Every finding on record at Westpark Rehabilitation and Living

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 7 residents (Resident #7, #9,#11, #12 and #13) reviewed for respiratory care. The facility failed to ensure Resident #7's Nasal cannula connected to the oxygen tank was properly stored on 04/01/26. The facility failed to ensure Resident #9's suction tip was properly stored on 04/01/26. The facility failed to ensure Resident #11's Nasal cannula connected to the oxygen concentrator was properly stored on 04/01/26. The facility failed to ensure Resident #12's Nasal cannula connected to the oxygen concentrator was properly stored on 04/01/26. The facility failed to ensure Resident #13's Oxygen humidified bottle was connected to the oxygen concentrator and dated on 04/01/26. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #7's Face Sheet, dated 04/01/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included Chronic Respiratory failure (low oxygen or high carbon dioxide in levels in the blood) and Type 2 Diabetes (High blood sugar). Record Review of Resident #7's undated care plan revealed, the resident is at risk for impaired cognitive function / Dementia (A progressive loss of memory, reasoning and communication skills) or impaired thought process. Record Review of Resident #7's Active physician's orders on 04/01/26 revealed an order for CHANGE O2 TUBING & HUMIDIFIER BOTTLE every night shift every Sun, no orders for Alka Seltzer or Nasal saline spray were noted. Record review of Resident #9's Face Sheet, dated 04/01/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis that includes Dementia (A progressive loss of memory, reasoning and communication skills). Record review of Resident #9's MDS Assessment, dated 01/16/26, revealed the resident's BIMS score of 6 indicated severe cognitive impairment. The MDS Assessment reflected that the resident had an active diagnosis of Dementia. Record Review of Resident #9's undated care plan revealed, the resident had Oxygen therapy related to disease process, with intervention to monitor for signs and symptoms of respiratory distress and report to physician as needed. Record Review of Resident #9's physician's order dated 01/22/26 revealed Oxygen AT 2-4 L/MIN VIA NC PRN as needed for shortness of breath. Record review of Resident #11's Face Sheet, dated 04/01/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis that includes Chronic Obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe). Record review of Resident #11's MDS Assessment, dated 01/16/26, revealed the resident's BIMS score of 15 indicated no cognitive impairment. The MDS Assessment reflected that the resident had an active diagnosis of COPD. Record Review of Resident #11's undated care plan revealed, has COPD (a progressive, long-term lung disease that makes it hard to breathe), with intervention to give oxygen therapy as ordered by the physician. Record Review of Resident #11's physician's order dated 11/28/25 revealed to elevate head of bed due to shortness of breath while laying flat every shift related to COPD. Record review of Resident #12's Face Sheet, dated 04/01/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis that include COPD, Acute and chronic respiratory failure (Acute failure happens suddenly (minutes to hours) due to injury or illness. Chronic failure develops slowly over time (months/years) due to long-term diseases). Record review of Resident #12's MDS Assessment, dated 01/30/26, revealed the resident's BIMS score of 13 indicated no cognitive impairment. The MDS Assessment reflected that the resident had active diagnoses of COPD and respiratory failure. Record Review of Resident #12's undated care plan revealed, he has altered respiratory status and oxygen therapy with intervention to monitor for signs and symptoms of respiratory distress and report to physician as needed. Record Review of Resident #12's physician's orders dated 01/14/26 revealed, apply oxygen via NC at 2-4LPM, to keep saturation at or above 90%. Titrate as indicated as needed. Record review of Resident #13's Face Sheet, dated 04/01/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that include Acute and chronic respiratory failure and Heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs). Record review of Resident #13's MDS Assessment, dated 01/06/26, revealed the resident's BIMS Score of 15 indicated no cognitive impairment. The MDS Assessment reflected that the resident had active diagnoses of heart failure and respiratory failure. Record Review of Resident #13's undated care plan revealed, the resident has a terminal prognosis related to Acute/chronic respiratory failure, has oxygen therapy related to respiratory illness with intervention to monitor for signs and symptoms of respiratory distress and report to physician as needed. Record Review of Resident #13's physician's orders dated 01/02/26 revealed CHANGE O2 TUBING & HUMIDIFIER BOTTLE every night shift every Sun, O2 AT 2-4L/MIN VIA NC as needed for SOB, RESPIRATORY DISTRESS, CYANOSIS (bluish or purplish discoloration of the skin, lips, or fingernails caused by a lack of oxygen in the blood ), and LABORED BREATHING. During an observation on 04/01/26 at 8:35 a.m. Residents #7's nasal cannula connected to oxygen tank was noted hanging on his wheelchair while the resident was in bed with another nasal cannula connected to the oxygen concentrator. During an observation on 04/01/26 at 8:45 a.m., Resident #9's suction machine tip was connected to the suction machine and was not bagged. During an observation on 04/01/26 at 8:40 a.m., Resident #11's nasal cannula connected to the oxygen concentrator was lying on the floor. During an observation and interview on 04/01/26 at 8:43 a.m., Resident #12 was laying in bed awake with his nasal cannula connected to the oxygen concentrator and hanging on his chair. He stated he usually hangs it on this chair when not in use and it is not bagged most times. During an observation on 04/01/26 at 8:55 a.m., Resident #13's Oxygen concentrator humidifier bottle was sitting on the nightstand, not connected to the machine, it was 1/4 full with an open crack on the top right corner. During an interview on 04/01/26 at 10:00 a.m. with RN A, she stated that all nasal cannulas, nebulizer masks and suction tips should be bagged and dated and changed weekly according to the facility policy. She stated the nurses were responsible to change, date and bag the items and the CNAs are responsible for notifying the nurses if they see it not bagged and exposed. She stated the risk of not storing the nasal cannulas and nebulizer masks properly could be infection caused by germs that can make respiratory issues worse. During an interview on 04/01/26 at 10:10 a.m. with CNA K, she stated that the nasal cannulas should be stored in a bag and dated, she stated the CNAs and nurses are responsible for making sure they were bagged and dated. She stated if the nasal cannula is not bagged, it will become contaminated and result in an infection to the residents. During an interview on 04/01/26 at 10:25 a.m. with CNA M she stated that the nasal cannula should be bagged and dated. She stated that she should report to the nurse whenever she sees it not bagged. She stated that the nasal cannula not being bagged could result in contamination and infection. During an interview on 04/01/26 at 10:40 a.m. with Med Tech A, she stated that the nasal cannula and nebulizer mask should always be bagged when not in use and it should be dated. She stated it is the responsibility of everyone to notify the nurse if they see it not bagged and dated. She stated the risk of not having the nasal cannula and nebulizer mask in a bag could result in them getting dirty, the residents could inhale germs from them and get sick with an infection. During an interview on 04/01/26 at 10:50 a.m. with LVN D, he stated that the facility policy is that all nasal cannulas and nebulizer masks should be always bagged, dated and changed weekly and as needed if dirty or soiled. He stated that everyone is responsible for making sure they are stored properly. He stated that if they are not bagged, they will collect dust and pose a risk for infection. He stated the Oxygen humidifier bottles are changed and dated weekly and as needed if empty. During an interview on 04/01/26 at 11:00 a.m. with the DON, she stated that the oxygen humidifier bottle, nasal cannula and humidifier mask are dated and changed weekly and as needed if empty or soiled. She stated that everyone is responsible for making sure they are stored in a bag and dated. She stated the nurses round as often as possible and managers do an angel round on all residents every 2-3 hours. She stated she does not know why the oxygen humidifier bottle was on the table and cracked and not connected to the oxygen concentrator. She stated that it should be changed when the water level is low. She stated the risk of not storing respiratory equipment's properly could result in infections. The Facility's Oxygen Equipment Policy Dated 05/17 revealed: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, masks and cannulas for residents receiving oxygen. This equipment is to be discarded after use. The facility will maintain clean tanks, connectors and concentrators. PROCEDURES: 1. Oxygen Tanks, Connectors and Concentrators A. Oxygen tanks, connectors and concentrators must be cleaned after use B. Gauges must be cleaned after use as follows: 1. Remove gauge from tank2. Clean gauge with disinfectant. Allow to dry thoroughly3. Place clean gauge in oxygen storage area C. Pre-filled humidifiers, when used, are to be dated and replaced every ten (7) days, according to manufacturer recommendation, or as needed 1. Tubing should be replaced every week2. Masks should be replaced every week3. Cannulas should be replaced every week4. Oxygen concentrator filters will be cleaned with water and detergent every week or according to manufacturers recommendations D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth. E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. F. Gauges should be cleaned after oxygen therapy is discontinued 1. Remove gauge from tank2. Clean gauge with disinfectant. Allow to dry thoroughly3. Place gauge in oxygen storage area 2. Nebulizer Equipment Procedures A. Nebulizer equipment generates aerosols small enough to be readily deposited in the lungs. Careful technique is required to prevent infecting the resident B. Medication will be added to the nebulizer immediately before use C. After each treatment, take the nebulizer apart and discard all unused medication. Rinse all parts thoroughly with warm water and air dry D. Daily dismantle entire breathing assembly including all hoses, wash with warm soapy water, rinse well and ensure parts are dry, including inside of hoses E. Reassemble pieces F. Store, clean, and dry until next use 3. Room Air Humidifier A. Use of these in facilities is discouraged by CDC. These may technically be called nebulizers since they aerosolize droplets, are difficult to thoroughly cleanse of microorganisms, and are not safe to use in a facility 4. Emergency Resuscitation Devices A. Mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. B. Disposable resuscitation equipment is recommended. It should be used once and disposed of.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys 3 of 7 residents (Residents #1, #7, and #10) reviewed for hazards. The facility failed to ensure Resident #1 did not have a bottle of Lumify eye drop in her room on 04/01/26 The facility failed to ensure Resident #7 did not have a pack of Alka Seltzer and saline nose spray in his room on 04/01/26 The facility failed to ensure Resident #10 did not have a jar of Vicks Vapor rub in her room on 04/01/26 These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings include: Record review of Resident #1's Face Sheet, dated 04/01/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnosis that include Limitation of activity due to disability, Primary generalize Osteoarthritis and generalized muscle weakness. Record review of Resident #1's MDS Assessment, dated 02/06/26, revealed the resident's BIMS score of 7 indicated severe cognitive impairment. Record Review of Resident #1's undated care plan revealed, she has impaired cognition with intervention to Give step by step instructions one at a time as needed to support cognitive function. Record Review of Resident #1's Active physician's orders on 04/01/26 revealed no orders for Lumify eyedrops Record review of Resident #7's Face Sheet, dated 04/01/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. with diagnosis that includes Chronic Respiratory failure (low oxygen or high carbon dioxide in levels in the blood), Type 2 Diabetes (High blood sugar) Record Review of Resident #7's undated care plan revealed, the resident is at risk for impaired cognitive function / Dementia (A progressive loss of memory, reasoning and communication skills) or impaired thought process. Record Review of Resident #7's Active physician's orders on 04/01/26 revealed and order for CHANGE O2 TUBING &HUMIDIFIER BOTTLE every night shift every Sun, no orders for Alka Seltzer or Nasal saline spray were noted. Record review of Resident #10's Face Sheet, dated 04/01/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. with diagnosis that includes Dementia (A progressive loss of memory, reasoning and communication skills), intellectual disability. Record review of Resident #10's MDS Assessment, dated 03/10/26, revealed the resident's BIMS score of 13 indicated intact cognitive status. The MDS Assessment reflected that the resident had an active diagnosis of Dementia. Record Review of Resident #10's undated care plan revealed, resident is at risk for impaired visual function related to macular Degeneration (Damage to the center of the retina of the eye). Record Review of Resident #10's active physician's orders on 04/01/26 revealed No order for Vicks Vapor rub. During an observation and interview on 04/01/26 at 8:30 a.m., Vicks vapor rub was noted in Residents # 10's plastic chest of drawers, when asked if the nurses knew she had it, she did not respond to the question and waved her hand for me to leave the room. During an observation on 04/01/26 at 8:35 a.m. Alka Seltzer was and Nasal Saline spray was noted on Residents #7's over the bed table. During an observation on 04/01/26 at 8:50 a.m., Resident #1 asleep in bed with a bottle of Lumify eyedrops was noted on her bedside table. During an interview on 04/01/26 at 10:00 a.m. with RN A, she stated that all medications should be secured for residents' safety. She stated that if residents have medications in their possession, it could interact with prescribed medications and cause undesirable side effects and potentially cause an overdose. She stated that the CNA's and nurses are responsible for checking and making sure that the residents have no medications in their possession. During an interview on 04/01/26 at 10:10 a.m. with CNA K, she stated that medications should not be in residents' room, she stated that if she finds any medications in residents' possession, she removes it reports to the nurse charge. She stated that residents can harm themselves with the medication by taking too much of it if not supervised. During an interview on 04/01/26 at 10:25 a.m. with CNA M, she stated that residents should not have medications on them, she stated she reports to the nurse if she finds any medications with the residents. She stated that the risk of the residents having medications. During an interview on 04/01/26 at 10:40 a.m. with Med Tech A, she stated that residents' medications should not be in their possession, that it should be on the medication cart. She stated that everyone is responsible for making sure if they find any medication in resident's possession to report to the nurse in charge. She stated that the risk of residents having medication and taking it without supervision will result in overdose, wrong medication being given, another resident could get hold of it and have an adverse reaction. During an interview on 04/01/26 at 10:50 a.m. with LVN D, he stated that residents are not allowed to medicate, he stated that all medications need an order and approval by the physician. He stated that the nurses are responsible for making sure that residents are not in possession of medications. He stated that residents could have an allergic reaction to medication. During an interview on 04/01/26 at 11:10 a.m. with the DON, she stated that the facility policy does not allow residents to have medications on them, all medications are administered by the nurses or medication Techs. She stated that every staff member is responsible for making sure no resident has personal medication in their possession. She stated that the risk could be duplication in therapy which could result in an overdose.

