted out of bed. * Resident #17's chair pressure alarm did not sound when the resident was assisted to stand. This failure could place 8 residents with personal safety devices at risk of injuries. Findings included: 1.) Resident #43's physician orders [REDACTED]. A quarterly MDS for Resident #43 dated 07/07/11 indicated her cognition was intact and she was independent in all ADLs including ambulation. An incident report noted Resident #43 fell [DATE] at 12:10 a.m. The report noted, "ADON down hall answering another resident call light noticed resident coming from bathroom trying to get into bed; bed moved resident fell on the floor. Resident complained of right hip pain and was transferred to the hospital for evaluation." Interventions included keeping the room free from clutter, the lights on, and for the resident to use the call light for assistance. A hospital consultation report for Resident #43 dated 8/20/11 read, "Present Illness: This is a [AGE] year old female resident of (a local) Nursing Home. She states she was trying to get into her bed this morning when the wheels slipped and she fell hitting her right hip. She complained of right hip pain and did hit her head but had no loss of consciousness. She is usually ambulatory with a walker. Proceed with fixation of her right hip." An incident report for Resident #43 dated 8/20/11 was signed by the former ADON and former administrator acknowledging the incident. A physician telephone order dated 08/26/11 noted Resident #43 was readmitted from the hospital with a [DIAGNOSES REDACTED]. An incident report for Resident #43 dated 08/20/11 was signed by the former ADON and former administrator acknowledging the incident. During an observation and interview on 09/14/11 at 9:00 a.m., Resident #43 was lying in bed and said she fell and broke her right hip on 08/20/22. She said the bed rolled away from her when she sat down and she fell because "the wheels would not lock." She said she was still in the same bed and it "was dangerous." She said she had asked the facility to fix the bed prior to her fall, but no one had repaired it. During an observation and interview on 09/14/11 at 9:30 a.m., CNA M attempted to lock the wheels on Resident #43's bed and was unsuccessful. She stated "a lot of the beds do not lock." During an observation on 09/14/11 at 9:40 a.m., CNA N attempted to lock the wheels on Resident #43's bed and was unsuccessful. During an interview on 09/14/11 at 10:10 a.m., Housekeeper O said most of the beds have wheels that did not lock. She could easily move beds to clean under them and did not have to unlock or lock them. During an interview on 09/14/11 at 10:14 a.m., CNA P said some of the beds had wheels that did not lock. During an observation and interview on 09/14/11 at 11:40 a.m., LVN R attempted to lock the wheels on Resident #43's bed and was unsuccessful. She said there was a potential for the resident to have another fall since the bed wheels would not lock. A significant change MDS for Resident #43 dated 09/13/11 noted she was totally dependent for transfers and locomotion off the unit and needed extensive assistance for bed mobility, locomotion on the unit, dressing, and toilet use. During an interview on 09/14/11 at 2:20 p.m., the PT for Resident #43 said her ADL capabilities had declined, since her fall. Resident #43's care plan dated 09/13/11 for falls did not address bed safety. 2.) Resident #70's closed record included physician orders [REDACTED]. An incident report for Resident #70 dated 06/21/11 at 3:25 p.m. noted a written statement from the PT that read, "While helping the patient to sit down back to bed, it slid backwards and patient's knees gave up and I was able to assist patient down to floor while holding the gait belt." No interventions or follow up were documented for that incident. An incident and accident report for Resident #70 dated 06/24/11 at 6:10 p.m. read, "Resident was found sitting on the floor beside bed A in front of bedside table and stated bed moved when she tried to sit down and she missed it; denies hitting head." The report indicated she was alert and oriented. The intervention was to monitor every 15 minutes. There were no interventions addressing bed repair. An incident report for Resident #70 dated 6/24/11 was signed by the former DON acknowledging the incident. Resident #70's care plan for falls dated 08/17/11 did not address bed safety. During an observation on 09/15/11 at 8:55 a.m., the surveyor attempted to lock the wheels on Resident #70's previous bed. The wheels would not lock. 3.) Resident #12's September 2011 consolidated physician orders [REDACTED]. Resident #12's care plan for falls dated 08/08/11 indicated she had a history of [REDACTED]. A 30 day MDS for Resident #12 dated 08/27/11 indicated her cognition was intact. Resident #12's fall risk assessment dated [DATE] noted she was at high risk for falls. During an observation and interview on 09/14/11 at 1:59 p.m., Resident #12 stated, "It scares the hell out of me" because the bed wheels will not lock. Resident #12 stated, "When they lay me down, my bed slides and so does my roommate's." