Every finding on record at Wells LTC Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 4 residents (Resident #4) reviewed for smoking.The facility failed to ensure Resident #4 did not have a lighter in his possession on 6/23/2026 that was not allowed.This failure could place residents at risk of injuries and burns.Findings included:Record review of an admission Record for Resident #4 dated 6/23/2026 indicated he was admitted to the facility on [DATE] and [AGE] years old. Diagnoses included Type 2 diabetes, vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain), bipolar disorder (extreme shifts in mood, energy, and activity levels) and major depressive disorder (persistent sadness or loss of interest in doing things).Record review of a Quarterly MDS Assessment for Resident #4 dated 5/7/2026 indicated she had moderate impairment in thinking with a BIMS score of 10. He was independent with ADLs except for showering/bathing and personal hygiene.Record review of a care plan for Resident #4 dated 5/12/2026 indicated he had an ADL performance deficit. There was not a care plan to indicate Resident #4 was a smoker with interventions.During an observation and interview on 6/23/2026 at 9:22 am, Resident #4 said he had been a resident at the facility for about four months. He said he was a smoker and the facility kept his cigarettes and lighters for him, but he had a lighter in his possession. He showed the Surveyor the lighter that he had in his pocket. When questioned again if he was supposed to have the lighter, he replied probably not.Record review of a safe smoking assessment for Resident #4 dated 3/31/2026 indicated he required direct supervision while smoking, all smoking materials would be kept at the nurse station, and care plan up to date or updated.Record review of an undated smoker's list indicated Resident #4 was a smoker.During an interview on 6/23/2026 at 2:00 pm, the ADON said Resident #4 was not deemed a safe smoker. She said the nurse should have cigarettes and lighters locked up in the nurse's cart after each smoke break. She said residents could hurt themselves or others or start a fire and not know it. She said the lighter that Resident #4 had in his possession had been confiscated earlier that day and was not aware he had a lighter in his possessionDuring an interview on 6/23/2026 at 2:20 pm, the DON said there were not any residents in the facility that were deemed as safe smokers. She said all residents who smoked should be supervised and the cigarettes and lighters were kept in the cart. She said no residents should have access to lighters or cigarettes without supervision. She said they could start fires and smoke inside the building if they had lighters in their possession. She said the staff had an in-service not long ago on the smoking policy and procedures.Record review of an in-service titled smoking residents dated 5/12/2026 provided by the DON indicated staff were trained that no residents should have a lighter.During an interview on 6/23/2026 at 2:51 pm, the RDO said to his knowledge no residents in the facility were allowed to keep their cigarettes or lighters with them. He said the lighters and cigarettes should be kept at the nurse station and if not could cause an accident.During an interview on 6/23/2026 at 3:06 pm, the Administrator said there were not any residents in the facility that were allowed to keep smoking paraphernalia on them. She said she was not aware that Resident #4 had a lighter and it had been confiscated that morning. She said staff would take residents to the smoke break, give them their cigarettes and the staff would use a lighter to light the cigarettes for the residents at smoke breaks. She said cigarettes and lighters were kept at the nurse station in a lock box after each smoke break. She said a resident could hurt themselves or others if they had lighters in their possession.Record review of a facility policy tiled Safety and Supervision of Residents revised July 2017 indicated, .Our facility strives to make the environment as free of accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident Risks and Environmental Hazards: 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: d. Smoking.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 3 smoking areas (smoking area for halls C/D) reviewed for smoking safety.The facility failed to ensure paper and plastic trash were not discarded into the fire safety can in the smoking area for halls C/D that was to be used for cigarette butts only on 6/23/2026.This failure could place residents at risk of injury, burns, and an unsafe smoking environment.Findings include:During an observation and interview on 6/23/2026 at 9:10 am, the smoking area outside of halls C/D had a red smoking can that had trash inside that included cigarette butts, a plastic wrapper, gloves, and a plastic wrist band. There was a sign on the wall above the red smoking can that read, put cigarette butts in ashtray, do not throw on ground. Thanks Administration Staff. The Housekeeping Supervisor was present and said she and the Maintenance supervisor checked the cans daily and emptied them. She said there was a sign above the red smoking can to notify staff not to place trash in the can. She said there was a risk of fires if trash were put in the butt cans. She said she had not checked the can that morning yet but would take care of it.During an interview on 6/23/2026 at 2:00 pm, the ADON said Maintenance was responsible for checking the smoking area daily and emptying the red cans and trash. She said trash should be placed in the trash can and not in the red smoking buckets. She said there was a risk of fires if trash was placed in the red cans.During an interview on 6/23/2026 at 2:20 pm, the DON said the Maintenance Supervisor and the Housekeeping Supervisor should check the smoking area daily during rounds. She said trash should be stored in the trash can and the red cans are for cigarette butts only. She said there was a sign outside the smoking area for staff not to put trash in the red cans. She said there could be a risk of fires if trash was placed in the red smoking can.During an interview on 6/23/2026 at 2:51 pm the RDO said Maintenance and Housekeeping were responsible for checking the smoking areas daily. He said trash should not be stored in the red cans and if trash were placed in the red cans a fire could start.During an interview on 6/23/2026 at 3:06 pm, the Administrator said on a day-to-day basis the Maintenance Supervisor would be responsible for checking the smoking areas daily. She said trash should be placed in the trash receptacle and not in the red can as a fire could start. She said they had placed a sign outside the smoking area for staff to place trash in the trash cans and not in the red smoking cans.During an interview on 6/23/2026 at 3:18 pm, the Maintenance Supervisor said he checked the smoking areas daily and emptied the trash cans and smoking cans. He said the staff were always putting trash in the smoking can and they placed a sign above it to help remind staff. He said the smoking area had a trash can and did not know why they did not place trash in it. He said if they placed trash in the red can there was a risk of fires and injuries.Record review of a facility policy titled Smoking Policy-Residents revised October 2023 indicated, .This facility has established and maintains safe resident smoking practices. 5. Metal containers, with self-closing cover devices, are available in smoking areas. 6. Ashtrays are emptied only into designated receptables.

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 under proper temperature controls, and permitted only authorized personnel to have access to 1 of 1 medication destruction storage closet reviewed for medication storage.The facility failed to ensure the medication destruction closet was secured and was unable to be accessed by unauthorized personnel between 12/04/2025 through 1/15/2026.This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.Findings included:During an observation on 2/23/2026 at 9:10 am, the medication destruction closet located inside the ADON office revealed the door to the ADON office was open with no staff present. The medication destruction closet had a pad lock that was locked, a door handle that was locked and a deadbolt lock that was not locked. Inside of the medication destruction closet revealed a safe that contained the narcotic medications waiting to be destroyed. The safe was not permanently affixed and was able to be picked up and moved.During an interview and observation on 2/23/2026 at 12:24 pm, the DON unlocked the pad lock and the door handle on the medication destruction closet door which contained the narcotic safe. The DON opened the narcotic safe and tilted the safe forward which indicated the narcotic safe was not permanently affixed to the shelf. During an interview on 2/23/2026 at 9:10 am the ADON said she had been trained by the previous ADON for about 1 week. She said all she knew was the medications were supposed to be in the closet locked but did not know they needed to be in the locked safe with the safe permanently affixed to the shelf. Review of the facility policy and procedure titled Controlled Substances, dated April 2019, stated 1. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. 3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. Review of the facility policy and procedure titled Discarding and Destroying Medications, dated November 2022, stated 1. All unused controlled substances are retained in a securely locked area with restricted access until disposed of. Review of the facility policy and procedure titled Medication Labeling and Storage dated February 2023 indicated: .7. Controlled substances (listed as schedule II-V of Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based interviews and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 7 residents (Resident #1), reviewed for drug diversion.The facility failed to prevent the misappropriation of Resident #1's hydrocodone-acetaminophen 5-325 mg (formerly known under the brand name Norco, this combination medication containing 5 mg of hydrocodone [an opioid analgesic] and 325 mg of acetaminophen [also known as Tylenol] is used to treat pain).This failure could place residents at risk for not receiving their prescribed medications, unrelieved pain, and decreased quality of life.Findings include:1.Record review of Resident #1's face sheet dated [DATE] indicated he was [AGE] years old, admitted to the facility on [DATE] and expired in the facility on [DATE] with diagnoses including: obstructive hydrocephalus (buildup of cerebrospinal fluid inside the brains ventricles), malignant neoplasm of brain (brain cancer), dementia (decline in memory, thinking and behaviors).Record review of the MDS dated [DATE] indicated Resident #1 was rarely/never understood. The MDS indicated Resident #1 BIMS was not assessed. The MDS indicated Resident #1 was dependent on staff with bed mobility, transfers, and toilet use.Record review of the care plan dated [DATE] indicated Resident #1 had complaints of pain. The care plan interventions included monitor/document for side effects of pain medication.Record review of the active physician order with a start date of [DATE] detailed Resident #1 was to be administered hydrocodone-acetaminophen 5-325 mg 1 tablet two times a day related to malignant neoplasm of brain.Record review of the provider investigation report (PIR) dated [DATE] detailed that the medication hydrocodone/acetaminophen 5/325mg for Resident #1 went missing between [DATE]-[DATE]. The medication was given to the ADON after Resident #1's discharge/death on [DATE]. The ADON logged the medication on her destruction list, paired the count sheet and medication together using a rubber band and placed it in the locked closet. On [DATE] the Pharmacist and DON pulled medications to destroy them and the hydrocodone/acetaminophen 5/325mg for Resident #1 that was listed on the destruction log was not located with the rest of the narcotics. During an interview on [DATE] at 10:10 am, the ADON said drug destruction was her responsibility and she was the only person who had a key to the closet. She said Resident #1 expired in the facility on [DATE], she said she had taken Resident #1's 43 tablets of hydrocodone/acetaminophen 5/325mg and logged it on the drug destruction log then placed the count sheet with the medication in the closet in her office. She said she did not place the medication in the safe in the closet, she said she locked the 1 door handle on the outside of the closet door. She said on [DATE] she was out that day and the DON did the drug destruction with the Pharmacist and that was when it was discovered that the medication was missing. She said at the time of the drug diversion the nurses would bring her discontinued narcotic medications, she would log them and place them in the closet not in the safe. She said she was trained to put the medications in the closet not in the safe. She said the door to her office could be bumped and would easily open. She said during the investigation of the missing medication, the DON had tried the closet door and you could easily get a butter knife in and open the door. She said her office door would be open at times when she got to work in the morning. She said she knew some of the staff would use her fridge and her bathroom at all hours when she was not at the facility. She said since she had taken the ADON position that was the only missing medication that she was aware of.During an interview on [DATE] at 12:24 pm, the DON said on [DATE] the ADON was out and she went to help the pharmacist do drug destruction and they discovered the missing hydrocodone/acetaminophen 5/325mg. She said it had been logged but was missing from the closet. She said after her investigation she believed someone had manipulated the locks on the ADON door and closet and was able to get in. She said the medications were not in the safe at the time of the drug diversion. She said anyone could bump there hip on the door and the door would come open. She said the closet handle door lock could easily be popped with a butter knife. She said they did not watch the facility camara's to see if they could tell who took the narcotics because staff was allowed to go in the ADON office at all hours because there was a fridge in that office. She said since the drug diversion they replaced the plate on the ADON office door, placed the additional pad lock on the closet door, and started putting narcotics in the safe inside the closet. She said staff are no longer allowed to go into the ADON office to use the fridge anymore. During an interview on [DATE] at 9:10am, The administrator said at the time of the drug diversion the ADON office door was not secure and was able to be easily opened by bumping the door with your hip. She said the drug destruction closet had 1 door handle lock. She said during the investigation of the drug diversion the DON was able to get a butter knife from the kitchen and easily break into the drug destruction closet. She said at the time of the drug diversion the narcotic medications were not being stored inside the locked safe. She said the new ADON had started logging the narcotics for destruction and that is how they were able to determine if there were missing narcotics. She said the prior ADON did not log the narcotics at the time of placing them in the closet but only logged them when the pharmacist was at the facility to do the drug destruction. She said the facility could not determine if there were any other missing narcotics because they were not being logged as they were received so anyone could take them without the facility knowing. Record review of the Facility Drug Destruction Log dated [DATE] indicated 43 tablets of Resident #1's hydrocodone/acetaminophen 5/325mg were Not destroyed, Not found in in lock box, DON will research signed by the DON and the Pharmacist.Review of the facility policy and procedure titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April of 2021, stated Develop and implement policies and protocols to prevent and identify: .theft, exploitation or misappropriation of resident property.Review of the facility policy and procedure titled Controlled Substances, dated [DATE], stated 1. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. 3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. Review of the facility policy and procedure titled Discarding and Destroying Medications, dated [DATE], stated 1. All unused controlled substances are retained in a securely locked area with restricted access until disposed of.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 15 (Resident #1) residents reviewed for supervision.The facility failed to protect Resident #1, who had a history of exit seeking, from eloping from the secured unit courtyard on 12/18/2025. Resident #1 was left unsupervised in the male unit's courtyard and the courtyard's exterior gate was unlocked. Resident #1 exited the courtyard and was located 2 blocks away in the local library parking lot. Resident #1 was located by a staff member who was leaving the facility from their shift. The facility was unaware Resident #1 was missing during this time. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/18/2025 and ended on 12/23/2025. The facility corrected the non-compliance before surveyor's entrance. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included:Record review of Resident #1's facility face sheet revealed Resident #1 was an [AGE] year-old male that was admitted on [DATE] with a diagnosis of dementia (impaired memory).Record review of Resident #1's comprehensive care plan dated 8/17/2024 indicated Resident #1 was an elopement risk and wanderer as evidenced by disoriented to place, history of attempts to leave facilityunattended, impaired safety awareness and was on the male secured unit.Record review of Resident #1's elopement risk assessment dated [DATE] indicated Resident #1 was a risk for elopement. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 could not complete a BIMS and a SAMS was completed indicating cognition was impaired and had poor decision making and required supervision. Record review of facility incident report for Resident #1 dated 12/18/2025 at 3:00 pm completed by the LVN D indicated Notified by staff speech therapist had picked resident up walking by library. Resident assisted back into building . I didn't know where I was going. assisted staff in getting resident back into building head to toe assessment done no injuries noted. Will continue to monitor for any adverse reactions or problems. Report indicated the physician and family were notified. Record review of Resident #1's order summary report dated 01/05/2026 indicated Resident #1 had an order to be admitted to the male secure unit for active exit seeking behaviors as of 9/24/2025.Record review of Resident #1's secured unit consent undated indicated Resident #1 required a secured unit due to pointless wandering and elopement attempts and placement was to protect him from unsafe environments such as busy streets signed by his family, physician and facility nursing staff. During an observation and interview on 01/05/2026 at 10:20 a.m., the secured male unit had 15 residents and 2 staff were present on the unit. Resident #1 was asleep in a recliner in the common area. CNA F said that the male secured unit staffed 2 persons, and all staff float to help when staff take breaks. She said that the secured unit doors were locked, and a keypad was used to enter and leave. She said to go outside, the door to the courtyard was secured and staff must supervise all residents when they were in the courtyard. She said the maintenance supervisor monitored the locks and changed the codes regularly. She said after Resident #1 eloped there was a camera in the courtyard until the gate was repaired. She said she had been trained in the supervision of residents that wander and are at risk for elopement and it was important to keep all residents safe. During an observation on 01/05/2026 at 10:23 a.m., the male secured unit exit doors were locked by a magnetic lock with a keypad code. The courtyard had a wooden fence around the perimeter, and the gate was locked with a magnetic lock and keypad as well. There was apparent new wood on the gate door, new locking mechanisms and the gate door was secure.During an interview on 01/05/2026 at 10:31 a.m., CNA B said she was working the male unit the day Resident #1 eloped. She said she and CNA A had taken all the residents to the main dining room for the resident Christmas party. She said she was not sure who brought Resident #1 back to the unit, but they had let him out to the courtyard unsupervised, and he left through the courtyard gate. She said that somehow the gate's magnetic lock stopped working and the door was open, and he just walked out. She said the maintenance director had completed a generator test earlier and the gate was secure. She had been told when a generator test happened, she had to check the doors to make sure they relocked. She said she was not sure what time Resident #1 had left and was told about it after he returned. She said afterwards the gate had a camera until it could get repaired and no residents were allowed to go into the courtyard without supervision now. She said that a gate left open for residents that suffer from memory issues could get lost or injured. During an interview on 01/05/2026 at 10:35 a.m., CNA A said that she was in the dining room for the party when the incident with Resident #1 happened. She said she did not know when he left the facility grounds and was later told when he returned. She said the nurse checked him out and a camera was placed in the courtyard until the gate could be repaired. She said since the incident someone came and fixed the lock on the courtyard gate, and they received training on the magnetic locks and checking them to ensure they were locked, and all residents must be accompanied by a staff member when they are in the courtyard. During an interview on 01/05/2026 at 10:50 a.m., the Maintenance Supervisor said that he checked all the locks on the doors almost daily and had checked all the locks the morning of 12/18/2025 on the male secured unit. He said he ran a generator test around noon and had personally gone to each secured unit to reactivate the magnetic locks on the doors and courtyard gate. He said they were all working fine and was not sure what happened after his last check. He said he called the company that repairs the locks and placed an order for repair. In the meantime, he placed a camera at the gate in the courtyard, and no residents were allowed outside in the courtyard without staff assistance. He said when the lock company came to do the repairs, they said the magnetic locks had lost their magnet and were all replaced. He said he continued to check them several times a week, after generator tests and as needed and had educated the staff to always check the gates when they were outside. He said when Resident #1 eloped he had assisted residents back on the secured unit after the party. He said the aide working the hall had asked about residents going outside and he had told her he could go outside but thought she knew he had to be supervised. He said that residents that required a secured unit should be supervised and if left unsupervised they could get hurt.During an observation and interview on 01/05/2026 at 11:30 a.m., Resident #1 was awake and sitting in a recliner in the common area of the men's secured unit. He was calm and pleasant. He was unable to recall leaving the facility and said he liked where he lived but wanted to find his car and go home to his wife soon.During an interview on 01/05/2026 at 12:45 p.m., CNA C said she was working the men's secured unit on 12/18/25 with CNA A. She said all the residents but one had gone to the Christmas party and she stayed on the unit. She said she did not recall letting Resident #1 outside the day he eloped and thought the Maintenance Supervisor let him outside. She said it was busy with the party and everyone coming back to the unit at the same time. She said she was not aware that Resident #1 had left the facility until the DON came to the unit and told her. She said the Maintenance Supervisor did something to the gate lock and placed a camera in the courtyard. She said she was inserviced that the residents could not go outside alone and how to check the locks to make sure they were working correctly. She said that residents that elope could get hurt. During an observation on 01/05/2026 at 1:00 p.m., there were 3 male residents including Resident #1 outside in the men's unit courtyard smoking. CNA F was present with them. Resident #1 was ambulatory without any assistive devices. During an interview on 01/05/2026 at 2:15 p.m., LVN C said the day of Resident #1's elopement, all the resident's had been in the main dining room for a Christmas party. She said CNA C was on the hall because 1 resident did not come to the party. She said after the party, unsure of the time, all the residents we assisted back to the secured unit. She said sometime after that the SLP called the activity director and told her that Resident #1 was in the parking lot at the library and she was bringing him back to the facility. She said when he returned, he was calm and pleasant but tired. She assessed him, called the doctor and the family and the maintenance supervisor and DON went to see how he had gotten out of the facility. She said they did every 15 minute head counts on the men's unit until a camera was placed the next day. She said the administrator monitored the camera footage until the gate was repaired a few days later. She said they were all inserviced in supervision, wandering and elopement and the residents were no longer allowed in the courtyard without supervision. During an interview on 01/05/2026 at 2:45 p.m., CNA E said she was working the day Resident #1 eloped. She said she had not known about the elopement until the DON inserviced her and all the staff on elopements, wandering and supervision at all times when in the courtyard. She said that it was important to keep all residents safe because they could get hurt. During an interview on 01/05/2026 at 2:48 p.m., the DON said the day of Resident #1's elopement he had been at the Christmas party and sometime after he returned to the hall an aide let him out in the courtyard unsupervised. She said at that time, he exited the courtyard through the gate that had somehow become unlocked. She said the activity director told her the SLP had called about Resident #1 being at the library and she was bringing him back to the facility. She said he was immediately assessed, the MD was called, and the family was notified. She said the Maintenance Supervisor and herself started looking to see how he got out and discovered the courtyard gate was unlocked. She said she started inservices on wandering, elopement and supervision in the courtyard and every 15 minute head counts were initiated on the male secured unit as well. She said the next day a camera was placed outside in the courtyard, and the video was monitored 24/7 by the administrator until the gate was repaired. She said she was responsible for oversight in the facility and training on safety of residents at risk for elopement. She said that elopements were taken seriously because residents could be injured if they elope.During an interview on 01/05/2026 at 3:13 p.m., the SLP said she had worked on 12/18/2025 and attended the Christmas party. She said she had left for the day and on her way down the street she saw Resident #1 walking in the library parking lot near the main highway. She said she pulled over and addressed him, and he said he was looking for his car. She said he was pleasant and got in her car without any issues and she drove him back to the facility. She said she had called the activity director from her car to let her know she had found him and was bringing him back. She said when they arrived back at the facility the nurses assisted him inside and started assessing him for any injuries. She said she was glad she drove that way because he could have gotten hurt if he wasn't found so quickly. She said afterwards the DON did inservices on supervision of residents at all times in the courtyard and the maintenance supervisor did repairs to the gate.During an interview on 01/05/2026 at 4:15 p.m., the Administrator said that as soon as they were notified of Resident #1's elopement they started their interventions. She said they discovered the gate lock was no longer working, put every 15 minute resident counts into effect until a camera was installed on 12/19/2025. At that time, she monitored the camera for activity 24/7 and kept a log of any activity. The staff were inserviced and the gate was repaired on 12/23/25. Resident #1 was assessed, and he had no injuries or negative outcomes. They started an action plan and contacted the doctor and family. She said the residents on the secured unit can no longer go into the courtyard unsupervised.Record review of the facilities Wandering and Elopements policy dated March 2019 indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.On 01/06/2026 at 12:26 p.m., the Administrator was informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on 12/18/2025 and ended on 12/23/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included:Record review of Resident #1's comprehensive care plan dated 12/18/2025 revealed Resident #1's care plan was updated for his elopement with new interventions to include: monitor for emotional distress times 72 hours, complete head to toe assessment to assess for any injuries or abnormalities, notify physician and family of incident, provide additional training to all staff regarding elopement and review elopement policy and procedure, resident to be supervised while out in courtyard and not to be left unattended and update elopement assessment. Record review of Resident #1's medical record revealed an incident report was completed on 12/18/2025 with physician and family notifications, comprehensive assessment was completed on 12/18/2025, emotional distress assessment was completed on 12/18/2025, 12/19/2025, and 12/20/2025 and a new elopement risk assessment was completed 12/18/2025.Record review of an in-service titled Secured unit outside supervision dated 12/18/2025 with 47 employee signatures. Record review of in-service titled Elopement and Wandering Residents dated 12/18/2025 with 47 employee signatures.Record review of a Every 15 Minute Head Count dated 12/18/2025 to 12/19/2025 revealed all residents on the male secured unit were accounted for starting 12/18/2025 at 3:00 pm until 12/19/2025 at 4:45 pm. Record review of a log titled Ring Camera revealed the camera was installed on 12/19/2025 and was monitored from 12/19/2025 until 12/23/2025 when the gate was repaired. Record review of elopement drills for day and night shifts dated 12/22/2025 with 27 employee signatures.Record review of an invoice from the repair company dated 12/23/2025 revealed the exterior gates magnetic lock and z bracket were replaced and working. During observations from 01/05/2026 to 1/07/2026 Resident #1 as well as all the residents on the male secure unit was supervised when outside in the courtyard. On 01/06/2026 at 12:26 p.m., the Administrator was informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on 12/18/2025 and ended on 12/23/2025. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that:The facility failed to ensure the dish machine reached recommended minimal 50-100 parts-per-million, (PPM), of hypochlorite (chlorine) and water temperature of 120 degrees Fahrenheit (F) during the final rinse cycle of the facility dish machine.The facility failed to keep the freezer surfaces clean and free of ice buildup.This failure could place the residents at risk of foodborne illnesses. Findings included:During an observation and interview on 12/01/2025 at 08:45 am upon request the dish machine was checked by the Dietary manager; there was no sanitation detected on the test strips used by the Dietary Manager and the water temperature indicated 118 degrees Fahrenheit, (F) during the final rinse cycle. The Dietary Manager said they had not checked the sanitation this am before cleaning the dishes. The Dietary Manager said the test should indicate 50-100 parts per-million, (PPM), of hypochlorite (chlorine), and the water temperature should be 120 degrees Fahrenheit, (F). The Dietary Manager said she would contact the service contracted for the dish machine to service the dish machine.During an observation on 12/01/2025 at 09:05 am the freezer had one and a half inches of ice layered across the bottom of the freezer unit with food substances lying in the ice inside the freezer. The outside had dried spilled food substance that had dripped down the freezer. The Dietary Manager said she had been working in the manager's role for 6 weeks and had been the cook for the past 7 years. The Dietary Manager said she had two new employees that were still in training. She said she was responsible for ensuring all sanitation requirements are met in the kitchen. During an interview with the Administrator on 12/01/2025 at 09:10 am, the Administrator said the kitchen would serve on paper products until the sanitation level for the dish machine was resolved. The Administrator said her expectation was for the Dietary Manager to ensure that all sanitation requirements were followed including pest control. During an observation on 12/02/2025 at 10:57 am the Dish machine was tested by the Dietary Manager with a temperature of 120 degrees and sanitation of 50-100 Parts per million, meeting regulations and policy. The DM said that the contract service for the dish machine made a service call yesterday and made necessary adjustments.Record review of a facility policy titled Dishwashing Machine Use dated 2001 and revised in May 2008 read .Food Service staff are required to operate the dishwashing machine will be trained in all steps of dishwashing machine use .Record review of a facility policy titled Sanitation dated 2001 and revised in November 2022 read .The food service area is maintained in a clean and sanitary manner .1. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are.Low-Temperature Dishwasher (Chemical Sanitization):(I) Wash temperature (120 F); Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and(2) The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one facility reviewed for pest control.The facility failed to ensure an effective pest control program was in place to keep roaches, rats and flies out of the kitchen and the remainder of the facility.This failure could place residents at risk of exposure to ineffective pest control at the facility and food borne illnesses. Findings included:During an observation in the kitchen on 12/01/2025 at 08:55 am a live roach was crawling on the door of the white freezer. The dry storage area had large rodent droppings below the bottom shelf on the floor. The area of droppings was a 6-inch circle of droppings and wet rodent urine. The DM said she would have the area cleaned and that the large rodent droppings were a sanitation issue.During an observation and interview on 12/01/2025 at 09:05 the kitchen freezer had a one and a half inch of ice layer across the bottom of the freezer unit with 3 dead flies lying in the ice inside the large three compartment freezer. Flies were observed flying in the food preparation area. The Dietary Manager said all residents consumed meals prepared in the facility kitchen. She said she had been working in the manager's role for 6 weeks and had been the cook for the past 7 years. She said she was responsible for ensuring all sanitation requirements were met in the kitchen. The Dietary Manager said she reported pest concerns to maintenance and the Administrator. Record review of pest control logs on 12/03/25 revealed that pest control was last at the facility on 10/27/2025 for monthly service with additional treatments when requested by the facility. Invoices revealed the kitchen was treated for flies, roaches and rodents and in other areas of the facility also. Requested invoice for November 2025 and no invoice was provided.During an interview with the Administrator on 12/01/2025 at 09:10 am, the Administrator said her expectation was for the Dietary Manager to ensure that all sanitation requirements were followed including pest control. She said pests and rodents in the kitchen were a sanitation problem.During a phone interview on 12/02/2025 at 2:30 pm the contract pest control consultant said he comes monthly with the last visit in November. He said he checks rodent traps and rebaits them. He said he treats the facility for large flies and roaches. He said he had been contacted 12/01/2025 to return to the facility for additional treatment after this surveyor had found pests and evidence of rodents in the kitchen. He stated that with all the structural issues, baseboards, and food debris, this issue has persisted. He stated that he had been treating this building for 7-8 years and this problem had been the same for the entire 7-8 years. During an interview on 12/03/2025 at 8:30 am the Maintenance Director said that he treats the kitchen when he is made aware that insects are visible. He said the last treatment by himself was on 11/20/2025 with a canned spray for roaches. He said he was not aware there were large rodents in the Kitchen.Record review on 12/03/2025 of policy titled Pest Control dated May 2008 stated .this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on interview and record review, the facility failed to ensure individuals identified with MI, DD, or ID were evaluated for services for 1 of 5 residents (Residents #48) reviewed for PASARR.The facility failed to ensure Resident #48 had a PASARR evaluation after being readmitted to the facility on [DATE] with a mental illness diagnoses of bipolar disorder. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs.Findings included:Record review of an admission Record for Resident #48 dated 12/2/2025 indicated he was admitted to the facility on [DATE] with a readmission on [DATE] and was [AGE] years old with diagnoses of bipolar disorder (extreme mood swings), dementia, hypertension, and cerebral infarction (stroke).Record review of a Quarterly MDS Assessment for Resident #48 dated 9/23/2025 indicated he had moderate impairment in thinking with a BIMS score of 12. He had diagnoses of non-Alzheimer's dementia and psychiatric/mood disorder of bipolar disorder. Record review of a PASARR Level 1 Screening form for Resident #48 dated 2/25/2025 indicated the referring entity was from a psychiatric hospital and he had a primary diagnosis of dementia, and he also had MI.Record review of a PASARR Evaluation for Resident #48 indicated there was no evidence of an evaluation when resident readmitted to the facility on [DATE] and there was not a Form 1012 (a form that the nursing facility completes for a resident with a negative PASARR Level 1 screening for mental illness to determine if a new positive PASARR level 1 screening should be submitted) in the medical record.Record review of a care plan for Resident #48 dated 9/10/2024 indicated he had a diagnosis of mental illness, but dementia made him PASARR negative. Interventions included form 1012 completed by MD and LA to be updated as needed.During an interview on 12/3/2025 at 10:45 AM, the MDS Coordinator said she had been the MDS Coordinator for 3 years and was responsible for PASARR. She said when a resident admitted to the facility, she submitted the Level 1 Screening Form into Simple (long-term care software portal that facilitates claims data analysis, regulatory compliance, reimbursement optimization, and quality measurement) and if they had a mental illness, ID, or DD then she would alert the LA to complete a PE. She said Resident #48 was admitted back into the facility following a psychiatric hospital stay and his Level I screening was positive for dementia and MI. She said he should have had a PE completed and it was missed. She said he had a previous form 1012 that was signed in the past and dementia was primary. She said she submitted a new PASARR Level 1 screening and a new Form 1012 yesterday (12/2/2025) and it was sent to the physician to get signed. She said the Form 1012 showed if a resident had mental illness but also dementia, then dementia was the primary diagnoses. She said a new PL 1 should be completed when a resident discharged for more than 30 days from the facility or if a resident was admitted to a psychiatric facility. She said if the assessments were not done, services could be missed if they were not completed.During an interview on 12/3/2025 at 2:00 PM, the Administrator said the MDS Coordinator was responsible for PASARR. She said residents should have a level 1 screening completed prior to admission that would indicate if a resident had a mental illness and the local authority would need to be contacted for an evaluation. She said if an evaluation was not completed then a resident might not get the services that they qualified for. She said she would make sure during the stand-up meetings they would discuss the status of the positive level I's. She said she expected the MDS Coordinator to contact the local authority when a resident had a positive level I for an evaluation to be conducted. Record review of a signed Form 1012 for Resident #48 dated 12/2/2025 by the physician indicated the resident had a primary diagnosis of dementia. PL1 remains negative and no new PL 1 needed to be completed.Record review of a new PL1 for Resident #48 dated 12/2/2025 indicated he had dementia as primary diagnosis. Record review of a facility policy tilted admission Criteria revised March 2019 indicated, .Our facility admits only residents whose medical and nursing care needs can be met. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level 1 PASARR screen for all potential admissions to determine if the individual meets the criteria for a MD, ID, or Rd. b. IF the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II screening process

Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for 1 of 6 residents (Resident #39) reviewed for behavioral health services.The facility failed to document an episode of resident behaviors in the clinical record for Resident #39 on 12/1/25. The facility failed to offer a prn medication for anxiety to Resident #39 when she was exhibiting signs of anxiety on 12/1/25.These failures could place residents at risk of additional stress, feelings of hopelessness and a diminished quality of life. Findings included: Record review of a facility face sheet dated 12/3/25 for Resident #39 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Schizophrenia (a serious mental health condition that affects how individuals think, feel, and behave. It is characterized by a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired functioning), anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that can interfere with daily activities), and schizoaffective disorder, bipolar type (a mental health condition characterized by symptoms of both schizophrenia and bipolar disorder). Record review of a quarterly MDS assessment dated [DATE] for Resident #39 indicated a BIMS score of 7, which indicated severe cognitive impairment. Resident #39 was not coded for any physical or verbal behaviors. Record review of a comprehensive care plan dated 11/26/25 for Resident #39 indicated she had the potential to demonstrate verbally, or physically abusive behaviors related to schizophrenia and had an intervention to monitor each shift and document observed behavior and attempted interventions in behavior log and also had an intervention to administer medications as ordered. Record review of a Medication Administration Record (MAR) dated 12/1/25 through 12/31/25 for Resident #39 indicated a prn (as needed) order for hydroxyzine pamoate oral capsule 50mg was not administered. Order read: .Hydroxyzine Pamoate Oral Capsule 50mg (hydroxyzine pamoate) Give 50mg by mouth every 4 hours as needed for Anxiety related to Anxiety Disorder, Unspecified, until 12/2/25 23:59. Order was dated 11/18/25. MAR was not signed off indicating medication was not given.Record review of nursing progress notes for Resident #39 indicated no progress note for Resident #39 pacing in female secured unit common area, yelling and cursing on 12/1/25 at 2:55 pm. Record review of a nursing progress note dated 12/1/25 at 6:01 pm for Resident #39 indicated she was transferred to a behavioral hospital after an escalation in behaviors. During an observation on 12/1/25 at 2:55 pm Resident #39 was observed pacing in the female secured unit common area visibly upset, yelling and cursing loudly. She stated loudly I already told you one fucking time Behavioral Support Staff observed attempting to redirect resident by talking to her calmly. Resident continued being loud. Staff took resident out to smoke at 3:00 pm, resident still appeared agitated but stopped yelling and cursing at this time.During an interview on 12/2/25 at 9:32 am Behavioral Support Staff said Resident #39 normally did not behave that way. She said she had reported resident's behaviors to the nurse. She was unsure of any interventions done by the nurse. She did not give a name of whom she had reported behaviors to.During an interview on 12/3/25 at 8:45 am LVN D said she was not working Monday (12/1/25) when Resident #39 was transferred to a behavioral hospital. She said if she had a resident that was exhibiting behaviors such as pacing, visible signs of agitation or anxiety, yelling and cursing, she would document the behaviors in a progress note or behavior note and give any prn medications that resident may have. She said Resident #39 did have an order for medication prn. During an interview on 12/3/25 at 8:52 am DON said the charge nurse that had been scheduled Monday called in sick and ADON was working the female unit on Monday 12/1/25. DON said she had not been made aware of Resident #39's behaviors prior to an escalation that occurred at approximately 3:50 pm on 12/1/25 resulting in Resident #39 being transferred to a behavioral hospital.During an interview on 12/3/25 at 9:00 am ADON said she was working the day shift on the female unit on Monday 12/1/25, due to the regular nurse calling in sick. She said she was not notified of Resident #39 having any behaviors that day prior to an incident with another resident. Attempted a follow-up interview with Behavioral Support Staff on 12/3/25 at 9:09 am. Telephone call would not go through due to lack of signal. A text message was sent requesting a returned phone call, but no response was received before exiting facility.During an interview on 12/3/25 at 1:50 pm LVN B said she was working Monday 12/1/25. She said she was not working the female unit and was not notified of any resident behaviors for Resident #39.During a follow-up interview on 12/3/25 at 2:07 pm ADON said she could not remember the last time she had been on the female unit and saw Resident #39 before the escalation occurred, she said she was probably passing medications on another hall during the time Resident #39 had been exhibiting behaviors. She said if the behaviors had been reported to her, she would have documented the behaviors in a progress note and given a prn medication. She said interventions should be done appropriately to prevent an escalation of behaviors. During a follow-up interview on 12/3/25 at 2:10 pm DON said she would expect her staff to report resident's behaviors if they exhibited behaviors that were outside of their normal. She said she expected her staff to be proactive in managing resident behaviors in an effort to prevent escalation and possible altercations. She said she would be in-servicing the staff and providing education regarding behaviors, communication between staff and identifying anxiety and agitation.During an interview on 12/3/25 at 2:15 pm Administrator said she expected her staff to implement any interventions in place for resident behaviors, report resident behaviors to charge nurses, and also doctors, if needed, to obtain new interventions. She said she would be in-servicing the staff on managing resident behaviors. She said if behaviors were not managed appropriately, it could lead to altercations, and possible resident injury.Record review of a facility policy titled Resident-to-Resident Altercations dated September 2022 read: .Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff. and .Behaviors that may provoke a reaction by residents or others include: a. verbally aggressive behavior, such as screaming, cursing.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 6 resident's personal refrigerators reviewed for food safety (Resident #42).The facility failed to ensure the refrigerator for Resident #42 did not contain expired melon, unidentified substance in white Styrofoam cup with glove over it, and open, unlabeled, undated bean dip.This failure could place residents at risk for food borne illnesses.Findings included:Record review of a facility face sheet dated 12/2/25 for Resident #42 indicated she was an [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including asthma and dementia. Record review of a comprehensive MDS assessment dated [DATE] for Resident #42 indicated a BIMS interview should not be completed due to resident being rarely/never understood. She had severely impaired cognition. She required set-up or cleanup assistance with eating and was dependent with all other ADLs. Record review of a comprehensive care plan dated 6/22/22 for Resident #42 indicated she had a preference to keep a refrigerator in her room. She had interventions for staff to ensure all foods were dated and for staff to check refrigerator daily for spoiled or outdated foods.During an observation on 12/1/25 at 9:00 am a personal refrigerator was observed in Resident #42's room with a white Styrofoam cup in refrigerator with a glove over the top. There was no label, no date, and it appeared to have a spoon inside underneath the glove. There was also an open container of bean dip with no opened date, and an unopened container of mixed melon (watermelon, cantaloupe, and honeydew melon) with a sell by date of 10/8/25. Melon in container appeared soft and submerged in liquid.During an observation and joint interview on 12/2/25 at 9:35 am CNA E said either the CNA or housekeeping were responsible for cleaning out residents' personal refrigerators. Housekeeping supervisor was in the hallway at the time of interview and walked into Resident #42's room and was observed removing items from the refrigerator. She said if residents were to eat old food, it could make them sick. CNA E agreed that residents could get sick.During an interview on 12/2/25 at 9:43 am DON said Dietary staff were responsible for checking personal refrigerators once per day. She said if residents ate food that was expired or not good, they could get sick. During a follow-up interview on 12/3/25 at 2:10 pm DON said if residents' refrigerators were not kept cleaned out, residents could accidentally eat something they were allergic to, or they could eat old food and get sick. She said she would be conducting an in-service and training staff that dietary was to check temps of personal refrigerators daily and during temperature checks, if it needed cleaned out, they would report that to the nursing staff, and if they found a problem with the functioning of the refrigerator it would be reported to maintenance staff. During an interview on 12/3/25 at 2:15 pm Administrator said CNAs and Housekeeping would be responsible for cleaning out resident's personal refrigerators going forward. She said she would be responsible for monitoring to ensure it was being completed. She said if a resident ate spoiled food, they might get sick. Record review of a facility policy titled Foods Brought by Family/Visitors dated March 2022 read .Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date . and .The nursing staff will discard perishable foods on or before the use by date .

Based on observations, interviews, and record reviews, 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 4 residents (Resident #8) reviewed for infection control.The facility failed to ensure CNA A and the DON followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #8 on 12/02/2025.This failure could place residents at risk for cross contamination and infection. Findings included:Record review of Resident #8's face sheet dated 12/02/2025 revealed Resident #8 was a [AGE] year-old female that admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease (lung disease that affects breathing) and extended spectrum beta lactamase (ESBL) resistance (bladder infection that is difficult to treat due to medication resistance).Record review of Resident #8's nurses note dated 11/27/2025 indicated Resident #8 had colonized ESBL.Record review of Resident #8's order summary report dated 12/02/2025 did not indicate EBP for Resident #8.Record review of Resident #8's comprehensive care plan had not been completed as it was not due yet.Record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 15 indicating intact cognition, required substantial assistance with toileting, and was always incontinent of bowel and bladder.During an observation on 12/01/2025 at 10:00 am there was neither an EBP sign on Resident #8's door nor PPE outside the room. After a record review Resident #8 was coded on the facility matrix to have a pressure ulcer and urinary tract infection. During an interview on 12/02/2025 at 9:11 am Resident #8 said she had some sores on her buttocks that she has had for a long time and that she has had infections in her urine on and off for a long time. She said she could not recall whether the staff wore a gown or not when they cared for her. During an observation on 12/02/2025 at 10:11 am the DON and CNA A were in Resident #8's room to complete a skin assessment and wound care to pressure ulcers on her buttocks. Resident #8 was turned on her side by CNA A while the DON assessed the resident's buttocks and provided wound care. Neither the CNA nor the DON applied PPE for EBP. During an interview on 12/02/2025 at 10:20 am CNA A said that she had been trained on EBP and residents that had open wounds and catheters should be on EBP but was not sure what types of infections and the nurses handled that. She said Resident #8 had a pressure ulcer on her buttock and should be on EBP and was not sure why she did not have a sign on her door and PPE outside of her room. She said the nurses put out the signs and PPE for them to know who needed EBP. She said by not following EBP germs could spread. During an interview on 12/02/2025 at 10:22 am the DON said that Resident #8 was admitted to the facility with pressure ulcers, but the wound did not require a dressing. She said Resident #8 also had colonized ESBL and should be on EBP for that reason. She said when EBP was needed there should be an order, care plan and a sign on the door notifying staff of the need to wear a gown and gloves with care. She said she was responsible for the infection control program and by not following EBP infections could spread. During an interview on 12/03/2025 at 10:13 AM LVN B said she cared for Resident #8 and had spoken to the urologist about her ESBL and that her urinary infection was colonized with ESBL and Resident #8 did not need contact isolation. She said she thought she was already on EBP for her wound but realized she was not and there was never an order put in to monitor EBP use. She said by not following the EBP guidelines infections could spread. During an interview on 12/03/2025 at 12:04 PM the Administrator said the DON was responsible for the infection control program, but all nurses should initiate EBP for any of the required reasons when admitted or when an issue was newly identified. She said the DON was responsible for making sure the EBP process was followed by placing signs on the door, PPE outside the room and ensuring the staff were following EBP. She said if EBP was not followed cross contamination could happen and expected the infection control program was followed in its entirety to prevent infections from spreading. Record review of a facility policy titled Enhanced Barrier Precautions dated August 2022 indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a.dressing;b.bathing/showering;c.transferring;d.providing hygiene;e.changing linens;f.changing briefs or assisting with toileting;g.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh.wound care (any skin opening requiring a dressing).4.EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following:a.Pan-resistant organisms; b.Carbapenemase-producing carbapenem-resistant Enterobacterales;c.Carbapenemase-producing carbapenem-resistant Pseudomonas spp;d. Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii; e.Candida auris;f.Methicillin-resistant Staphylococcus aureus (MRSA); g.ESBL-producing Enterobacterales;h.Vancomycin-resistant Enterococci (VRE);I. Multidrug-resistant Pseudomonas aeruginosa; and j.Drug-resistant Streptococcus pneumonia.10.Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPB required.11.PPE is available outside of the resident rooms

Based on observation, interview, and record review the facility failed to maintain the appropriate temperature range for resident-use hot water for 2 of 4 Halls (Halls C and D) observed for the residents' environment. The facility failed to ensure the resident rooms and shower room for halls C and D had sufficient water pressure and hot water on 10/20/2025 and 10/21/2025.This failure could place residents at risk for a diminished quality of life.The findings included:1.Record review of an admission Record dated 10/21/2025 for Resident #3 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, morbid obesity (overweight), hypertension, and cerebral infarction (stroke).Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated he did not have any impairment in thinking with a BIMS score of 15. He was dependent on staff for showering/bathing.Record review of a care plan dated 11/27/2023 for Resident #3 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he was dependent on staff to provide a bath how often (3 times weekly) and as necessary.During an observation and interview on 10/20/2025 at 9:55 AM, Resident #3 was in his room in bed. He was alert and oriented to person, place, time, and situation. He said he had been at the facility for 2 years and was a member of the Resident Council. He said there was a lack of hot water getting to the rooms in the facility for months and last he heard when he talked to the Administrator as of 2 weeks ago was that they were waiting on an estimate from [Plumbing company]. He said he received his showers and bed baths on Tuesday, Thursday, and Saturdays. He said the last time he had a bath was last Tuesday and normally he requested a bed bath after the morning meal. He said on Saturday (October 18, 2025) the staff told him to skip his bath because there was not any hot water, and he had not shaved in a few days.2. Record review of an admission Record dated 10/21/2025 for Resident #9 dated 10/21/2025 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of nonrheumatic mitral valve insufficiency (heart condition where the valve does not close properly), cardiomegaly (enlarged heart), bradycardia (slow heartbeat), and hypertension.Record review of an Annual MDS assessment dated [DATE] for Resident #9 indicated he did not have any impairment in thinking with a BIMS score of 15.Record review of a care plan dated 5/15/2024 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he required staff assistance x1 with bathing.During an observation and interview on 10/21/2025 at 1:24 PM, Resident #9 was in his room on D hall sitting in a chair. Resident #9 said he had been at the facility for 1.5 years and things were going ok. He said his shower days were scheduled for Monday, Wednesday, and Friday and sometimes he missed getting them because of the water issues. He said the water in the facility was not working properly with low pressure or no hot water. He said he was supposed to get a shower on yesterday 10/20/2025 but did not because the facility had water issues. He said his bathroom never had hot water. He said if he did not get a shower, he did not care, but his family did not like it and told him to take a shower tomorrow 10/22/2025.3. Record review of an admission Record dated 10/21/2025 for Resident #8 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type (combines symptoms like hallucinations and delusions), type 2 diabetes, and generalized anxiety disorder (excessive and persistent worry and anxiety that is difficult to control).Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated he rarely/never understood and did not have a BIMS score. He required setup or clean up assistance with showering/bathing.Record review of a care plan revised on 7/7/2025 for Resident #8 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he required assistance x1 with bathing/showering three times weekly and as necessary.During an observation and interview on 10/21/2025 at 2:09 PM, Resident #8 was sitting in a chair in the dining room. He said he had been at the facility for a while. He said he was not sure of his scheduled shower days, and he did not get a shower yesterday on 10/20/2025. He said the facility always had issues with the water where it barely ran or did not have any hot water. He said not having hot water made it hard for him to shave. He said it aggravated him sometimes when the facility did not have hot water or not enough pressure.Record review of the facility's Resident Council Meeting notes dated 8/19/2025, 9/2/2025, and 9/16/2025 indicated residents who were in attendance voiced complaints of having problems with the hot water and pressure in the facility with no changes or resolutions.Record review of a shower schedule for Halls C and D undated indicated Resident #8 and #9 were scheduled for showers on Monday, Wednesday, and Friday on the 6 am-6 pm shift. Both were to get a shower.During an interview on 10/20/2025 at 1:04 PM, the AD said during the resident council meetings the past few months, the residents had been complaining about the water saying it did not get hot, and it had low pressure. She said the [plumbing company] came out and did something but was not sure what it was. She said the residents had been able to get bed baths/sponge baths when the water pressure was too low or the water was not getting hot. She said the staff would have to get the hot water from wherever they could at the facility. She said most staff would get hot water from the kitchen and carried it in basins to where they needed it. She said she would not like it if she wanted a shower and could not get one because of low water pressure or if the water was not hot enough.During an interview on 10/20/2025 at 2:28 PM, the Maintenance Supervisor said he had been employed at the facility for 3 years. He said the facility had some pipes repaired before he started as they had lime buildup and sometimes would not have good water flow in the facility. He said he changed out the water filters about twice or more a month. He said after he changed the filters, the water pressure would work for a while and then slow down again. He said the facility was working on getting a new water filtration system and [plumbing company] came out and gave them a quote for the repairs. He said he kept a log of water temperatures in the facility weekly as the water temperatures fluctuated. He said sometimes the facility would have hot water on some halls but low water pressure on others. He said sometimes the residents would have to get a bed bath instead of a shower because of the water issues and the staff would have to get water from the laundry room or kitchen. He said the staff would carry the water in a basin to where they needed it. He said it had been an issue for 3 years, but he tried to keep the filter changed to help.During an observation on 10/20/2025 at 3:24 PM, CNA B was observed exiting the shower room on Hall C with a basin of water in her hand.During an observation and interview on 10/20/2025 at 3:29 PM, CNA B was in room [ROOM NUMBER] on C Hall said she had to get water from the shower room because there was not any hot water in the bathroom to give the resident a bed bath. The hot water was turned on at the sink in the bathroom and the temperature was checked by the Surveyor and it was 72 degrees.During an interview on 10/20/2025 at 3:36 PM, the Administrator said she was aware the facility had water issues, and they had a plumber that came out and informed her they would need to replace the system. She said she followed up a week later via email to ask about a quote so she could submit it to corporate but had not heard anything back. She said she knew if the kitchen was using water to wash dishes, then the staff would have to wait an hour or so for the water temperature or pressure to come back up for the halls and shower rooms. She said she was not aware staff carried hot water from the kitchen or laundry to the rooms to give baths.During a phone interview on 10/20/2025 at 3:57 PM, the Plumber said the last time (6/19/2025) he visited the facility he checked the back flow valve and took it apart because it failed. He said it had a white, heavy film from the city water supply. He said another plumber from [Plumbing company] was working on getting a water filtration system for the facility and had requested the facility send him their monthly water usage as he would have to custom built it. He said he was going back to the facility that day to get a water sample to test the system to ensure the correct size system would work for the facility. He said the facility was not given a quote yet because they were not sure what size system and how many tanks it would require. He said it would take about 2-3 days to build and then would have to install it. He said there had been buildup in the lines from years ago on two halls in the facility and at that time they replaced the copper pipes and put in pex piping for the two halls. He said the copper pipes had so much buildup that a pencil could not fit inside the pipes. He said the buildup in the lines would not allow water to flow properly and it could cause fluctuations in the water temperatures. He said they tested the back blow valves yearly and the last time he checked it; he could not get it to work properly and had to take it apart.Record review of a back flow valve test dated 6/19/2025 at the facility by the [Plumbing company] indicated the back flow valve failed on initial test, repaired and was tested again without any leaks. They installed a complete repair kit and cleaned out trash.During a phone interview on 10/21/2025 at 8:50 AM, LVN D said the residents have not been getting showers like they needed to because the water pressure was low or there was not any hot water. She said if they needed hot water they would get warm water from the kitchen in a basin. She said it had been going on for several months. She said residents should never go without a bath or shower and they could give a bed bath and get hot water from the kitchen. She said the kitchen always had hot water. She said she would be upset if she had to wait on hot water to take a bath/shower. She said she always told the staff to offer the residents a bed bath.During an interview on 10/21/2025 at 9:36 AM, CNA C said she had been working at the facility for a while in the kitchen but had been a CNA for about 6 months. She said she was always assigned to work halls C and D. She said the water issue had been low since she started on the floor, if water was not hot enough or the pressure was low, they would get water from the kitchen and put the water in a basin and take it to the resident room to give a bed bath or in the shower room. She said she would not like it and would complain if she would get a proper shower with hot water and water pressure. She said she was never informed to wait until later in the day to give a shower due to the water pressure.During an interview on 10/21/2025 at 10:17 AM, [NAME] F said he had been employed at the facility for 2 months and worked split shifts. He said he had observed staff asking for hot water from the kitchen about 1-2 times since he had been employed. He said the staff told him they needed hot water to give a resident a bath. He said they told him the water was not getting hot in the resident rooms.During an interview on 10/21/2025 at 2:43 PM, the DON said she started at the facility on 9/29/2025. She said the week she started the water pressure was low and was told if they gave showers before 9 am-10 am before the kitchen started washing dishes and then after lunch the water pressure would be better. She said she would be upset and would feel like she should have services available to her for which she was paying. She said she was not aware of resident's not getting their showers as scheduled.During an interview on 10/21/2025 at 3:13 PM, the Administrator said the plumbing company had finally given them a quote that day (10/21/2025) and planned to install a mixer valve and it would be a separate line that would go to the water heater from the kitchen to the halls. She said she started 8/18/2025, and was not aware at that time the facility had an issue with the water. She said she had been emailing back and forth with the plumbing company for the past month to see about how much it was going to cost. She said the Maintenance Supervisor was responsible for checking the water and temperatures in the facility at least daily. The facility had a system in place where they could report maintenance issues. She said she did not know staff carried water from the kitchen or laundry room and would not want that to happen as there could be a risk of injury.Record review of a maintenance log dated 9/24/2025 indicated the shower on A-hall did not have any water pressure. The issue was completed on 10/14/2025. Comments indicated, fixed.During an interview on 10/21/2025 at 3:30 PM, the Regional Director of Operations said he was aware Halls C and D did not have hot water in the rooms. He said they would first repair the mixing valve for the facility and then would get to the issue with the halls. He said all residents in rooms on those halls had hand sanitizer in the bathrooms and if a shower was needed, those residents could go to one of the other halls that usually had hot water. He said the plumber was at the facility and had given them a quote and repairs would be made. He said in the meantime, there would be 2 staff members in the shower rooms when residents were given showers. One staff would monitor the temperature of the water to ensure it did not drop and get cold while the other gave the shower. He said all staff would be inserviced on the changes until the repairs had been made.Record review of a facility policy titled Homelike Environment revised February 2021 indicated, .Resident are provided with a safe, clean, comfortable, and homelike environment. 2. The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 9 residents (Resident #3) reviewed for accident hazards.The facility failed to ensure two cans of air freshener were not left in Resident #3's room on 10/20/2025 and 10/21/2025.This failure could place residents at risk of injuries due to environmental hazards. Findings included:Record review of an admission Record dated 10/21/2025 for Resident #3 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, morbid obesity (overweight), hypertension, and cerebral infarction (stroke).Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated he did not have any impairment in thinking with a BIMS score of 15. He was dependent on staff for showering/bathing.Record review of a care plan dated 11/27/2023 for Resident #3 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he was dependent on staff to provide a bath how often (3 times weekly) and as necessary.During an observation and interview on 10/20/2025 at 9:55 AM, Resident #3 was in his room and in bed awake. He said he had been a resident at the facility for 2 years. There were two aerosol cans of air freshener on his nightstand. He said the staff had left them in his room. One can read to keep out of reach of children on the label. He asked if he needed to remove the cans as one of the cans he had purchased, and the other can was one that staff had left in the room. He said there have not been any residents who wander into his room.During an observation on 10/21/2025 at 2:01 PM, Resident #3 was not in his room. The two cans of air freshener were still in his room on the nightstand.During an interview on 10/21/2025 at 2:43 PM, the DON said she started at the facility on 9/29/2025. She said there should not be any residents in the facility to have access to air fresheners in their possession. She said the air fresheners should be locked in a cart or room and not stored in the resident rooms. She said she was not aware Resident #3 had air freshener in his room and would talk to him. She said there could be a risk for fires or cause other people to get sick from the inhalants.During an interview on 10/21/2025 at 3:13 PM, the Administrator said residents should not have aerosols in their rooms. She said the air fresheners should be stored in a locked closet or in housekeeping. She said residents could be at risk for respiratory issues. She expected staff to keep aerosols on their carts or lock them in a closet after use.Record review of a facility policy titled Hazardous Areas, Devices and Equipment revised July 2017 indicated, .All hazardous area, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environment hazards include, but are not limited to: g. Access to toxic chemicals.