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, recognizing each resident's individuality for 2 of 4 residents (Resident #1 and #5) reviewed for dignity.CNA E was observed standing over Resident #1 feeding her while the resident was lying in bed.Resident #5 was observed lying in bed and her catheter bag could be observed hanging from her bed without a privacy bag.These deficient practices could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect.Findings include:Record review of Resident #1's Face Sheet, dated 04/01/26, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included difficulty swallowing.Record review of Resident #1's Quarterly MDS assessment, dated 02/26/26, reflected a BIMS score of 00 (severe cognitive impairment). The resident had an active diagnosis of difficulty swallowing. The resident's ADL indicated the resident received maximum assistance with feeding.Record review of Resident #1's Comprehensive Care Plan, dated 03/09/26, reflected the resident had a nutritional problem; however, there was no intervention indicating the resident required assisted feeding. During an interview and observation on 04/01/26 at 08:24 a.m., CNA E was observed standing over Resident #1 feeding her while the resident was lying in bed. She stated staff was expected to be sitting down while feeding the resident. She stated the chair was too low. She stated they should be at eye level to observe the resident to ensure no swallowing issues.During an interview on 04/01/26 at 09:50 a.m., the DON was informed by the Investigator of CNA E feeding Resident #1 while standing over her. She stated the CNA should be sitting down while feeding residents to monitor their eating and swallowing to ensure no concerns. She stated it was also a dignity concern.Record review of Resident #5's Face Sheet, dated 04/01/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included a weak bladder.Record review of Resident #5's Quarterly MDS assessment, dated 03/27/26, reflected a BIMS score of 11 (moderate impairment). The resident had a diagnosis requiring the use of an indwelling catheter. Record review of Resident #5's Comprehensive Care Plan, dated 04/01/26, reflected the resident had a plan of care for an indwelling catheter.During an observation on 04/01/26 at 08:31 a.m., Resident #5 was observed lying in bed, her catheter bag could be observed from the hallway hanging from her bed, and no privacy bag was covering it.During an interview and observation on 04/01/26 at 08:33 a.m., the MDS Nurse observed Resident #5 not having a privacy bag over her catheter bag. She stated the resident needed a privacy bag to cover the catheter bag for her dignity. She stated it was the nursing staffs' responsibility to ensure the resident had a privacy bag.During an interview on 04/01/26 at 10:30 a.m., the DON was informed by the Investigator of Resident #5's catheter bag not having a privacy bag. She stated the resident needed a privacy bag to cover the catheter bag for her dignity. She stated the resident had one yesterday and she was not sure what happened.Review of the facility's policy on Resident Rights (07/13/2017) revealed As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 12 residents (Residents #6, and #8) reviewed for accident prevention. The facility failed to ensure Resident #6's fall mat was placed alongside her bed while she was lying in it on [DATE].The facility failed to ensure Resident #8 did not have a can of Lysol Spray in his room on [DATE].These failures could prevent residents from having an environment that was free from hazards. Findings include:Record review of Resident #6's Face Sheet, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included fall history.Record review of Resident #6's Quarterly MDS assessment, dated [DATE], reflected a BIMS score of 6 (severe cognitive impairment). The resident had active diagnoses of lack of coordination and unsteadiness on feet.Record review of Resident #6's Comprehensive Care Plan, dated [DATE], reflected the resident was a fall risk and an intervention included to have a fall mat at bedside. During an observation on [DATE] at 08:24 a.m., Resident #6 was observed lying in bed and her fall mat was observed away from her bed and not placed alongside her bed. During an interview and observation on [DATE] at 09:45 a.m., CNA C was informed by the Investigator of Resident #6 observed lying in bed, her fall mat was observed away from her bed and not placed alongside her bed. Her bed was also in a raised position. She stated the resident was a fall risk and needed the fall mat placed alongside her bed for fall prevention. She stated the resident raised her bed and did not allow staff to lower it.During an interview on [DATE] at 12:32 p.m., the DON was informed by the Investigator of Resident #6's lying in bed and her fall mat was observed away from her bed and not alongside her bed. She was also informed of the resident's bed not being in the lowest position. She stated the resident was a fall risk and needed the fall mat placed alongside her bed to protect her from injury if she fell out of bed. She stated the resident often raised her bed. Record review of Resident #8's Face Sheet, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included mental disorder and lack of coordination. Record review of Resident #8's MDS Assessment, dated [DATE], revealed the resident's BIMS score of 14 indicated intact cognitive function with minimal to no impairment.Record Review of Resident #8's undated care plan revealed, has an altered respiratory status related to cough with intervention to Administer medication/puffers as ordered. Monitor for effectiveness and side effects.Record Review of Resident #8's Active physician's orders on [DATE] revealed an order for Albuterol-Budesonide Inhalation Aerosol 90-80 MCG/ACT (Albuterol-Budesonide) 2 puff inhale orally every 4 hours as needed for wheezing.During an observation on [DATE] at 8:45 a.m., Resident #8 was observed with a can of Lysol Spray on his bedside table. During an interview on [DATE] at 10:00 a.m. with RN A, she stated residents should not have Lysol sprays in their rooms, she stated that all staff were responsible for making sure any harmful items were removed from residents' room. She stated that having Lysol spray in the room if used could exacerbate respiratory issues for other residents or even poison them. During an interview on [DATE] at 10:10 a.m. with CNA K, she stated Lysol sprays should not be in the resident's room, it should be removed by any staff member who finds it and reports to the nurse. She stated that if used could cause injury or burns if oxygen was in use.During an interview on [DATE] at 10:25 a.m. with CNA M, she stated Lysol spray should not be in resident's possession, she stated that CNAs and housekeeping should report to the nurse if they find such things. She stated that if used it could cause an allergic reaction to residents who have allergies.During an interview on [DATE] at 10:40 a.m. with Med Tech A, she stated Lysol should not be in resident room, they are not allowed to have such items in their rooms. She stated that if any staff member finds such items, it should be removed and reported to the nurse. She stated that the risk to any resident who gets it sprayed on them could cause an allergic reaction, it could make respiratory issues worse and cause trouble breathing.During an interview on [DATE] at 10:50 a.m. with LVN D, he stated Lysol spray should not be in the residents' room for any reason and if the resident representative brings it in, they need to be educated not to bring such items into the facility. He stated that everyone is responsible for making sure that any items not allowed should not be in resident rooms. He stated that the risk of having the Lysol spray could be allergic reaction by the residents and it could be expired or even contaminated. During an interview on [DATE] at 11:10 a.m. with the DON, she stated residents should not have Lysol sprays in their rooms, she stated that Resident #8 goes out on medical pass and buys them, and that they are unable to stop him. She stated that they will continue to educate him about the risk of having such sprays. She stated that all staff take part in angel rounds and will continue to monitor and educate Resident #8. She stated that the risk of having such sprays could cause or worsen respiratory issues.Review of the facility's policy on Resident Rights ([DATE]) revealed As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. You have a right to a safe, clean, comfortable and homelike environment, and use of your personal belongings to the extent possible, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #1 ) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected an intervention which included assisted feeding. This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #1's Face Sheet, dated 04/01/26, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included difficulty swallowing.Record review of Resident #1's Quarterly MDS assessment, dated 02/26/26, reflected a BIMS score of 00 (severe cognitive impairment). The resident had an active diagnosis of difficulty swallowing. The resident's ADL indicated the resident received maximum assistance with feeding.Record review of Resident #1's Comprehensive Care Plan, dated 03/09/26, reflected the resident had a nutritional problem; however, there was no intervention indicating the resident required assisted feeding. During an interview and observation on 04/01/26 at 08:24 a.m., CNA E was observed feeding Resident #1 while the resident was lying in bed. She stated the resident required staff to feed her because she was unable to feed herself.During an interview on 04/01/26 at 10:30 a.m., the DON was informed by the Investigator of Resident #1 not having an intervention for assisted feeding. She stated the resident had a change of condition and now required assistance with her feeding. She stated she could not recall when the resident had a change in condition. She stated the intervention of assist feeding needed to be on the resident's care plan because it was part of her plan of care and if it was not on it, she may not receive the appropriate care. She stated it was the MDS Nurse, ADON, and DON's responsibility to update care plans.During an interview on 04/01/26 at 10:30 a.m., the MDS Nurse was informed by the Surveyor of Resident #1 not having an intervention for assisted feeding. She stated she was unaware of the resident requiring assistance with her feeding. She stated updating the residents' care plans was a collaborative effort between her, the ADON , and DON.Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure resident received services in the facility with reasonable accommodation of resident needs for 2 of (Resident #1 and Resident #2) 7 resident rooms reviewed for reasonable accommodations. The facility failed to ensure the call light was accessible to Resident #1 and Resident #2 when lying in bed. This failure could place residents at risk of being unable to have a means of directly contacting caregivers.Findings Included: Record review of Resident #1's face sheet, dated 03/18/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebral infraction (a type of ischemic (blood clot block artery) stroke), type 2 diabetes mellitus (body resist insulin or fails to produce enough), vitamin deficiency (body lacking sufficient iron), pure hypercholesterolemia (genetic disorder with high bad cholesterol levels), vascular dementia (decline in thinking skills), mood affective disorder (mental health condition characterized by long-term emotional disturbances), Alzheimer's disease (incurable neurological disorder characterized by memory loss, cognitive decline and behavioral changes), insomnia (difficulty falling asleep or staying asleep), hypertension (blood pushing too hard against artery walls), muscle weakness (a reduction in physical strength), neuralgia (intense, sharp, stabbing and burning pain along a damaged nerve) and neuritis (inflammation of a nerve), lack of coordination (muscle movements are clumsy or unsteady), cognitive communication deficit (difficulty with verbal or non-verbal communication), aphasia (a language disorder cause by brain damage), adult failure to thrive, and need for assistance with personal care. Record review of Resident #1's MDS assessment, dated 12/30/25, reflected BIMS a score of 05, which indicated severe cognitive impairment. The MDS assessment under Section GG-Functional Abilities reflected Resident #1 needed setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, substantial assistance with upper body dressing and personal hygiene. Record review of Resident #1's care plan, date initiated 12/24/25, reflected Resident #1 was at risk for falls related to an unstable gait. Interventions included: Ensuring the call light was within reach and encouraging to use it to call for assistance, keeping needed items within reach, maintaining a clear pathway, free of obstacles, and a safe environment including floors free from spills and/or clutter, glare-free light, working and reachable call light, bed in a low position at night, side rails as ordered. Further review reflected Resident #1 had an actual fall on 01/27/26. Interventions included: educating resident how to use call light for assistance and neuro-checks as ordered. Record review of Resident #2's face sheet, dated 03/18/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Alzheimer's disease (incurable neurological disorder characterized by memory loss, cognitive decline and behavioral changes), dementia (decline in mental ability), mild protein-calorie malnutrition (nutritional deficiency characterized by inadequate intake of protein and calories), muscle weakness (a reduction in physical strength), age-related osteoporosis (a condition where bones become brittle and fragile), unsteadiness on feet, cognitive communication deficit (difficulty with verbal or non-verbal communication), dysphagia (difficulty swallowing), lack of coordination (muscle movements are clumsy or unsteady), contracture right and left knee (permanent, abnormal tightening or shortening of muscles, tendons, skin or tissues), weakness, normal pressure hydrocephalus (brain disorder causing excess cerebrospinal fluid buildup in the brain's ventricles), constipation (infrequent bowel movements or difficulty passing stool), major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), insomnia (difficulty falling asleep or staying asleep), seizures (sudden, uncontrollable electrical surges in the brain), cataract (clouding of the eye's natural lens), generalized anxiety disorder (persistent, excessive and uncontrollable worry), hypothyroidism (underactive thyroid gland), gastro-esophageal reflux disease (chronic digestive disorder where stomach acid frequently flows back into the esophagus), and visual hallucinations (perceptions of objects, shapes, people, or lights that are not actually present). Record review of Resident #2's MDS assessment, dated 03/02/26, reflected a score of 09, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities reflected Resident #2 setup or cleanup assistance with eating, partial assistance with oral hygiene and upper body dressing and substantia assistance with showering and bathing. Record review of Resident #2's care plan, date initiated 10/18/23, reflected Resident #2 had alteration in musculoskeletal status, had contractures and tightness, impairment to range of motion of bilateral shoulders, spine, neck, hip and knees. Interventions included: anticipating and meeting need, ensuring call light was within reach and responding promptly to all requests for assistance, assisting with gentle passive/active range of motion as tolerated, educating resident/family/caregivers on joint conservation techniques, giving analgesics as ordered by physician, monitoring for fatigue, monitoring/documenting for risk falls, and monitoring/documenting/reporting to MD PRN signs and symptoms or complications related to arthritis. In an interview and observation on 03/17/26 at 3:39 PM, Resident #2 stated she had to wait a long time for staff to assist her whenever she did use her call light. Resident #2 stated she was not always able to use her call light because it was not near her. She stated sometimes she needed to use her call light to have staff put her in bed. She stated her roommate sometimes went to get staff to help her when her call light was not near. An observation revealed Resident #2's call light was not in her bed. Further observation revealed Resident #2's call light was on the floor behind a mat that was against her wall. In an interview and observation on 03/17/26 at 4:19 PM, Resident #1 stated she could not call staff when she needed assistance. Resident #1 stated she did not have a way to call staff to her room because she did not have a call light. Resident #1 stated she asked a guy about her call light and was told that she did not have one. Resident #1 stated she did not know who the staff was that she asked. Resident #1 stated she had not had a call light for some time, but did not know exactly how long it had been. During an observation, call light was not found on the bed or within Resident #1's side of the room. Further observation revealed Resident #1's call light was on the side of her roommate's bed intertwined with her roommate's call light. In an interview and observation on 03/17/26 at 4:27 PM, the DON removed Resident #1's call light from Resident #1's bed and placed it on Resident #1's bed within reach. The DON stated she did not know how it got attached to Resident #1's roommate bed. In an interview and observation on 03/17/26 at 4:30, the DON found Resident #2's call light that was placed on the floor behind a mat that was against the wall. The DON placed the call light on Resident #2's bed within reach. She stated she did not know how it got on the floor, but it should be on Resident #2's bed. She stated if the call light was not within reach, the risk was that the resident was unable to call for assistance. Record review of the facility policy, Call Light/Bell, revised 08/03/2021, reflected in part the following: Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: 1. Answer the light/bell within a reasonable time.2. Listen to the resident's request/need. 3. Respond to the request. If the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions.4. Leave the resident comfortable. Place the call device within residents' reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #10, #150 and #60) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA K wore a gown while changing Resident #10's linen, who was on enhanced barrier precautions due to having a g-tube, on 02/03/2026. 