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. 4.) Resident #2's September 2011 consolidated physician orders [REDACTED]. Resident #2's 30 day MDS dated [DATE] indicated her cognition was intact. During an observation and interview on 09/14/11 at 1:46 p.m., Resident #2 stated, "I'm afraid I may fall out of the bed if I slide over because the brakes don't work. I'll break my hip. There was a lady that fell out of bed and broke her hip. My bed just goes where it wants to." Resident #2 said the broken brakes had been reported to the maintenance man, LVN X, a therapist, and the business office manager. Resident #2 said the maintenance man had been told several times. Resident B said he "promises each day he will do it, but he does nothing." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. During an interview on 09/15/11 at 8:48 a.m., the maintenance supervisor said he had fixed the brakes on Resident #2's bed, but had not received any complaints from other residents about the brakes not working on their beds. During an interview on 09/15/11 at 10:26 a.m., the business office manager denied any resident had reported problems with the brakes on their beds. 5.) Resident #10's September 2011 consolidated physician orders [REDACTED]. Resident #10's care plan for falls dated 06/27/11 indicated she had a history of [REDACTED]. Resident #10's fall risk assessment dated [DATE] noted she was at high risk for falls. Resident #10's 60 day MDS dated [DATE] indicated her cognition was intact. During an interview on 09/14/11 at 1:56 p.m., Resident #10 stated, "They just blow it off" when it was reported the brakes on the bed did not lock. Resident #10 stated, "When I get on the bed, it slides over." The surveyor attempted to lock the wheels. The wheels on the resident's bed would not lock. 6.) During an observation of Hall 400 on 09/14/11 at 1:40 p.m. with CNA N, the following beds had wheels that did not lock: * 401 bed A and B (bed A unoccupied) * 402 bed B (unoccupied) * 406 bed A (unoccupied) * 408 bed A * 410 bed A and B (bed B unoccupied) * 412 bed A and B * 414 bed A and B * 416 bed A and B (bed A unoccupied) * 415 bed A * 409 bed A (unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 300 on 09/14/11 at 1:45 p.m., the following beds had wheels that did not lock: * 303 bed B * 304 bed A and B * 305 bed A and B (bed A unoccupied) * 307 bed A and B (bed A unoccupied) * 309 bed A * 313 bed A and B (bed A unoccupied) * 315 bed A and B (bed A unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 100 on 09/14/11 at 1:46 p.m., the following beds had wheels that did not lock: * 101 bed A and B * 103 bed A * 105 bed B * 106 bed A and B * 107 bed B * 109 bed A and B * 110 bed B * 111 bed A and B (bed B unoccupied) * 112 bed A and B (both beds unoccupied) * 114 bed A and B (bed A unoccupied) * 113 bed A * 116 bed A (unoccupied) * 115 bed A (unoccupied) * 118 bed A and B * 108 bed A (unoccupied) The beds easily rolled when pushed by the surveyor. During an observation of Hall 200 on 0 9/14/11 at 3:00 p.m., the wheels on the unoccupied bed in Room 207A would not lock. In-service records for dated April 2011 through September 2011 indicated no training that pertained to bed safety. During interviews on 09/14/11, the following staff said they had not received training at the facility regarding bed safety with fall prevention: at 9:30 a.m., CNA M, at 9:40 a.m., CNA N, at 10:14 a.m., CNA P, and at 10:15 a.m., CNA Q. On 9/14/11 at 3:20 p.m., the survey team determined the failure to ensure a safe environment related to bed wheels that did not lock constituted an Immediate Jeopardy. On 9/14/11 at 3:20 p.m., the survey team notified administrator and the regional nurse consultant of the Immediate Jeopardy. On 09/14/11 at 7:15 p.m., the facility's Plan of Removal was accepted and included the following: "1. All nonfunctioning beds will be removed and replaced with a bed that is in good repair. Resident's room rounds will be completed by 18:45 on 09/14/11 by Administrator /Administrative staff. 2. All resident's who have been identified for increased fall risk will have care plans to include checking for bed safety. 3. Staff checked bed immediately of Residents who were identified as increased risk completed task at 6:15 p.m. on 09/14/11. 4. The Administrator/Designee will monitor logs on a weekly basis and as needed. 5. The Maintenance Director will be responsible for ensuring issues in maintenance log are followed up on in a timely manner. 