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 2 of 9 residents (Residents #8 and #9) reviewed for medical records.The facility failed to ensure Resident #8 and Resident #9's medical records were accurate when CNA C documented both residents received a bath on 10/20/2025 when they did not.This deficient practice could place residents at risk of improper care due to inaccurate medical records.The findings include:1.Record review of an admission Record dated 10/21/2025 for Resident #9 dated 10/21/2025 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of nonrheumatic mitral valve insufficiency (mitral valve in the heart does not close properly), cardiomegaly (enlarged heart), bradycardia (slow heart beat), and hypertension.Record review of an Annual MDS assessment dated [DATE] for Resident #9 indicated he did not have any impairment in thinking with a BIMS score of 15. He required setup or clean up assistance with showering/bathing.Record review of a care plan dated 5/15/2024 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he required staff assistance x1 with bathing.Record review of the nurse aide tasks for Resident #9 for October 2025 indicated his baths were scheduled for Monday, Wednesday, and Friday. Further review revealed on 10/20/2025 CNA C documented the resident received his bath.During an observation and interview on 10/21/2025 at 1:17 PM, Resident #9 was in his room on D hall sitting in a chair. Resident #9 said he had been at the facility for 1.5 years and things were going ok. He said his shower days were scheduled for Monday, Wednesday, and Friday and sometimes he missed getting them because of the water issues. He said the water in the facility was not working properly with low pressure or no hot water. He said he was supposed to get a shower on yesterday 10/20/2025 but did not because the facility had water issues. He said his bathroom has never had hot water. He said if he did not get a shower, he did not care, but his family did not like it and told him to take a shower tomorrow 10/22/2025.2. Record review of an admission Record dated 10/21/2025 for Resident #8 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type, type 2 diabetes, and generalized anxiety disorder.Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated he rarely/never understood and did not have a BIMS score. He required setup or clean up assistance with showering/bathing.Record review of a care plan revised on 7/7/2025 for Resident #8 indicated he had an ADL self-care performance deficit. Interventions for bathing indicated he required assistance x1 with bathing/showering three times weekly and as necessary.Record review of the nurse aide tasks for Resident #8 for October 2025 indicated his baths were scheduled for Monday, Wednesday, and Friday. Further review revealed on 10/20/2025 CNA C documented the resident received his bath.During an observation and interview on 10/21/2025 at 2:09 PM, Resident #8 was sitting in a chair in the dining room. He said he had been at the facility for a while. He said he was not sure of his scheduled shower days, and he did not get a shower on yesterday 10/20/2025. He said the facility always had issues with the water where it barely ran or did not have any hot water. He said not having hot water made it hard for him to shave. He said it aggravated him sometimes when the facility did not have hot water or not enough pressure.Record review of a shower schedule for Halls C and D undated indicated Resident #8 and #9 were scheduled for showers on Monday, Wednesday, and Friday on the 6 am-6 pm shift. Both were to get a shower.During an interview on 10/21/2025 at 9:36 AM, CNA F said she had worked at the facility for a while but had been a CNA for about 6 months. She said on 10/20/2025 there were five residents who were scheduled to get a bath/shower on halls C and D. She said Resident #9 did not get a shower because he wanted to wait until after breakfast and whenever she let him know that they were going to do it after lunch, when she went to tell him he was lying down in the room. She said Resident #8 did not get a shower on yesterday 10/20/2025. She said she accidentally documented that both received their showers in the charting system, but they did not. She said only three of the five residents received a bath on 10/20/2025 that were scheduled.During an interview on 10/21/2025 at 2:43 PM, the DON said she started at the facility on 9/29/2025. She said when a resident refused a shower, the nurse aides should notify the nurse and the nurse should try to persuade the resident to take a shower; if they still refuse, they should document the refusal in a progress note. She said the nurse aide should document a refusal in the charting system under the task for bathing. She said it was false documentation if they documented a shower was received when it was not given. The charge nurse should supervise the nurse aides to ensure the residents are getting their showers.During an interview on 10/21/2025 at 3:13 PM, the Administrator said if a resident refuses a shower, they should tell the nurse, and the nurse should talk to the resident and document that they all documented and refused and have told them to make a 3rd attempt. She said the DON and ADON were responsible for conducting audits to ensure residents are not refusing and review the 24-hour report. She said if a resident did not receive a shower, they need to document that they did not receive the care. She said documenting care received when it was not was falsifying a document. She stated it was her expectation for staff to strike out and make a correction if there was a documentation error.Record review of a facility policy titled Charting and Documentation revised July 2017 indicated, .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observations, interviews, and record reviews 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 9 residents (Resident #4) and 1 of 4 staff (CNA A) reviewed for infection control.The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #4 on 10/20/2025.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include:Record review of an admission Record for Resident #4 dated 10/21/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (paralyzed on one side of the body), malignant neoplasm of prostate (cancer in the prostate gland), cerebral infarction (stroke), and dysphagia (difficulty eating or swallowing).Record review of a Quarterly MDS Assessment for Resident #4 dated 9/14/2025 indicated he had moderate impairment in thinking with a BIMS score of 9. He was dependent on staff for personal hygiene. He was always incontinent of urine and bowel.Record review of a care plan for Resident #4 dated 9/9/2025 indicated he had bladder incontinence. Interventions included checking the resident every 2 hours and as required for incontinence.During an observation on 10/20/2025 at 1:47 PM, in the room of Resident #4. CNA A and CNA C were present to perform incontinent care. CNA A and CNA C both washed their hands and applied gloves. Both staff removed the resident's pants and the lift sling and placed them in a plastic bag. CNA C opened the resident brief and pulled it down between his thighs. CNA A removed wipes from the package and wiped the residents' inner thighs and placed the wipes in the trash. CNA A removed more wipes and then wiped the shaft of his penis and pulled the foreskin back and cleaned in a circular motion and then pulled foreskin back over and placed the gloves in the trash. CNA A removed her gloves and placed them in the trash and put on clean gloves without washing or sanitizing her hands. CNA A removed wipes and CNA C rolled the resident onto his left side and CNA A wiped his rectal area using multiple wipes and placed them in the trash. CNA A rolled the brief underneath the resident's buttocks and removed the brief and placed it in the trash along with her gloves. CNA A placed clean gloves on her hands without washing or sanitizing them and applied skin protectant to his buttocks and removed her gloves and placed them in the trash. CNA A applied clean gloves without washing or sanitizing her hands. A clean brief was placed underneath the resident's buttocks and secured, and the resident was repositioned in the bed. CNA A removed her gloves and placed them in the trash and washed her hands in the bathroom. CNA C removed her gloves and washed her hands.During an interview on 10/20/2025 at 2:06 PM, CNA A said she had been employed at the facility for over a year. She said she worked all over the facility. She said the last time she had a skills check off with staff was with the ADON about 2 weeks ago. She said during the care provided to Resident #4; she did not wash or sanitize her hands between glove changes. She said she had sanitizer in her pocket and did not know why she did not use it. She said there was a risk for infections and UTI's if staff did not wash or sanitize their hands between glove changes.Record review of a Nurse Aide Proficiency for CNA A dated 8/1/2025 by the ADON indicated she had training on perineal care with a male resident and was satisfactory with hand hygiene.During an interview on 10/20/2025 at 2:11 PM, the ADON said she was responsible for training staff and conducting skills check offs with the staff in the facility. She said she did it yearly. She said she observed the staff provide incontinent care and perform handwashing. She said staff should wash or sanitize their hands before care was started, anything they were visibly soiled, between glove changes and after care was completed. She said there was a risk of infections if staff did not wash or sanitize their hands between glove changes.During an interview on 10/21/2025 at 2:43 PM, the DON said she and the ADON were responsible for training staff on their competency for skills check off once a year that included hand hygiene and infection control. She said hand hygiene before, in between when changing, when gloves are changed, and after care completed and can use sanitizer between. Risk for cross contamination and carrying germs to another resident.During an interview on 10/21/2025 at 3:13 PM, the Administrator said the DON and ADON were responsible for training staff on infection control. She said she was aware of the observation of staff not washing their hands with glove changes on yesterday 10/20/2025. She said staff should perform hand hygiene before care was started, between residents, when going from dirty to clean, after care, and can use hand sanitizer if hands were not visibly soiled. She said residents could be at risk for cross contamination.Record review of a facility policy titled Handwashing/Hand Hygiene revised October 2023 indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for hand hygiene: 1. Hand hygiene is indicated: c. after contact with blood, bloody fluids, or contaminated surfaces; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 5. The use of gloves does not replace hand washing/hand hygiene.

Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) of 8 residents reviewed for abuse and neglect.The facility neglected to ensure enough staff to monitor the residents in the male secure unit which lead to the resident-to-resident abuse.The facility failed to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice.The facility failed to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind.The facility failed to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face.The facility failed to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital. An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern 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 evaluate the effectiveness of the corrective systems. This failure could place all residents in the facility at risk for injuries, hospitalization and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.Findings Included: 1.Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia (high cholesterol). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, book. 2.Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed the incident description that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to Resident #2 and resident # 2 shoved Resident #1 causing her to fall. Both residents were assessed for injuries. A skin tear to the left elbow and a raised area was noted to the left side of resident #1's head. An xray revealed age indetermination fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement from CNA F dated 6/25/2025 revealed on the day of 6/25/2025. I saw [Resident #2] push [Resident #1], causing [Resident #1] to fall down. [Resident #2] was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character . 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Section E of the MDS indicated Resident #3 had not had any behaviors. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 (1 staff member to 1 resident) monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all parties were notified by nurse and RN. Record review of a progress note for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse and no injuries were noted and no pain or discomfort was noted. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #4. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Section E of the MDS indicated Resident #4 had not had any behaviors. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 was placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated the resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of a progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated the behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to go out the back door of the dining room to the smoking area. Resident #4 was redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on an undisclosed date and time the interviewee said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking . Section E of the MDS indicated Resident #5 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by the nurse> All parties were notified. The resident was placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM completed by LVN D indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. Resident #5 was assessed by the nurse no and issues were noted. Resident #5 was redirected by the nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. She said it had been reported to the ADON and the DON multiple times by nothing had been done. She said the nurse came to the male secured unit while the nurse was making her round or when she was asked to come in by the CNA but that was the only time the nurse was on the male secure unit. She said MA M was on the male secured unit only while MA M was passing out medications. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Section E of the MDS indicated Resident #6 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address behaviors prior to the incident. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected and placed 1:1 supervision. During a confidential interview on an undisclosed date and time the interviewee said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on an undisclosed date and time the interviewee said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video as desperation to get more help on the male secure unit. Observation of a video on 9/02/2025 at 12:32 PM on 9/02/2025 at 12:32 PM taken on 8/28/2025 revealed Resident #5 was sitting at a table in the dining room of the male secure unit, and Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation. She said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNAs had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. She said Resident #6 was still at the behavioral hospital at the time of the interview. She said Resident #6 was still at the behavioral hospital at the time of the interview. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was after surveyor entrance that she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Section E of the MDS indicated Resident #7 had not had any behavioral symptoms. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behaviors: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in a resident-to-resident incident approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this Resident #7 lying on the right side behind Resident #8 facing the window. Observed Resident #7 having sexual intercourse with Resident #8. Upon entering and discovering Resident #7 removed penis and both residents remained lying quietly. This nurse requested help from CNA K to remove Resident #7 from behind Resident #8 and separate them so assessments and investigation of incident could be performed. Resident #7 verbalized that he knew what he had done and said this incident was the first time. When questioned further Resident #7 began stating he was sad after the recent loss of his son and did not want to discuss any further. Resident #7 requested medication for anxiety and nerves. This nurse medicated Resident #7. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Section E of the MDS indicated Resident #8 had not had any behavioral symptoms. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of a progress note for Resident #8 dated 9/02/2025 at 1:30 AM written by LVN V indicated: A nurse entered the resident's room and witnessed him being sexually assaulted by his roommate. This resident was immediately cleaned and moved to another room. No injuries or bleeding noticed by assessing nurse at the time. On-call Nurse notified as well as Administrator. [town] Police Department also called and resident is being sent out to ER to be assessed 0230 EMS and Police arrived.)253 Resident leaving facility in route in [Hospital] to be assessed. The resident RP also notified. Record review of hospital paperwork for Resident #8 dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of a facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7's] arm was across [Resident #8's] waist, when [Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8's] buttocks, [Resident #7] had BM on his hands and could see where he had placed his penis in [Resident #8] rectum, [Resident #8] he had BM on his butt cheek and around his rectum, myself and nurse helped [Resident #8] get up out the bed, got him cleaned up and clothes on and covered up in bed. He was weak and very confused to what was going on!! After removing [Resident #8] to another room, I asked [CNA N] to help me to get [Resident #7] cleaned up, had him to get up in his wheelchair, so bed could be cleaned up, he had took his soiled brief off and it was thrown at the end of the bed when we entered the room, (I) saw it, the bed had a small urine stain that was wet under where [Resident #7] was laying & BM on the sheet on the back side where he [Resident #7] was laying., he had BM on his hands, face, legs!! I asked [Resident #7] why he did that to [Resident #8], he stated he didn't know, I asked him had he did that to him before and he said NO!! End of Statement!!! During an interview on 9/02/2025 at 10:20 AM CNA B said Resident #7 would make sexual comments such as you can suck it or can you touch it while she would provide care. She said when she told Resident #7 to stop talking like that he would. She said she knew Resident #7 had made sexual comments to staff but she had never seen Resident #7 make inappropriate sexual comments or gestures to any other residents prior to the incident. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident at the facility. He said it was not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 lying in Resident #7s bed with Resident #7

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 8 of 8 residents reviewed for accidents and supervision. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) The facility failed to adequately provide supervision to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to adequately provide supervision to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice. The facility failed to adequately provide supervision to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind. The facility failed to adequately provide supervision to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face. The facility failed to adequately provide supervision to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital. The facility failed to adequately supervise residents on the secured unit to maintain safety and to prevent resident to resident altercations. An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern 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 evaluate the effectiveness of the corrective systems. This failure placed all residents in the secured unit at risk of injury and death. Findings included: 1.Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, book. 2.Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed incident description that resident #1 was standing over resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents was assessed for injuries, skin tear to left elbow and raised area noted to left side of resident #1's head. Xray revealed age indetermination fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement dated 6/25/2025 CNA F stated on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. 3. Record review of Resident #3's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros x72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 9/03/2024 indicated Resident #3 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted no acute distress or discomfort noted. Residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by nurse and all parties were notified by nurse and RN. Record review of progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in dining room at his table when Resident #4 hit him in the head from behind. Record review of facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by roommate Resident #5; assessment completed by his nurse no injuries noted resident denies pain or discomfort. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by another resident. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 placed on Q15 monitoring. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of Resident #4's care plan dated 9/30/2024 indicated Resident #4 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Resident #4 was at risk for elopement/wandering as evidenced by a history of attempts to leave facility unattended with interventions that included: Monitor location ever 2 hours and as needed. Document wandering behavior and attempted diversional interventions in behavior log. Record review of progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident in right side of head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated resident placed 1 on 1 with housekeeping sitting with resident at that time. Record review of progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated behavioral hospital was there to pick resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 in right side of head from behind while attempting to come in back door. Resident #4 redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on 9/02/2025 at 10:54 AM She said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, Moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of Resident #5's care plan dated 8/27/2025 indicated Resident #5 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated notified by CNA to floor nurse that resident hit roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by nurse, all parties notified, resident placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by CNA Resident #5 hit roommate in the head twice and had a shoe in his hand, resident was redirected. Resident assessed by nurse no issues noted, resident redirected by nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident with were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.etc) and document per facility protocol. Record review of progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected. Record review of facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected, resident placed 1:1 supervision. During a confidential interview on 9/02/2025 at 10:54 AM She said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on 9/02/2025 at 12:32 PM She said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video is desperation to get more help on the male secure unit. Observation of a video taken on 8/28/2025 showed Resident #5 sitting at a table in the dining room of the male secure unit, Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation, she said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNA's had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was not until after she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of Resident #7's care plan dated 7/22/2025 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes related to dementia with interventions that included: Monitor/document/report to MD any changes in cognition function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: this resident involved in resident-to-resident incident approximately 2:30 AM resident placed on 1-on-1 monitoring and will be referred to psych services. Record review of facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this resident lying on right side behind other resident facing the window. Observed this resident having sexual intercourse with resident. Upon entering and discovering this resident removed penis and both residents remained laying quietly, this nurse request help from CNA K to remove resident from behind resident and separate them so assessments and investigation of incident could be performed. This resident verbalized that he know what he done and said this incident was the first time, when questioned further this resident began stating he is sad after the recent loss of his son and doesn't want to discuss any further, this resident request he as needed medication for anxiety and nerves, this nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of Resident #8's care plan dated 7/31/2025 indicated Resident #8 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of hospital paperwork dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7] arm was across [Resident #8] waist, when [Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8] buttocks, [Resident #7] had BMon his hands and could see where he had placed his penis in [Resident #8] rectum, [Resident #8] he had BM on his butt cheek and around his rectum, myself and nurse helped [Resident #8] get up out the bed, got him cleaned up and clothes on and covered up in bed. He was weak and very confused to what was going on!! After removing [Resident #8] to another room, I asked [CNA N] to help me to get [Resident #7] cleaned up, had him to get up in his wheelchair, so bed could be cleaned up, he had took his soiled brief off and it was thrown at the end of the bed when we entered the room, (I) saw it, the bed had a small urine stain that was wet under where [Resident #7] was laying & BM on the sheet on the back side where he [Resident #7] was laying., he had BM on his hands, face, legs!! I asked [Resident #7] why he did that to [Resident #8], he stated he didn't know, I asked him had he did that to him before and he said NO!! End of Statement!!! During an interview on 9/02/2025 at 10:20 AM CNA B said Resident #7 would make sexual comments such as you can suck it or can you touch it while she would provide care. She said when she told Resident #7 to stop talking like that he would. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident here at the facility. He said it was not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 laying in Resident #7s bed with Resident #7 behind Resident #8 and both residents were laying on their right sides facing the window in the room. She said she was shocked with what she saw so she stepped back in the hallway and called for the CNA to come and help her. She said when they walked back in the room they said, what's going on? She said when they said that Resident #7 jumped and turned to see who was coming in the room which caused his penis to withdraw from Resident #8's rectum. She said both residents had a large amount of feces on them, but Resident #7 had feces caked in his front groin area. She said she asked both residents what happened, and Resident #8 said he did not know what happened. She said Resident #7 said he knew what he did and then said, I'm sad my son died. She said Resident #8 seemed to be extremely confused and k