2. The facility failed to ensure RN E wore a gown when disconnecting Resident #150's antibiotic via PICC line, who was on enhanced barrier protection, on 02/05/2026.3. The facility failed to ensure MA G removed her gloves and performed hand hygiene between checking Resident #60's blood pressure and using the laptop on her medication cart on 02/04/2026. These failures could place residents at risk of cross-contamination and development and spread of infections.Findings include:1. Record review of Resident #10's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing).Record review of Resident #10's Comprehensive MDS Assessment, dated 12/19/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. Record review of Resident #10's Comprehensive Care Plan, dated 12/20/2025, reflected the resident had a peg tube (procedure to place a feeding tube in the stomach), (a flexible feeding tube inserted directly to the stomach) and one of the interventions was to check patency and g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) placement.Record review of Resident #10's Physician Order, dated 09/28/2025, reflected Enteral Feed Order every shift FLUSH G-TUBE WITH 30-50 ML OF WATER.Record review of Resident #10's Physician Order, dated 01/21/2026, reflected Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Implanted feeding device every shift.An observation on 02/04/2026 at 10:41 AM, revealed CNA K was inside Resident #10's room and was changing the resident's beddings. She was not wearing a gown when she changed the linens. The resident had a g-tube and there was a sign outside the resident's door indicating that the resident was on EBP and a gown was required when changing the linens.In an interview on 02/04/2026 at 10:48 AM CNA K stated she was not aware she still needed to wear a gown when she was changing Resident #10's linen even though the resident was not in her bed. Then she said, Come to think of it, the resident still had a g-tube and something from the g-tube might leak to the linens and into the bed. She said she should still wear a gown because when she was changing the linens, she would lean over the mattress of the resident. She said the gown was to prevent cross contamination.2. Record review of Resident #150's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection).Record review of Resident #150's Comprehensive MDS Assessment, dated 02/06/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had pneumonia.Record review of Resident #150's Comprehensive Care Plan, dated 02/02/2026, reflected that the resident had pneumonia and one of the interventions was to administer medications as ordered.Record review of Resident #150's Physician Order, dated 02/02/2026, reflected Meropenem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously (administering fluids or medications directly into a vein) every 8 hours for PNA for 3 Days.Record review of Resident #150's Physician Order, dated 02/03/2026, reflected PICC (tubing inserted into a vein for long-term intravenous therapy) LINE FLUSHING: FLUSH WITH 10 CC 0.9 % NS IV SOLUTION BEFORE EACH MEDS ADMINISTRATION. FLUSH WITH 10 CC 0.9 % NS IV SOLUTION AND 5 CC HEPARIN LOCK FLUSH SOLUTION AFTER EACH MEDS ADMINISTRATION.An observation on 02/05/2026 at 8:15 AM, revealed RN E was about to disconnect Resident #150's IV via her PICC line. She went inside the room, washed her hands, put on a pair of gloves, and started to disconnect the resident's IV. After she disconnected the IV, she flushed the PICC line. She did not wear a gown while disconnecting the IV and while flushing the PICC line. There was a sign outside the resident's door indicating that the resident was on EBP and PPE was required during device care and use of the central line.In an interview on 02/05/2026 at 8:26 AM, RN E stated she knew she was supposed to wear a gown in disconnecting the IV to prevent spread of infection. She said she did not know why she forgot to wear a gown.In an interview on 02/06/2026 at 8:11 AM, the DON stated if a resident had a g-tube and was not in her bed, the staff did not need to wear a gown when changing the resident's linen. She said when connecting or disconnecting an IV, the staff should have worn a gown because residents with IVs was on EBP and PPE was required. She said the enhanced barrier precautions added an extra barrier of protection and was important to help prevent cross-contamination and infection. She said she already started an in-service about infection control.In an interview on 02/06/2026 at 8:47 AM, ADON B stated he was the infection preventionist of the facility. He said if a staff was changing the linens of a resident with a g-tube, the staff should still wear a gown even though the resident was not inside the room because there could be leaks from the g-tube that could adhere to bed that could have contact with the scrubs of the staff. He said every resident that was on EBP had a sign outside of their rooms to remind the staff that they needed to wear a gown and gloves every time they had contact with the resident. He said EBP was for residents on dialysis, with a catheter, wound, IV, g-tube and anything that required a dressing. He stated most of the residents were elderly and some were immunocompromised. He said EBP was implemented to protect the residents from cross contamination and probable infection. He said the DON already started an in-service about infection control and he would closely monitor the staffs' adherence to the policy of infection control.In an interview on 02/06/2026 at 9:17 AM, the Administrator stated he was not a clinician, but he knew that if there was an EBP sign outside the resident's room, then the staff should wear a gown in addition to the gloves. He said would let the DON take the lead about the issue.3. Record review of Resident #60's Face Sheet, dated 02/06/2026, reflected a [AGE] year-old female who admitted on [DATE]. The resident was diagnosed with hypertension (elevated blood pressure) and diabetes (the body does not use insulin effectively causing the blood sugar level to rise).Record review of Resident #60's Quarterly MDS Assessment, dated 12/02/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 7. The Quarterly MDS Assessment indicated that the resident required assistance with all self-care needs. Record review of Resident #5's Comprehensive Care Plan, dated 02/01/2026, reflected the resident had difficulty breathing related to nasal congestion. An intervention was to monitor for signs of respiratory distress and report to the doctor as needed. During an observation and interview on 02/05/2026 at 8:23 AM, MA G was observed in Resident #60's room. She had on gloves and placed an electronic blood pressure cuff on Resident #60's wrist. After obtaining a blood pressure reading, MA G exited returned to medication cart just outside the resident's door. MA G did not remove her gloves before entering the vital signs in the laptop on the medication cart. She removed her gloves, used hand sanitizer, and applied clean gloves prior to sanitizing the blood pressure cuff. MA G removed the gloves and used hand sanitizer. MG A stated she should have removed her gloves before touching the laptop to prevent cross contamination and infection. During an interview on 02/05/2026 at 12:18 PM, ADON B stated MA G should not have left with room with gloves on to prevent contamination. He stated that was part of infection control. He stated staff should also not wear gloves from one room to another. He stated once you are finished, remove your gloves and sanitize the hands. He stated the facility had already provided in-service training to staff on hand washing and donning (putting on) and doffing (taking off) gloves. Record review of the facility's policy Infection Control IPCP Standard and Transmission-Based Precautions revised March 2024 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provideopportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident . c. Examples of high-contact resident care activities requiring gown and glove use for EnhancedBarrier Precautions include . v. Changing linens . vii. Device care or use: central vascular line.Record review of the facility's Infection Control policy, revised March 2024, reflected It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions.b. Personal protective equipment.Don PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's for one of one kitchen reviewed for food and nutrition services. The Dietary Manager failed to wear a beard cover in the kitchen while prepared food was present.The facility failed to ensure dietary staff properly labeled and dated stored food received by vendors.The facility failed to ensure stored food in the freezer was concealed from air-borne contaminants.The facility failed to ensure the tea dispenser was covered. The facility failed to ensure the following were thoroughly cleaned and/or sanitized: ice machine and ice scoop in the kitchen, sugar and flour bins, the serving table, serving table had a sanitizer container (red bucket) for sanitization, the dining room ice dispenser, the dining room counter and sink, and the ice chest on the 300-hall.These failures could place residents at risk of exposure to food contamination and illness. Findings included:Observations on 02/04/26 from 9:06 a.m. to 9:12 a.m. in the facility's only kitchen revealed: The Dietary Manager was observed walking around the kitchen area, near prepared and uncovered food with no beard cover. The DM3's beard was approximately a quarter of an inch in length. One freezer bag of frozen chicken nuggets, located in the freezer, was not labeled with the date stored. Two large white storage bins, located in the dry storage area, containing sugar and flour had brownish stains along the outside and inside of the bins. Packages of hamburger buns and croissants, located in the walk-in cooler, were not labeled with the date stored. Four packages of deli meat, located in the walk-in cooler, were not dated with the month, day, and year it was stored upon receipt from the vendor. Two packages of grilled mixed vegetables, located in the freezer, were not dated with the month, day, and year it was stored upon receipt from the vendor. Two packages of sliced zucchini squash, located in the freezer, were not dated with the month, day, and year it was stored upon receipt from the vendor. One large package of tater tots, located in the freezer, were not dated with the month, day, and year it was stored upon receipt from the vendor. The package also had a 1 inch in diameter sized hole, exposing the food to air-borne contaminants. Thirteen large pitchers of tea and juices, located in the walk-in cooler, were uncovered and exposed to air-borne contaminants. One large tea dispenser, located in the kitchen area, had tea in it, but it did not have a lid placed on the top of the dispenser to avoid air-borne contaminants. An ice machine, located in the kitchen had stains along the inside panel wall of the ice machine. The ice machine scoop holder, hanging on the wall, had brown dirt particles on the inside bottom of the holder. Three large steam trays on the serving table had brownish stains along the walls of the units and water inside of them had light brownish particles floating in it. The ice dispenser in the dining area had thick white substances all over the outside of the unit and the tray area had thick black dirt along the bottom of it. The bottom legs had a thick rust-like substance. The dining room counter and sink had brownish stains and white substances on and around the faucet area. During an interview and observation on 02/04/26 at 09:05 a.m., the Dietary Manager was observed walking around the kitchen area, while food was prepared and he did not have a beard cover. The DM3 had a beard that was at least a quarter of an inch in length. The DM3 stated no food was being prepared in the kitchen area; however, there were at least two large pans of cake near him, a large tea dispenser uncovered, and large pitchers of juices within his vicinity. The DM3 was shown the large tea dispenser, filled with tea, uncovered. He stated his team prepared the tea at about 7:00 a.m He stated it was his responsibility to ensure the items had the stored date when received from the venders. He states the bag of tater tots needed to be properly sealed to avoid contamination. The DM3 stated the storage bins and the serving table were cleaned weekly. He stated it was his responsibility to ensure they were cleaned. The DM3 was shown the inside of the ice scoop holder and the insides of the ice machine and he stated the items were cleaned once a week. He stated he and his team were responsible for cleaning the drink counter area and Housekeeping was responsible for cleaning the floor. He stated not addressing these areas could result in food contamination.During an observation on 02/04/26 at 10:50 a.m., an ice chest, located on the 300-hall, had light brownish stains all over the lower portion of the chest, which contained ice. During an interview and observation on 02/04/26 at 11:01 a.m., the DM3 was shown the inside of the ice chest located on the 300-hall. He stated he and his team sprayed out the ice chest daily before filling it with ice. He stated ice could not have germs, so the dirty ice chest did not have a negative impact on residents. The DM3 took the ice chest and brought it back clean and the stains were gone. During an interview and observation on 02/05/26 at 11:30 a.m., the [NAME] was plating residents' lunch at the serving table. There was no sanitizer container (red bucket) observed to clean and sanitize the table. The DM stated the red bucket with sanitizing fluid to keep the table clean and sanitized while serving the resident's food. During an interview on 02/06/26 at 11:36 a.m., the Administrator was shown pictures of the concerns observed by the surveyor in the kitchen and dining area. He stated they should be labeling and dating the food properly, following kitchen sanitation, and keeping food safe. He stated the concerns observed could cause health complications to the residents. He stated this was the resident's home and it could also cause an infection.Record Review of the Facility's policy titled Dietary Services, dated 10/2007, revealed, It is the policy of this facility that the food services shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Ice, which is used in connection with food and drinks, shall be from a sanitary source and shall be handled and dispersed in a sanitary manner. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for two direct care staff (RN D and MA G) and one (Crash Cart) of four carts reviewed for other environmental conditions.1. The facility failed to ensure that the drawers of the crash cart was not easily opened when not in use on 02/05/2026.2. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the treatment cart at the wander unit unattended on 02/05/2026. 3. The facility failed to ensure MA G did not leave a container of germicidal wipes on top of her cart unattended on 02/05/2026.These failures could prevent the residents from having an environment that was safe for the residents, staff, and public. Findings include:1. An observation on 02/05/2026 at 8:15 AM revealed a crash cart was parked at the entry of hall 100. The drawers of the crash cart was not secured and could easily be opened. The first drawer had a [NAME] screwdriver and the other drawers had tubing in them.In an interview on 02/05/2026 at 8:17 AM, the Administrator stated that what he knew was the crash cart should not be locked.In an interview on 02/05/2026 at 8:18 AM, the DON said that they do not lock the crash cart.In an interview on 02/05/2026 at 2:16 PM, ADON A stated the crash cart should be easily accessed by the staff in cases of emergency but at the same time secured enough that when not in use, the residents would not be able to open the drawers. She said the residents might be able to get some equipment or supplies from the crash cart and harm themselves and others. She said resident might get hold of the [NAME] screwdriver and use it to hurt himself or others or might be able to get some tubing and put it around his neck. She said the crash cart had a flap at the side to secure the drawers. The staff just needed to flip the flap in order to use the crash cart.2. During an observation on 02/05/2026 at 8:33 a.m., a container of germicidal wipes (substance that destroys germs and microorganism) was on top of an unattended cart parked in a hallway inside the memory care unit. It was observed that several residents were walking down the hallway.During an interview on 02/05/2026 at 11:45 a.m., RN D stated that she went inside one of the resident's rooms to assess a wound. She said she should have placed the germicidal wipes inside the cart before leaving the cart because there were confused residents and they might use them to clean their faces and eyes that could result in irritations. She said she would put the germicidal wipes inside the cart.3. An observation on 02/05/2026 at 10:13 AM revealed a container of germicidal wipes was on top of a cart parked in a hallway. The cart was facing the hallway and was unattended. It was observed that several residents were walking down the hallway.During an observation and interview on 02/05/2026 at 10:15 AM, MA G stated she walked away from her cart because the DON called her. She said they use the germicidal wipes to clean the cart. She said she should have secured the germicidal wipes before leaving the cart because residents might use it improperly or even eat it. She said the container of germicidal wipes should be locked inside the cart. she took the container of germicidal wipes and put it on the last drawer of the cart.In an interview on 02/06/2026 at 8:11 AM, the DON stated the germicidal wipes should be locked inside the carts and not left on top of the carts unattended. She said it should be secured inside the carts so that the residents would not be able to access the wipes that had chemicals on them. She said she was not sure what chemical was on the wipes but considering the wipes were used to disinfect, then the wipes could be harmful to the residents. She said confused resident might get hold of the wipes and wipe their face and body that could result to irritations. She said the expectation was for the staff to be mindful and never leave the germicidal wipes on top of the carts unattended. She said on the same token, the crash cart should be secured that resident would not be able to open the drawers for safety. She said they already took the screwdriver and made sure the drawers were secured. She said she already started an in-service about not leaving the germicidal wipes on top of the carts unattended and making sure the crash cart was secured.In an interview on 02/06/2026 at 8:47 AM, ADON B stated the germicidal wipes should be stored inside the cart for safety reasons. He said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin. He said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. He said the DON already started an in-service about not leaving the germicidal wipes on top of the carts.In an interview on 02/06/2026 at 9:17 AM, the Administrator stated the germicidal wipes should be placed somewhere not accessible to the residents. He said if the wipes had chemicals in them that could be harmful when consumed or had contact with the eyes. He said, as for the crash cart, they would make sure the residents would not be able to open the drawers. He said the DON already started an in-service about germicidal wipes and the crash cart.Record review of the facility's policy Medication Access and Storage/Drug Destruction Policy/Procedure - Nursing Clinical revised July 2023 reflected Potentially harmful substances (e.g., urine test reagent tablets, household poisons,cleaning supplies, disinfectants) are clearly identified and stored in a locked areaseparately from medications.Record review of Safety Data Sheet (SDS) on 01/21/2026 reflected Safety Data Sheet Medline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity - oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children.Policy for securing the crash cart requested on 02/05/2026 at 9:13 AM via email to the Administrator.In an interview on 02/06/2026 at 12:45 PM, the Administrator stated the facility did not have a policy for securing the crash cart.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for ten (Resident #10, #18, #21, #31, #53, #73, #98, #102, #103, and #68) of twenty-eight residents reviewed for medication storage. 1. The facility failed to ensure Resident #10 did not have an anti-fungal cream on top of her bedside table on 02/04/2026.2. The facility failed to ensure Resident #102's zinc oxide was not left inside the resident's room on 02/04/2026.3. The facility failed to ensure Resident #103's zinc oxide was not left inside the resident's room on 02/04/2026.4. The facility failed to ensure Resident #21 did not have containers of zinc oxide on the resident's shelf on 02/04/2026.5. The facility failed to ensure Resident #73's zinc oxide was not left inside the resident's room on 02/04/2026.6. The facility failed to ensure Resident #18 did not have a bottle of nasal spray on top of her overbed table on 02/04/2026.7. The facility failed to ensure Resident #31's insulin pen was not left on top of the cart unattended on 02/04/2026.8. The facility failed to ensure RN D did not leave a container of wound cleanser and skin barrier on top of her cart unattended on 02/05/2026,9. The facility failed to ensure Resident #103's liquid Lorazepam, with instruction Refrigerate, was not stored inside the cart's lock box on 02/06/2026. 10. The facility failed to ensure Resident #53's insulin had date when it was opened to determine if it was past its shelf life on 02/06/2026.11. The facility failed to ensure Resident #98's insulin had a date when it was opened to determine if it was past its shelf life on 02/06/2026.12. The facility failed to ensure Resident #103's insulin had a date when it was opened to determine if it was past its shelf life on 02/06/2026. 