6. When an incident report is completed, the Director of Nursing/Designee will review for completion and content to ensure compliance. DON/Designee will review the who, what, when, where, and why of the incidents. This information will be analyzed to determine if incident is reportable and if we followed all policy and procedures. Staff will notify responsible party and physician. 7. The Maintenance Director will complete weekly/month reports to include all mobility aids/bed to ensure they are in good repair, and functioning properly and without safety hazards. 8. Administrator/Designee will interview residents and if they express any fears, they will reassure them that all safety concerns will be addressed by Administrator/Designee. 9. All bed/chair alarms will be checked to ensure batteries are fully functional to increase resident's safety. Residents with essential equipment/alarms will be checked by the Administrative Staff/Designee and will be completed by 8:30 p.m. on 09/14/11. 10. All residents who have bed/chair alarms will have care plans to include checking to ensure batteries are properly functioning. 11. Administrative staff/Designee checked bed alarms immediately of residents who were identified. Task was completed at 8:15 p.m. on 09/14/11. 12. The DON/Designee will monitor logs on a weekly basis and as needed. 13. The DON/Designee will be responsible for ensuring issues with essential equipment such as bed/chair alarms are followed up on in timely manner. 14. When an incident report is completed, the Director of Nursing/Designee will review of completion and content to ensure compliance. DON/Designee will review the who, what, when, where, and why of the incidents. This information will be analyzed to determine if incident is reportable and all policy and procedure have been followed. DON/Designee will notify responsible party and physician with any findings. 15. The DON/Designee will review documentation on weekly and as needed basis to include bed/chair alarms are in good repair, functioning properly, and without safety hazards. 16. DON/Designee will interview residents and if they express any fears, they will reassure them that all safety concerns will be addressed by Administrator/Designee. 17. Any negative findings will be discussed by QA Committee." During an interview on 09/14/11 at 8:30 p.m., the administrator said the audit of all beds to ensure resident safety and proper functioning of bed wheel locks indicated there were 58 beds with wheels that would not lock. The facility removed the wheels from the beds and received new beds on 09/15/11. The survey team determined the facility implemented its plan of removal. Beds were checked and found to not roll. The facility provided resident care plans that had been updated. The facility interviewed residents and ensured their safety concerns were addressed. The facility provided the surveyors with the itnerviews. Monitoring logs were presented to ensure beds were in good repair; sufficiently to remove the Immediate Jeopardy and the Immediate Jeopardy no longer existed on 09/15/11 at 9:30 a.m. On 09/15/11 at 9:30 a.m., administrator and regional nurse consultant was informed the Immediate Jeopardy was lifted. The facility remained out of compliance because of the facility's need to monitor and evaluate whether the systems put in place were effective. The noncompliance continued at a pattern of actual harm. Non-Immediate Jeopardy 7.) Resident #56's September 2011 consolidated physician orders [REDACTED]. The orders included a chair alarm to be used due to falls. Resident #56's care plan dated 08/13/11 indicated the resident had a history of [REDACTED]. The 60 Day Medicare MDS dated [DATE] indicated Resident #56 had experienced falls. A fall risk assessment dated [DATE] indicated Resident #56 was at high risk for falls. During an observation and interview on 09/14/11 at 5:09 p.m., Resident #56 was lying on the floor in the dining room area. Her wheelchair was adjacent to her and there was a white pressure pad in the seat of the wheelchair. MA S said the resident was propelling herself down the hall to the dining room when her feet got stuck under the chair and she tumbled onto the floor. She said the pressure chair alarm did not go off. During an observation and interview on 09/14/11 at 5:23 p.m., Resident #56 was in her room with RN T and LVN U. The resident's pressure alarm mat remained in the seat of the wheelchair and the attached power box was hanging off the arm. The cover was missing from the battery compartment, and only two batteries were present. There were slots for three batteries. RN T said the alarm would not work because a battery was missing. During an interview on 09/14/11 at 5:40 p.m., LVN U said she had been employed for approximately three and a half months and did not monitor the alarms on a routine basis. She glanced at the alarms when working with the residents and did not document monitoring alarms. She said Resident #56 always picked at the power box on the alarm and took the batteries out. She said the cover to the battery compartment had been missing for as long as she worked there. The manufacturer instructions for the pad chair alarm, revised 10/24/08, noted, " ...place resident so that resident ' s buttocks are in center of bed or chair pad. When resident is placed on pad, alarm will automatically be set to alarm if patient attempts to get out of bed or chair." 