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, when reviewing the facility for sufficient staffing for 2 of 4 hallways (Hallways A and B). The facility failed to adequately staff the A and B hallway (secured units) to prevent resident to resident abuse.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital.An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern 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 evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injuries, abuse, severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included:Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia (high cholesterol). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents were assessed for injuries. A skin tear to left elbow and raised area noted to the left side of Resident #1's head. An x-ray revealed age indeterminate fifth digit proximal phalanx head fracture (fracture to left fifth toe but unable to determine the age of the fracture) for Resident #1. A Record review of a witness statement from CNA F dated 6/25/2025 stated, on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he had moderate cognitive impairment. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate assistance with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being hit in the face 2 times by Resident #5 on 7/13/2025. Interventions that included: residents separated and both placed on 1:1 monitoring (a staff member is assigned to stay with the resident at all times), assessed both residents for injury, emotional distress, and neuros for 72 hours (neurological assessment for 72 hours), moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being slapped by Resident #4 on 7/30/2025. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind. Interventions included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs were notified. Both residents assessed for emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all responsible parties were notified by the RN. Record review of a progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse. No injuries were noted and the resident denied pain and discomfort. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #5. Redirected Resident #5 away from Resident #3 and placed Resident #5 on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring and Resident #3 placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries. None found on initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident-to-resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in the back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated a behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to come in the back door. Resident #4 was redirected away from Resident #3 with the nurse so he could be 1 to 1 at that time. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident, but the resident was redirected by nurse. All parties were notified. The resident was placed on 1:1 and separated from other residents. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. The resident was assessed by the nurse and no issues were noted. The resident was redirected by the nurse and placed on 1:1 monitoring. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc.) and document per facility protocol. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable. Nurse reports that the resident continues to try and hit at a fellow male resident. Staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected and resident placed 1:1 supervision. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing; toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in resident-to-resident incident at approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found the resident lying on his right side behind another resident facing the window. The nurse observed the resident having sexual intercourse with the other resident. Upon entering the room, the resident removed his penis from the other resident and both residents remained lying quietly. This nurse requested help from CNA K to separate the residents so assessments and investigation of incident could be performed. This resident verbalized that he knew what he had done and said this incident was the first time. When questioned further this resident stated he was sad after the recent loss of his son and doesn't want to discuss any further. This resident requested medication for anxiety and nerves. This nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. During an observation on 9/2/2025 at 10:42am of the female unit, there was one CNA providing care for 7 residents. 4 female residents were sitting in the common area watching TV, 2 female residents were sitting at the table doing activities (coloring) and one female resident was sitting outside alone smoking (in an enclosed sitting/smoking area and could be seen by staff through a large window). During an interview on 09/02/2025 at 11:40am the MA said staffing had been an issue due to people calling in or not showing up for work. She said there were times other staff had come in for extra shifts and times they could not get coverage for the workers who did not show up. She said the facility was staffed with only four CNAs and two nurses. One nurse worked the A & B halls (secured units), one nurse works C&D halls and one CNA staffed on each hall. She said she felt the facility would benefit from having more available CNAs and nurses. She said she felt the residents would receive a better quality of care with an increase of staff. During an interview on 9/4/2023 at 9:15am CNA-F said on most days more help was needed. She said she had worked up to 16 hours straight but had heard of other workers working 18 to 24 hours straight and going home for a 6-hour break and coming back for their regular 12-hour shift. She said staff volunteered to work the hours if the facility was short staffed. She said they had been provided walkie talkies on 9/04/2025 to call for help when needed, such as when giving a resident a shower, other resident needs or if they needed a break. She said she felt that more staff would be a plus to resident care. She said instead of doing the basic care staff would be able to provide a better quality of care and prevent things such as resident to resident altercation, falls, toileting and any negative incidents. During an interview on 9/4/2023 at 9:40am the Housekeeping Supervisor said she helped in the kitchen, housekeeping and monitored on the halls. She said she did not provide direct care for residents but did monitor the residents (kept residents separated) on the unit (A & B halls) when the CNA needed to take a break or leave the unit for short periods. She said staffing was an issue some days and more staff would be a plus when caring for residents. She said on the unit most days there were behaviors to address, and one person could not see that all needs were being addressed at all times. She said the female unit had 7 residents that wanted constant interactions of some kind. She said most of them just wanted continual attention from staff as if they felt lonely and it was hard for one staff to assure all needs were met. She said on the male unit there were 15 residents, most with aggressive behaviors or wanted constant attention and it was impossible for one staff to ensure all needs were addressed for all residents on any shift. She said she had not witnessed anyone working more than 12 hours per shift. She said she mainly did housekeeping and did not have to stay over. During an interview on 9/4/2025 at 11:49AM RN-L said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and was not aggressive and mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. She said the incident may have been prevented if there were at least two staff working together on all halls especially the halls A&B (secured units) due to the residents with behavior issues were housed on those halls. She said daily staffing included 2 nurses, one for A&B hall and 1 for C&D hall, 1 med aid, 1 CNA on A hall, 2 CNAs on B hall, one CNA on C hall and one CNA on D hall. She said she felt like there should be sufficient staffing at all times, but not all employees showed up for work as scheduled. She said when staff did not show up to work the on-call person was notified, and they were responsible for getting someone to come in and cover that shift. She said she had not worked more than 12 hours at a time. She said the least amount of CNAs she worked with in the facility was 2 nurses and 2 CNAs. She said when there were only 4 workers in the building at night it left them one worker short. She said one CNA floated from hall to hall helping the other CNAs. She said she had witnessed staff working 6A to 10P due to short staffing. She said she had not seen anyone working close to 24 hours at a time and but did hear that it had happened. She said if there were more staff to cover shifts it would make a difference in the quality of care provided to residents. During an interview on 9/4/2025 at 4:00pm CNA-B said she had not worked 24 hours straight but knew that some of the other staff worked 20-24 hours at a time. She said she volunteered to work extra hours but no more than 12-16 hours straight. She said she was not asked to or felt forced to work the extra hours by the administrative staff. She said she they had been short staffed due to a Covid outbreak and some people quitting, calling in or just not showing up. During an interview on 9/4/2025 at 1:24PM the ADON said the staffing pattern was usually two CNAs on halls C and D, one CNA on hall A, 1 CNA on hall B, one MA and two nurses (1 on hall A&B and 1 on hall C&D) during the day. She said the only staffing changes for the night shifts was one aide on the B hall and no MA was scheduled for the night shift. She said when someone called in, she would come in and cover the shift or another staff was called in to work. If they could not find someone to work, the person on call would cover the shift. She said they had worked with only 4 workers for the entire building in the past. She said it was not ideal but when staff did not come to work, they did the best they could to ensure all of the residents' needs were met. She said they would pull a CNA from A hall, leaving one CNA on the male unit (hall A) occasionally to make sure every hall had at least one CNA. She said sometimes they were fully staffed and other times they were short staffed. She said due to Covid and staff quitting they were short staffed and needed to hire 3 CNAs before the facility would be fully staffed. She said they were trying to hire workers at that time. She said they did allow their staff to work 20 plus hours. She said they never asked staff to work 20 plus hours and knew it was not safe for staff or residents if staff worked exhausted. She said the facility was short staffed and some staff volunteered to work extra hours, and they were allowed to work such long hours due to being short staffed and the facility needing coverage. During an interview on 9/4/2025 at 1:24PM the Administrator said she had been notified of low staffing issues. She said the facility was in the process of hiring at least 3 more CNAs. She said the staff especially the CNAs had issues with calling in and not coming for their scheduled shift. She said they tried to staff 1 CNA on hall C and one CNA on hall D for daytime, 2 CNAs on Hall A (Male Unit) and 1 CNA on hall B (Female Unit). She said for the male secure unit there should always be at least 2 CNAs. She said she did not know that staff was working 20-24 hours straight and did not feel it was safe for the staff or the residents to work that many hours. She said she did not feel it was safe for the residents to have resident to resident altercations as someone could get hurt. She said there could be a decline in care if there was not enough staff to sufficiently always address the needs of all residents. Record review of the Facility assessment dated [DATE] indicated Staffing will be based upon the needs and acuity of the residents in-house. If acuity increases so will the staffing departments. This also goes for an overall increase in total census. The administrator will identify needs based on each admission and discharge and will make corrective action in staffing needs. Record review of the payroll detail indicated CNA-H worked 22.72 hours in a 24-hour time frame beginning on 8/25/25 at 5:46am through 8/26/2025 at 5:46am. Record review of the payroll detail report indicated CNA-B worked 23.67 hours in a 24-hour time frame beginning on 8/30/2025 at 1:25pm thru 8/31/2025 at 1:25pm. Record review of facility policy, dated September 2022, titled Resident to Resident Altercations indicated, .1. Facility staff monitor residents for aggressive/inappropriate behaviors toward other resident, family members, visitors, or to the staff.Record review of facility policy, Inservice: Redirecting Dementia Patients dated 06/25/2025 indicated, Objective: To equip staff with effective techniques for safely and respectfully redirecting residents with dementia during episodes of confusion, agitation, or repetitive behavior. Record Review of facility policy titled Hours of Work, Indicated, Our facility has established hours of work in accordance with resident needs and current regulations governing our facility's staffing requirements. *Employees take 8 hours break after working 16 hours. This was determined to be an Immediate Jeopardy (IJ) on 9/03/2025 at 3:36 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 9/03/2025 at 3:36 p.m. and a plan of removal was requested. The facility's plan of removal was accepted on 9/04/2025 at 12:18 PM and included: The following is a plan of removal, which has been immediately implemented at [Facility], to remedy the immediate jeopardy which was imposed 9/3/25 at 3:32pm.All items listed will be completed by 9/4/25 at 2:00 pm with continued follow up for scheduled staff. 1. Resident #2 was placed on 1:1 while contact was made for psych services on 6/25/25. Psych services reviewed the information and initiated a medication review with change of medication order regarding the resident-to-resident altercation. Resident #1 was moved to Q15 minute checks on 6/25/25 and a telehealth visit was completed on 6/26/25. Resident #1 was monitored for emotional distress for 72 hours post the incident. 2. Resident #1 was assessed for pain and injuries on 6/25/25. Resident #1 was administered a medication for pain (OTC medication) following the event. Facility obtained orders for X ray per hospice regarding a fracture that resulted in age indeterminate fracture of the 5th digital proximal phalanx. Neuros were initiated per protocol for Resident #1 as well as injury monitoring for 72 hours. Resident #1 was monitored for emotional distress for 72 hours post the incident and none exhibited. Resident #2 was on hospice services and is now deceased . 3. 7/30/25 Resident #3 had emotional distress assessment completed for 72 hours post the incident of #3 being hit. 7/30/25 Resident #3 was assessed for injuries and no injuries were present from the altercation with Resident #4. Psych referral was completed on 7/31/25 for Resident #3 and NP visit took place on 8/11/25 with order changes. 4. 7/30/25 Resident #4 was placed on 1:1 following the incident. Resident #4's psych physician was updated regarding the incident 7/30/25 and gave an order for psych behavioral placement. Resident #4 left the faciity on 7/31/25.5. 7/13/25 Resident #5 was placed on 1:1 supervision in response to the incident that occurred. Resident #5 was moved to a different hallway on 7/13/25. A psych physician visit took place on 7/14/25 with orders for behavioral health placement. Resident #5 was admitted to behavioral psych services on 7/14/25.6. Resident #3 was assessed for injuries on 7/13/25 and none were present. Resident #3 had emotional distress monitoring completed for 72 hours post the incident with Resident #5. Neuros were initiated per protocol. Resident #3 had no emotional distress related to the incident with resident #5.7. Resident #6 was placed on 1:1 supervision in response to the resident-to-resident altercation with resident #5 on 8/28/25. Psych services was contacted on 8/28/25 regarding the incident and orders were obtained to send to behavioral health for review. Resident #6 left the facility per the order on 8/28/25. Resident #5 had no injuries in response to the incident.8. Resident #8 was assessed by the nurse and sent to the ER for evaluation and admitted for alternate placement as the admitting diagnosis. Resident #8 is set to return to the facility on 9/3/25 with no updated orders at this time and the facility will change interventions according to any new orders.9. Res

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 of 12 residents reviewed for abuse. (Resident #1 and Resident #3) in that: The facility failed to protect Resident #1 from Abuse on [DATE] when Resident #2 stuck his hand into Resident #1's shirt and groped her breast. The facility failed to protect Resident #3 from Abuse on [DATE] when Resident #4 pushed Resident #3's wheelchair over and hit him in the face. The noncompliance was identified as PNC. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: 1. An admission record dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy and secondary diagnoses of stage 3 pressure ulcer of sacrum, chronic kidney disease, and rhabdomyolysis (disorder of muscle breakdown). An MDS dated [DATE] revealed she had a BIMS of 7 which indicated severe cognitive impairment. She was dependent on staff for most ADLS, and she was always incontinent of both bowel and bladder. Resident #1 expired in the facility on [DATE]. A closed record comprehensive care plan for Resident #1 indicated she had impaired cognitive function or impaired thought processes related to diagnosis of metabolic encephalopathy. Interventions were in place to engaging resident in simple, structured activities, and keeping resident's routine consistent to decrease confusion. An admission record dated [DATE] indicated Resident #2 was a [AGE] year-old male with a primary diagnosis of Alzheimer's disease and secondary diagnoses of vascular dementia (altered cognition), hemiplegia (weakness on one side of the body), and major depressive disorder. An MDS dated [DATE] indicated a BIMS was not conducted due to resident being rarely or never understood. He was dependent on staff for assistance putting on/taking off footwear, upper and lower body dressing, shower/bathing; he required maximum assistance with personal hygiene and toileting hygiene; he required setup assistance with eating and oral hygiene. He was continent of bowel and bladder. A comprehensive care plan dated [DATE] for Resident #2 revealed he had potential to demonstrate physical behaviors related to poor impulse control and was transferred to the men's secured unit following groping Resident #1's breast. During an observation and interview on [DATE] at 10:52 a.m. Resident #2 was observed sitting in his wheelchair in his room. He appeared clean and well-groomed with no offensive odors and had no visible marks, bruising, or skin tears. Resident #2 said he put his hand inside Resident #1's shirt and touched her breast. He said he had no prior relationship with Resident #1, and she had not given him consent to touch her. He said he does not know why he touched her breast. During an interview on [DATE] at 9:45 a.m. the ADM said Resident #1 was sitting in her geri chair (specialized recliner) by the nurse's station when Resident #3 rolled his wheelchair up beside her and stuck his hand inside her shirt. ADM said the incident was witnessed by several staff members and they intervened immediately, separating residents. ADM said she watched the security camera footage and confirmed the incident did happen. The ADM said Resident #2 was transferred to the secured men's unit following the incident. Review of a witness statement from ADM dated [DATE] given after reviewing facility camera revealed Resident #2 rolled his wheelchair beside Resident #1, reached over with his left hand, and touched her. Resident #1 grabbed his arm and started to push it away when staff intervened. Review of a witness statement from the Social Worker following an interview of Resident #1 after the incident. The witness statement revealed Resident #1 responded yeah when asked if a man had recently reached under her shirt and touched her breast. Resident #1 responded I think he should have been decked when asked if the incident left her emotionally upset. 2. An admission record dated [DATE] indicated Resident #3 was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis of major depressive disorder with psychotic symptoms and secondary diagnoses of dementia and psychotic disorder (disconnection from reality) with delusions. An MDS dated [DATE] revealed he had a BIMS of 11 which indicated moderately impaired cognition. He required moderate to substantial assistance for all ADLs except eating, which required setup/cleanup assistance. A comprehensive care plan dated [DATE] for Resident #3 indicated he had exhibited aggressive behaviors including hitting the secure unit door, yelling, and cursing at staff, going through other residents' belongings, and attempting to wake residents up. Interventions were in place including encouraging facility involvement, recognizing resident stressors, and provide resident with as many options for control over his care as possible. He was transferred to a behavioral health facility on [DATE]. An admission record dated [DATE] indicated Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease and secondary diagnoses of bipolar disorder and unspecified psychosis. An MDS dated [DATE] revealed a BIMS had not been conducted due to resident being rarely/never understood. He was dependent on staff for personal hygiene and toileting hygiene; he required moderate assistance for upper body/lower body dressing and putting on/taking off footwear; he required supervision for oral hygiene; he required setup assistance for eating. He was always incontinent of bowel and bladder. A comprehensive care plan for Resident #4 indicated he had a history of exhibiting aggressive behaviors toward others and had been previously referred to a behavioral health facility. The same care plan indicated he required psychotropic medications for diagnosis of Mood Changes/Behavior management and took Risperidone. During an observation and attempted interview on [DATE] at 10:30 a.m. Resident #4 was sitting in the day room on the men's secured unit, he appeared clean and well-groomed with no offensive odors and had no visible marks, bruising, or skin tears. Resident #4 did not respond to questions and could not be interviewed due to cognitive impairment. During an interview on [DATE] at 1:30 p.m., the ADM said she reviewed the facility camera and observed Resident #4 walking down the hallway, Resident #3 was going in the opposite direction of same hallway in his wheelchair. She said the video showed Resident #3 moved his wheelchair in front of Resident #4 which blocked his path. ADM said Resident #4 lifted Resident #3's wheelchair and tilted it backwards until it fell . She said Resident #3 was lying on his back, still in the wheelchair, and tried to kick Resident #4. She said Resident #4 bent down and punched Resident #3 in the nose. The ADM said following the incident both residents were separated, assessed, notifications were made, and both residents were placed on one-to-one observation until they were transferred to a behavioral health facility for evaluation. ADM said QAPI (Quality Assurance and Performance Improvement) had met concerning resident to resident altercations and the facility provided additional training to staff as well as re-evaluated roommate pairings on the men's secure unit. Requested to view facility camera recordings of incidents; the facility did not provide recordings. Review of an incident report dated [DATE] for Physical Aggression completed by LVN A indicated Resident #3 had an injury, redness to his nose, because of the altercation with Resident #4. Facility took appropriate actions to correct the non-compliance prior to surveyor entry and there was no current non-compliance due to: Facility took immediate action following the incidents including separating, assessing, and notifying. Resident #1 expired. Resident #2 was moved to the mens unit. In-services were conducted. QAPI meetings conducted following each incident. Review of QAPI Committee Report dated [DATE] which discussed topics Abuse, Neglect, and Misappropriation. Review of QAPI Committee Report dated [DATE] which discussed topics Reporting Abuse, Neglect and Misappropriation and Resident to Resident Abuse. Review of in-service dated [DATE] titled Identifying Sexual Abuse and Capacity to Consent. Review of in-service dated [DATE] titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Review of in-service undated titled Resident Rights Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on [DATE] indicated the following: . The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, and misappropriation of property by anyone including, but not necessarily limited to: a. Facility staff; b. Other residents; c. Consultants; d. Volunteers; e. Staff from other agencies; f. Legal representatives; g. Friends; h. Visitors; and/or i. Any other individual

Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 5 of 5 residents (Residents #13, #25, #26, #36, and #42) reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Residents #13, #25, #26, #36, and #42 on 9/4/24. This failure could place residents who received pureed foods at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: 1. Record review of a facility face sheet dated 9/3/24 for Resident #13 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Alzheimer's, aphasia (loss of ability to understand or express speech, caused by brain damage), and dysphagia (difficulty swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 reflected that he had a BIMS score of 9, which reflected that he had moderate cognitive impairment. He required supervision assistance with eating. Record review of a comprehensive care plan revised on 8/6/24 reflected that he had a swallowing problem, received a pureed diet and interventions included to follow diet as prescribed. Record review of a Physician's Order Summary Report dated 9/3/24 indicated the following diet order dated 9/6/23: .Regular diet, pureed texture . 2. Record review of a facility face sheet dated 9/5/24 for Resident #25 reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: urinary tract infection and dysphagia (difficulty swallowing). Record review of a comprehensive MDS assessment dated [DATE] for Resident #25 reflected that had a BIMS score of 9, which reflected that he had moderate cognitive impairment. He was dependent with eating. Record review of a comprehensive care plan dated 9/26/23 for Resident #25 indicated that he was at risk for potential nutritional problems and interventions included to provide and serve diet as ordered. Record review of a Physician's Order Summary Report dated 9/5/24 for Resident #25 indicated that he had the following order dated 8/16/24: .No salt on tray diet, pureed texture . 3. Record review of a facility face sheet dated 9/6/24 for Resident #26 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's and dysphagia (difficulty swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated that Brief Interview for Mental Status should not be completed due to resident being rarely/never understood. She had severely impaired cognition. She required partial/moderate assistance with eating. Record review of a comprehensive care plan dated 8/19/24 for Resident #26 indicated that she was at risk for nutritional problems and received a pureed diet. Interventions included to provide and serve diet as ordered. Record review of a Physician's Order Summary Report dated 9/6/24 for Resident #26 indicated that she had the following order dated 8/8/24 .Regular diet, pureed texture . 4. Record review of a facility face sheet dated 9/6/24 for Resident #36 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: acute pancreatitis (inflammation of the pancreas that causes abdominal pain and can affect other organs) and dysphagia (difficulty swallowing). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #36 indicated that Brief Interview for Mental Status should not be completed due to resident being rarely/never understood. She had severely impaired cognition. She required partial/moderate assistance with eating. Record review of a comprehensive care plan dated 8/19/24 for Resident #36 indicated that she had a potential for nutritional problem and received a puree diet. Interventions included to provide and serve diet as ordered. Record review of a Physician's Order Summary Report dated 9/6/24 for Resident #36 indicated that she had the following order dated 8/17/24: .No salt on tray diet, pureed texture . 5. Record review of a facility face sheet dated 9/6/24 for Resident #42 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Dementia, pneumonia (an infection in the lungs), and dysphagia (trouble swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #42 indicated that he had a BIMS score of 13, which indicated that he was cognitively intact. He required set up or clean up assistance with eating. Record review of a comprehensive care plan dated 8/12/24 for Resident #42 indicated that he had a potential for nutritional problem and received a pureed diet. Interventions included to provide and serve diet as ordered. Record review of a Physician's Order Summary Report dated 9/6/24 for Resident #42 indicated that he had the following order dated 4/27/24: .regular diet, pureed texture . During an observation on 9/4/24 at 11:45 am revealed [NAME] F was pureeing foods for noon meal. She pureed the meat; she said it was still too grainy and pureed it again. After pureeing a second time, she said it was much better. Surveyor asked [NAME] F if they ever tasted the pureed foods for texture and she said that she did not. DM was also in kitchen and said that she did taste the food for texture as needed. DM nor [NAME] F tasted the meat after pureeing. During an observation and joint interview on 9/4/24 at 12:40 pm to 12:45 pm surveyors received test tray of regular and pureed foods. Pureed meat was visibly lumpy and had a chewy texture to it. Pureed greens were stringy in texture. Administrator and DM were both brought to room to taste puree food. Administrator said the texture was not smooth and DM said meat was too grainy and greens were stringy. DM said if pureed foods were not served at the correct texture, residents receiving puree diets could be at risk of choking. During an interview on 9/5/24 at 9:18 am Administrator said residents who need pureed diets could be at risk of swallowing issues and aspiration. She said they would be providing education to dietary staff to ensure pureed foods were served at the correct consistency going forward. She said she expected her staff to serve foods in the correct texture. During a telephone interview on 9/5/24 at 10:02 am Corporate Dietician said they check purees every time they come to facility. She said she expects a pudding like consistency without lumps. She said she had started an in-service yesterday (9/4/24) with the dietary staff for pureed foods. She said she expected the cooks to taste the pureed foods for texture before serving. She said residents requiring puree foods could be at risk of choking if served the wrong consistency foods. Record review of a facility policy titled Therapeutic Diets dated 2001 and revised October 2017 read .A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: .d. Altered consistency diet . Record review of a Guidance Form for puree foods provided by facility and put out by International Dysphagia Diet Standard Initiative read .Pureed food for adults .do not require chewing .and .have a smooth texture with no lumps .

Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA A pushed and struck Resident #1 on his face causing him to fall. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. Findings include: Record review of a facility face sheet dated 03/12/2024 indicated Resident #1 was a [AGE] year-old male that admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Unspecified Dementia (altered thinking, usually due to aging process), psychotic disturbances with delusions (a mental disorder characterized by a disconnection with reality), and Alzheimer's disease (a neurodegenerative disease with moods swings and difficulty remembering). Record review of an admission MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 09 indicating moderate impaired cognition. Section C indicated inattention and disorganized thinking were continuously present. Record review of comprehensive care plan with revision date of 11/29/2023 for Resident #1 revealed the care plan had been updated on 10/05/2023 with focus: The resident has a psychosocial well-being problem/potential related to physical aggression received. 10/04/2023 - Resident threw water on a staff member and staff member retaliated by shoving resident and hitting him on left side of face causing him to fall. Goal: The resident will have no psychosocial well-being problem by/through review. Interventions included: 10/05/2023 - CNA involved in incident suspended pending investigation and police notified and statements given, head to toe assessment, emotional distress assessment, and hall safe survey performed on all residents on A hall. Resident sent to emergency room for evaluation and neuro checks will be completed on return from hospital. Monitor/document residents' feelings relative to isolation, unhappiness, anger, or loss. Record review of a facility event report dated 10/04/2023 at 7:45 p.m. indicated CNA A reported Resident #1 had fallen in the dining area and did not hit his head. Resident #1 was assessed, and no injuries found, resident denied pain and was unable to give a description of what had happened. Record review of a facility event dated 10/05/2023 at 10:45 a.m. indicated the Administrator had reviewed video footage of the above reported incident in the dining area of the men's locked unit. It was reported to the nurse by the CNA that resident fell in the dining room. It was reported that resident did not hit his head. The nurse assessed resident and did not see any injuries. However, the morning of 10/05/2023, upon review of the surveillance cameras to see how the fall occurred, it was seen that resident (Resident #1) and CNA (CNA A) were standing by the water cooler in the dining room on A hall. CNA and resident are seen conversing with each other, and resident (Resident #1) becomes agitated and tosses a cup of water at the CNA, splashing her in the face and front of her shirt. CNA (CNA A) then reaches out and shoves resident on the shoulder and hits him (with what appears to be an open hand) across the left side of his head. Resident stumbles backwards, tripping, and falls on the floor, hitting his back on the chair behind him and his head on the chair seat. The CNA then walks away and gets a towel for her shirt. Record review of an emergency room summary report dated 10/05/2023 indicated Resident #1 had CT (computed tomography) scans of the head, face, spine, neck, chest, abdomen, and pelvis with no negative findings and was discharged back to the facility with no new orders. Record review of an employee file for CNA A indicated a hire date of 08/28/2023. The file included a termination report for CNA A with a suspension date of 10/05/2023 and termination dated 10/06/2023 due to workplace violence, violating federal or state care standards and was signed by the Administrator and DON. A completed criminal history check, nurse aide registry check and referrals indicated CNA A had an active certification and was employable. CNA A had completed abuse training on 08/24/2023 before her active hire date on 08/28/23. During an interview and observation on 03/11/2024 at 10:00 am CNA D was assisting CNA C with Resident #1 preparations for a shower. Resident #1 was walking in the hallway to the shower room. When asked if he was doing well today, Resident #1 looked up and nodded yes. CNA D stated he had cared for Resident #1 since his admission in September of 2023 to the male locked unit. CNA C said he has worked the unit for [AGE] years and resident altercations of abuse and must be reported to the administrator immediately. He said it is difficult with the A Hall locked unit being all male but by working with them for so long he can recognize a mood change and intervene early but sometimes the newer residents you don't know their signs yet. He said that Resident #1 he gets aggravated quickly and will strike out towards other residents and staff. He said Resident #1 had been to the Psych hospital after the incident on 10/04/23. He said he had been better recently. CNA C said all abuse physical, verbal, mental, financial, and sexual was to be reported immediately to the administrator. He said if a resident reports something it was his responsibility to report so the resident was protected. He said once things are reported the administrator starts her investigation and reports the abuse to the state. He said that residents have to be able to report without being afraid and no staff should retaliate against a resident or family for reporting. CNA C said if retaliation occurs the administrator will terminate them. He said he has been trained on deescalating behaviors and how to deal with difficult behaviors. He said at no time can a staff member hit a resident. During an interview on 03/11/2024 at 3:14 pm LVN C said he has worked at the facility for 1 1/2 years and resident altercations are reported to the DON and Admin. He said he tries to recognize a behavior change early before an altercation occurs but does not always work that way. He said if an altercation occurs residents are separated and depending on the severity 1:1 and or every 5 min checks are done. 1:1 continues until behavioral hospital admission or psych MD evaluates and makes changes, it really depends on the resident and their behaviors. No 2 incidents are the same. LVN C said he has been trained on abuse and knows the types of abuse: physical, verbal, sexual, mental and financial. He said no one is to take any resident belongings or money at no time. He said that all forms of abuse must be reported immediately to the administrator and then management starts their investigation. He said all abuse should be reported to the state. He said no matter how difficult the resident is never okay to hit or harm them. He said they have been trained on how to report abuse, preventing abuse, dealing with dementia and how to deescalate behaviors and to use those training tools to deal with difficult residents. During an interview on 3/11/2024 at 4:00 pm the Administrator said she would see if she could retrieve the video footage of the incident involving Resident #1 and CNA A, since it had been some time since the incident of abuse occurred on 10/04/23. The Administrator said she gave the Chief of Police a copy for his investigation when she reported the abuse to the required authorities. The Administrator said she reported to the police department, HHS, the Ombudsman, Resident #1's medical doctor and psychiatric doctor and his family after she saw the footage of the strike made by CNA A. She said the DON received orders to send Resident #1 to the emergency room for evaluation. Resident #1 had several CT scans and returned to the facility, there were no injuries. The Administrator said the staff were in serviced on 10/05/23 on numerous topics to prevent and ensure reporting and she would provide evidence of those trainings. She said the incident was reviewed by the QAPI team on 10/05/23 to determine if any other topics needed to be addressed. During an interview on 03/12/2024 at 10:20 am with the Chief of Police, he said there was an open case #OR- 100423-01 for the arrest of CNA A. He said he had conducted an investigation after receiving a report of abuse from the facility Administrator on 10/05/23 at 10:55 am. The Chief of Police said the administrator had advised him when she arrived at work on the morning of 10/05/23 she had been advised that one of the residents (Resident #1) had gotten disruptive during the evening of 10/04/23 and had fallen but had no injuries. The Chief of Police said the Administrator had told him she located the video footage of the dining area for viewing, as she usually does after an incident in the area. The Administrator was able to determine the event was not as previously reported by the CNA, as the resident (Resident #1) was pushed and hit by CNA A and had not just fallen as reported by CNA A. The Chief of Police said he had viewed the video footage of the incident on 10/04/2023 involving Resident #1 and CNA A provided to him by the Administrator. He said he had concluded his investigation, which included assessing for injuries and making pictures of the resident at the facility but was not able to document any injuries from the resident being hit and knocked down. He said based on the video evidence which shows the suspect intentionally and knowingly striking an elderly person over the age of 65 ([AGE] years of age) with a closed fist, causing bodily injury, a warrant for injury to the elderly was requested. The Chief said there was an open warrant for CNA A's arrest, but she had not been apprehended yet. He said that most likely until she had a traffic violation or another issue, it would remain outstanding. Record review of a facility policy titled Abuse and Neglect-Clinical Protocol dated March 2018 indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes deprivation by an individual, including a caretaker or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Treatment/Management 3. The physician will order measures required to address the consequences of an abuse situation. The facility took the following action to correct the non-compliance on 10/05/2023: The facility conducted a physical assessment including skin assessments on all residents in the locked unit, safe surveys were completed on all residents 10/05/2023. In-services included: Retaliation, abuse, preventing resident accidents and incidents, Reporting abuse to the abuse coordinator, Reporting abuse to facility management, Recognizing signs and symptoms of abuse, Abuse investigations, Abuse, neglect, exploitation and misappropriation-reporting and investigating, Investigating resident injuries, Quick safety de-escalation in healthcare, Preventing accidents and incidents, were conducted with all staff on 10/05/2024 then was referred to QAPI (quality assurance performance improvement) committee for efficacy of plan and monitoring frequency. Record Review of a QAPI meeting dated 10/05/2023 indicated the committee meet for discussion of the event involving abuse. A Performance Improvement plan was developed including all reviewed trainings and assessments on 10/05/2023. Record review of an In-service Training report named Retaliation, abuse, preventing resident accidents and incidents, dated 10/05/2023 and conducted by the DON to the facility staff included: Complaints are reported in good faith, it is illegal for the facility or any employee to intimidate or retaliate in any way against the resident or the family reporting. Record review of an In-service Training report named Reporting abuse to the abuse coordinator dated 10/05/2023 and conducted by the DON to the facility staff included: The abuse coordinator is the administrator. Record review on an In-service Training report named Reporting abuse to facility management dated 10/05/23 conducted by the DON to facility staff included: Condemnation of resident abuse, retribution for reporting abuse, responsibility of reporting resident abuse, notifying agencies/individuals of resident abuse, notifying administration of resident abuse, methods of resident abuse, contents of notice of abuse. Record review on an In-service Training report named Recognizing signs and symptoms of abuse/neglect, dated 10/05/23 conducted by the DON to facility staff included: signs and symptoms of abuse, neglect, and psychological abuse and neglect. Record review on an In-service Training report named Abuse investigations, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Nursing facility must report no later than two hours after an allegation is made for abuse. The investigation process including all reports of abuse/neglect and injuries will be promptly reported and investigated. Record review on an In-service Training report named Abuse, neglect, exploitation, and misappropriation- reporting and investigating, to facility management dated 10/05/23 conducted by the DON to facility staff included: Definitions of Abuse, neglect, exploitation and misappropriation, steps of reporting and investigations. Record review on an In-service Training report named Investigating resident injuries, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility policy stating all resident injuries are investigated. Record review on an In-service Training report named Quick safety de-escalation in healthcare, to facility management dated 10/05/23 conducted by the DON to facility staff included: De-escalation is the first line response to prevent potential violence and aggression. Record review on an In-service Training report named Preventing accidents and incidents, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility will work to prevent any accident or incident. The facility will change the plan of care in the event of an accident and or incident. All new hires will continue to be required to complete the abuse training on hire as required by regulation. Interviews with staff members, (CNA A, CNA B, CNA C LVN E, LVN F) starting at 11:45 am - 2:00 pm on 03/12/2024, revealed they were in-serviced and verbalized training regarding Abuse. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) could identify understanding of Retaliation, abuse, preventing resident accidents and incidents. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of when to report abuse to the abuse coordinator, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Reporting abuse to facility management, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Recognizing signs and symptoms of abuse, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Abuse investigations, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding Abuse, neglect, exploitation, and misappropriation-reporting and investigating. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Investigating resident injuries. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Quick safety de-escalation in healthcare. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Preventing accidents and incidents. During an interview on 03/12/2024 at 3:00 pm the Administrator stated she expected her staff to report any abuse, neglect or exploitation. She said that retaliation was not tolerated. She stated that the monitoring would continue with the facility QAPI meetings. During an interview on 3/12/2024 at 3:15 pm the DON said she expected all staff to treat the residents with dignity and respect. The DON said that abuse will not be tolerated in the facility and any staff members that is accused of abuse will be immediately placed on suspension and terminated pending the investigation. The DON said her focus is now on her hiring process to ensure that quality staff members are brought into the facility. The noncompliance was identified as PNC. The IJ began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 2 residents reviewed for resident rights (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Resident # 46 on the secured unit of him kicking the door and posted the video on social media. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of him making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #46: Record review of a facility face sheet dated 8/8/23 for Resident #46 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizoaffective disorder bipolar type (episodes of mania and sometimes major depression), anxiety, and hypertension (high blood pressure). Record review of the Quarterly MDS for Resident #46 dated 5/29/23 indicated that he was rarely/never understood and had severe cognitive impairment. Question E0200 indicated that resident exhibited physical, verbal, and other behaviors 4-6 times a week to daily. Record review of the comprehensive care plan revised on 6/13/22 for Resident #46 indicated an intervention stating .when the resident becomes agitated, intervene before agitation escalates: guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #46 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 08/07/23 at 09:11 AM Resident #46 observed lying in bed sleeping. Resident did not speak when spoken to. Resident #54: Record review of a facility face sheet dated 8/8/23 for Resident # 54 indicated that he was an [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypotension (low blood pressure), and personality change due to known physiological condition (may include being unable to think ahead or understand the consequences of their actions). Record review of the Quarterly MDS for Resident #54 dated 7/6/23 indicated a BIMS score of 6, indicating severe cognitive impairment. Question E0200 indicated that resident exhibited verbal and other behaviors 1-3 times a week to daily. Record review of comprehensive care plan initiated on 6/14/23 for Resident #54 indicated that he had poor impulse control related to dementia and would sometimes make sexually inappropriate comments to staff. Interventions included: .when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #54 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 8/9/23 at approximately 6:00 pm, video of Resident #54 showed him standing in front of the camera making inappropriate sexual advances. A female voice could be heard laughing at him and asking him to repeat what he said. Interviews with facility staff above indicate that the female voice in the video was that of CNA A. Video of Resident #46 had been deleted and was no longer available for observation. During an interview with the DON on 8/9/23 at 8:15 am, she said that Resident #54 had been discharged home on 7/25/23. She said that he had been admitted to the unit for sexual inappropriateness and had inappropriate behaviors with females. She said that on 6/19/23, CNA A had worked the weekend before, that was her first weekend and she was going to be prn, not full time. She said that on Monday afternoon (6/19/23) about 4 pm, CNA G on the female side was made aware of a video and showed a paused image to her. It was in the dining room of the men's unit and there was 1 resident in the still image. The DON asked the aide where she got the video and CNA G replied that someone had seen it on [social media app] and sent it to her on [social media app]. She said that in the video you could hear CNA A's voice off camera, and Resident #54 was talking to the aide, standing in front of her. CNA A kept asking him what he said, and he said, do you want to fuck, he repeated it twice and she laughed about it. The DON said that they called the family and notified them immediately, and they also immediately called CNA A. She said that CNA A was told she was suspended pending investigation and she never came back. She was told that it was against policy, and she said that she didn't realize it was a big deal. She said that the facility has a direct policy regarding social media. The DON said that immediately after the incident, an in-service training was conducted with a 3-question test on what was considered questionable for private health information. She said that they reported the video to the police, and they came out immediately. From that incident prompted agency to no longer be staffed in the unit by themselves, especially overnight and she added an extra aide to the night shift as a float. She said it took about 2 days for the video to be taken down. A phone call was attempted on 8/9/23 at 8:55 am with CNA G, but there was no answer and surveyor was unable to leave a voicemail. During an interview with the previous ADON on 8/9/23 at 9:16 am, she said that the day she was notified about the video on 6/19/23, she was sitting in her office and CNA G told her to look at what was sent to her in a video. She said there was a video of Resident #54 and CNA A was sitting with the camera facing him and enticing him to say what he wanted to do with her, and he was asking her if he could have sex with her and she kept asking him to say it again and would laugh about it. She said the camera was in his face and he was the only resident in the video. She said that she called CNA A and informed her that she broke HIPPA and told her to take the video down. She had posted the video to [social media app]. The Previous ADON said that the aide did not think she had done anything wrong. She said the police were contacted and the officer was sent a copy of the video. She said that the aide was informed that she was suspended pending investigation for 3 days. During an interview with CNA A on 8/9/23 at 9:25 am, she said that she had only worked at the facility for one week. She said that she had posted 2 videos, one of Resident #46 kicking the door and the other of Resident #54. She said the video included Resident #54 talking to her. She said that he was just saying crazy stuff. She said that she was never specifically trained regarding posting on social media. She said that she did not talk to the police regarding incident. Said that she immediately deleted the videos after the facility asked her to on 6/19/23. She said that she only posted it because she thought that it was funny. She said that she did not think that it was a HIPAA violation. She said that she understands now that it was not funny, and she would probably be upset if this had happened to one of her family members. During an interview with family member of Resident #46 on 8/9/23 at 9:50 am, she said that the facility had called her around 6/19/23 and told her that a video had been posted. She said that she has not seen the video but was told that Resident #46's face was covered up. She said that she did not talk to the police. She said that when she heard about the video, it made her sad to think that her family member had been treated that way. She said that it was wrong to make fun of people when they can't help it. She said that she was not upset with the facility in any way because she said that they could not control an employee's actions. She doesn't think that he would be able to understand if he was told about the video because he doesn't understand things day to day anyway. She said that she has not noticed any behavior changes in him since the incident. During an interview with the family member of Resident #56 on 8/9/23 at 10:15 am, she said that she had not seen the video. She said that [another family member]had seen it. She said that she does not think the incident has affected his behavior at all, as he does not understand due to his dementia. She said that she was extremely upset about the video, and about it being posted on social media. She said that it upsets her to think that the aide was making fun of her family member and posted it for everyone to see. She said that the facility told her the employee was terminated and reported to State. During an interview with family member B of Resident #56 on 8/9/23 at 3:30 pm, she said that the facility had called and told her about the incident around 6/19/23, and she was very upset. She was crying while on the phone with the surveyor. She said that her family member was no longer himself since the dementia and Alzheimer's had gotten so bad. She was very upset that the aide was treating her family member like that and posting it on the internet. She said that he cannot help his behavior due to the dementia and did not deserve to be treated like that. During an interview on 8/10/23 at 10:00 am, the DON said that in the videos, Resident #46's face was covered with a smiley face emoji, but anyone that worked here would know who it was. She said that she expected it to not happen again. From now on, new hires were not allowed to work until after a personal interview by her. She said that they have now changed recruiting companies and no longer allow prn staff to work in the unit, and also have 2 aides at all times. During an interview on 8/10/23 at 9:25 am CNA J said he had been working at the facility for about a week and a half. He said that he had been trained on abuse, neglect, exploitation. He said that he had never witnessed any in the facility but if he did, he would immediately take steps to protect the resident and then immediately report to the Administrator/DON. He said that he had been trained on the social media policy and to not be on his cell phone while working or to video residents. During an interview on 8/10/23 at 9:45 am CNA K said that she had been employed by the facility for about [AGE] years. She said that she had been trained on abuse, neglect, and exploitation. She said that there were in-services the day of the incident with the video on the men's unit. She said that she had never witnessed any abuse, neglect, or exploitation, but would immediately intervene to protect the resident and then report to administrator/DON if she did. She said that she had been trained on social media and cell phone policy. She said that they are not allowed to be on their cell phones while working, and they are also not allowed to video residents without consent. During multiple observations on multiple occasions during onsite 8/7/23-8/10/23, no staff members were observed taking photos or videos of residents, and no staff were observed on their phones while working. Record review of a personnel file for CNA A indicated that her hire date was 6/1/23. Criminal history check indicated that it had been performed on 5/24/23. Employee misconduct registry check indicated a date of 5/24/23. No unemployable actions on either were indicated. Record review of a witness statement dated 6/19/23 signed by CNA F stated .On June 19th around 4:15 pm I saw a [name of social media app] of one of our residents online and immediately reported it to my ADON [name]. She had me send her the video and write a statement . Record review of a witness statement dated 6/19/23 signed by CNA G stated .On June 19th around 4:15 pm I acknowledged a [name of social media app] that was sent to my phone after another employee seen the same video on her 'fyp' on the [name of social media app]. I immediately recognized the unit the video was taken on and reported it to my DON and ADON [names] in the office . Record review of a police statement, undated, signed by DON stated .on 6/19/23 I was made aware of a video that had been posted on [social media name] that had one of our residents in it. The video was inappropriate in nature because this resident had dementia and inappropriate behaviors due to his disease process. This video showed his face and violated his rights to privacy, and his family did not consent to social media posts. We immediately reported the event and suspended that employee. The employee who posted it was [name] (CNA A). Her [social media app] name is[screen name]. [Name] CNA G found the video when it was sent to her and reported it to me . Record review of a police statement, undated signed by CNA G indicated .On June 19th around 4 pm I seen a [social media app] online consisting of footage containing one of our residents. I immediately reported this to my supervisors . Record review of QAPI notes dated 6/20/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Activity Director, Dietary Manager, Maintenance Supervisor, Social Worker, Rehab Director, and Medical Director. The interventions and plan for correction included: 1. Inservice over abuse and neglect policy and procedure. In-services dated 6/19/23 included the following topics: Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media 2. Inservice over social media policy with 3 question posttest. In-service dated 6/19/23 and post test completed by all current staff between the dates of 6/19/23 and 6/26/23. Staff were required to complete this before being allowed to return to work if they had been off. 3. New hires will be required to complete additional Relias course including policies and HIPAA guidelines before first day of orientation. 4. Cell phone policy re-instated and enforced. All current staff re-educated and new hires must complete training before allowed to work. Record review of sign in sheets for all in-services dated 6/19/23 indicated that 59 staff members had signed the sign in sheet for the in-services on Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media Record review of an Associate Separation Report dated 6/19/23 for CNA A indicated that she was terminated on 6/19/23 for violating social media policy, failure to protect resident rights, as well as violation of cell phone policy. Record review of an in-service dated 6/19/23 covering Social Media indicated .residents have rights, and they have the right to privacy. Under no circumstance is it acceptable to video them or record them. Especially, the residents on our secure units are there because they no longer can care for themselves, and it is not a matter to take lightly or record and share for your entertainment. It is disgusting and shameful to record them while they do not know what they are saying or doing. This is an immediate termination, and possibly revoking of your license . Three question posttest indicated .1. Resident pictures and videos are considered health care records. True or False; 2. Taking pictures or videos of residents and posting them to any social media outlet or sharing them with friends is a violation of resident's rights. True or False; and 3. If you suspect a staff member has or is taking pictures or videos of a resident, you need to report this to the Abuse Coordinator immediately. True or False . Sign in sheet indicated that all current staff have completed questionnaire. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 with revision date of April 2021 indicated .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . Record review of facility policy titled Videotaping, Photographing, and Other Imaging of Residents dated 2001 with revision date of April 2017 indicated that .Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities . and .transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered abuse and will be reported and investigated as such . Record review of facility policy titled Abuse and Neglect - Clinical Protocol dated 2005 with revision date of March 2018 indicated .Abuse is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . On 8/9/23 at 2:48 pm Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began.