13. The facility failed to ensure a bottle of over-the-counter peroxide was not in Resident #68's room on 02/04/2026.These failures could place residents at risk of not receiving the full benefit of the medications, misuse of medications that could lead to adverse reactions or overdose.Findings include: 1. Record review of Resident #10's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and diabetes mellitus (high blood sugar).Record review of Resident #10's Comprehensive MDS Assessment, dated 12/19/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had dementia and diabetes mellitus. Record review of Resident #10's Comprehensive Care Plan, dated 12/20/2025, reflected the resident had an impaired cognitive function and thought process, and diabetes mellitus and the interventions for both were to administer medications as ordered.Record review of Resident #10's Physician Order on 02/04/2026 reflected that the resident did not have an order for anti-fungi cream.An observation on 02/04/2026 at 9:20 AM, revealed Resident #10 was not inside her room. It was observed that a tube of antifungal cream was on top of her side table.2. Record review of Resident #102's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and muscle weakness.Record review of Resident #102's Comprehensive MDS Assessment, dated 12/02/2025, reflected the resident had severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident was frequently incontinent for bladder and bowel. Record review of Resident #102's Comprehensive Care Plan, dated 12/01/2025, reflected the resident had an impaired cognitive function and thought process and one of the interventions was to administer dementia medications. The plan also indicated that the resident had bladder and bowel incontinence and one of the goals was the resident would be free from skin breakdown.During an observation and interview on 02/04/2026 at 9:06 AM, revealed Resident #102 was in her bed, awake. It was observed that there were a tube and a sachet of zinc oxide (medicated cream used to prevent skin irritation) on top of her side table.During an observation and interview on 02/04/2026 at 9:23 AM, LVN F stated zinc oxide was a form of medication applied topically to prevent any skin issues. He said it should not be inside the room because confused residents might consume it. He said the cream should be stored in the cart and just put some in a cup for use. He said the cup should be disposed after use. He said the anti-fungal cream should not be also inside the room of the resident for the same reason. He went inside Residents #10 and #102's room and took the zinc oxide and the anti-fungal. He said he did not know why the medications were inside the rooms.3. Record review of Resident #103's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obesity and delusional disorder.Record review of Resident #103's Comprehensive MDS Assessment, dated 01/06/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel.Record review of Resident #103's Comprehensive Care Plan, dated 01/13/2026, reflected the resident had an impaired cognitive function and thought process and one of the interventions was to administer medication for delusional disorder. The plan also indicated that the resident had bladder and bowel incontinence and one of the goals was the resident would be free from skin breakdown.During an observation and interview on 02/04/2026 at 11:26 AM, revealed Resident #103 was in his bed, awake. It was observed that two cups with white cream were on top of the resident's side table. The resident said the staff used them whenever they changed his brief. He said he did not know how long the cups of cream were in his side table and who left them there. He said the cream looked like toothpaste.During an observation and interview on 02/04/2026 at 11:38 AM, CNA J stated she saw the cups of white cream when she did her morning rounds but it did not occur to her that the cream should not be there. She said she should have thrown it away because residents could eat them. She said the white cream would be barrier creams and most probably it would be the nurse that left them. She picked up the cups of cream and threw them away. She then went to LVN F.In an interview on 02/05/2026 at 11:40 AM, LVN F stated he did not leave the cups of barrier creams inside Resident #103's room. He said it might be the night nurse.4. Record review of Resident #21's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness.Record review of Resident #21's Comprehensive MDS Assessment, dated 11/07/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #21's Comprehensive Care Plan, dated 12/04/2025, reflected the resident had bladder and bowel incontinence and one of the goal was the resident would be free from skin breakdown.During an observation and interview on 02/04/2026 at 9:43 AM, revealed Resident #21 was not inside her room. It was observed that two containers of zinc oxide were on the resident's shelf. 5. Record review of Resident #73's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and muscle weakness.Record review of Resident #73's Comprehensive MDS Assessment, dated 01/08/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had dementia and muscle weakness. Record review of Resident #73's Comprehensive Care Plan, dated 07/30/2025, reflected the resident was at risk for impaired cognitive function and thought process and one of the interventions was to provide with necessary cues. The plan also indicated that the resident was dependent on staff related to disease process and one of the interventions was to assist with ADLs.During an observation and interview on 02/04/2026 at 9:43 AM, revealed Resident #73 was in his bed, awake. It was observed that a cup of white cream was on top of the resident overbed table. When asked what the cream was for, the resident did not reply.In an interview on 02/04/2026 at 9:52 AM, CNA L stated the cream in the cup was a skin barrier. She said it should not be left inside the rooms of the residents, especially on the table where they eat, because the resident might mistake it as sauce or dips and eat them. She said she did not know who left the cup with barrier cream on the resident's overbed table. She went inside Resident #73's room and said she would throw it away. She said she would also ask the nurse where to put Resident #21's skin barrier.6. Record review of Resident #18's Face Sheet, dated 02/04/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (blockage in the blood vessels of the brain) and cognitive communication deficit (impaired ability to communicate).Record review of Resident #18's Comprehensive MDS Assessment, dated 12/02/2025, reflected the resident had severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident had cerebral infarction and cognitive communication deficit.Record review of Resident #18's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had history of cerebral vascular accident (blood supply to the brain was interrupted) and one of the interventions was to administer medications as ordered.Record review of Resident #18's Physician Order on 02/04/2026 reflected that the resident did not have an order for a nasal spray.An observation on 02/04/2026 at 9:37 AM, revealed Resident #18 was not inside the room. It was observed that a container of nasal spray was on top of the resident's overbed table.7. Record review of Resident #31's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus.Record review of Resident #31's Comprehensive MDS Assessment, dated 12/30/2026, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #31's Comprehensive Care Plan, dated 01/28/2026, reflected had diabetes and one of the interventions was to administer medications as ordered. Record review of Resident #31's Physician Order, dated 10/22/2025, reflected Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 43 unit subcutaneously (administer under the skin) two times a day for DM.An observation on 02/04/2026 at 9:35 AM, revealed an insulin pen was on top of a cart unattended. The insulin pen was under a laptop but could still be seen from the hallway.During an observation and interview on 02/04/2026 at 9:40 AM, RN C stated she answered a call light that was why she stepped away from her cart. She said she should have secured the insulin pen before answering a call light because a resident might get hold of it and use. She said the resident might be allergic to it or misuse the insulin pen. She took the insulin pen and put it inside her cart. She said medications should be inside the residents' room for their safety. She said residents might misuse the medication or they might be overdosed if they were the one giving the medications to themselves. She went inside Resident #18's room and saw the nasal spray. She said she did not notice the nasal spray when she checked on the resident. She said she would wait for the resident to come back to her room so she could talk to her and explain why there should be no medications inside the room. She logged on to her computer and said there was no for the nasal spray. She said she would request for an order as soon as she assessed that the resident needed it. She said if the nasal spray would remain then the nasal should be in the cart and the staff should be one administering the nasal spray. 8. Observation on 02/05/2026 at 8:33 AM, revealed a bottle of wound cleanser and barrier cream was on top of an unattended cart parked in the hallway of the wander unit. It was observed that several residents were walking down the hallway.In an interview on 02/05/2026 at 11:45 AM, RN D stated the resident should have no access to the wound cleanser and barriers creams because the residents might take them and consume them. She said she should have placed the wound cleanser and the barrier cream inside the cart before leaving her cart. She said she would put the wound cleanser and barrier cream inside the cart.In an interview on 02/06/2026 at 8:11 AM, the DON stated zinc oxide, anti-fungal cream and nasal spray should not be left inside the residents' rooms to prevent accidental ingestion. She said if the medications were left at bedside, there was a possibility that other residents might get hold of the medications and consume them. She said the insulin pen, wound cleanser, and barrier creams should not be left on top of the carts unattended for the same reason. She said the expectations were for the staff to always scan the residents' rooms to make sure there were no medications inside the residents' room, they were not leaving zinc oxide inside the room, and they were not leaving any medications on top of the carts. She said she already started an in-service about no medications inside the rooms of the residents and not leaving any medication on top of the cart unattended. She said they would also educate the family members about the medications that they were bringing to the facilityIn an interview on 02/06/2026 at 8:47 AM, ADON B stated zinc oxide was a form of medicated cream and should not be left inside the resident's room because confused resident might consume it and might cause allergic or adverse reactions. He said an anti-fungal cream should not be also inside the resident's room for the same reason. He said wound cleansers and skin barriers should not be left on top of the cart, specially inside the wander unit, because residents might get and hide them, and them use them, eat, the, or drink them. He said the DON started an in-service about the issue.In an interview on 02/06/2026 at 8:54 AM, ADON A stated the insulin pen should have been secured first before the staff answered the call light. She said resident might get hold of it and misuse it. She said there should be no nasal spray inside the resident's room because the staff should be the one administering it. She said the resident might be using it every hour and nobody would know. She said they would also educate the family that if they were bringing any medication, they should give it to the staff first and the staff would be the one administering them.In an interview on 02/06/2026 at 9:17 AM, the Administrator stated the expectation was for the staff to be mindful not to leave zinc oxides inside the residents' rooms or on top of the carts to prevent accidental consumption. He said he was not a clinician and would let the DON take a lead about the issue.9. Record review of Resident #103's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder (intense or excessive fear or worry).Record review of Resident #103's Comprehensive MDS Assessment, dated 01/06/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had anxiety and was taking anti-anxiety medication.Record review of Resident #103's Comprehensive Care Plan, dated 01/13/2026, reflected the resident had anxiety and one of the interventions was to give anti-anxiety medications.Record review of Resident #103's Physician Order, dated 01/05/2026, reflected Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Anxiety Agitation AND Give 0.5 ml by mouth every 2 hours as needed for Anxiety AND Give 0.75 ml by mouth every 2 hours as needed for Anxiety AND Give 1 ml by mouth every 2 hours as needed for Anxiety.10. Record review of Resident #53's Face Sheet, dated 02/06/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar).Record review of Resident #53's Comprehensive MDS Assessment, dated 01/28/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin.Record review of Resident #53's Comprehensive Care Plan, dated 11/27/2025, reflected the resident had diabetes mellitus and one of the interventions was to give medications as ordered.Record review of Resident #53's Physician's Order, dated 01/22/2026, reflected Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 52 unit subcutaneously at bedtime for Hyperglycemia (too much sugar in the blood).Record review of Resident #53's Physician's Order, dated 01/22/2026, reflected (Insulin Glargine) Inject 52 unit subcutaneously one time a day for DM related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE.11. Record review of Resident #98's Face Sheet, dated 02/06/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus.Record review of Resident #98's Comprehensive MDS Assessment, dated 12/31/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin.Record review of Resident #98's Comprehensive Care Plan, dated 11/22/2025, reflected the resident had diabetes mellitus and one of the interventions was to give medications as ordered.Record review of Resident #98's Physician's Order, dated 03/03/2025, reflected Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals for DM Hold for BS less than 150.12. Record review of Resident #103's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus.Record review of Resident #103's Comprehensive MDS Assessment, dated 01/06/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin.Record review of Resident #103's Comprehensive Care Plan, dated 01/13/2026, reflected the resident had diabetes mellitus and one of the interventions was to give medications as ordered.Record review of Resident #103's Physician's Order, dated 01/01/2026, reflected Humulin R 100 UNIT/ML Solution Inject as per sliding scale: if 151 - 200 = 2; 201 -250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401+ = 12 notify hospice, subcutaneously four times a day for DM related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA.An observation on 02/06/2026 at 10:52 AM revealed that there were three insulins inside the cart that did not have a date to when they were opened. It was also observed that a liquid lorazepam was stored inside the locked box of the cart.During an observation and interview on 02/06/2026 at 11:02 AM, RN D looked at the boxes of the insulins for the dates and said there were no dates. She took the bottles one by one and said there were no dates also on the bottles of the insulins. She said the insulins should have dates on when they were opened because most of the insulins had a shelf life twenty-eight day. She said after twenty-eight days, the insulin should be discarded because they become less effective. She said since there were no dates, the insulins would be presumed less effective. She said Lorazepam's should be stored inside the refrigerator and not inside the cart. She said they would only get the lorazepam when they are about to use it. She said the Lorazepam was already in the cart when counted the narcotics at around 6:00 AM. She said the lorazepam was a PRN and did not know when was the last time it was used. She read the instruction at the back of the bottle of the lorazepam and said the instruction said to refrigerate. She segregated the insulins and said would get new ones. She said she would also put the lorazepam inside the refrigerator.During an observation and interview on 02/06/2026 at 11:06 AM, ADON A stated the insulins should have a date when they were opened because insulins lose its effectiveness once exposed to air rendering them ineffective. She said, once opened, insulins were usually used only for twenty-eight days. She said since the insulins were not dated, then the staff would not know if they needed to dispose them or not. She said they would also audit the cart to check if the insulins had opened date on them. She said the liquid lorazepam should be stored inside the refrigerator inside the medication room and not inside the locked box of the carts. She said the lorazepam might lose its effectiveness as well. She said they include in their in-service about the insulins and the lorazepam.In an interview on 02/06/2026 at 11:15 AM, the DON stated she was made aware about the undated insulin and the lorazepam inside the locked cart. She said insulins should be dated to know when to dispose them. She said the liquid lorazepam should not be stored in the locked box and should be in the refrigerator. She said the staff should only get the lorazepam when they administer it and then put it back after administering it. She said the effectiveness of the lorazepam would be compromised. She said the expectation was that the staff would put dates on the insulin and store the lorazepam inside the refrigerator. She said she would add about the dating the insulins and storing lorazepam in their inservice.In an interview on 02/06/2026 at 12:45 PM, the Administrator stated he was not a clinician and would let the DON take the lead about the issues about the medications. 13. Record review of Resident #68's face sheet, dated 02/04/2026, reflected an [AGE] year-old female who admitted to the facility on [DATE]. She was diagnosed with dementia. Record review of Resident #68's Quarterly MDS Assessment, dated 11/03/2025, indicated severe cognitive impairment with a BIMS score of 7. She required assistance with showers. Record review of Resident #68's Comprehensive Care Plan, dated 02/03/2026, reflected she was at risk for impaired cognitive function or impaired thought processes related to dementia. An intervention was to provide supervision/assistance with all decision making, with assistance from family. Record Review of Resident #68's Physician's Orders revealed there was no order to use peroxide. During an observation and interview on 02/04/2026 at 10:38 AM, Resident #68 was lying on her bed. There was a bottle of peroxide on her bedside table. Resident #68 stated it had been there a while but she did not know why. She stated she did not remember if she had ever used it. During an observation and interview on 02/04/2026 at 10:53 AM, MDS Nurse H was sitting at a table in the hall. She stated she was unsure why resident had peroxide on her bedside table. She picked up the bottom of peroxide and stated she would put it in the medication cart. She stated she if had seen it earlier, she would have removed it. She stated the resident did not have an order for it. She stated families bring in items and do not think to ask staff. She stated they would need to educate the family. She stated the resident was confused. She stated they do not want anything at the bedside that could be harmful. During an interview on 02/05/2026 at 12:18 PM, ADON B stated peroxide should not be left in Resident #68's room or any other residents' rooms. He stated it was a medication. He stated aides and nurse should be observant when rounding to ensure items like that were not left in a resident's room. He stated the family would be notified the resident could not have peroxide in her room. He stated staff members were expected to monitor to ensure family members had not brought something residents should not have in their room. He stated a confused resident might think it's juice in a bottle and drink it. During an interview on 02/05/2026 at 12:50 PM, the DON stated Resident #68 should not have peroxide in her room. She stated staff removed it and called the family. She stated they left a message but had not received a return call. She stated they will be reminded about what not to bring. She stated staff was educated that if they saw something that should not be in a resident's room to remove it and tell the nurse. She stated some of their residents had dementia and may accidentally swallow it.Record review of the facility's policy, Medication Access and Storage/Drug Destruction Policy/Procedure - Nursing Clinical revised July 2023 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . PROCEDURES . Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications . Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring.Record review of the facility's policy, Medication Labeling and Storage 2001 MED-PASS, Inc. revised February 2023 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls . Policy Interpretation and Implementation . Medication Storage . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Record review of the facility's policy, Physician Orders Policy/Procedure - Nursing Clinical revised July 2022 reflected POLICY: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs . PROCEDURES: 1. No drugs or biologicals shall be administered except upon the order of a person lawfullyauthorized to prescribe for and treat human illnesses.