8.) Resident #66's September 2011 consolidated physician orders [REDACTED]. The orders included, " May have bed alarm due to fall history. " Resident #66's admission care plan dated 08/01/11 indicated a risk for falls and injuries and approaches included the use of a bed and/or wheelchair alarm. A care plan for Resident #66 dated 09/14/11 addressed a history of falls and approaches included a bed alarm while in bed to alert staff of attempts to get out of bed. Resident #66's fall risk assessment dated [DATE] indicated she was at high risk for falls. During an interview on 09/14/11 at 5:50 p.m., RN F said when the alarm device was blinking, that meant the battery was getting low. She said Resident #66's alarm was blinking at that time and she had reported that to maintenance supervisor at approximately 4:30 p.m. She said she monitored alarm devices as she worked with residents, but she did not routinely monitor the alarms nor document monitoring. During an observation on 09/14/11 at 5:59 p.m., Resident #66 was lying in her bed with a bed alarm device present and the power box light was blinking. During an interview on 09/14/11 at 6:02 p.m., the maintenance supervisor said he did not monitor the functionality of the bed and chair alarms; it was a nursing responsibility. He said he replaced batteries in the devices when nursing staff requested. He said he had not received a request for battery replacement for Resident #66 that day or recently. During an interview on 09/14/11 at 6:12 p.m., CNA V said Resident #66's alarm device had been blinking for awhile and he reported it to the charge nurse 10 days ago. 9.) Resident #54's September 2011 consolidated physician orders [REDACTED]. The orders included, "May have bed alarm to alert staff when resident is in an unsafe position." A face sheet dated 03/23/11 indicated an original admission date of [DATE]. Resident #54's care plan dated 09/13/11 indicated a history of falls and approaches included a bed alarm while in bed to alert staff of attempts to get out of bed. Resident #54's quarterly MDS dated [DATE] indicated she had experienced falls. Resident #54's fall risk assessment dated [DATE] indicated she was at high risk for falls. During an observation on 09/15/11 at 11:12 a.m., Resident #54 was sitting on her bed. CNA W assisted the resident up, and the bed alarm did not sound. CNA W began hitting the mattress with her hand, and after four hard strikes, the alarm sounded. The sound was barely audible and was muffled. CNA W found the device under the pillow and pulled it out, and the sound was louder. The battery cover was missing and the batteries were exposed. CNA W had to hit the button numerous times to get the device to stop sounding. During an interview on 09/14/11 at 5:40 p.m., LVN U, one of two charge nurses, said Resident #56 was her only resident that had an alarm. During an interview on 09/14/11 at 5:50 p.m., RN F, the other charge nurse, said she had three residents with alarms. A list of physician orders [REDACTED]. The two charge nurses were unaware of all the residents that had alarms. The administrator was asked for a policy and procedure for monitoring bed and chair alarm use and functionality on 09/14/11 at 6:06 p.m. No policy was provided. 10.) Resident #17's September 2011 consolidated physician orders [REDACTED]. Resident #17's care plan for falls dated 06/08/11 indicated he had an unsteady gait and history of falls. Resident #17's significant change MDS dated [DATE] noted his cognition was severely impaired and he required limited assistance with transfers. During an observation on 09/14/11 at 6:17 p.m., Resident #17 was sitting in a wheelchair in the dining room. A pressure alarm mat was in the seat of the chair and an attached power box was hanging off the arm of the wheelchair. When RN F and the activity director assisted the resident to stand, the alarm did not sound. During an interview on 09/14/11 at 7:10 p.m., RN F said she did not know why the device did not sound. The manufacturer instructions for the pad alarm revised 10/24/08 noted, "...place resident so that resident's buttocks are in center of bed or chair pad. When resident is placed on pad alarm will automatically be set to alarm if patient attempts to get out of bed or chair..." A list provided 09/22/11 indicated 33 occupied resident beds with broken wheel locks. A list of physician orders [REDACTED].