Based on observation, interview and record review the facility failed to ensure residents the right to be free from abuse for 2 of 2 residents reviewed for abuse (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Residents # 46 on the secured unit of facility and posted the video on social media of him kicking the door. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of facility making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #46: Record review of a facility face sheet dated 8/8/23 for Resident #46 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizoaffective disorder bipolar type (episodes of mania and sometimes major depression), anxiety, and hypertension (high blood pressure). Record review of the Quarterly MDS for Resident #46 dated 5/29/23 indicated that he was rarely/never understood and had severe cognitive impairment. Question E0200 indicated that resident exhibited physical, verbal, and other behaviors 4-6 times a week to daily. Record review of the comprehensive care plan revised on 6/13/22 for Resident #46 indicated an intervention stating .when the resident becomes agitated, intervene before agitation escalates: guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #46 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 08/07/23 at 09:11 AM Resident #46 observed lying in bed sleeping. Resident did not speak when spoken to. Resident #54: Record review of a facility face sheet dated 8/8/23 for Resident # 54 indicated that he was an [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypotension (low blood pressure), and personality change due to known physiological condition (may include being unable to think ahead or understand the consequences of their actions). Record review of the Quarterly MDS for Resident #54 dated 7/6/23 indicated a BIMS score of 6, indicating severe cognitive impairment. Question E0200 indicated that resident exhibited verbal and other behaviors 1-3 times a week to daily. Record review of comprehensive care plan initiated on 6/14/23 for Resident #54 indicated that he had poor impulse control related to dementia and would sometimes make sexually inappropriate comments to staff. Interventions included: .when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress, engage calmly in conversation . Record review of a progress note dated 6/19/23 and signed by previous ADON for Resident #54 stated .there is a reported incident of a staff member recording the patient and posting him to social media, [name] Administrator, RP [name] notified, and [name] NP notified . During an observation on 8/9/23 at approximately 6:00 pm, video of Resident #54 showed him standing in front of the camera making inappropriate sexual advances. A female voice could be heard laughing at him and asking him to repeat what he said. Interviews with facility staff above indicate that the female voice in the video was that of CNA A. Video of Resident #46 had been deleted and was no longer available for observation. During an interview with the DON on 8/9/23 at 8:15 am, she said that Resident #54 had been discharged home on 7/25/23. She said that he had been admitted to the unit for sexual inappropriateness and had inappropriate behaviors with females. She said that on 6/19/23, CNA A had worked the weekend before, that was her first weekend and she was going to be prn, not full time. She said that on Monday afternoon (6/19/23) about 4 pm, CNA G on the female side was made aware of a video and showed a paused image to her. It was in the dining room of the men's unit and there was 1 resident in the still image. The DON asked the aide where she got the video and CNA G replied that someone had seen it on [social media app] and sent it to her on [social media app]. She said that in the video you could hear CNA A's voice off camera, and Resident #54 was talking to the aide, standing in front of her. CNA A kept asking him what he said, and he said, do you want to fuck, he repeated it twice and she laughed about it. The DON said that they called the family and notified them immediately, and they also immediately called CNA A. She said that CNA A was told she was suspended pending investigation and she never came back. She was told that it was against policy and considered resident abuse, and CNA A said that she didn't realize it was a big deal. She said that the facility has a direct policy regarding social media. The DON said that immediately after the incident, an in-service training was conducted with a 3-question test on what was considered questionable for private health information. She said that they reported the video to the police, and they came out immediately. From that incident prompted agency to no longer be staffed in the unit by themselves, especially overnight and she added an extra aide to the night shift as a float. She said it took about 2 days for the video to be taken down. A phone call was attempted on 8/9/23 at 8:55 am with CNA G, but there was no answer and surveyor was unable to leave a voicemail. During an interview with the previous ADON on 8/9/23 at 9:16 am, she said that the day she was notified about the video on 6/19/23, she was sitting in her office and CNA G told her to look at what was sent to her in a video. She said there was a video of Resident #54 and CNA A was sitting with the camera facing him and enticing him to say what he wanted to do with her, and he was asking her if he could have sex with her and she kept asking him to say it again and would laugh about it. She said the camera was in his face and he was the only resident in the video. She said that she called CNA A and informed her that she broke HIPPA and told her to take the video down. She had posted the video to [social media app]. The Previous ADON said that the aide did not think she had done anything wrong. She said the police were contacted and the officer was sent a copy of the video. She said that the aide was informed that she was suspended pending investigation for 3 days. During an interview with CNA A on 8/9/23 at 9:25 am, she said that she had only worked at the facility for one week. She said that she had posted 2 videos, one of Resident #46 kicking the door and the other of Resident #54. She said the video included Resident #54 talking to her. She said that he was just saying crazy stuff. She said that she was never specifically trained regarding posting on social media. She said that she did not talk to the police regarding incident. Said that she immediately deleted the videos after the facility asked her to on 6/19/23. She said that she only posted it because she thought that it was funny. She said that she did not think that it was a HIPAA violation or resident abuse. She said that she understands now that it was not funny, and she would probably be upset if this had happened to one of her family members. During an interview with family member of Resident #46 on 8/9/23 at 9:50 am, she said that the facility had called her around 6/19/23 and told her that a video had been posted. She said that she has not seen the video but was told that Resident #46's face was covered up. She said that she did not talk to the police. She said that when she heard about the video, it made her sad to think that her family member had been treated that way. She said that it was wrong to make fun of people when they can't help it. She said that she was not upset with the facility in any way because she said that they could not control an employee's actions. She doesn't think that he would be able to understand if he was told about the video because he doesn't understand things day to day anyway. She said that she has not noticed any behavior changes in him since the incident. During an interview with the family member of Resident #56 on 8/9/23 at 10:15 am, she said that she had not seen the video. She said that [another family member]had seen it. She said that she does not think the incident has affected his behavior at all, as he does not understand due to his dementia. She said that she was extremely upset about the video, and about it being posted on social media. She said that it upsets her to think that the aide was making fun of her family member and posted it for everyone to see. She said that the facility told her the employee was terminated and reported to State. During an interview with family member B of Resident #56 on 8/9/23 at 3:30 pm, she said that the facility had called and told her about the incident around 6/19/23, and she was very upset. She was crying while on the phone with the surveyor. She said that her family member was no longer himself since the dementia and Alzheimer's had gotten so bad. She was very upset that the aide was treating her family member like that and posting it on the internet. She said that he cannot help his behavior due to the dementia and did not deserve to be treated like that. During an interview on 8/10/23 at 10:00 am, the DON said that in the videos, Resident #46's face was covered with a smiley face emoji, but anyone that worked here would know who it was. She said that she expected it to not happen again. From now on, new hires were not allowed to work until after a personal interview by her. She said that they have now changed recruiting companies and no longer allow prn staff to work in the unit, and also have 2 aides at all times. During an interview on 8/10/23 at 9:25 am CNA J said he had been working at the facility for about a week and a half. He said he was not agency staff, but regular facility staff. He said that he had been trained on abuse, neglect, exploitation. He said that he had never witnessed any in the facility but if he did, he would immediately take steps to protect the resident and then immediately report to the Administrator/DON. He said that he had been trained on the social media policy and to not be on his cell phone while working or to video residents. He said that he was required to complete the trainings on abuse, neglect, exploitation and social media and cell phone policies before he was allowed to begin working. During an interview on 8/10/23 at 9:45 am CNA K said that she had been employed by the facility for about [AGE] years and was not agency staff. She said that she had been trained on abuse, neglect, and exploitation. She said that there were in-services the day of the incident with the video on the men's unit. She said that she had never witnessed any abuse, neglect, or exploitation, but would immediately intervene to protect the resident and then report to administrator/DON if she did. She said that she had been trained on social media and cell phone policy. She said that they are not allowed to be on their cell phones while working, and they are also not allowed to video residents without consent. During multiple observations on multiple occasions during onsite 8/7/23-8/10/23, no staff members were observed taking photos or videos of residents, and no staff were observed on their phones while working. Record review of a personnel file for CNA A indicated that her hire date was 6/1/23. Criminal history check indicated that it had been performed on 5/24/23. Employee misconduct registry check indicated a date of 5/24/23. No unemployable actions on either were indicated. Record review of a witness statement dated 6/19/23 signed by CNA F stated .On June 19th around 4:15 pm I saw a [name of social media app] of one of our residents online and immediately reported it to my ADON [name]. She had me send her the video and write a statement . Record review of a witness statement dated 6/19/23 signed by CNA G stated .On June 19th around 4:15 pm I acknowledged a [name of social media app] that was sent to my phone after another employee seen the same video on her 'fyp' on the [name of social media app]. I immediately recognized the unit the video was taken on and reported it to my DON and ADON [names] in the office . Record review of a police statement, undated, signed by DON stated .on 6/19/23 I was made aware of a video that had been posted on [social media name] that had one of our residents in it. The video was inappropriate in nature because this resident had dementia and inappropriate behaviors due to his disease process. This video showed his face and violated his rights to privacy, and his family did not consent to social media posts. We immediately reported the event and suspended that employee. The employee who posted it was [name] (CNA A). Her [social media app] name is[screen name]. [Name] CNA G found the video when it was sent to her and reported it to me . Record review of a police statement, undated signed by CNA G indicated .On June 19th around 4 pm I seen a [social media app] online consisting of footage containing one of our residents. I immediately reported this to my supervisors . Record review of QAPI notes dated 6/20/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Activity Director, Dietary Manager, Maintenance Supervisor, Social Worker, Rehab Director, and Medical Director. The interventions and plan for correction included: 1. Inservice over abuse and neglect policy and procedure. In-services dated 6/19/23 included the following topics: Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media 2. Inservice over social media policy with 3 question posttest. In-service dated 6/19/23 and post test completed by all current staff between the dates of 6/19/23 and 6/26/23. Staff were required to complete this before being allowed to return to work if they had been off. 3. New hires will be required to complete additional Relias course including policies and HIPAA guidelines before first day of orientation. 4. Cell phone policy re-instated and enforced. All current staff re-educated and new hires must complete training before allowed to work. Record review of sign in sheets for all in-services dated 6/19/23 indicated that 59 staff members had signed the sign in sheet for the in-services on Abuse, Neglect, Exploitation, and Misappropriation, Recognizing Signs and Symptoms of Abuse/Neglect, Protection of Residents During Abuse Investigations, Abuse/Neglect Clinical Protocol, and Use of Electronic Communications and Social Media Record review of an Associate Separation Report dated 6/19/23 for CNA A indicated that she was terminated on 6/19/23 for violating social media policy, failure to protect resident rights, as well as violation of cell phone policy. Record review of an in-service dated 6/19/23 covering Social Media indicated .residents have rights, and they have the right to privacy. Under no circumstance is it acceptable to video them or record them. Especially, the residents on our secure units are there because they no longer can care for themselves, and it is not a matter to take lightly or record and share for your entertainment. It is disgusting and shameful to record them while they do not know what they are saying or doing. This is an immediate termination, and possibly revoking of your license . Three question posttest indicated .1. Resident pictures and videos are considered health care records. True or False; 2. Taking pictures or videos of residents and posting them to any social media outlet or sharing them with friends is a violation of resident's rights. True or False; and 3. If you suspect a staff member has or is taking pictures or videos of a resident, you need to report this to the Abuse Coordinator immediately. True or False . Sign in sheet indicated that all current staff have completed questionnaire. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 with revision date of April 2021 indicated .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . Record review of facility policy titled Videotaping, Photographing, and Other Imaging of Residents dated 2001 with revision date of April 2017 indicated that .Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities . and .transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered abuse and will be reported and investigated as such . Record review of facility policy titled Abuse and Neglect - Clinical Protocol dated 2005 with revision date of March 2018 indicated .Abuse is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . On 8/9/23 at 2:48 pm Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 1 resident reviewed for accidents/supervision (Resident #28) in that: Facility failed to ensure a resident environment as free of accidents/hazards as possible due to not ensuring the locks were engaged on the secure unit and not ensuring that the alarm was functioning on the emergency door on secure unit. Resident #28 eloped from the facility on 6/23/23 and was discovered by a local citizen approximately 2 blocks from the facility. The non-compliance was identified as past non-compliance. The IJ began on 6/23/23 and ended on 6/23/23. The facility had corrected the noncompliance before survey began. This failure could place all residents at risk of eloping which could lead to severe injuries or death. Findings included: During an observation on 8/10/23 at 9:35 am on female secure unit, 2 aides were present. Resident #28 observed wandering aimlessly, ambulating independently, resident did not speak, would only make facial expressions and occasionally grunt. Record review of a facility face sheet dated 8/8/23 for Resident #28 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, repeated falls, and history of traumatic brain injury. Record review of a quarterly MDS dated [DATE] for Resident #28 indicated that resident was unable to complete interview for BIMS score and had severely impaired cognitive status. Question E0900 indicated that resident exhibited wandering behavior 4-6 times per week. Record review of comprehensive care plan for Resident #28 dated 12/20/22 indicated that she was an elopement risk/wanderer as evidenced by impaired safety awareness, resident wanders aimlessly. Interventions included .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Record review of an elopement nurses note for Resident #28 dated 6/23/23 at 5:45 pm and signed by DON, indicated that resident was missing for 18 minutes. Record review of a behavior nurses note for Resident #28 dated 6/23/23 at 8:22 pm and signed by LVN H indicated that resident eloped from building in rain and was walking on 2nd street towards the highway. Record review of a progress noted for Resident #28 dated 6/23/23 at 8:12 pm indicated .CMA notified nurse of receiving a phone call from a lady stating y'all have a resident with a pink helmet on over on second street walking I then proceeded to exit building in attempt to locate resident which I did, and she was walking on second street with a male that lived near the nursing home. Upon reaching resident redirected her into care and back to the nursing home. Head to toe assessment done, no injuries noted, removed damp clothes from the rain and placed dry clean clothes onto her . signed LVN H. During an interview on 8/7/23 at 9:37 am, CNA D said that she was not here when Resident #28 eloped. She said that Resident #28 does not speak, she will only grunt at times. During an observation and interview on 8/7/23 at 10:20 am, Administrator said that on the day Resident #28 eloped, the facility received a phone call from a lady saying that there was a resident with a pink helmet on walking down 2nd street toward the highway. Staff immediately went and got her and brought her back. She said that the emergency switch (this was a light switch on the wall that turned the locks on the doors off and on) had somehow gotten flipped off, so the doors were unlocked. Administrator demonstrated that there was a clear plastic cover over the switch now that was locked and could no longer be accidentally or purposefully switched off unless it was unlocked with a key. Administrator said that she has the key. She said they do not know how long it had been off or who turned it off, but the emergency switch controls the locks on the unit doors and the end door. The alarm on the end door did not go off. The resident got out of the end door and out of the gate (which did not have a lock on it at that time). Resident walked down the sidewalk with several steps and got to the roadway near the front of the facility. Administrator said that the alarm did not go off when end door was opened. Administrator said that after the incident, a cover was placed over the emergency switch, which cannot be opened without a key. All staff were in serviced on elopements, a new door alarm was placed on end door and outside gate [NAME] lock placed on it. During an interview on 8/7/23 at 3:20 pm, LVN H said that she was on the men's unit doing finger sticks on 6/23/23 when someone yelled we need you. She said she immediately went to help. She said that a first responder picked her up and they went toward the resident in the vehicle. She said that she got the resident in the car, and they brought her back to the facility and changed her out of her wet clothes, did a head-to-toe assessment and notified everyone of the incident. She does not remember which aides were working that day. She said that the resident was able to get out of the door because the emergency switch had been flipped off. She said that everyone was in-serviced on elopements immediately after the incident and they monitored the alarm switches hourly to ensure they were not turned off again. During an interview on 8/7/23 at 3:00 pm, LVN E said that he has been working here since October of this year. He was working on 6/23/23 and said that someone had turned the switch off to the release switch which [NAME] the doors. He said Resident #28 was able to get out and walked to the intersection. He said he was the one who answered the phone when the lady told him there was a resident walking down the road, he immediately went out to get Resident #28. He said she had made it to the intersection of 2nd street and [NAME] Street, which was 2 blocks from exit point of facility. He said that they got her back in and they had to change her out of her wet clothes because it was raining, and she had gotten wet. He said that they did a head-to-toe assessment to make sure she didn't have any injuries. He said she was not injured. He said the lady that called apparently lives in one of the houses across the street and that a male first responder was following closely behind the resident to help ensure that she did not get into the road. He said that in-services were done the day the incident occurred on elopements and emergency procedures. He said they also did a head count of all residents in the facility and alarms were monitored hourly until all new systems were put into place. During an interview on 8/10/23 at 10:00 am, the DON said after the elopement, they secured both units doors immediately by turning the switch back on and placing a temporary cover over the switch until a new permanent one could be delivered and installed. She said there was also a striker alarm placed on the end emergency door until a new alarm could be delivered and installed. DON said that they no longer allow staff members to go out the emergency end doors. She said that they always do a head count when the door alarms go off. She said that elopements put residents at risk of falls and injury because they are close to a highway and also at risk of heat exposure. She said that she expected her staff to not allow it to happen again. Record review of a QAPI Committee Report dated 6/23/23 indicated that there was a meeting held on 6/23/23 at 6:00 pm consisting of Administrator, DON, ADON, Dietary Supervisor, Activity Director, MDS nurse, Maintenance Supervisor, Social Worker, Rehabilitation Director, and Medical Director. The following interventions were put in place: In-services: Elopements, Emergency Procedure - Missing Resident, Reporting Maintenance Tasks. Door Alarms - Monitor door alarms every shift, and monitor that cover is over the door alarm and is intact Maintenance will be notified of any non-working equipment. Alarm and door check will be checked off by nursing staff every shift. Record review of sign in sheet for in-service on Emergency Procedure - Missing Resident, dated 6/23/23, indicated that 59 staff members signed the in-service. Record review of sign in sheet for in-service on Elopements, dated 6/23/23, indicated that 59 staff members signed the in-service. Record review of in-service dated 6/23/23 for Maintenance indicated that the following education was provided to staff: .all maintenance tasks must be reported to the maintenance supervisor. This can be reported in the maintenance log located at the nurse's station. When reporting maintenance tasks you must put the date, what the task is and where the maintenance task is located. The maintenance supervisor and/or designee will update the maintenance binder once a maintenance task has been completed. If you find any maintenance tasks that need immediate attention, then you must report to the Administrator immediately. Examples of tasks that need to be reported immediately: Alarms not working, doors not locking, broken equipment, etc .If you are ever in doubt, report it . Record review of a Secure Unit Door and Alarm Check form dated 6/23/23 -6/28/23 indicated that door alarms and unit doors were monitored hourly by nursing staff beginning immediately after incident on 6/23/23 until new door alarms were placed on 6/26/23 and for 48 hours after new alarm placed. Record review of Elopement Risk assessments dated 6/19/23 indicate that assessments were done on all residents in facility on 6/19/23. Record review of Inservice for Maintenance Supervisor (who is no longer employed) dated 6/26/23 to test door alarms and ensure they are working properly. Return demonstration done and signed by Administrator and Maintenance Supervisor. Record review of alarm monitoring form indicated that new alarm for emergency end door arrived and was placed on 6/26/23 and that permanent cover was installed on 7/3/23. Daily monitoring for functioning was documented daily until 8/4/23. Record review of Work History Report dated 8/7/23 indicated that outside gate had lock placed and was checked for proper functioning on 6/30/23. Record review of a facility policy titled Emergency Procedure - Missing Resident dated 2001 with revision date of August 2018 indicated .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety . On 8/8/23 at 10:25 am Administrator, DON and Corporate staff were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 6/23/23 and ended on 6/23/23. The facility had corrected the noncompliance before survey began. 46273

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 22 residents (Resident #1) reviewed for Resident Abuse. CNA A hit Resident #1 in the face resulting in redness and bleeding from his right nostril. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began and ended on 6/15/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Review of a face-sheet dated 06/17/23 showed Resident #1 was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease with late onsite, Dementia with other behavioral disturbances, Psychotic disorder with delusions due to known physiological condition, major depression, diabetes, and anxiety. Review of MDS dated [DATE] showed Resident #1 had a BIMS score of 7, which indicated he was alert to person but had severe to moderate cognition deficit. He required one-person assistance with bed mobility, personal hygiene, and toileting. Resident #1 was always incontinent to bladder. Review of a care plan dated 03/09/23 showed Resident #1 was a moderate risk for falling due to confusion. Resident #1 was having adjustment issues since admission. CNAs were to provide Resident #1 with as many situations as possible which would give him control over his environment and care delivery. Resident #1 resided on the secure unit and had a history of exit seeking behaviors. Resident #1 had cognitive dementia, impaired thought process and impaired decision-making skills. CNAs were to provide Resident with necessary cues-stop and return if agitated. When conflict arises, CNAs were to remove Resident #1 to a calm environment and allow to vent and share feelings. Resident #1 had communication problems due to language barrier. Resident #1 speaks Spanish and understands English. Staff were to encourage Resident #1 to continue stating thoughts even if Resident #1 was having difficulty. Staff were to focus on a word or phrase that makes sense or respond to the feeling resident was trying to express. Resident #1 had a history of physical aggression toward staff. Staff were to provide ADL and incontinent care as needed. During an interview on 06/17/23 at 11:30 a.m. and review of a video surveillance tape provided by the administrator dated 06/15/23, showed on 06/15/23 at 2:14 AM, Resident #1 (Identified by the administrator) was in the hallway on the secure unit. Resident #1 and CNA A (Identified by the administrator) had a physical altercation involving physically hitting. It was not clear as to which one hit who because of the distance away from the camera, but later in the video, CNA A was seen near the exit door when Resident #1 approached CNA A. CNA A was observed pushing Resident #1 in the face with her hand and pushing Resident #1 away. CNA A was observed attempting to run away from Resident #1 by quickly moving around Resident #1 and running down the hallway. During an interview on 06/19/23 at 9:21 a.m. with assistance from RTA A, who served as Spanish/English interpreter, Resident #1 said he remembered the incident with CNA A. Resident #1 said he was standing in the hallway talking to CNA A when she kicked him two times. Resident #1 said CNA A did not kick or hit him in his room. Resident #1 said CNA A scratched him on his nose. Resident #1 said the bleeding on his nose was from the scratch, but he did not know if it was from fingernails or jewelry. Resident #1 said the nurse took him to the nurse's station. Resident #1 said he was not in pain when he was at the nurse's station, but he was upset because he wanted to hit CNA A and couldn't. Resident #1 said he felt safe when he was at the nurse's station, but he did not know if other staff working at the facility would hurt him. During an interview on 06/18/23 at 1:49 p.m., CNA A said she was working on A-Hall, (Men's secure unit) on 06/15/23 on the night shift. CNA A said around 2:30 a.m., she heard Resident #1 yelling and went to see what he needed. CNA A said she had changed Resident # earlier that evening with no issue. CNA A said when she attempted to provide incontinent care to Resident #1, he became combative and started hitting her and pulling her hair. CNA A said Resident #1's nose may have been scratched by her jewelry at this time she attempted to get away from him, but she was not sure. CNA A said she did not hit Resident #1. CNA A said she left the room and went into the hallway. CNA A said she attempted to return to the room to provide care, but Resident #1 would not let her in the room. CNA A said she was standing in the hallway outside Resident #1's room when Resident #1 came out and started attaching her. CNA A said Resident #1 hit her on the left side of her head. CNA A said she went to the exit door and knocked to get the nurse's attention who was sitting at the nurse's station just outside the exit door. CNA A said when she turned around, she saw Resident #1, walking towards her in an aggressive manner. She said she held her hand out and told Resident #1 to go on. CNA A said she skited around Resident #1 and ran down the hall. CNA A said she did not remember pushing Resident #1 in the face. CNA A said LVN A opened the door. CNA A said LVN A came in the unit and took Resident #1 to the nurse's station. CNA A said the nurse asked her to make a written statement about what happened and asked her to clock out. CNA A said she clocked out and left the facility about 2:40 a.m. CNA A said when she started her shift on 06/14/23 at 10:00 p.m. the CNA who had been working the 2-10 shift told her Resident #1 was a fall risk and to keep an eye on him. CNA A said the CNA also told her that Resident #1 yells out in the night and to try to keep him calm and quit so he will not disturb the other residents. CNA A said this was the second time she had worked at the facility and had no problems the first time. During an interview on 06/19/23 at 12:03 p.m. LVN A said she was working on 06/15/23 on the night shift. LVN A said she was not assigned to A-hall (Men's secure unit) but was sitting at the nurse's desk just outside the unit, when she heard knocking at the exit door. LVN A said she opened the door and when she entered the unit, she saw CNA A. LVN A said CNA said Resident #1 was coming at her and she had to knock him out. LVN A said she escorted Resident #1 outside the unit to the nurse's station and observed blood on the right side of his nose. LVN A said she called the Administrator and DON to report the incident but did not get an answer. LVN A said she then call the Regional Nurse Consultant and received instructions to have CNA A write a statement, clock out and leave the facility. LVN A said she called the police to report the incident. LVN A said she contacted another CNA working at the time to cover A-hall. LVN A said while she was making phone calls and dealing with CNA A, LVN B cleaned the blood off Resident #1's nose and offered emotional support to Resident #1. LVN A said Resident #1 was visibly upset at the time and crying. LVN A said her assessment of Resident #1 at the time showed no other injuries other than the skin tear on his nose. During an interview on 06/19/23 at 9:41 a.m. the DON said she had been the DON at the facility since March 2023. The DON said on 06/15/23 at 2:30 a.m. she missed a call from the facility because the ringer on her phone was off. The DON said at 5:30 a.m. she noticed the missed call and called the facility. The DON said LVN A told her about the incident and said she had contacted the Regional Nurse Consultant. The DON said LVN A had already contacted the police. The DON said she arrived at the facility around 8:00 a.m. and the Medical Director was also at the facility. The DON said the Medical Director ordered x-rays for Resident #1, but Resident #1 said his hip was hurting so it was decided to discontinue the orders for x-rays and send Resident #1 to the hospital for evaluation and treatment to be on the safe side. The DON said CNA A was immediately asked to clock out and leave the facility. The DON said CNA A worked for an agency and the agency was contacted and told CNA A could not longer work at the facility. The DON said In-service training on preventing, identifying, and reporting resident abuse and neglect. The DON said staff also received training on resident rights and dealing with residents with aggressive behaviors. The DON said staff will be trained prior to working their next shift. The DON said the QAPI plan for intervention included that only employees of the facility will work in the secure units and agency staff will not work in the units unless there is no other alternative. The DON said she and the Administrator are responsible to ensure all staff are trained and they are to monitor to ensure compliance with the QAPI plan. During an interview on 06/17/23 at 2:55 p.m. Administrator said CNA A was an agency staff and first worked for the facility on 05/30/23 for one shift. Administrator said on 06/15/23 CNA A was working the night shift on the men's secure unit. Administrator said this was the second time CNA A had worked at the facility. Administrator said she was notified of the incident and reported the incident to the medical director, agency employer, the local police, Resident #1's family (RP), and the state agency as required. Administrator said after the incident staff received training on abuse prohibition, resident rights and dealing with residents with aggressive behaviors. Administrator said notification was given to the employment agency that CNA A is not longer eligible to work at the facility due to physically abusing Resident #1. Administrator said on 06/15/23 the QAPI had a meeting to discuss interventions to ensure residents were safe from abuse. Review of QAPI notes dated 06/15/23 showed a meeting was held to discuss the incident with Resident #1 and CNA A on 06/15/23. Members present included the administrator, DON, Medical Director, MDS Coordinator, Charge Nurse, Social Worker, and Dietary Supervisor. The interventions and plan for correction included o Agency Staff was removed immediately o Notified Agency Staff Employer of incident o Made a police Report o Sent resident to hospital for eval and treatment o DON completed skin assessment on all residents on a hall emotional assessment completed on Resident #1 o Abuse/neglect training to be completed with all staff o Staff working on the secure units will be employees of the facility and not agency staff. Review of nurse progress notes written by LVN A for Resident #1 dated 06/15/23 at 2:30 a.m. showed CNA banged on door to get someone's attention from outside the unit. LVN A, walked to the A hall unit to see what was going on. After arriving the CNA said, I had to lay him out because he tried to jump on me, he tried to fight on me, and I had to lay him out LVN asked who? Resident began walking out of his room and CNA pointed at resident and said, Him, him right there. CNA said, I tried to change him, and he refused and charged at me and does he do that all the time. LVN A replied, yes, he does sometimes. Resident began speaking in Spanish and said in English, Someone call the police. LVN A immediately removed resident off the unit to separate both parties. LVN A and LVN B immediately began calling Administrator, DON and ADON. LVN B performed care to Resident #1 was active bleeding on the right side of his nose. LVN B clean up his nose. LVN A called the sheriff's office and was given direct time of 7:30 AM, when sheriff office will come to the facility. Review of nurse progress notes Resident #1 dated 06/15/23 at 10:42 a.m. the DON recorded Due to resident's progressive pain to hip and abrasion to face, decided to send resident to ER for further evaluation. Review of nurse progress notes written by LVN C for Resident #1 dated 06/15/23 at 10:49 a.m. showed Ambulance arrived at this time to transfer resident to ER. Awake and alert at time of leaving this facility. Review of nurse progress notes written by the administrator for Resident #1 dated 06/15/23 at 12:17 PM, Administrator spoke with RP regarding altercation this morning. A police report had been filed and the case number is OR-06152301. Review of hospital records for Resident #1 dated 06/15/23 showed: Resident #1 arrived at ER. Complaint: Fall injury to [AGE] year-old- male .presented to emergency department .from home with complaints of hip pain. The patient reports that he had a fall last night landing on his left side injuring his hip. Patient notes that he was assaulted by a medical aide at the nursing home and would like a CT scan. (A scan combines a series of X-ray images taken from different angles around your body and uses computer) Patient has had Tylenol .is not on blood thinner .also complained of chest pain. Review of X-ray report for Resident #1 dated 06/15/23 at 12:58 PM, showed no fractures to pelvis. Review of CT scan of Resident #1's head dated 06/15/23 at 2:27 PM showed Clinical indication: Assault. Findings included: No Acute intracranial hemorrhage (No bleeding), No acute infarction (obstruction of the blood supply). No acute intracranial abnormalities (nothing abnormal found). Review of nurse progress notes written by LVN C for Resident #1 dated 06/15/23 at 4:20 PM, Resident returned to facility at 3:40 PM. MD notified. Recommendation from NP to monitor per nursing protocol and to notify them of any increase in anxiety or unusual behavior. On 06/19/2023, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 06/15/23 involving Resident #1 and CNA A by: 4 LVN's (on all shifts) 6 CNA's (on all shifts) said they received training regarding resident abuse, neglect, rights and dealing with residents with aggressive behaviors. The nursing staff verbalized understanding of the trainings and said they were to follow resident's plan of care dealing with behaviors. Review of facility policy showed Residents have the right to be free from abuse . 1. Protect residents from abuse .by anyone including, a. facility staff, .c. staff from other agencies .j. any other individual. 7. Implement measures to address factors that may lead to abusive situation, for example: a. adequately prepare staff for caregiving responsibilities; . c. instruct staff regarding appropriate ways to address interpersonal conflicts, and help staff understand how cultural religious and ethnic differences can lead to misunderstanding and conflict. 8. Identify and investigate all possible incidents of abuse . 9 report any allegations within timeframe required by federal requirements. 10. Protect residents from any further harm during investigation. 11. Establish and implement a QAPI review and analysis of reports, allegations, or findings of abuse .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program and ensure the facility was free of pests for 3 of 8 residents (Resident's #1, #2 and #3) reviewed for incidents and accidents related to pests. The facility failed to ensure ants were kept out of the rooms and beds of Resident #1, #2 and #3. This failure could place residents at risk for ant bites and injury due to an ineffective pest control program at the facility. Findings included: 1. Record review of an Admission Record dated 12/19/2022 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia (difficulty remembering), [CONDITION(S)] [CONDITION(S)] (low oxygen in the blood), Alzheimer's disease (a progressive disease that destroys memory), and [CONDITION(S)] (a group of lung diseases). Record review of A Significant Change MDS Assessment for Resident #1 dated 9/12/2022 indicated he had severe impairment in thinking with a BIMS score of 6. He required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of a care plan for Resident #1 (undated) indicated he had an actual impairment to skin integrity related to ant bites on right rib cage and right upper thigh. Interventions included for Ecolab call for ground rounds for insects, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and follow facility protocols for treatment for injury. Record review of a self-report to the state agency dated 11/10/2022 indicated an incident occurred at the facility on 11/10/022 with Resident #1. Resident #1 was found in his bed with ants on him. Ants were removed by staff and upon investigation it was noted that Resident #1 had multiple ant bites on his body. He was treated with hydrocortisone to the affected areas. Record review of a late entry nurse progress note dated 11/17/2022 with an effective date of 11/10/2022 by the DON indicated Resident #1 was assessed by the DON and LVN D and he had 12 to 15 red raised areas to the right rib cage area and approximately 20-25 bites were noted to his right hip/upper thigh area. Hydrocortisone cream was applied as ordered to prevent Resident #1 from scratching. Ants noted were immediately killed by staff and resident was immediately removed from the area and assessed and room was examined for entry site as well and Ecolab to be contacted. No noted entry site could be determined at this time. Administrator updated on findings and action taken/needed. During an observation and interview on 12/19/2022, Resident #1 was sitting up in a wheelchair in his room alert to person, place, and time. He said he had been a resident at the facility for a long time. He said he was in the bed when he was bitten by ants not too long ago. He said he felt where they stung him on his body. He said he has not noticed any ants since that incident. He said the staff got him out of bed, treated the bites and pest control came out and sprayed his room. 2. Record review of an Admission Record dated 12/19/2022 for Resident #2 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory), major depressive disorder (persistent feeling of sadness or loss of interest), malignant neoplasm of prostate (cancer in the prostate) and hypertension (high blood pressure). Record review of a Significant Change MDS Assessment for Resident #2 dated 10/25/2022 indicated he had moderate impairment in thinking with a BIMS score of 9. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of an undated care plan for Resident #2 indicated a focus of ants in room. Interventions included 9 pm rounds by nursing staff for pest monitoring/source of pest attractions, Ecolab notified and will be here on 12/20/2022 to treat rooms affected and facility grounds, every 30-minute monitoring for 72 hours and every shift rounds for pests or sources that attract pests. Record review of a nursing progress note for Resident #2 dated 12/16/2022 by LVN C indicated she was notified that Resident #2 had ants in the bed. Upon entering room aide had removed Resident #2 from the bed and ants were visible crawling on his sheets. There was about 50 ants crawling. Resident #2's clothing was removed, and he was assessed for pain and discomfort. Resident #2 was removed from the room and a shower was provided by the aide. Resident #2 was noted to have 20 ant bites in total. Resident #2's bedding was removed, and he was removed from the room to check for more ants. Administrator, DON, and Responsible party was notified. Resident #2 denied any itching at that time. During an interview on 12/19/2022 with CNA A said Resident #2 had ants in his bed on Friday 12/16/2022. She said maintenance came and sprayed in the men's secured unit for ants. She said Resident #3 had ants in his bed this morning found by CNA B. He was removed from his bed and taken to the shower. She said administration staff were notified. 3. Record review of an Admission Record for Resident #3 dated 12/19/2022 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Type 2 diabetes, [CONDITION(S)] [CONDITION(S)] (low oxygen in the blood), and major depressive disorder (persistent sadness or loss of interest). Record review of an Admission MDS assessment dated [DATE] for Resident #3 indicated he had moderate impairment in thinking with a BIMS score of 12. He required limited assistance with bed mobility and eating. He required supervision with transfers, dressing and toilet use. Record review of an undated care plan for Resident #3 indicated a focus of ants in room and actual impairment to skin integrity related to ant bites. Interventions included 9 pm rounds by nursing for pest monitoring/sources of pest attractions, Ecolab to be here 12/20/2022 to treat affected rooms and facility grounds, and every 30-minute surveillance for 72 hours. Record review of a pest control invoice from Ecolab dated 11/13/2022 indicated they treated the facility for ants and used a product called Wisdom Lawn Granular. Condition found/actions taken indicated that pest activity was found during service. Exterior area-ants noted during service, fire ants noted at front walks, this area serviced for ants. Record review of a pest control invoice from Ecolab dated 11/29/2022 indicated they treated he facility for ants and used a product called Tempo Ultra WP and the exterior area was treated. During an observation on 12/19/2022 at 10:24 AM in Resident #3's room, this surveyor noted 2 ants crawling on the electrical outlet behind the bed. Also 2 dead ants were noted on the nightstand by Resident #2's bed on top of a clean brief and a closed container of toothpaste. Resident #3 was not in the room at that time. During an interview on 12/19/2022 at 10:25 AM, the Administrator said last week the facility had ants that were found in the men's secured unit. She said she contacted pest control and was told he would be coming out tomorrow. She said Resident #1's room was an isolated event with the ants. She said they treated his room and has not had any ants in the facility since Friday 12/16/2022. She said at 9 pm the nursing staff conducted a check of all the beds to make sure no food or crumbs were in the beds. She said she called all this past weekend to make sure the staff were checking. She said the department heads treated the outside area of any ant beds they noted. She said one mound was found at the end of D hall that was treated and there was a pile between Hall C and D on this past Saturday. She said they were treating the ant mounds with Orthene ant killer. During an interview on 12/19/2022 at 10:33 AM, CNA B said the housekeepers reported to him this morning that they saw ants on the floor by the fall mat in Resident #3's room. He said he then went to the room and got Resident #3 out of bed but never saw any ants. He said last week ants were found in Resident #2's room, but they were on the floor by the baseboard and on the walls. He said he did not have any ant bites. He said Resident #3 had 15 ant bites on both hands and on his back when he took him to the shower. He said Resident #3 did not complain of any pain related to the ant bites, but LVN C did give him some pain medicine earlier following a fall. He said the ants have been a problem for a while. During an interview on 12/19/2022 at 10:49 AM, LVN C said CNA B came out and got her and said Resident #3 complained about being bitten this morning. She said Resident #3 had 15 ant bites on him. She said the bites were on different locations all over his body. She said there has been issues with ants at the facility for a long time. She said the ants are in various locations on the men's secured unit. She said Resident #2 had ants in his bed last Friday 12/16/22. She said CNA A went in the room to get Resident #2 up and she was called into his room, and he had 20 ant bites. She said they got Resident #2 out of the room and deep cleaned the room and sprayed. She said staff had to complete every 30-minute check on his room for 72 hours and it should end this morning. She said every evening the nurse at 9pm was supposed to go in and check to see if the room had ants or not and complete a progress note in the charting system. During an interview on 12/19/2022 at 11:15 AM, Ecolab pest control technician said he was called to come out to the facility on [DATE] and he treated the facility for ants. He said on 11/13/2022 he treated the exterior of the facility with a granular poison which was effective for ants. He said the facility has had a problem with ants for over 8 years since and he had been the technician coming to the facility. He said there was not a product that would be a 100% guarantee to stop them. He said he would be at the facility tomorrow 12/20/2022 to treat the exterior for ants with a poison called Tremidor that can only be used once every 6 months. He said the poison could not be put out when there was any chance of rain or precipitation. He said the poison was used to treat termites but was labeled for ants as well. He said he would treat the rooms that had ants present when he goes back along with any cracks or crevices. He said sanitation is a huge issue because the ants go into the facilities looking for food and could be in dirty linens etc. He said the facility should do daily walk arounds outside and treat the mounds as they see them and that would help prevent the ants from coming inside. During an interview and observation on 12/19/2022 at 12:10 PM, Resident #3 was in his room with CNA B present. Resident #3 said he had been a resident at the facility for a little while but was unable to recall exactly how long. He said ants were found in his bed this morning and he had been bitten on his hands and back. He had a total of 15 small red bumps noted to both hands and his back. He said there was a bag of food on his nightstand from yesterday that had ants in is as well earlier. During an interview and observation on 12/20/2022 at 9:58 AM, Resident #3's room has several ants crawling on the wall, ceiling and coming out of the electrical outlet behind the bed. Resident #3 was not in the room at that time. CNA B came into the room and observed the ants, he pulled the bedding back to check to be sure no ants were in the bed and on top of the linens, crumbs were present along with dirt debris present. CNA B said he would change the linens on the bed and notify the Administrator. During an observation and interview on 12/20/2922 at 10:00 AM, the Administrator and RDO were shown the ants in Resident #3's room. Resident #3 was not in the room. Both the Administrator and RDO said Ecolab would be coming to the facility today to spray and treat the room and exterior of the facility. She said Resident #3 was moved out of the room earlier today after and after Ecolab came to treat the room, Resident #3 would not be allowed to go back into the room for 24 hours. During an interview on 12/20/2022 at 12:30 PM, the Administrator said going forward the facility was going to have to do room round checks daily because the ants were more frequent than they had initially thought. She said Ecolab was present at this time and was going to spray a treatment that he can do every 6 months and will schedule for them to come out every 6-month spray. She said the risk involved with the residents and the current ant problem was that residents could get bitten and scratch the areas and cause an infection. Record review of a facility policy titled Pest Control with a revised date of May 2008 indicated, .Our facility shall maintain an effective pest control program. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free from insects and rodents .