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #51) of six residents reviewed for significant medication errors.The facility failed to ensure Resident #51's propranolol (blood pressure medication) was administered as ordered on 02/05/2026.This failure could place residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician. Findings included:Review of Resident #51's Face sheet, dated 02/05/2026, reflected a [AGE] year-old female who admitted on [DATE]. She was diagnosed with hypertension (elevated blood pressure). Resident #51 was on hospice care services. Record review of Resident #51's MDS Assessment, dated 01/06/2026, reflected severe cognitive impairment with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had hypertension.Record review of Resident #51's Comprehensive Care Plan, dated 01/19/2026, reflected the resident had hypertension and one of the interventions was to administer anti-hypertensive medication as ordered. Review of Resident #51's Physician's Order, dated 12/31/2025, reflected to administer Propranolol 20 mg by mouth two times a day for hypertension. Review of Resident #51's medication administration record revealed she did not receive the morning dose of Propranolol on 02/05/2026.During an observation and interview on 02/05/2026 at 8:37 AM, MA G stated she did not see Resident #51's Propranolol in the medication cart. She stated she would check the emergency kit. MA G returned to her medication cart and stated the medication was not in the emergency kit. MA G stated she spoke with ADON A who was going to call the hospice nurse about the medication. During an interview on 02/05/2026 at 12:38 PM, ADON A stated she called hospice and was told the medication would be delivered that afternoon. She stated staff should order medication 3 or 4 days prior to running out of medication. She stated it was important to ensure medications were re-ordered on time so residents did not miss a dose.During an interview on 02/05/2026 at 12:50 PM, the DON stated staff should reorder medication before the last pill was given. She stated she would follow up with staff regarding the medication. She stated there had not been any issues with residents running out of a medication. She stated it was important to ensure residents received medication as ordered. Record review of the facility's policy Medication Administration, revised 08/31/2023, reflected It is the policy of this facility that medication shall be administered as prescribed by the attending physician.Medications are reordered when supplies are needed or supply has been exhausted. Medications will be available using the resident's supply in cart of if needed, through the emergency medication supply in the facility.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Residents #16, #26, #59, #85, #107, and #72) of sixteen residents reviewed for respiratory care.1. The facility failed to ensure Resident #16 's nasal cannula was stored properly when not in use on 02/04/2026.2. The facility failed to ensure Resident #26's breathing mask was properly stored when not in use on 02/04/2026. 3. The facility failed to ensure Resident #59's breathing mask was properly stored when not in use on 02/04/2026. 4. The facility failed to ensure Resident #85 's nasal cannula was stored properly when not in use on 02/04/2026.5. The facility failed to ensure Resident #107's nasal cannula was stored properly when not in use on 02/04/2026.6. The facility failed to ensure Resident #72's breathing mask was stored properly when not in use on 02/04/2026.These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #16's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive lung disease and respiratory failure (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #16's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 01/14/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #16's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had oxygen therapy and one of the interventions was O2 at 2 - 5 l/min via nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs).Record review of Resident #16's Physician Order, dated 01/07/2026, reflected Apply oxygen via NC at 3-5 LPM continuous to keep saturation at or above 90% every shift.During an observation and interview on 02/04/2026 at 9:16 AM, revealed Resident #16 was in her bed, awake. It was also observed that a nasal cannula was hanging on the resident's wheelchair and was not bagged. it was also observed that there was no bag at the back of the wheelchair. The resident said she would use the nasal cannula on her wheelchair every time she would go out of her room. She said a staff would be assisting her with her transfer to her wheelchair. She said the staff assisting would be the one replacing her oxygen with the one on her wheelchair and also would take it off when she transferred to her bed. She said she did not see a bag at the back of her wheelchair.2. Record review of Resident #26's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #26's Comprehensive MDS Assessment, dated 01/23/2026, reflected the resident had moderate impairment (resident may need additional support and monitoring) with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #26's Comprehensive Care Plan, dated 02/04/2026, reflected the resident required respiratory therapy as needed and one of the interventions was to administer nebulization (method of delivering medication by converting liquid medication into an inhalable mist) as ordered.Record review of Resident #26's Physician Order, dated 11/14/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer (machine used for breathing treatment).An observation on 02/04/2026 at 9:09 AM, revealed Resident #26 was not inside the room. It was observed that a breathing mask (used to receive medications by breathing in mist through nose and mouth) was on top of the resident's shelf. The breathing mask was not bagged.3. Record review of Resident #59's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #59's Comprehensive MDS Assessment, dated 11/03/2025, reflected the resident had severe impairment (resident required significant assistance and support in daily life) with a BIMS score of 01. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #59's Comprehensive Care Plan, dated 02/03/2026, reflected the resident had altered respiratory status and one of the interventions was administer nebulization as ordered.Record review of Resident #59's Physician Order, dated 14/17/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally three times a day for SOB/ wheezing.An observation on 02/04/2026 at 9:11 AM, revealed Resident #59 was not inside the room. It was observed that a breathing mask was on the resident's chair. The breathing mask was not bagged.4. Record review of Resident #85's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with asthma (lung disorder caused by narrowing of the airways). Record review of Resident #85's Comprehensive MDS Assessment, dated 11/26/2025, reflected the resident had severe impairment with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had asthma. Record review of Resident #85's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had oxygen therapy and one of the interventions was O2 at 2 - 4 l/min via nasal cannula.Record review of Resident #85's Physician Order, dated 01/20/2026, reflected Oxygen 2-4 LPM via nasal cannula to keep SpO2 (percentage of the blood that had oxygen) greater than 90% as needed.An observation on 02/04/2026 at 9:13 AM, revealed that Resident #85 was not inside his room. It was observed that a nasal cannula was attached to an oxygen concentrator, the nasal cannula was on the floor and was not bagged.5. Record review of Resident #107's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and respiratory failure.Record review of Resident #107's Comprehensive MDS Assessment, dated 01/16/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease and respiratory failure. Record review of Resident #107's Comprehensive Care Plan, dated 01/18/2026, reflected the resident had COPD and one of the interventions was to give oxygen therapy as ordered. Record review of Resident #107's Physician Order, dated 06/14/2025, reflected Oxygen 2-4 LPM via nasal cannula to keep SpO2 greater than 90% as needed.During an observation and interview on 02/04/2026 at 9:15 AM, revealed Resident #107 was in her bed, awake. It was observed that an oxygen concentrator was at the bedside with a nasal cannula attached to it. The prongs of the nasal cannula was on the floor. She said she would only use it when she needed it. She said nobody checked on her nasal cannula.6. Record review of Resident #72's face sheet, dated 02/04/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with COPD (lung condition that makes it difficult to breathe).Record review of Resident #72's Quarterly MDS Assessment, dated 11/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident received oxygen therapy. Record review of Resident #72's Comprehensive Care Plan, dated 12/29/2025, reflected the resident had COPD. An intervention was to provide breathing treatments as ordered and monitor for effectiveness. Record review of Resident #72's Physician's Order, dated 11/10/2025, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally two times a day for shortness of breath.During an observation and interview on 02/04/2026 at 9:21 AM, Resident #72 was sitting in a wheelchair in her room. Her nebulizer mask was on the nightstand unbagged. Resident #27 stated she used it every day but had not noticed it in a bag. During an observation and interview on 02/04/2026 at 9:23 AM, LVN F stated the nasal cannula and the breathing masks should be in a bag if the resident was not using them to prevent any respiratory infections. He went inside Resident #26's room and saw the breathing mask on the shelf. He said his breathing treatment was on an as needed basis so the breathing mask should be bagged. He said he did not notice Resident #26's breathing mask on the resident's shelf. He took the breathing mask and threw it away and said he will just get a new one when Resident #26 would need the breathing treatment. He then went to Resident #59's room and saw the breathing mask on the chair. He said he did not know why the breathing mask was on the chair. He took the breathing mask and threw it away and said he would get a new one because the staff would administer Resident #59's breathing treatment three times a week. He said Residents #85 and Resident #107's oxygen was as needed so their nasal cannula should be bagged. He went to Resident #16's room and saw HK I putting Resident #16's nasal cannula in a bag. He said, maybe she was going around to check if the nasal cannula and the breathing masks was bagged. He said before they were placed inside the bags, they were already dirty and he did not know how long they had been in contact with the shelf, chair, wheelchair, and the floor. He said since he was the charge nurse, then he was responsible in making sure that breathing masks and the nasal cannula was bagged.In an interview on 02/04/2026 at 9:27 AM, HK I stated she checked the rooms of the residents in hall 400 and saw some nasal cannulas that was not bagged. She said she put them in the bags because they should not be exposed. She then said she would tell the nurse to change the nasal cannula that she saw not bagged because they were already dirty. She said the breathing masks and the nasal cannula had already been in contact with something dirty and might cause other respiratory issues.During an observation and interview on 02/04/2026 at 11:02 AM, MDS Nurse H was sitting at a table on Resident #72's hall with her laptop open. She entered Resident #72's room with the surveyor. The nebulizer mask was on the nightstand unbagged. MDS Nurse H stated the nebulizer mask should have been bagged. She stated she would get a new mask and place it in a bag. She stated the Resident #27 had breathing treatments twice a day. She stated it was important to keep the nebulizer mask bagged for infection control purposes. During an interview on 02/05/2026 at 12:18 PM, ADON B stated Resident #72's nebulizer mask should have been bagged when not in use for infection control. He stated the expectation was for all oxygen tubing and nebulizer masks to be bagged when the resident was not using them. During an interview on 02/05/2026 at 12:50 PM, the DON stated Resident #72's nebulizer mask should have been in a bag. She stated when rounding, she reminded residents to call before taking off a mask or oxygen. She stated if a nurse puts on a nebulizer mask for a breathing treatment, the nurse should go back and place the mask in a bag. She stated aides and nurses should notice when rounding if respiratory was bagged. She stated she had provided education to staff. If it's not in a bag, get new tubing or a breathing mask, and place it in a bag. She stated staff also educate residents, when appropriate, to tell staff before removing respiratory items. She stated it was important for infection control. In an interview on 02/06/2026 at 8:11 AM, the DON stated the nasal cannula and the breathing mask should be bagged when not in use to primarily prevent cross contamination and development of infection. She said she had been preaching about this issue and there was still unbagged nasal cannulas and breathing masks observed. She said the expectation was for the staff to scan the rooms of the residents to check the nasal cannulas and the breathing masks. If the order was as needed then the nasal cannula and the breathing masks should be bagged or the staff disconnect them and just get a new one when needed. She said she already started an education pertaining to the issue.In an interview on 02/06/2026 at 8:47 AM, ADON B stated the breathing masks and the nasal cannulas should be stored properly inside a plastic bag if the residents were not using them to prevent cross contamination and respiratory infections. He said the staff was responsible in monitoring if the breathing mask and the nasal cannula was bagged. He said the expectation was for the staff to be mindful and bag the breathing masks and the nasal cannula. He said if the order was PRN, they should be bagged until the residents needed to use them. If the order for the breathing treatment was to administer daily, then the staff should bag them after the treatment was done. If the resident had oxygen on the wheelchair, then the nasal cannula should be bagged. He said the DON already started an in-service about bagging the nasal cannulas and the breathing masks.In an interview on 02/06/2026 at 9:17 AM, the Administrator stated they were vigilant in reminding the staff to bag the respiratory paraphernalia that the residents were using. He said the nasal cannulas and the breathing masks should be inside a plastic bag when the resident was not using them to prevent respiratory infections. He said the expectation was for the staff to be mindful that when they do their rounds, they should also check if the nasal cannula and the breathing masks was bagged. He said the DON already started an in-service pertaining to bagging the nasal cannula and the breathing masks. Record review of the facility's policy Oxygen Equipment Policy/Procedure - Nursing Clinical revised May 2017 reflected POLICY: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner . PROCEDURES . 1. Oxygen Tanks, Connectors and Concentrators . E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms . 2. Nebulizer Equipment Procedures . F. Store, clean, and dry until next use.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 11 of 20 resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) and 2 of 2 shower rooms observed for cleanliness. The facility failed to ensure Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were thoroughly cleaned and sanitized. The facility failed to ensure two of two shower rooms were thoroughly cleaned and sanitized. This facility failure could place residents at risk of living in an unclean and unsanitary environment, leading to a decreased quality of life.Findings included: During an observation on 02/04/26 at 10:35 a.m. of room [ROOM NUMBER], reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. Observation reflected the bathroom floor had thick dark substances in the corners of the floor and behind the toilet. During an observation on 02/04/26 at 10:37 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust covered the front of the unit and between the vents. Observation reflected the bathroom floor had thick dark substances in the corners, behind the toilet, and inside of the toilet bowl were dark stains. Observation reflected the floor had built up dirt in the corners of the door frame and corners of the floor. The door frame had a rust-like substance on the bottom of the frame. During an observation on 02/04/26 at 10:40 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had thick dark substances in the corners of the floor and behind the toilet. The entryway of the room floor had a thick yellowish stain. The door frame had a rust-like substance on the bottom of the frame. During an observation on 02/04/26 at 10:44 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had thick dark substances in the corners of the floor and behind the toilet. The floor under the sink had thick black dirt. The room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 02/04/26 at 10:58 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bedside table had a thick rust-like substance all over the lower frame. The bathroom floor had thick dark substances in the corners of the floor and behind the toilet. The floor under the sink had thick black dirt. The room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 02/04/26 at 11:04 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bedside table had a thick rust-like substance all over the lower frame. The bathroom floor had thick dark substances in the corners of the floor and around the toilet. During an observation on 02/04/26 at 11:07 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The room floor had built up dirt in the corners of the door frame and corners of the floor. The bathroom floor had thick dark substances in the corners of the floor, under the sink, and around the toilet. During an observation on 02/04/26 at 11:15 a.m. of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet. The shower floor had dark stains near the rear wall and thick dirt around the drain. The room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 02/04/26 at 11:19 a.m. of room [ROOM NUMBER], reflected the bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet. The shower floor had dark stains near the rear wall and thick dirt around the drain. The room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 02/04/26 at 11:25 a.m. of room [ROOM NUMBER], reflected the bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet.During an observation on 02/04/26 at 11:30 a.m. of room [ROOM NUMBER], reflected the bathroom floor had reddish substances along the edges of the wall, near the shower, behind the toilet, and under the sink. During an observation on 02/06/26 at 10:34 a.m. of the shower room on the 100-hall, reflected the shower floor had dark stains and thick dirt around the drain.During an observation on 02/06/26 at 10:36 a.m. of the shower room on the 100-hall, reflected the shower floor had dark stains and thick dirt around the drain. During an interview on 02/06/26 at 10:58 a.m., Housekeeping A stated she cleaned the 300 and 400 halls. She stated they were to clean everything in the room. She stated they wiped down the air conditioner units, and the bathrooms. She was shown pictures of the concerns observed by the surveyor in the resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 and the shower rooms. She stated not cleaning the room thoroughly could result in the spread of bacteria. She stated a lot of the stains observed on the floors required something stronger to get the stains up. During an interview on 02/06/26 at 10:58 a.m., Housekeeping N stated she cleaned the 200 - hall, and she cleaned the shower rooms. She stated they are to clean everything in the room. She stated they wiped down the air conditioner units, and the bathrooms. She was shown pictures of the concerns observed by the surveyor in room [ROOM NUMBER], #11, and shower rooms and she stated she cleaned the bathrooms every day and there was an ant problem in the bathrooms. She stated she was not sure what the impact would be to the residents if their rooms were not thoroughly cleaned.During an interview on 02/06/26 at 11:20 a.m., the Housekeeping supervisor was informed and shown pictures of the concerns observed by the surveyor in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 and the shower rooms, the shower rooms, and the dining room. She stated the housekeeping staff are trained to cleaned from the windows to the front door of the resident rooms, including bathing rooms. She stated the floor tech cleaned the shower rooms, and the dining room floors. She stated they deep cleaned the rooms daily and the floor machines were unable to clean the corners of the floor. She stated maintenance cleaned the vents of the air conditioner units. She stated not thoroughly cleaning the rooms could cause infections.During an interview on 02/06/26 at 11:36 a.m., the Administrator was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 and the shower rooms. He stated he expected housekeeping to provide a clean environment for the residents. He stated this was the resident's home and it could also cause an infection. Review of the facility's policy on Safe/Comfortable/Homelike Environment, dated 01/2022, revealed, Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics includes cleanliness and order.