Based on observation, interview, and record review the facility failed to notify the physician of weight loss for 1 of 15 residents reviewed for weight loss. (Resident #18) Resident #18 experienced weight loss of 14% in 5 months. The physician was not consulted until 09/13/11. This failure could place the census of 69 residents at risk for not receiving appropriate medical interventions. Findings included: Physician orders [REDACTED]. blood pressure, irregular heart rates, and altered mental status. The most recent MDS assessment dated [DATE] indicated Resident #18 was alert, oriented, and able make herself understood and could understand others. During an observation and interview on 09/12/11 at 1:50 p.m., Resident #18 was noted to be thin and frail. LVN A said Resident #18 was interviewable. A registered dietitian assessment dated [DATE] indicated Resident #18 was 67 inches tall with an ideal body weight of 135 pounds. The weight change comparison record for Resident #18 indicated the following: 05/10/11: 132 pounds 06/01/11: 129 pounds 07/10/11: 128 pounds 08/10/11: 124 pounds 09/10/11: 121 pounds. Resident #18 was re-weighed on 09/13/11 and weighed 114 pounds. Her weight loss indicated a 6% loss in 3 months and a 14% loss in 5 months. The weight management policy dated 11/28/02 indicated the interdisciplinary team would assure weights were documented and the physician would be notified. During an interview on 09/13/11 at 5:00 p.m., RN F said she did the monthly resident summaries but did not put the weights on the report although there was a place on the form to document weights. She said she did not know where to find resident weights in the chart. She also said weight loss would be a reason to contact the physician. During an interview on 9/14/11 8:45 a.m., Resident #18's nurse practitioner said she was not aware of significant weight loss. She said during her last visit in August 2011, the weights for August were not documented, so she looked at the July weights. The nurse practitioner said weight loss had not been reported to her in August or September 2011. The CMS 672 dated 09/15/11 indicated a census of 69 residents.

Based on observation, interview, and record review the facility failed to provide interventions to prevent weight loss for 1 of 15 residents reviewed for weight loss. (Resident #18) Resident #18 experienced a 6% weight loss in 3 months and a 14% loss in 5 months. The physician and dietician were not consulted about her weight loss and no interventions to prevent weight loss were implemented. This failure could place the 68 residents who consumed oral diets at risk for weight loss. Findings included: Physician orders [REDACTED]. Her diet was regular. The most recent MDS assessment dated [DATE] indicated Resident #18 was alert, oriented, and able to make herself understood and could understand others. During an observation and interview on 09/12/11 at 1:50 p.m., Resident #18 was noted to be thin and frail. LVN A said that Resident #18 was interviewable. A registered dietitian assessment dated [DATE], indicated Resident #18 was 67 inches tall with an ideal body weight of 135 pounds. The weight documented was 133 pounds. The weight change comparison record indicated the following: 05/10/11: 132 pounds 06/01/11: 129 pounds 07/10/11: 128 pounds 08/10/11: 124 pounds 09/10/11: 121 pounds Resident #18 was re-weighed on 09/13/11 and weighed 114 pounds. Her weight loss indicated a 6% loss in 3 months and a 14% loss in 5 months. A weight management policy dated 11/28/02 indicated weights may be done more frequent basis such as daily or weekly depending on disease condition, risk for weight loss, or as deemed by the physician or registered dietitian. The policy also indicated the interdisciplinary team would ensure the physician was notified of weight loss and the registered dietitian would assess the resident. During an interview on 09/13/11 at 12:45 p.m., Resident #18 said she weighed 115 pounds the week before. During an interview on 9/14/11 at 10:05 a.m., the restorative aide said she weighed Resident #18 monthly. She said her September weight was 121 pounds. She said she reported the weight loss to the charge nurse who told her they were going to get an order for [REDACTED]. Resident #18's physician orders [REDACTED]. During an interview on 09/14/11 8:45 a.m., Resident 18's nurse practitioner said she was not aware of any significant weight loss. She said on the last visit in August 2011, the weights for August were not documented, so she looked at the July report. The nurse practitioner said weight loss had no been reported to her in August or September 2011. During an interview on 09/14/11 at 9:00 a.m., the registered dietician said she was aware of some weight loss for Resident #18 but it did not trigger on the weight variance log. She said that was what triggered her to see residents. She said she had not been called about any weight loss problems for Resident #18 and her last visit was in August 2011. During an interview on 09/13/11 at 5:00 p.m., RN F said she did the resident monthly summaries but did not put weights on the report even though there was a place on the form to document weights. She said she did not know where to find resident weights in the chart. She also said weight loss would be a reason to contact the physician. During an interview on 09/14/11 at 8:30 a.m., Resident #18 said she did not get her cereal and only got one sausage that morning. She said she told a CNA but did not receive it. Resident said she ate all on her plate except the egg. During an interview on 09/14/11 at 8:35 a.m., CNA N said she did not set up the tray that morning but would take care of it. She stated, "I don't know why they can't get the trays right; you never know what is going to come out." Menus for 09/14/11 indicated regular diets should receive 2 sausage patties and hot or cold cereal. During observations on 9/13/11 at 12:15 p.m. and 09/14/11 at 12:10 p.m., Resident #18 ate 100% for both noon meals. The CMS 672 dated 9/12/11 indicated 68 residents consumed oral diets.