Based on observation, interview, and record review, the facility failed to consult with the resident's physician regarding a significant change in physical status and need to alter treatment for 1 of 5 residents reviewed for physician notification. (Resident #1) The facility did not inform Resident #1's physician she was observed to have a deformity to her right leg on 01/29/19 with severe pain upon movement . Resident # 1 was found to have a fractured right hip on 02/07/19 that required surgical intervention . An Immediate Jeopardy situation was identified on 02/14/19 at 12:06 p.m. The Immediate Jeopardy was removed on 02/14/19 at 4:00 p.m., the facility remained out of compliance at actual harm with a scope identified as a pattern. This failure could place residents at risk for neglect, injury, or death. Findings included: An order summary report dated 02/13/19 indicated Resident # 1 a [AGE] year-old female admitted [DATE], with [DIAGNOSES REDACTED]. The report indicated Tylenol Tablets 325 mg 2 tablets by mouth every 8 hours as needed for mild pain. The summary report indicated a start date of 02/25/18. A telephone order dated 02/07/19 indicated a [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident # 1 was severely impaired cognitively and required extensive assistance of two staff for ADLs to include bed mobility and transfers. The MDS also indicated she had unclear speech and was sometimes understood and sometimes understand others. A care plan dated 05/24/16 indicated Resident # 1 required the use of assist bars to maintain bed mobility with assist, interventions included pad assist bars, resident will utilize assist bars for aiding in bed mobility, turning and CNA reposition within the bed. A care plan dated 11/28/16 indicated Resident #1 had ADL self-care performance deficit related to [MEDICAL CONDITION]. Interventions included: Resident #1 was 2 persons assist with ADL care, requires extensive assistance of 2 staff to turn and reposition in bed as necessary, and totally dependent on 2 staff for transfers may use Hoyer lift with 2 persons assist. A care plan dated 11/28/16 indicated Resident #1 had communication problems related to [MEDICAL CONDITION]. Resident can shake head yes or no occasionally say/repeat simple words, point to objects in room she wants. Interventions included: monitor /document for physical nonverbal indicators of discomfort or distress and follow up as needed. A care plan dated 12/26/18 indicated Resident #1 had as needed Tylenol for pain. Interventions included: administer medication as ordered by physician, monitor and document side and effectiveness every shift. Ask physician to review medication if side effects persist. The (MONTH) 2019 MAR indicated [REDACTED] 1/29/19 at 10:27 p.m., pain level of 10. The (MONTH) 2019 MAR indicated [REDACTED] 2/2/19 at 10:00 p.m., pain level 10. The (MONTH) 2019 MAR indicated [REDACTED] 02/04/19 at 8:04 p.m. pain level of 2, 02/05/19 at 3:05 a.m. pain level 10, 02/06/19 03:15 p.m. pain level 8, 02/06/16 8:10 p.m. pain level 7, 02/07/19 at 3:59 p.m. pain level at 10, and 02/07/19 at 7:30 p.m. pain level at 0. A nurse note dated 01/29/19 at 10:00 pm by LVN G indicated Resident # 1 complained of knee pain and when assessed knee was red and slightly swollen. Tylenol 325 mg 2 tablets were given and new order for X-ray of knee. The order summary report indicated a telephone physician by the primary physician dated 01/29/19, Resident #1 was to have an X-ray of the right knee. A nurse noted dated 01/30/19 at 2:51 am by LVN G indicated Tylenol 325 mg 2 tablets were for mild pain. The nurse noted indicated at 05:37 am knee still red and more swollen. X-ray due this a.m. since they were unable to come last night. tolerated Tylenol well and some relief of pain noted. A mobile X-Ray report dated 01/30/19 at 3:01 p.m. indicated an examination date of 01/30/19 at 1:02 p.m. of the right knee 1-2 views with results as followed: *The bones demonstrate diffuse demineralization. No fractures were present and there was small joint effusion (fluid) at the suprapatellar bursa region. *Conclusion: Small joint effusion. A note dated 01/31/19 at 05:13 a.m.by LVN G indicated knee red and complained of pain, Tylenol administered and seems to help, will monitor pain, negative for fracture per X-Ray. A nurse note dated 02/02/19 at 04:40 am by LVN G indicated Resident complained of pain to knee and Tylenol was administered. The note indicated knee without redness but still swollen. A nursing note dated 02/03/19 at 05:59 a.m., completed by LVN A indicated Resident #1's right hip appeared swollen, and Tylenol was administered with pain level of 4. The nursing notes also indicated communication was sent to the local physician. A nursing note dated 02/03/19 11:46 pm completed by LVN A indicated Resident #1's right hip and right knee was swollen during the shift, and the resident cried out in pain upon manipulation of extremities. The note indicated the local physician was notified and new orders were received for [MEDICATION NAME] every eight hours as needed for pain/inflammation. The note indicated the local physician stated no diagnostic at this time. A telephone order dated 02/03/19 indicated [MEDICATION NAME] 800 mg by mouth every 8 hours as need for pain/inflammation. A nursing note dated 02/04/19 at 10:45 a.m. indicated Resident #1's responsible party was notified of swelling of the right knee and hip with [DIAGNOSES REDACTED]. An incident report dated 02/06/19 at 9:45 p.m. indicated a bruise was found to Resident #1's right inner thigh, the DON was notified at 8:50 p.m. According to a nurse note dated 02/07/19 at 7:30 p.m. by LVN E [MEDICATION NAME] 800 mg was administered for pain/inflammation due to resident pointing towards leg and head when asked pain level Resident shook head yes at 6. A nurse note dated 02/07/19 at 9:20 p.m. by LVN E indicated [MEDICATION NAME] 800 mg was not effective. An X-ray report dated 02/07/19 at 9:02 p.m. for Resident #1 indicated an examination date of 02/07/19 at 4:30 p.m. with results as follows: There is a right intertrochanteric fracture with moderate displacement. A nursing note dated 02/07/19 at 9:36 p.m. written by LVN E indicated at 6:00 p.m. Resident #1 received an X-ray of her right hip showing fracture. The physician was notified and Resident #1 was sent out to the local hospital for evaluation. An X-ray report dated 02/07/19 at 10:44 p.m. of Resident #1's pelvis indicated a displaced and angulated intertrochanteric [MEDICAL CONDITION] proximal femur. The report indicated the bones were osteopenic. A consultation notes from the local hospital dated 02/08/19 at 3:14 p.m. indicated Resident #1's right lower extremity was shortened and externally rotated. A process notes from the local hospital dated 02/10/19 at 4:05 p.m. indicated Resident #1 was a [AGE] year old nursing home resident who had been bedbound with right [MEDICAL CONDITION] of unknown duration. The note indicated the orthopedic physician was consulted with successful surgery. During an interview on 02/12/19 at 2:36 p.m., agency CNA D said on the morning of 01/29/19 Resident #1 was yelling and pointing at her leg and appeared to be in extreme pain. CNA D said Resident #1's right leg seemed to be deformed. She said since she had not previously worked with Resident #1, she told the charge nurse at approximately 11:30 a.m. CNA D said around 1:00 p.m., she asked the DON to go and assess Resident #1 since the charge nurse had not. She said the DON asked if Resident #1 had been given a snack or something to drink as that was probably what was wrong with her. CNA D said Resident #1's leg was deformed; her knee was turned inward, and her foot was pointed away from her body and off the bed. CNA D said on 01/29/19 at 1:17 p.m., she sent a text to her supervisor at the agency because she could not get anyone to look at Resident #1's leg. She said she reported to the oncoming staff something was wrong with Resident #1's leg. She said CNA H looked at Resident #1's leg and said it was not normal and reported it to the nurse. During a telephone interview on 02/14/19 at 9:24 a.m., the agency supervisor said CNA D sent a text message on 01/29/19 at 1:17 p.m., to her cellphone that indicated there was a nonverbal resident who was able to point at her right leg while yelling, indicating there was something wrong. The agency supervisor said the text indicated the charge nurse and DON had been informed about Resident #1's pain. She said CNA D worked from 6 a.m. to 10 p.m. on 01/29/19. During an interview on 2/13/19 at 3:10 p.m., CNA H said she was working on 1/29/19 on the 2-10 shift when CNA D asked her to come look at Resident #1's leg. She said Resident #1's right knee was rotated inward and the heel was outward which was not normal for her. CNA H said she told LVN E that was not normal for Resident #1. CNA H said the following night Resident #1 was crying and indicated she was in pain by nodding, she said an unnamed nurse held up fingers to assess her pain. CNA H said she had never seen her leg in that position before, she said Resident #1 could not lift her leg because of the pain. CNA H said I immediately said it was broke when I saw it During an interview on 2/13/19 at 2:50 p.m., LVN E said she was the nurse for Resident #1 on 1/29/19 during the 2-10 shift. She said CNA H called her to Resident #1's room at approximately 10 p.m. She said the resident's knee looked swollen, and she was yelling out and pointing to her leg. LVN E said when she tried to move Resident #1's leg she would yell more. LVN E said Resident #1's right knee was rotated toward the midline of her body and her heel was positioned away from her body. LVN E said it was an obvious change and the position of her leg was abnormal. LVN E indicated she asked LVN G to help with assessing Resident #1, she said she called the doctor and notified the local X-ray company, she said LVN G initiated the documentation. During a telephone interview on 02/12/19 at 12:41 p.m., LVN G said on 01/29/19 on the 10 p.m.- 6 a.m. shift, Resident #1's right knee was red. LVN G said the physician was notified and an X-ray was ordered. She said she did not look at the hip area on 1/29/19 because Resident #1 was pointing to her knee and it was slightly rotated in. LVN G said she only looked at the knee, she said she had no reason to look at anything else because Resident #1 only pointed at her knee. During an interview on 2/13/19 at 1:53 p.m., LVN A said she was working on the 10-6 shift on 2/3/19 when a CNA told her Resident #1 looked like she had a broken hip. LVN A said she assessed Resident #1 and her right hip looked swollen, but she did not think it was broken. LVN A said Resident #1's right leg was laying in an awkward position and looked uncomfortable and the resident was unable to straighten the leg. She said when the CNAs tried to change the resident she was in pain. LVN A said Resident #1 could not speak but could point to the area that hurts. LVN A said Resident #1 was indicating her right hip down to her right knee was hurting by pointing. LVN A said Resident #1's leg was unusually positioned. She said Resident #1 had previously been able to straighten her right leg. LVN A said she did not inform the doctor of the deformity in the right leg. LVN A said she only informed him of the swelling in the right hip and knee with pain and reminded him an X-ray to the right knee had already been done. During an interview on 02/12/19 at 3:36 p.m. LVN K said on 02/06/19 CNA H reported Resident #1 had a bruise to her inner right thigh. She said the bruise was approximately 5 cm. She said she notified the DON and was instructed to do an incident report. During an interview on 02/12/19 at 10:00 a.m., the DON said she was notified Resident #1 had a bruise to her inner right thigh on 02/06/19. She said she instructed the charge nurse to do a skin assessment and incident report. She said the next morning on 02/07/19 she assessed the bruise to Resident #1 and noticed Resident #1's leg appeared to be misaligned and had dark bruising to her thigh and groin area. She said the physician was notified and an order for [REDACTED].>During an interview on 2/13/19 at 4:55 p.m., the DON said she first became aware that there was an issue with Resident #1's leg on 2/7/19, and no one had notified her of any problem with Resident #1's leg. The DON said she had seen in the progress notes that Resident #1 had an X-ray of her right knee on 01/30/19 and that it showed she had bursitis to her right knee. The DON said Resident #1's leg was turned in, and the knee was rotated toward the midline. The DON said the facility called the doctor and got the order for a stat x-ray. The DON said a prudent nurse would notify the physician of a change in condition such as a limb deformity or sudden onset of severe pain especially if they had no pain previously and now report pain rated as a 10. During an interview on 02/13/19 at 9:22 a.m. Resident's #1 primary physician said he was never told that Resident #1 was having severe pain upon manipulation of her right leg. He said he would have ordered an X-ray of her hip and leg due to the fact Resident #1 could not communicate and was bedbound. The primary physician said he was not told there was any deformity or that the resident was experiencing severe pain. During an interview on 2/14/19 at 9:45 a.m., Resident #1's primary physician said when he spoke with facility staff on 1/29/19 he was not informed that Resident #1's knee was rotated toward the midline and her right foot was positioned away from her body. The physician said he did not give the facility a [DIAGNOSES REDACTED]. A policy on physician notification dated 2006, indicated Our facility shall promptly notify the resident, his or her attending physician, and representative (spouse) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care billing/payments, resident rights, etc.) Policy Interpretations and implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on call physician when there has been: a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; c. A reaction to medication; or an allergy d. A significant change in the resident's physical /emotional /mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medication (i.e., two or consecutive times); g. A need to transfer the resident to a hospital /treatment center h. A discharge without proper medical authority; and/or i. Instructions to notify the physician of changes in resident condition. The administrator and RDO was informed on 02/14/19 at 12:06 p.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on 02/14/19 at 2:46 p.m., and included: .The following is a plan of removal, which has been immediately implemented at Wells LTC, to remedy the immediate jeopardy which was imposed on (MONTH) 13, 2019. 1. Resident (# 1) has been assessed for pain. The MD and family have been notified and all received orders are being carried out. 2. All bed bound residents in the facility have been assessed for pain with an emphasis on lower extremities by the Regional MDS Nurse and Facility MDS nurse. No negative findings were discovered. 3. All other residents not bed bound were assessed for pain with an emphasis on lower extremities by the Regional MDS Nurse and Facility MDS nurse. No negative findings were discovered. 4. The following in-services have been completed. (a) Signs and Symptoms of hip pain/fx with proper steps for nursing to follow (b) Transfers (c) abuse and neglect with emphasis on pain and monitoring (d) accident/incident 5. All staff were ins-serviced on recognizing and reporting a change of condition. All nursing staff were in-serviced on notifying MD of change of condition with a complete picture of the status of the resident. The staff were in-serviced to use the SBAR. All in-services completed by DON and Regional MDS Nurse. 6. All care plans for residents with pain have been reviewed and updated. All residents have the potential to be affected by the this alleged deficient practice. An investigation will be conducted on any potential incident identified, which includes interviews with staff and/or residents, chart review, etc. Any injury will receive appropriate care. This will be completed by the end of the day 2/14/19 by qualified nursing staff. The Medical Director was initially made aware of the immediate jeopardy and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will run a weekly Standards of Care meeting to include monitoring of all residents identified for pain. In this meeting all incident reports from the past week will be reviewed for any notations of pain with weekly follow up by the DON and/or designee. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 2/14/19 and will be monitored through completion by corporate and regional staff Plan of Removal completion date is 2/14/19 . On 02/14/19 the surveyors confirmed the Plan of Removal had been implemented sufficiently/ to remove the Immediate Jeopardy by interviewing licensed nursing staff to determine knowledge of in-services provided by the facility. Nursing staff (2 LVNs and 4 CNAs) were interviewed and said they received training regarding recognizing and reporting changes in condition, signs and symptoms of hip pain/fractures with proper steps to follow, abuse/neglect with emphasis on pain and monitoring. Nurses said they had also been in-serviced on notifying the physician on changes in condition. On 02/14/19 at 4:00 p.m., the facility RDO and RNC was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 1 of 5 residents reviewed for accidents. (Resident # 1) The facility did not properly assess Resident #1's right leg for eight days after she complained of extreme pain to her right leg and the leg was noted to have a deformity (turned inward) on 1/29/19. On 02/07/19 the resident was found to have a [MEDICAL CONDITION] that required surgical intervention. An Immediate Jeopardy situation was identified on 02/14/19 at 12:06 p.m. The Immediate Jeopardy was removed on 02/14/19 at 4:00 p.m., the facility remained out of compliance with a scope identified as isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for neglect, injury, or death. Findings included: An order summary report dated 02/13/19 indicated Resident # 1 a [AGE] year-old female admitted [DATE], with [DIAGNOSES REDACTED]. The report indicated Tylenol Tablets 325 mg 2 tablets by mouth every 8 hours as needed for mild pain. The summary report indicated a start date of 02/25/18. A telephone order dated 02/07/19 indicated a [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident # 1 was severely impaired cognitively and required extensive assistance of two staff for ADLs to include bed mobility and transfers. The MDS also indicated she had unclear speech and was sometimes understood and sometimes understand others. The MDS indicated Resident # 1 had no pain. A care plan last updated 12/21/18 indicated Resident # 1 required the use of assist bars to maintain bed mobility with assist, interventions included pad assist bars, resident will utilize assist bars for aiding in bed mobility, turning and CNA reposition within the bed. A care plan dated 11/28/16 indicated Resident #1 had ADL self-care performance deficit related to [MEDICAL CONDITION]. Interventions included: Resident #1 was 2 persons assist with ADL care, requires extensive assistance of 2 staff to turn and reposition in bed as necessary, and totally dependent on 2 staff for transfers may use Hoyer lift with 2 persons assist. A care plan dated 11/28/16 indicated Resident #1 had communication problems related to [MEDICAL CONDITION]. Resident can shake head yes or no occasionally say/repeat simple words, point to objects in room she wants. Interventions included: monitor /document for physical nonverbal indicators of discomfort or distress and follow up as needed. A care plan dated 12/26/18 indicated Resident #1 had as needed Tylenol for pain. Interventions included: administer medication as ordered by physician, monitor and document side and effectiveness every shift. Ask physician to review medication if side effects persist. A nurse note dated 01/29/19 at 10:00 pm by LVN G indicated Resident # 1 complained of knee pain and when assessed knee was red and slightly swollen. Tylenol 325 mg 2 tablets were given and new order for X-ray of knee. The order summary report indicated a telephone physician by the primary physician dated 01/29/19, Resident #1 was to have an X-ray of the right knee. The (MONTH) 2019 MAR indicated [REDACTED] 1/29/19 at 10:27 p.m., pain level of 10. A nurse noted dated 01/30/19 at 2:51 am by LVN G indicated Tylenol 325 mg 2 tablets were for mild pain. The nurse noted indicated at 05:37 am knee still red and more swollen. X-ray due this a.m. since they were unable to come last night. tolerated Tylenol well and some relief of pain noted. The (MONTH) 2019 MAR indicated [REDACTED] 2/2/19 at 10:00 p.m., pain level 10. The (MONTH) 2019 MAR indicated [REDACTED] 02/04/19 at 8:04 p.m. pain level of 2, 02/05/19 at 3:05 a.m. pain level 10, 02/06/19 03:15 p.m. pain level 8, 02/06/16 8:10 p.m. pain level 7, 02/07/19 at 3:59 p.m. pain level at 10, and 02/07/19 at 7:30 p.m. pain level at 0. A mobile X-Ray report dated 01/30/19 at 3:01 p.m. indicated an examination date of 01/30/19 at 1:02 p.m. of the right knee 1-2 views with results as followed: *The bones demonstrate diffuse demineralization. No fractures were present and there was small joint effusion (fluid) at the suprapatellar bursa region. *Conclusion: Small joint effusion. A nursing note dated 01/31/19 at 05:13 a.m.by LVN G indicated knee red and complained of pain, Tylenol administered and seems to help, will monitor pain, negative for fracture per X-Ray. A nursing note dated 02/02/19 at 04:40 am by LVN G indicated Resident complained of pain to knee and Tylenol was administered. The note indicated knee without redness but still swollen. A nursing note dated 02/03/19 at 05:59 a.m., completed by LVN A indicated Resident #1's right hip appeared swollen, and Tylenol was administered with pain level of 4. The nursing notes also indicated communication was sent to the local physician. A nursing note dated 02/03/19 11:46 pm completed by LVN A indicated Resident #1's right hip and right knee was swollen during the shift, and the resident cried out in pain upon manipulation of extremities. The note indicated the local physician was notified and new orders were received for [MEDICATION NAME] every eight hours as needed for pain/inflammation. The note indicated the local physician stated no diagnostic at this time. A telephone order dated 02/03/19 indicated [MEDICATION NAME] 800 mg by mouth every 8 hours as need for pain/inflammation. A nursing note dated 02/04/19 at 10:45 a.m. indicated Resident #1's responsible party was notified of swelling of the right knee and hip with [DIAGNOSES REDACTED]. An incident report dated 02/06/19 at 9:45 p.m. indicated a bruise was found to Resident #1's right inner thigh, the DON was notified at 8:50 p.m. According to a nurse note dated 02/07/19 at 7:30 p.m. by LVN E [MEDICATION NAME] 800 mg was administered for pain/inflammation due to resident pointing towards leg and head when asked pain level Resident shook head yes at 6. A nurse note dated 02/07/19 at 9:20 p.m. by LVN E indicated [MEDICATION NAME] 800 mg was not effective. An X-ray report dated 02/07/19 at 9:02 p.m. for Resident #1 indicated an examination date of 02/07/19 at 4:30 p.m. with results as follows: There is a right intertrochanteric fracture with moderate displacement. A nursing note dated 02/07/19 at 9:36 p.m. written by LVN E indicated at 6:00 p.m. Resident #1 received an X-ray of her right hip showing fracture. The physician was notified and Resident #1 was sent out to the local hospital for evaluation. An X-ray report dated 02/07/19 at 10:44 p.m. of Resident #1's pelvis indicated a displaced and angulated intertrochanteric [MEDICAL CONDITION] proximal femur. The report indicated the bones were osteopenic. A consultation notes from the local hospital dated 02/08/19 at 3:14 p.m. indicated Resident #1's right lower extremity was shortened and externally rotated. A process notes from the local hospital dated 02/10/19 at 4:05 p.m. indicated Resident #1 was a [AGE] year old nursing home resident who had been bedbound with right [MEDICAL CONDITION] of unknown duration. The note indicated the orthopedic physician was consulted with successful surgery. During an interview on 02/12/19 at 2:36 p.m., agency CNA D said on the morning of 01/29/19 Resident #1 was yelling and pointing at her leg and appeared to be in extreme pain. CNA D said Resident #1's right leg seemed to be deformed. She said since she had not previously worked with Resident #1, she told the charge nurse at approximately 11:30 a.m. CNA D said around 1:00 p.m., she asked the DON to go and assess Resident #1 since the charge nurse had not. She said the DON asked if Resident #1 had been given a snack or something to drink as that was probably what was wrong with her. CNA D said Resident #1's leg was deformed; her knee was turned inward, and her foot was pointed away from her body and off the bed. CNA D said on 01/29/19 at 1:17 p.m., she sent a text to her supervisor at the agency because she could not get anyone to look at Resident #1's leg. She said she reported to the oncoming staff something was wrong with Resident #1's leg. She said CNA H looked at Resident #1's leg and said it was not normal and reported it to the nurse. During a telephone interview on 02/14/19 at 9:24 a.m., the agency supervisor said CNA D sent a text message on 01/29/19 at 1:17 p.m., to her cellphone that indicated there was a nonverbal resident who was able to point at her right leg while yelling, indicating there was something wrong. The agency supervisor said the text indicated the charge nurse and DON had been informed about Resident #1's pain. She said CNA D worked from 6 a.m. to 10 p.m. on 01/29/19. During an interview on 2/13/19 at 3:10 p.m., CNA H said she was working on 1/29/19 on the 2-10 shift when CNA D asked her to come look at Resident #1's leg. She said Resident #1's right knee was rotated inward and the heel was outward which was not normal for her. CNA H said she told LVN E that was not normal for Resident #1. CNA H said the following night Resident #1 was crying and indicated she was in pain by nodding, she said an unnamed nurse held up fingers to assess her pain. CNA H said she had never seen her leg in that position before, she said Resident #1 could not lift her leg because of the pain. CNA H said I immediately said it was broke when I saw it During an interview on 2/13/19 at 2:50 p.m., LVN E said she was the nurse for Resident #1 on 1/29/19 during the 2-10 shift. She said CNA H called her to Resident #1's room at approximately 10 p.m. She said the resident's knee looked swollen, and she was yelling out and pointing to her leg. LVN E said when she tried to move Resident #1's leg she would yell more. LVN E said Resident #1's right knee was rotated toward the midline of her body and her heel was positioned away from her body. LVN E said it was an obvious change and the position of her leg was abnormal. LVN E indicated she asked LVN G to help with assessing Resident #1, she said she called the doctor and notified the local X-ray company, she said LVN G initiated the documentation. During a telephone interview on 02/12/19 at 12:41 p.m., LVN G said on 01/29/19 on the 10 p.m.- 6 a.m. shift, Resident #1's right knee was red. LVN G said the physician was notified and an X-ray was ordered. She said she did not look at the hip area on 1/29/19 because Resident #1 was pointing to her knee and it was slightly rotated in. LVN G said she only looked at the knee, she said she had no reason to look at anything else because Resident #1 only pointed at her knee. During an interview on 2/13/19 at 1:53 p.m., LVN A said she was working on the 10-6 shift on 2/3/19 when a CNA told her Resident #1 looked like she had a broken hip. LVN A said she assessed Resident #1 and her right hip looked swollen, but she did not think it was broken. LVN A said Resident #1's right leg was laying in an awkward position and looked uncomfortable and the resident was unable to straighten the leg. She said when the CNAs tried to change the resident she was in pain. LVN A said Resident #1 could not speak but could point to the area that hurts. LVN A said Resident #1 was indicating her right hip down to her right knee was hurting by pointing. LVN A said Resident #1's leg was unusually positioned. She said Resident #1 had previously been able to straighten her right leg. LVN A said she did not inform the doctor of the deformity in the right leg. LVN A said she only informed him of the swelling in the right hip and knee with pain and reminded him an X-ray to the right knee had already been done. During an interview on 02/12/19 at 3:36 p.m. LVN K said on 02/06/19 CNA H reported Resident #1 had a bruise to her inner right thigh. She said the bruise was approximately 5 cm. She said she notified the DON and was instructed to do an incident report. During an interview on 02/12/19 at 10:00 a.m., the DON said she was notified Resident #1 had a bruise to her inner right thigh on 02/06/19. She said she instructed the charge nurse to do a skin assessment and incident report. She said the next morning on 02/07/19 she assessed the bruise to Resident #1 and noticed Resident #1's leg appeared to be misaligned and had dark bruising to her thigh and groin area. She said the physician was notified and an order for [REDACTED].>During an interview on 2/13/19 at 4:55 p.m., the DON said she first became aware that there was an issue with Resident #1's leg on 2/7/19, and no one had notified her of any problem with Resident #1's leg. The DON said she had seen in the progress notes that Resident #1 had an X-ray of her right knee on 01/30/19 and that it showed she had bursitis to her right knee. The DON said Resident #1's leg was turned in, and the knee was rotated toward the midline. The DON said the facility called the doctor and got the order for a stat x-ray. The DON said a prudent nurse would notify the physician of a change in condition such as a limb deformity or sudden onset of severe pain especially if they had no pain previously and now report pain rated as a 10. During an interview on 02/13/19 at 9:22 a.m. Resident's #1 primary physician said he was never told that Resident #1 was having severe pain upon manipulation of her right leg. He said he would have ordered an X-ray of her hip and leg due to the fact Resident #1 could not communicate and was bedbound. The primary physician said he was not told there was any deformity or that the resident was experiencing severe pain. During an interview on 2/14/19 at 9:45 a.m., Resident #1's primary physician said when he spoke with facility staff on 1/29/19 he was not informed that Resident #1's knee was rotated toward the midline and her right foot was positioned away from her body. The physician said he did not give the facility a [DIAGNOSES REDACTED]. A policy on physician notification dated 2006, indicated Our facility shall promptly notify the resident, his or her attending physician, and representative (spouse) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care billing/payments, resident rights, etc.) Policy Interpretations and implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on call physician when there has been: a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; c. A reaction to medication; or an allergy d. A significant change in the resident's physical /emotional /mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medication (i.e., two or consecutive times); g. A need to transfer the resident to a hospital /treatment center h. A discharge without proper medical authority; and/or i. Instructions to notify the physician of changes in resident condition. The administrator and RDO was informed on 02/14/19 at 12:06 p.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on 02/14/19 at 2:46 p.m., and included: .The following is a plan of removal, which has been immediately implemented at Wells LTC, to remedy the immediate jeopardy which was imposed on (MONTH) 13, 2019. 1. Resident (# 1) has been assessed for pain. The MD and family have been notified and all received orders are being carried out. 2. All bed bound residents in the facility have been assessed for pain with an emphasis on lower extremities by the Regional MDS Nurse and Facility MDS nurse. No negative findings were discovered. 3. All other residents not bed bound were assessed for pain with an emphasis on lower extremities by the Regional MDS Nurse and Facility MDS nurse. No negative findings were discovered. 4. The following in-services have been completed. (a) Signs and Symptoms of hip pain/fx with proper steps for nursing to follow (b) Transfers (c) abuse and neglect with emphasis on pain and monitoring (d) accident/incident 5. All staff were ins-serviced on recognizing and reporting a change of condition. All nursing staff were in-serviced on notifying MD of change of condition with a complete picture of the status of the resident. The staff were in-serviced to use the SBAR. All in-services completed by DON and Regional MDS Nurse. 6. All care plans for residents with pain have been reviewed and updated. All residents have the potential to be affected by the this alleged deficient practice. An investigation will be conducted on any potential incident identified, which includes interviews with staff and/or residents, chart review, etc. Any injury will receive appropriate care. This will be completed by the end of the day 2/14/19 by qualified nursing staff. The Medical Director was initially made aware of the immediate jeopardy and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will run a weekly Standards of Care meeting to include monitoring of all residents identified for pain. In this meeting all incident reports from the past week will be reviewed for any notations of pain with weekly follow up by the DON and/or designee. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 2/14/19 and will be monitored through completion by corporate and regional staff Plan of Removal completion date is 2/14/19 . On 02/14/19 the surveyors confirmed the Plan of Removal had been implemented sufficiently/ to remove the Immediate Jeopardy by interviewing licensed nursing staff to determine knowledge of in-services provided by the facility. Nursing staff (2 LVNs and 4 CNAs) were interviewed and said they received training and able to recall training to surveyor regarding recognizing and reporting changes in condition, signs and symptoms of hip pain/fractures with proper steps to follow, abuse/neglect with emphasis on pain and monitoring. Nurses said they had also been in-serviced on notifying the physician on changes in condition. On 02/14/19 at 4:00 p.m., the facility RDO and RNC was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to: 1. Immediate Jeopardy Ensure safe water temperatures in resident rooms for 3 of 3 residents reviewed for hot water safety. (Residents #13, 15, and 17) Water temperatures in the sinks of Resident #s 13, 15, and 17's rooms ranged from 117 degrees F to 144 degrees F. They resided on the secure unit and were able to turn on the hot water, but were cognitively unable to mix cold water to avoid burn injuries. The State Operations Manual Interpretive Guidelines noted the following: Table 1. Time and Temperature Relationship to Serious Burns Water Temp Time Required for a 3rd Degree Burn to Occur 155?F 68?C 1 sec 148?F 64?C 2 sec 140?F 60?C 5 sec 133?F 56?C 15 sec 127?F 52?C 1 min 124?F 52?C 3 min 120?F 48?C 5 min 100?F 37?C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. An Immediate Jeopardy was identified on 01/09/13. The Immediate Jeopardy was removed on 01/10/13. The facility remained out of compliance at a pattern of 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 the 10 residents who resided on the secure unit at risk for burn injuries. 2. Non Immediate Jeopardy a. Provide supervision to prevent falls for 1 of 13 residents reviewed for falls (Resident #22) and failed to supervise 1 of 1 resident reviewed for elopement risk. (Resident #43) Resident #22 had two falls from his wheel chair. The facility failed to provide a safety alarm and a fall mat as ordered. b. Resident #43 was confused with a history of wandering. She wandered outside the facility. The door alarms and locks were not functioning properly on the front and back doors. These failures could place 2 residents who used chair alarms and 1 wandering resident at risk for injuries. Findings included: 1. Immediate Jeopardy During observations on 01/07/13, the following hot water temperatures were obtained from resident rooms on the secure unit: 09:40 a.m., Room 14 (Resident #13), 144 degrees F 09:55 a.m., Room 15 (Resident #15), 127 degrees F 10:20 a.m., Room 18 (Resident #17),120.6 degrees F During an interview on 01/07/13 at 9:45 a.m., the maintenance director said a check valve probably stuck and he would adjust it. He said he checked the water temperatures weekly and had no issues He said the hot water for A Hall and the secure unit was controlled by the same valve. Weekly temperature logs dated 12/01/12 through 01/07/13 indicated water temperatures in the secure unit resident rooms ranged from 104 to 130 degrees F. During observations on 01/09/13, the following hot water temperatures were obtained from rooms on the secure unit: 1:36 p.m., Room 14 (Resident #13), 117 degrees F 1:40 a.m., Room 15 (Resident #15), 131 degrees F Physician orders [REDACTED].#13 was admitted on [DATE] and resided on the secure unit. Her [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #13 was very confused, had disorganized thinking, and psychomotor retardation. She required extensive assistance with ADLs. During an interview on 01/09/13 at 1:35 p.m., Resident #13 said she goes to her bathroom, but she was unable to describe how to adjust the water faucet and cool the hot water. Resident #13 resided in Room #14. Physician orders [REDACTED].#15 was admitted on [DATE] and resided on the secure unit. Her [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 was very confused, easily distracted, had disorganized thinking, and psychomotor retardation. She was independent with ADLs except bath and eating supervision. During an interview on 01/09/13 at 1:41 p.m., Resident #15 was unable to communicate how to adjust the water temperature, but said she did use water in her bathroom. Resident #15 resided in Room #15. Physician orders [REDACTED].#17 was admitted on [DATE] and resided on the secure unit. His [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #17 was alert and forgetful and needed limited assistance with ADLs. A care plan dated 11/9/12 indicated Resident #17 had repetitive physical movements, an unsteady gait, mental retardation, was delusional at times, and poor decision making, and poor safety awareness. During an interview on 01/09/13 at 2:25 p.m., Resident #17 said the water in his bathroom got hot . Resident #17 resided in Room #18. The administrator and DON were notified on 01/09/13 at 4:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 01/09/13 at 5:15 p.m. and included: "The maintenance director and the administrator checked and adjusted the water temperatures in the hot water room utilizing the mixing valve and the hot water heater thermostat. The last current water temperature average on the Secure Unit or Bridge unit was 96. It may drop lower as we adjust and monitor but will stabilize at approximately 105 for resident safety and comfort." "The maintenance director/or administrator will monitor water temperatures throughout the night tonight and continuously for 24 hours to make sure the water temperatures are stable. After that it will be monitored every 4 hours for 24 hours for compliance. After that it will be monitored every shift for a period of one week. This means it will be monitored for 9 days starting today for water temperature compliance." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: During observations on 01/10/13 at 8:32 a. m., water temperatures were checked in resident rooms on the secure unit and the following was noted: Room 17 was 100.6 degrees F, Room 14 (Resident #13) was 100 degrees F, and Room 21 was 101.8 degrees F. During an observation on 01/10/13 at 9:50 a.m., the maintenance director was monitoring temperatures on the secure unit. No temperatures were above 105 degrees F. On 01/10/13 at 11:00 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential of more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. A list dated 01/10/13 indicated 10 confused residents resided on the secure unit. 2. Non Immediate Jeopardy a. Physician orders [REDACTED].#22 was admitted on [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. He had an order for [REDACTED]. He also had an order for [REDACTED]. An admission MDS dated [DATE] indicated Resident #22 was confused and needed assistance with all ADLs. A care plan dated 10/30/12 indicated Resident #22 was a high risk for falls. It indicated he could not call for help and required the use of a chair/bed alarm and a low bed. The fall mat was not on the care plan. Nursing notes dated 12/30/12 at 5:35 p.m. indicated Resident #22 fell out of his wheel chair. He sustained a hematoma (bruise) to his left eye. He was transported to the hospital emergency room for evaluation. At 9:25 p.m., a head scan was negative and he returned at 11:30 p.m. A treatment record for Resident #22 dated 01/01/13 indicated a chair alarm at all times for personal safety due to poor safety awareness and a low bed with a fall mat at the bedside due to fall risk. The start date was 10/17/12. The treatment record was initialed from 01/01/13 through 01/07/13 indicating the wheel chair alarm, low bed, and fall mat were in place. During an observation on 01/07/13 at 9:20 a.m., Resident #22 was in his room on the secure unit in a wheel chair. He had a dark purple bruise under his right eye. He had no alarm on his wheelchair and no fall mat was in the room. During an interview on 01/07/13 at 9:21 a.m., CNA S said Resident #22 fell out of the wheel chair about a week ago. During an interview on 01/08/13 at 12:30 p.m., CNA R said Resident #22 had never had a chair/bed or fall mat while on the unit. During an interview on 01/08/13 at 12:15 p.m., LVN U said she was not aware of any orders for chair alarm or fall mat for Resident #22. During an interview on 01/08/13 at 12:30 p.m., CNA R said Resident #22 has never had a chair/bed or fall mat while on the unit. During an interview on 01/08/13 at 12:45 p.m., LVN B said she was initialing the treatment records for Resident #22 just like everyone else. She said that the alarms were on now since his fall. She said 2 residents had chair alarms. b. Physician orders [REDACTED]. Her [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #43 was confused and had daily occurrences of wandering. She needed limited assistance with ambulation. The most recent elopement risk assessment dated [DATE] indicated Resident #43 was not an elopement risk due to no prior attempts Her score was 9; a score of 10 indicated elopement risk. A care plan updated 10/07/12 indicated Resident #43 wandered and had poor cognition due to Alzheimer's and dementia. Interventions included to monitor for changes in condition and report. The maintenance trouble log dated 02/29/12 and 11/10/12 indicated the rear door alarms were not working. During an observation on 01/07/13 at 9:30 a.m., the front door had cracks in the glass with tape holding the cracks in the door together. The door closure was not working and the door slammed shut. The door lock was not locking every time the door closed. An incident report dated 01/08/13 at 3:00 p.m. indicated Resident # 43 had attempted elopement by following a family outside the facility. During an interview on 01/08/13 at 3:30 a.m., CNA H said that the rear door had been broken for at least 3 months. During an interview on 01/08/13 at 3:38 a.m., Resident # 43's family member said he had spoken to the administrator 4 times over the last 2 to 3 months and nothing had been done. The complaint log dated 07/09/12 through 12/26/12 had no complaints listed related to alarms or doors not working. During an interview on 01/08/13 at 3:45 p.m., the administrator said Resident #43's family had probably spoken to him, but he could not remember the specifics of the conversation. He said he had no answer as to why it was not documented in the complaint log and addressed. During an interview on 01/08/13 at 3:55 p.m., the maintenance director said the back door had been broken at least two months. He said he had not repaired the door because the administrator had not made it a priority. He said he had no idea how to repair the locks or keypad. He said (company name omitted) does the repairs and may want their money before they would do the repairs because it had been a problem before. He said the locks and the keypad were the system they have always had to alert staff. He said if the key code was working, after the door opened, it should lock after about 15 seconds. If the code was not used and the door was pushed on for 15 to 20 seconds, the door would open, but the system was not working. During an observation on 01/09/13 at 8:30 a.m., the front door alarm and lock were still not functioning correctly. The alarm did not sound when pushed on and the door would not lock after 15 or 20 seconds. During an interview on 01/09/13 at 8:35 a.m., the administrator said he thought the doors were repaired, but had not checked them. He said he would get repair people back out to repair the front and rear doors. During an interview on 01/10/13 at 11:00 a.m., LVN B said the door alarms were the system they had for alerting staff that residents might be out. A list dated 01/10/13 indicated 3 residents were at risk for falls on the secure unit. A list dated 01/10/13indicated there was one wandering, Resident #43.