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #6) of fourteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6's room was in a position that was accessible to the resident on 02/04/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #6's Face Sheet, dated 02/04/2026, reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. The resident was diagnosed with cerebral palsy (affects body movement and muscle coordination due to brain injury or malformation). Record review of Resident #6's Comprehensive MDS Assessment (tool used to measure health status), dated 11/20/2025, reflected intact cognition with a BIMS (tool used to measure cognitive status) score of 15. The Quarterly MDS Assessment indicated the resident required staff assistance with mobility and self-care needs. Record review of Resident #6's Comprehensive Care Plan, dated 12/19/2025, reflected the resident was at risk for fall r/t impaired transition during transfers and is able to use slide board for transfers. One intervention was to ensure the resident had a working and reachable call light. During an observation and interview on 02/04/2026 at 9:07 AM, Resident #6 was lying in bed asleep. A fall mat was placed next to his bed. The resident's nightstand was approximately 18 to the right of his bed. The top drawer of the nightstand was open, and the call light was draped across the drawer and hung over the side of the drawer that was closest to the bed. The call light was not within the resident's reach. The Assistant Business Office Manager was in the hall checking on the residents and came to Resident #6's room. She pulled on the call light cord, which barely touched the sheet on the resident's mattress, and stated that was as far as the call light would reach. She stated it was important to the resident to be able to call staff for assistance. During an interview on 02/04/2026 at 1:35 PM, RN C stated she had seen maintenance in the resident's room that morning but did not know if it was related to the call light. She stated she did not notice the call light was not in the resident's reach. She stated the resident may want a drink or something and he could not reach the call light. She stated Resident #6 was at risk for falls. RN C stated if the resident cannot reach the call light, he cannot communicate his needs. During an interview on 02/04/2026 at 1:40 PM, CNA L stated during her initial round, she did not notice the call light was not close enough for the resident to reach. She stated it was important for the call light to be within reach because he depended on her for care. She stated that was the point of having a call light.During an interview on 02/05/2026 at 12:18 PM, the ADON stated the call lights were different lengths. He stated the expectation was for the call light to be placed where the resident did not have to stretch his arm to reach it. He stated it was important for all residents to be able to reach their call light to ensure care was not delayed. He stated someone might need to go to the restroom, and it could be degrading to the resident if they could not wait and had an accident. He stated some residents may try to get up without help if they cannot reach their call light. During an interview on 02/05/2026 at 12:50 PM, the DON stated the residents' call lights should always be in reach to call for assistance if needed and for their safety. During an interview on 02/06/2026 at 10:35 AM, the Administrator stated the roommate in Resident #6's room had a longer call light so they swapped them. He stated it was important for Resident #6's call light to be in reach in case he needed to reach out for help. Record review of the facility's policy, revised 08/03/2021, reflected It is the policy of this facility to provide the resident a means of communication with nursing staff.Place the call device within resident's reach before leaving room.

Based on interview and record review the facility failed to notify the State Mental Health Authority to inform them of a significant change in mental condition for two (Residents #2 and #3) of eight residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR).1. The facility failed to notify the SMHA to ensure Resident #2 received a new PASRR level 1 screening following identification of his diagnosis of major depressive disorder on 06/20/2017, delusional disorder on 04/15/2021, and dementia on 01/08/2023.2. The facility failed to notify the SMHA to ensure Resident #3 received a new PASRR level 1 screening following identification of his diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder on 11/14/2023.These failures could place the residents at risk of not receiving the care and services they need in the most appropriate setting, when a significant change in their status occurs.Findings included:1. Review of Resident #2's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosis with major depressive disorder (persistent feeling of sadness or loss of interest) on 06/20/2017, delusional disorder (brain disorder were an individual who have delusional thoughts) on 04/15/2021, and dementia (a condition characterized by loss of memory and ability to reason) on 01/08/2023.Record review of Resident #2's Comprehensive Care Plan reflected the resident's care plan for depression was initiated on 11/22/2017, care plan for occasional hallucinations was initiated on 04/14/2021, care plan for impaired cognitive function was initiated on 10/18/2023, and care plan for mood problem was initiated on 07/23/2024.Record review of Resident #2's PASSR Level 1 Screening, dated 12/26/2016, reflected the resident was negative for mental illness, intellectual disability, and developmental disability when he was admitted to the facility.Record review of Resident #2's Documents on 02/05/2026 reflected the resident did not have a PASSR II, PE, or a new PASSR I.During an observation and interview on 02/04/2026 at 9:38 AM revealed Resident #2 was in his wheelchair, awake. He said he just had his breakfast and was feeling ok. He said he had a good sleep, and he said he was ready for the day. The resident then started rolling himself out of the room.2. Review of Resident #3's Face Sheet, dated 02/05/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosis with major depressive disorder and bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows) on 11/14/2023.Record review of Resident #3's Comprehensive Care Plan reflected the resident's care plan for bipolar disorder was initiated on 11/15/2023.Record review of Resident #3's PASSR Level 1 Screening, dated 11/14/2023, reflected the resident was negative for mental illness, intellectual disability, and developmental disability when he was admitted to the facility.Record review of Resident #3's Documents on 02/05/2026 reflected the resident did not have a PASSR II, PE, or a new PASSR I.During an observation and interview on 02/04/2026 at 9:46 AM revealed Resident #3 was in his bed, awake. He said he was feeling okay and would like to sleep some more.During an observation and interview on 02/05/2026 at 11:44 a.m., the MDS Nurse said she was responsible in doing the PASSR of the residents if needed. She stated that a PASSR level I was required to all individual seeking placement in a nursing facility. She said that PASSR level I were done to identify individuals with mental illness, intellectual disability, and developmental disability, and to ensure right placement and access to specialized services. She said if a resident was PASSR positive, meaning the resident was diagnosed with any mental illness or had indicators for intellectual and developmental disability, then a PASSR level II should be done to determine if the resident needed any specialized services. She said if a resident was PASSR I negative and during resident's stay in the facility was diagnosed with a new mental illness such as depression, anxiety, dementia, bipolar disorder, and delusional disorder, then a new PASSR I should have been done again for the same reason. She logged on to her computer and looked at Resident #2's profile. She said Resident #2 was PASSR negative when he was admitted to the facility but was diagnosed with major depressive disorder on 06/20/2017, delusional disorder on 04/15/2021, and dementia on 01/08/2023. She then checked if the there was a new PASSR I that was done and she said there was none. She then checked on Resident #3's profile. She said Resident #3 was diagnosed with bipolar disorder six days after admission. She said, same with Resident #2, a new PASSR I should have been done. She said both residents' issue with PASSR was before she was hired but said it was not an excuse and she should have done an audit when she took over. She said she would start the process and would also audit the PASSRs of the other residents.In an interview on 02/06/2026 at 8:11 AM, the DON stated she was not familiar with PASSR. She said she knew Resident #2 and Resident #3 had mental illnesses.In an interview on 02/06/2026 at 8:47 AM, ADON B stated Resident #2 and Resident #3 were taking psychotropic medications. He said he had no idea how PASSR worked.In an interview on 02/06/2026 at 9:17 AM, the Administrator stated there should be a process in place to determine if a new PASSR was need as soon as a new mental illness was diagnosed. He said he would personally coordinate with the MDS Nurse to determine where the break in communication was. Policy for PASSR requested on 02/05/2026 at 1:58 PM via email to the Administrator.In an interview on 02/06/2026 at 12:45 PM, the Administrator stated the facility did not have a policy for PASSR but would use the one from state.Review of the facility's Resident Assessment Instrument (RAI Version MDS 3.0) A1500: PASSR dated April 2012 Page A-16 reflected, Individuals who have or are suspected to have MI, or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through level II PASSR determination, those residents covered by Level II PASSR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State . Review of the facility's Resident Assessment Instrument Manual (RAI Version MDS 3.0) A1500: PASSR Planning for Care dated April 2012 Page A-17 reflected, The nursing home is required to provide all other care and services appropriate for the resident's medical condition .that should be addressed in the plan of care .

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 12 residents (Resident #22 and #36 ) reviewed for care plan. The facility failed to ensure Resident #22's care plan reflected a plan of care for the cancer lesion on her forehead. The facility failed to ensure Resident #36's Comprehensive Care Plan reflected the resident had a midline intravenous catheter for antibiotic administration.These failures could place residents at risk of their needs not being met. Findings included:Record review of Resident #22's Face Sheet, dated 02/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had paralysis on the left side of her body. Record review of Resident #22's Quarterly MDS Assessment, dated 10/18/25, reflected Resident #22 resident's BIM indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had an active diagnosis of paralysis on the left side of her body. Record review of Resident #22's Comprehensive Care Plan, dated 02/05/26, which was after the facility was informed of the exclusion of an intervention for the wound doctor's weekly skin assessment, reflected for actual skin impairment to forehead, Wound Care MD to evaluate and treat weekly until wound resolved. During an interview on 02/05/26 at 12:20 p.m., ADON A stated Resident #22 was required to receive weekly skin assessments from the Wound Care Doctor. She stated she did not think this needed to be care planned for the resident, but she would add it to her interventions. She stated the resident had a cancer lesion on her forehead and had this diagnosis for a while. She stated the care plan included the interventions needed to properly care for the resident. During an interview on 02/05/26 at 01:45 p.m., ADON A, RN D, the DON, and Clinical Nurse, the DON stated the resident had a cancer lesion on her forehead, and stated the resident received weekly head-to-toe assessments for pressure ulcers and the nursing staff checked her skin for the condition of the cancer lesion as well. ADON A stated a Wound Doctor was scheduled to assess the resident weekly to monitor the lesion to ensure it did not worsen. The DON stated the resident should have the cancer lesion care planned to ensure the resident received the care. The DON stated it was the ADON's and DON's responsibility to ensure the care plan was updated. Record review of Resident #36's face sheet, dated 02/05/2026, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with neuromuscular dysfunction of the bladder (damage to the nervous system that causes bladder problems). Record review of Resident #36's Quarterly MDS Assessment, dated 02/05/2026, reflected intact cognition with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) indicated Resident #36 received intravenous medications. Record review of Resident #36's face sheet, dated 02/05/2026, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with neuromuscular dysfunction of the bladder (damage to the nervous system that causes bladder problems). Record review of Resident #36's Quarterly MDS Assessment, dated 02/05/2026, reflected intact cognition with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) indicated Resident #36 received intravenous medications. Record review of Resident #36's Comprehensive Care Plan, dated 12/10/2025, did not reflect a midline (long, flexible catheter inserted into a vein in the upper arm for treatments that last longer than a few days) for IV antibiotics. Record review of Resident #36's Physician's Orders, dated 01/29/2026, reflected an order for Cefepime (antibiotic) 1 gm/50 ml intravenously two times a day for 7 days for a urinary tract infection. During an interview on 02/04/2026 at 11:02 AM, MDS Nurse H stated Resident #36 had an iv for antibiotics. She stated the resident was out of the facility for an appointment. During an observation on 02/04/2026 at 12:45 PM, a staff member was observed taking Resident #36 to her room in her wheelchair. She told the resident she would ask the kitchen staff to bring her lunch. When the surveyor entered the room, Resident #36 was sitting in her wheelchair. She stated she was doing ok and denied having any concerns. A staff member brought a lunch tray to Resident #36, and the surveyor exited the room. During an interview on 02/05/2026 at 11:44 AM, ADON B stated Resident #36 received the last dose of iv antibiotics the previous day. He stated he should have added the midline to the resident's care plan. ADON B immediately updated the care plan and stated it was important to monitor the resident for complications and signs of infection. During an interview on 02/05/2026 at 12:50 PM, the DON stated the midline should have been included in the resident's care plan to ensure the interdisciplinary team was on the same page. She stated the MDS Nurse and Infection Preventionist (ADON B) were responsible for ensuring the mid-line for antibiotics was included in the care plan. During an interview on 02/06/2026 at 12:20 PM, the MDS Nurse H stated the midline for antibiotics should have been included in Resident #36's care plan. She stated the interdisciplinary team discussed clinical changes during morning meetings and ADON B normally added that it to a resident's care plan. She stated it was important for the care plan to reflect a resident's complete plan of care. Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #114) reviewed for ADL care. The facility failed to ensure Resident #114 received any scheduled showers for January 2026 and no indication of refusal. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings included: Record review of Resident #114's Face Sheet, dated 02/05/26, reflected a 48 -year-old male who was admitted to the facility on [DATE]. Resident #114 had a diagnosis of morbid obesity. Record review of Resident #114's MDS Assessment, dated 11/25/25, reflected the resident's BIM (12) indicated a moderate cognitive impairment. The MDS Assessment reflected the resident had active diagnoses of morbid obesity and paraplegia (paralysis of lower body). The resident required maximal assistance for ADL care. Record review of Resident #114's Comprehensive Care Plan, dated 11/20/25, reflected the resident had an ADL self-care deficit and the resident was totally dependent on staff to provide ADL care. There was no mention of the resident refusing showers.Record review of Resident #114's Progress notes for the month of January 2026, reflected no documentation of resident refusing showers.During an observation and interview on 02/04/2026 at 10:43 a.m., Resident #114 stated he was not receiving his showers, and he had not refused them. He stated he sometimes received bed baths but wanted showers. During an interview and record review on 02/05/26 at 1:30 p.m., ADON A provided showers sheets for the month of January 2026 and stated that was all the shower sheets for every resident. Record review of the shower sheets revealed no shower sheets for Resident #114. ADON A was informed there were no shower sheets found for Resident #114, and she stated she would try to find them. She stated Resident #114 often refused showers. She stated the CNA who provided care to the resident was running late today and was not available. She stated the resident was scheduled to receive his showers on Tuesday, Thursday, and Saturday by the evening CNA. During an interview on 02/05/26 at 2:00 p.m., RN A stated she was the charge nurse for the 300-hall. She stated Resident #114 slept in a B bed and his showers were provided by the evening staff. RN A stated she did not know if he was receiving his showers. She stated if the resident was not receiving his showers he could have skin breakdown.During an interview and record review on 02/06/26 at 9:00 a.m., the ADON A stated Resident #114 received bed baths and often refused showers. She stated if a resident refused a shower, the charge nurse must attempt to persuade the resident into taking a shower, and if they were unsuccessful, the ADON would attempt to persuade the resident. She stated they would also contact the resident's RP emergency contact to persuade the resident into taking a shower. She stated if the resident did not receive his showers, he could have skin breakdown. ADON A provided a stack of shower sheets for Resident #114 and stated they were stored somewhere else and were found last night. ADON A provided Resident #114's shower sheets indicating the following: 01/02/26 (shower), 01/03/26 (bed bath), 01/05/26 (shower), 01/06/26 (bed bath), 01/07/26 (bed bath), 01/08/26 (bed bath), 01/09/26 (bed bath), 01/10/26 (shower), 01/12/26 (bed bath), 01/13/26 (bed bath), 01/14/26 (bed bath), 01/15/26 (shower), 01/16/26 (shower), 01/17/26 (shower), 01/19/26 (nothing marked), 01/20/26 (bed bath), 01/22/26 (bed bath), 01/24/26 (refused bed bath), 01/31/26 (bed bath). In an interview on 02/06/26 at 10:00 a.m., Resident #114 was asked if he received showers on the dates referenced on the shower sheets, and he stated he did not receive any showers nor did he receive all the bed baths mentioned. He could not verify which bed baths were received.In an interview on 02/06/26 at 10:02 AM, the DON stated Resident #114 often refused showers. She stated if a resident refused showers, the charge nurse should attempt to persuade the resident to take a shower and if they still refused, they were to contact the RP and document the refusal. She stated if the resident had not received showers he could have skin impairment. She stated they had to search for his shower sheets because they were not placed with the others. Record review of the facility's policy titled Showers/Bed baths, dated 05/2022, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided. 2. If a resident is unable to be showered on their scheduled day related to room changes or appointments, will attempt to reschedule. 3. Shower and bed baths will be documented on shower sheet and/or medical record 4. Charge nurse and/or ADON to review and sign. If resident has areas of concerns nurse/ADON to further investigate as needed and document as necessary.