Based on interview and record review, the facility failed to implement interventions to prevent falls for 1 of 8 residents reviewed for falls. (Resident #51) Resident #51 had two falls with injury from his wheel chair within two days. The facility failed to re-assess him for falls, update his written plan of care, and implement a more adequate safety alarm to prevent his second fall. These failures could place 2 residents with falls at risk for injuries. Findings included: Physician orders [REDACTED]. [DIAGNOSES REDACTED].#51 had senile dementia, anxiety state, Alzheimer's disease, and a history of falls. A fall risk assessment for Resident #51 dated [DATE] indicated a score of 26, high risk for falls. The fall risk assessment instructions read, "Upon admission, re-admission, quarterly, and after a significant change in condition, assess the resident status in the ten clinical condition parameters listed. Total score of 16 or greater equals high risk and requires a care plan". There was no updated quarterly assessment or upon re-admission on [DATE]. Care plans dated [DATE] for Resident #51 indicated: "...high risk for falling due to decreased cognition and will not or cannot call for assist. A chair alarm is required. Interventions listed included: chair alarm should be attached to his clothing so when he attempts to get out of his wheelchair without assistance, the sensor will detach from the base making a loud sound". "...potential for falls related to decreased cognition. Approaches indicated fall risk assessment to be completed every three months". There were no updated fall care plans. A telephone physician order [REDACTED]. An incident report dated [DATE] indicated Resident #51 was self-propelling in his wheel chair into the common area towards the nurse aide and then fell forward onto the floor striking his face causing some bleeding. His pressure chair alarm was in place and sounding. Resident #51 was transported to the hospital and diagnosed with [REDACTED]. A telephone physician order [REDACTED]. Hospital discharge instructions dated [DATE] indicated to protect Resident #51's face and "prevent his falling for the next three weeks". An incident report dated [DATE] for Resident #51 indicated: *At 4:15 p.m., he was sitting in the day room in his wheelchair. Resident #51 bent over and fell out of his wheelchair hitting his head on the left side. The resident was admitted to the hospital and returned to the facility on [DATE] with a small laceration to his right eyebrow area. He had multiple bruises to his face from previous falls. *Interventions listed: applied a wheelchair alarm which clips to resident's shirt at his shoulder area so when resident leans forward, it will sound alarm versus pressure wheelchair alarm. *Follow-up/outcome indicated as of [DATE], resident had used the pull (clip) chair alarm for three days and had no further falls. Corrective counseling forms dated [DATE] indicated: *LVN B and CNA C did not report Resident #51 changed from the pressure alarm to the pull (clip) wheelchair alarm to the oncoming shift resulting in another fall for Resident #51. *CNA D saw the new chair alarm for Resident #51, but did not ask the nurse about it which resulted in resident's fall. Nursing notes for Resident #51 indicated the folliowing: *[DATE] at 1:00 p.m., spoke with the ADON regarding resident falling more frequently. Decision was made to change out chair alarm from one which lies in the wheelchair to one which attaches to wheelchair, then clips to resident's shirt due to possibility of chair alarm sliding with resident. *[DATE] at 5:00 p.m., resident fell from wheelchair and hit head on floor. A MDS dated [DATE] indicated Resident #51: *was severely impaired in cognition, *had one fall without injury, *had one fall with minor injury, and *had one fall with major injury. During an interview on [DATE] at 2:45 p.m., CNA D said she was sitting at a bedside table and Resident #51 was looking down in his wheelchair when he fell . She said he had a cushion (pressure) chair alarm when he fell on [DATE] and not an alarm clipped to the resident. During an interview on [DATE] at 3:04 p.m., the ADON said after Resident #51's fall on [DATE], she placed a new clip chair alarm on him and left the facility. She said the nurse aide and nurse on the day shift did not report the change in alarms to the oncoming shift. She said CNA D saw the new alarm, but did not know to use it so she used the pressure alarm instead. She said when she came back and saw Resident #51 had fallen, but did not have the new alarm on, she was upset. She said the new clip alarm was put into place to prevent him from falling or at least to reduce injury of a fall. She said the care plan was updated and MDS Coordinator F should have it. During an interview on [DATE] at 3:40 p.m., MDS Coordinator F said both fall care plans for Resident #51 completed in [DATE] were the most current care plans for him and both were active. She said one care plan noted his alarms, but the other did not. She said at the time the care plan was completed, he had a clip chair alarm, later changed to a pressure chair alarm. She said there was no updated fall care plan for him because she was in the middle of completing his significant change MDS assessment when he died . During an interview on [DATE] at 3:59 p.m., MDS Coordinator E said she completed the fall assessments quarterly and everything she did was in the clinical record. During an interview on [DATE] at 3:09 p.m., the administrator said they did not have a policy specifically for falls. The facility 802 dated [DATE] indicated two residents had falls.