Based on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #114) reviewed for hazards. The facility failed to ensure Resident #114 did not have a bottle of rubbing alcohol in his room on 02/04/26.This failure could prevent the residents from having an environment that was free from hazards. Findings include:Record review of Resident #114's Face Sheet, dated 02/05/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #114 had a diagnosis of major depressive disorder. Record review of Resident #114's MDS Assessment, dated 11/25/25, reflected the resident's BIM (12) indicated a moderate cognitive impairment. The MDS Assessment reflected the resident had an active diagnosis of schizophrenia.In an observation on 02/04/2026 at 10:43 AM, Resident #114 was observed with a bottle of rubbing alcohol on his bedside table.During an interview on 02/04/26 at 2:24 PM, RN C She stated the resident was not allowed to have the chemical in his room because it was not safe for him because he could drink it. She stated the nursing staff should check to ensure residents did not have unsafe chemicals in their rooms.In an interview on 02/06/26 at 10:02 AM, the DON stated the resident could not have possession of the item because he could ingest it. She stated they removed the item and provided him with alcohol free wipes. Record review of Safety Data Sheet (SDS) on 01/21/2026 reflected Safety Data SheetMedline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity - oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for two (Resident #16 and Resident #32) of sixteen residents and one (Nurse's Cart) of two carts reviewed for pharmaceutical services. 1. The facility failed to dispose of an over-the-counter gas relief dated 12/2025.2. The facility failed to dispose of Resident #16's expired Linzess capsules dated 12/2025.3. The facility failed to dispose of Resident #32's expired Clonidine tablets with discard after date of 04/30/2024.These failures could place residents at risk of not receiving the medication's full therapeutic benefits and possible adverse reactions when taken. Findings included:An observation of the nurse's cart on 02/06/2026 at 10:52 AM, revealed the following:-Linzess capsules for Resident #16 with an expiration date of 12/2025, -Clonidine tablets for Resident #32 with a discard after date of 04/30/2024, and -Gas Relief over-the-counter with an expiration date of 12/2025. Record review of Resident #16's Face Sheet, dated 02/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with rheumatoid arthritis (swelling of the joints). Record review of Resident #16's Comprehensive MDS Assessment, dated 01/14/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had rheumatoid arthritis and was occasionally in pain. Record review of Resident #16's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had chronic pain and one of the interventions was administer medications as ordered.Record review of Resident #16's Physician Order, dated 01/07/2026, reflected Percocet (pain medication that could cause constipation) Oral Tablet 10-325 MG (Oxycodone w/Acetaminophen) Give 1 tablet by mouth every 6 hours for pain hold for sedation.Record review of Resident #16's Physician Order on 02/05/2026 reflected the resident did not have an order for Linzess (constipation medication) capsules.Record review of Resident #32's Face Sheet, dated 02/06/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure).Record review of Resident #32's Comprehensive MDS Assessment, dated 12/30/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had hypertension.Record review of Resident #32's Comprehensive Care Plan, dated 01/29/2026, reflected the resident had hypertension and one of the interventions was to give anti-hypertensive medications.Record review of Resident #32's Physician's Order, dated 11/24/2025, reflected Clonidine HCl Oral Tablet 0.1 MG (Clonidine HCl) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for B/P less than 110/60.During an observation and interview on 02/06/2026 at 11:02 AM, RN D read the expiration dates of the medications in question and said the medications were already expired. She stated that expired medications should not be inside the carts so that staff administering the medications would not mistakenly use the expired ones. She said, when the medications were already expired, the effectiveness of the medication could be less or there could be adverse reactions from the expired medication. She said the medications were PRNs and she did not use any of them. She said Resident #32 had blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for her clonidine and they did not use the ones in the plastic bottle. She said Resident #16 did not take the Linzess anymore. She said, since she was one of the nurses using the cart, then she was also responsible in checking the medications inside the carts.During an observation and interview on 02/06/2026 at 11:06 AM, ADON A stated there should not be expired medication inside the carts. She said the nurses and medication aides was responsible in ensuring there was no expired medications. She said she was also responsible in checking and auditing the carts for expired medications. She said they would also audit the other carts for expired medications. She took the expired medications and undated insulins and said she would dispose of them. She also said she would start an in-service about checking the carts for expired medications.In an interview on 02/06/2026 at 11:15 AM, the DON stated she was made aware about the expired medications. She said expired medications could be less potent or could cause adverse effects depending on the medication. She said the nurses and the medication aides was responsible in checking their carts for expired medications. She said the ADONs was responsible in going behind the nurses and the medications aides and she was responsible in checking if the ADONs was checking the carts. She said ADON A was already preparing the in-service with regards to disposing expired medications accordingly.In an interview on 02/06/2026 at 12:45 PM, the Administrator stated he was not a clinician and would let the DON take the lead about the expired medications. He said, but one thing was for sure, expired medication should not be inside the cart and should not be used. He said they already started an in-service regarding the expired medication.Record review of the facility's policy Medication Access and Storage/Drug Destruction Policy/Procedure - Nursing Clinical revised July 2023 reflected Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review, the facility failed to follow policies and procedures to ensure that each resident or the resident's representative had the opportunity to refuse immunization for 1 of 6 residents (Resident #33) reviewed for vaccinations. The facility failed to ensure Resident #33 did not receive the influenza vaccination on 10/17/25. This failure could place residents at risk of having an adverse reaction and suffering harm.Findings included: Record review of Resident #33's Face Sheet, dated 02/05/26, reflected a [AGE] year-old female admitted [DATE]. Resident #33 had diagnoses of dementia (cognitive decline) and anemia (low red blood cells). Record review of Resident #33's Quarterly MDS Assessment, dated 11/20/25, reflected the resident's BIM (3) indicated a severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnosis of dementia. Record review of Resident #33's Immunization detail regarding the Influenza Vaccine, dated 10/17/25, reflected Family refused.Record Review of Resident #33's Progress Notes on 10/18/25, revealed, Resident received influenza vaccine and tolerated well without allergy reaction, resident vitals within normal limits. During an interview on 02/06/26 at 8:30 a.m., Resident #33's RP stated she told the nursing staff not to give Resident #33 the influenza vaccine and later found out she was given one anyway. She stated she did not want the resident to receive a shot because she was concerned about her having an allergic reaction.During an interview on 02/06/26 at 09:50 AM, ADON A and the DON stated Resident #33 was accidently given the Influenza vaccine on 10/17/26 because she and another resident had the same last name. She stated someone from state had investigated the allegations and they were not cited for it. She stated the resident could have had an allergic reaction to the shot. She stated they completed an in-service with the nursing staff to verify consent and having a second person verify the resident was to receive the vaccination in the future.Record review of the facility's policy titled, Medication Administration, dated 08/31/23, reflected, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Identification of the resident must be made prior to administering medication to the resident.

Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Residents #7) of 6 residents reviewed for resident abuse. The facility failed to ensure Resident #7 was free from physical abuse from LVN B during an incident on 01/04/2025 that subsequently required surgery on 01/09/2025. A Past Non Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 02/19/2025 at 11:37 AM. The noncompliance began on 01/04/2025 and ended on 01/06/2025. The facility corrected the noncompliance before the investigation began. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings Included: Review of Resident #7's Face Sheet, dated 02/18/2025 at 1:30 PM, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizophrenia, generalized anxiety disorder, osteoporosis, opioid dependence, and anorexia. Review of Resident #7's Quarterly MDS dated [DATE] revealed she was cognitively intact with a BIMS score of 15. She received both scheduled and PRN pain medication. She was prescribed antipsychotics for her mental health. Review of Resident #7's Care Plan, revised 01/22/2025, revealed she had . falls . resulted in ulnar styloid avulsion fracture (bony projection of the wrist) . right wrist fracture . fracture of the olecranon (part of the elbow) . and interventions included to anticipate resident needs, encourage resident to leave splints in place on wrists for proper healing, monitor pain level, educate/encourage resident to wear appropriate footwear, educate/encourage resident to ask for assistance when needed, pharmacy consult to evaluate medications, ensure personal belongings were with resident's reach, enhanced monitoring for pain, bruising, and change in mental status, ensure environment was safe, and therapy evaluation and treatment per orders. Review of Resident #7's Radiology Results Report on 01/06/2025 at 12:41 PM revealed acute fracture of the right elbow and right wrist. Review of Resident #7's Clinical Record from her orthopedic surgery on 01/09/2025, dated 01/10/2025 at 10:00 am revealed Resident #7 presented for outpatient surgery for ORIF left and right wrist and ORIF right elbow . Patient sustained injuries with a previous fall . In interview with Resident #7 on 02/18/2025 at 11:25 AM, she stated that last month, LVN B threw her across the room and slammed her down to the ground. She stated LVN B caused injury to both of her arms and wrists. Resident #7 stated she had to have surgery because of her injuries. She declined further interview at this time and could not provide further detail. In an attempt for a follow up interview with Resident #7 on 02/19/2025 at 12:22 PM, she declined interview at this time. Interview attempted with LVN B on 02/18/2025 at 12:18 PM and 02/19/2025 at 2:00 and 02/19/2025 at 2:30 PM was unsuccessful. Record review of Progress Note by LVN B, dated 01/04/2025 at 8:41 PM revealed, [Resident #7] punched nurse. [LVN B] pushed resident away from her. Resident dramatically fell against the wall and slid to the floor. [LVN B] attempted to assist resident. [Resident #7] refused. [Resident #7] then lied down in the supine position. [CNA A] attempted to assist resident. Resident again refused . In interview with CNA A on 02/18/2025 at 2:28 PM, she stated she worked the time of the incident, but she did not recall the exact time the incident occurred. She stated she was not present for the specific incident but arrived afterward the alleged incident to assist Resident #7 from the floor to her bed. She stated she did not suspect any abuse at this time, and stated Resident #7 did not report any allegations during any time after the interaction. Record review of Progress Note by LVN T, dated 01/05/2025 at 11:15 AM revealed: [Resident #7] called nurse to give her pain pill and noticed bruising in her elbow and wrist asked when that happened, she replied 'it happen last night after the dinner in the hallway' doctor, DON, ADON, family notified, as per doctor's order R elbow, hand, skull X-RAY stat ordered. vitals are stable, call button is in place, nurse is monitoring resident closely. Interview attempted with LVN T at 02/18/2025 at 3:25 was unsuccessful. In interview with DON at 2/18/2025 at 3:00 PM, she stated LVN B was a good nurse and denied any complaints or suspicions of abusive conduct prior to the incident. She stated that LVN B reported to her that she specifically witnessed the resident sit on the floor and that was why LVN B did not report the incident as a fall, accident, or abuse. DON stated that once LVN T noticed bruising on Resident #7's wrists and reported to her the incident, she immediately began interventions. She stated she immediately suspended LVN B, contacted law enforcement, and conducted a thorough investigation with facility's Administrator. DON stated while she did not feel LVN B's action was willful or malicious, she stated LVN B was terminated out of an abundance of caution and her license was referred for further review. In interview with Administrator at 02/18/2025 at 12:43 AM, he stated he immediately suspended LVN B pending investigation, contacted law enforcement, and conducted a thorough investigation after LVN T reported the allegation regarding Resident #7. He stated after he completed his investigation, he stated LVN B reported to him that her actions were defensive, and not willful or malicious. Administrator stated that as a result of his investigation, he concluded her actions were out of line and terminated her employment at the facility. Additionally, he stated he referred her license out of an abundance of caution. Following the incident his leadership team conducted safe-surveys with the residents and multiple in-services related to abuse, neglect, exploitation and employee burnout. Review of Facility in-services on 02/18/2025 revealed multiple staff were in-serviced on what Abuse and Neglect consist of, policy, protocol and procedures following any suspected abuse, neglect, and/or exploitation, and specifically whom to report to and the timeframe required. Further review revealed complementary Abuse & Neglect Knowledge Check quiz completed by all staff to ensure comprehension of the in-service information provided. In interview with Administrator, DON, ADON, RN D, CAN E, CNA F, CNA A, LVN Z, LMSW, and Activity Director between 02/18/2024 9:00 AM - 3:00 PM revealed staff were knowledgeable on what abuse and neglect consisted of, facility policy, protocol, and procedures, whom to specifically report suspected abuse, neglect, and/or exploitation to and the timeframe required. Review of Facility safe surveys on 02/18/2025 conducted by Administrator on 01/05/2025 revealed no additional allegations of Abuse, Neglect, and/or Exploitation from the residents at the facility. Review of LVN B's In-services, dated 01/06/2025 at 10:57 AM revealed she was in-serviced on Preventing and De-escalating Crisis Situations, on 12/27/2024 and received a 100% on the post-test. Additional in-services included Knowing the Rights of the Residents, Working with Residents with Substance Use Disorder, Tips on Managing Challenging Behaviors, Effective Communication, Pian Management, Fall Prevention, and Abuse, Neglect and Exploitation all completed on 12/27/2024. Review of LVN B's Termination Form dated 01/06/2025 revealed she was involuntarily terminated due to gross misconduct and additional explanation of termination: conclusion of the investigation, employee did not express regret, no remorse. Termination effective immediately and is not rehire-able. A Past Non Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 02/19/2025 at 11:37 AM. The noncompliance began on 01/04/2025 and ended on 01/06/2025. The facility corrected the noncompliance before the investigation began. Record review of Facility Policy, Resident Rights and Protections, dated 12/2014, signed by LVN B on 10/23/2024 revealed Our residents are entitled to . be treated with respect and dignity . be free from verbal, sexual, physical, and mental abuse . have a physician and/or representative notified any time a resident is injured in an accident or needs to see a doctor . Review of Facility Policy, Reporting and Preventing Abuse, Neglect and Mistreatment, dated 12/2014, revealed Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment . whether alleged, suspected, or observed, must report the incident to the Administrator . immediately. Record review of Facility Policy, Abuse: Prevention and Prohibition Against, dated 11/2017 revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 11 residents (Resident #1) reviewed for abuse and/or neglect. The facility failed to protect Resident #1, who was not verbal, from sexual abuse when a confidential interviewee provided video footage of the resident trying to cover her breasts and vaginal area with her hands while CNA A was undressing her and when CNA A had her hands between Resident #1's legs and moved her hand in a fast motion inside the vaginal area for eight (8) minutes and two seconds (.02) after changing her. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 08/09/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect. This failure could place residents at risk of abuse, neglect, humiliation, and psychosocial harm. Findings include: Record review of Resident #1's admission record, dated 07/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (trouble reasoning and making decisions while communicating), Dementia (a group of thinking and social symptoms that interferes with daily functioning), Psychotic Disorder with Delusions (an unshakeable belief in something untrue), Paranoid Schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly), Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Muscle Weakness (decreased strength in the muscles). Record review of Resident #1's Modified Admission MDS assessment, dated 02/12/24 , this was the most recent comprehensive assessment on file, reflected Resident #1 had no speech. She usually understood and comprehended most conversations. Resident #1 had severe cognitive impairment, the BIMS score was not indicated, Resident #1 was unable to participate. Resident #1 was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 01/31/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected Resident #1 was totally dependent on staff for all her activities of daily living. Observation on 07/25/24 at 10:38 a.m. the State Surveyor received and reviewed the video provided by a confidential interviewee of the alleged incident involving CNA-A and Resident #1. The video revealed the following: Video dated 7/21/24 at (19:30:00) 7:30 PM, CNA-A entered the room with Resident #1, within camera view CNA-A began to remove the clothes off Resident #1, at (19:30:50) 7:30:50 PM the resident's blouse was completely removed, and CNA-A took the resident to her bed by grabbing her by the right arm. CNA-A used her right hand to turn back the cover on the bed. The resident was observed in the video using her left arm to cover her breast while CNA-A was walking her toward the bed. CNA-A stood the resident by the bed and pulled down the resident's pants before laying the resident on the bed, then reached to grab her feet from the floor and placed her feet in the bed. At (19:31:58) 7:30:58 PM CNA-A put the resident in bed and removed her pants leaving on the adult brief, during this time the resident was watching CNA-A while covering her breast with both of her arms. At (19:32:04) 7:32:04 PM CNA-A unfastened the adult brief of Resident #1 and walked away from the bed out of camera view, while the resident was lying on the bed covering her breast with both of her arms and the open adult brief was open exposing her vaginal area. CNA-A returned to the bedside of the resident at (19:32:38) 7:32:38 PM. When CNA-A returned to the bedside of the resident she returned with adult briefs and wipes. CNA-A was observed using the wipes to clean the resident. While CNA-A was cleaning the resident, Resident#1 was observed holding both of her arms in a bent position covering her breast while shaking her hands in a clasped position in front of her. CNA-A then turned the resident toward the wall and removed the soiled adult brief and bed pad. CNA-A stepped away from the bed again to dispose of the soiled items, as she left the resident lying on the bed completely naked. CNA-A returned to the bedside of the resident, and she placed two clean adult briefs under the resident by turning the resident from side to side. Once the open briefs were under Resident #1, CNA-A moved to the head of the bed and repositioned the pillow under the head of the resident before returning to the middle of the bed and grabbed the gown and shook the gown before she placed the gown over the head of the resident and put her arms inside the gown. At (19:35:19) 7:35:19 PM, while the resident's vaginal area was still uncovered CNA-A used her hands to open the bent legs of the resident and placed her hands in the vaginal area. The resident was observed raising up her right forearm and tapping the left arm of CNA-A while grimacing her face. The resident was observed stretching out her right leg and reaching her right hand toward CNA-A while looking at her. CNA-A was observed looking toward the resident while she had her hands in the open vaginal area of the resident. At (19:35:54) 7:35:54 PM Resident #1 was observed placing her shaking left hand in front of her face, while CNA-A was looking toward her. Resident #1 was observed raising her head slightly off the pillow and patting her left foot on the bed. At (19:36:17) 7:36:17 PM CNA-A continued to have her hands in the vaginal area of the resident when the resident raised her right arm and was moving it toward CNA-A, as CNA-A looked toward the resident. At (19:36:22) 7:36:22 PM CNA-A continued to have her hands in the vaginal area of Resident #1 as CNA-A's right arm was observed to be moving in a fast motion until the resident looked toward something behind CNA-A at (19:36:29) 7:36:29 PM. CNA-A then looked behind her, then she continued to keep her hands in the open vaginal area of the resident until the resident looked behind CNA-A again at (19:36:35) 7:36:35 PM. At (19:36:35) 7:36:35 PM CNA-A stood up as if she was talking to Resident #1. At (19:36:46) 7:36:46 PM CNA-A opened the legs of Resident #1 with her vaginal area still uncovered and then she walked away from the bed off camera. During this time Resident #1 used her hands to cover her open vaginal area. CNA-A returned to the bedside of Resident #1 at (19:36:52) 7:36:52 PM and she moved the hands of the resident, CNA-A leaned over and placed her right hand between the still bent legs of the resident at (19:37:02) 7:37:02 PM and the resident looked behind CNA-A and CNA-A looked at the resident. At (19:37:13) 7:37:13 PM the resident was observed moving her hand and looking behind CNA-A while CNA-A continued to have her hand moving it in a fast motion. At (19:37:24) 7:37:24 PM Resident#1's legs were stretched on the bed while CNA-A's hands were still moving fast in her vaginal area. This action continued in the open vaginal area of the resident until (19:37:32) 7:37:32 PM when CNA-A bent Resident #1's right leg back up before returning her hands to the open vaginal area. At (19:37:55) 7:37:55 PM, CNA-A moved her body closer to the head of the bed of the resident exposing her vaginal area more, CNA-A's right hand was observed on the vagina of Resident #1 moving in a fast motion until (19:38:02) 7:38:02 PM when CNA-A reached down and pulled up both adult briefs and fastened them at (19:38:21) 7:38:21 PM. At (19:38:30) 7:38:30 PM, CNA-A pulled down the gown of Resident #1 then repositioned her in bed. At (19:38:43) 7:38:43 PM, CNA-A covered Resident #1 with the bed covers, lowered the resident's bed, and repositioned her pillow at (19:39:26) 7:39:26 PM. A confidential interview revealed it was observed on 07/21/24 in the evening time, the confidential interviewee stated they were not sure of the specific time of the original viewing of the video. The confidential interviewee stated it was observed via video CNA-A was in the bedroom of Resident #1 putting Resident #1 in bed when they touched her inappropriately. The confidential interviewee stated Resident #1 was not verbal. The confidential interviewee stated there was audio on the camera, the interviewee stated when CNA-A entered the room with the resident CNA-A said, Let me lay you down. The confidential interviewee stated there was not much communication after that statement. The confidential interviewee stated after Resident #1's clothes were taken off, and the resident was put on the bed and the incident happened. The confidential interviewee stated the abuse was reported to the Administrator in Training, and law enforcement. The confidential interviewee stated Resident #1 was taken to the hospital for an exam on 07/22/24. The confidential interviewee stated the hospital stated it would take several weeks to receive the results of the exam. The confidential interviewee stated Resident #1 was anxious when her adult brief was changed, and she would grab the hand of the person who was changing her. The confidential interviewee stated it was hard to determine if the incident had caused the resident harm at this time. The confidential interviewee stated the family requested Resident #1 not be visited because she was non-verbal and could not contribute to the investigation. The confidential interviewee they had contacted the police and Resident #1 was removed from the facility on 07/22/24 at 3:50 p.m. The confidential interviewee stated Resident #1 would not be returning to that facility. The confidential interviewee stated the video would be sent via text. In an interview with the Administrator in Training, acting abuse coordinator on 07/25/24 at 9:40 a.m. revealed he was notified of the abuse allegation on 07/22/24 late in the afternoon by the POA of Resident #1 . He stated the POA notified LE prior to coming to the facility. He stated he was told Resident #1 had been abused, he was not given specifics and was told there was a video, but he had not seen the video. He stated while LE and the POA was at the facility they removed Resident #1 from the facility when they left. He stated CNA A last worked 07/21/24 and was suspended on 07/22/24. He stated the facility's investigation was still ongoing at that time. He stated the facility was conducting safe surveys of all the residents and angel rounds (department heads are making rounds on assigned residents) and skin assessments on the two non-verbal residents. He stated the facility conducted an in-service with all staff on 07/22/24. He stated there was not any previous warnings or incidents regarding CNA-A at the facility. He stated CNA-A received the employee of the month for the month of June. He stated several families complimented her work. He stated at that time the facility was not able to verify if the incident had happened because the investigation was still ongoing. He stated the nursing staff was responsible to ensure the CNA's took proper care of the residents, the DON, and then the Administrator. In an interview on 07/24/24 at 12:08 p.m. with Detective from the local PD revealed he went to the facility on [DATE] and he was not provided the information for CNA-A until he returned on 07/23/24. He stated after the facility provided him with the location information of CNA-A an arrest warrant was issued. He stated due to the nature of his investigation he did not want CNA-A to be interviewed by the State Surveyor prior to her arrest. During an interview on 07/25/24 at 12:20 p.m., LVN B said the abuse coordinator should be notified immediately after an allegation of abuse was made. She said she could tell the abuse coordinator, the administrator or administrator in training in person or call them. She said she could also tell the DON of an allegation of abuse. She said she was trained on abuse and neglect several times. She said the abuse policy was a topic that was trained frequently. She said when abuse allegedly occurred she would also need to ensure the resident and other residents were kept safe from the person who allegedly did the abuse. During an interview on 07/25/24 at 1:17 p.m., CNA C said if a resident alleged that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator, the administrator and the DON, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she was in-serviced on all these principals' multiple times. During an interview on 07/25/24 at 2:47 p.m., CNA-D said she had been in-serviced on the facility abuse policy several times. She said if an allegation of abuse was made, they were to immediately report the allegation to the abuse coordinator, the administrator. She said she could also report to the charge nurse and the DON as well as call the abuse coordinator. She said she would also need to ensure the person who did the abuse did not have access to any resident and have them leave the building. In a follow-up interview with the Administrator in training on 07/25/24 at 3:43 p.m., he stated he interviewed CNA-A prior to the State Surveyor's entrance. He stated, CAN-A described and demonstrated the service she provided to Resident #1 as cleaning her and changing her bed and her brief. She stated she did not have any issues with Resident #1. He stated CAN-A did not provide a written statement of the services she provided to Resident #1. The Administrator in training stated the facility had psych services at the facility and they came and talked to the residents whom CNA-A had provided care . He stated psych services noted no concerns for other residents on Hall 500, where Resident #1 resided. He stated CNA-A would be terminated on 07/25/24, now that he knew the allegation was substantiated. He stated the facility became aware of the incident when the POA and police came to the facility on [DATE]. He stated the facility started in-services on abuse with the facility staff on 07/22/24. He stated their abuse and neglect policy required that all residents be protected after an allegation of abuse. He stated they ensured the protection of residents by conducting the safe surveys and angel rounds. He stated the residents were at risk of having their rights violated, risk of no longer being free from abuse, and risk of trauma. Record review of the facility's in-service, dated 03/26/24, reflected CNA A was in-serviced on the facility abuse policy. Abuse policy educated staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of the facility in-service, dated 07/22/24, reflected all staff signed they were in-serviced on facility abuse policy. Record review of residents residing on Hall 500 evaluated by Psych services dated 07/23/24 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable and the recent incident did not affect the resident. Record review of CNA A's Date of Hire-01/10/2023 Background check completed reflected: 01/04/2023-Federal Criminal National-clear, Healthcare Sanctions-clear, Sex Offender-clear 01/04/23-Criminal History Conviction Name Search with Department of Public Safety-No search results found 01/03/23-Texas Health and Human Services Not listed on the EMR, NAR: Active 07/15/23-Employability Status Check Search Results-Not listed on EMR-NAR status: Active; Certification expiration date: 07/03/2025 07/22/2024-Criminal History Conviction Name Search Results-No search results found 07/23/2024-Employability Status Check Search Results-Nurse Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. Record review of facility Termination Form dated 7/25/24 to CNA A reflected her last day of work was 07/21/24 and she was involuntary terminated for gross misconduct on 7/25/24. Record review of facility Abuse: Prevention of and Prohibition Against dated 11.2017 revised 12.2023 reflected, The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use technology that would infringe on the resident's right to personal privacy. Sexual abuse is non-consensual sexual contact of any type with a resident. An IJ was identified on 08/07/24. The IJ template was provided to the Administrator on 08/07/24 at 1:30 p.m. and a Plan of Removal was requested. The POR was accepted on 08/08/24 at 4:23 p.m. The POR revealed the following: Abuse: Per the information provided in the IJ Template given on 8/7/2024, the facility has started but has not completed in-services with all staff as of 07/25/24. The facility received verbal information alleging that a staff member had touched a resident inappropriately. This allegation was given to the facility by the police and by an HHSC surveyor. 1. The Medical Director was notified of the IJ on 08/07/2024 at 2:10 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MDS Nurse and RN/ED Partners by the Clinical Resource. The training included regarding abuse to include resident rights to be free of sexual abuse. Started in-service training on 7/22/2024 on Abuse: Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7 /24. 3. Training and knowledge checks were completed with all staff regarding abuse to include resident rights to be free of sexual abuse. Skills check offs and skin assessments started on pericare [sic] 7/22/2024. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. This training was given by the ED, DON, ADON, MDS Nurse Clinical Resource and RN/ED Partners, was initiated on 8/7/24 will be completed on 8/8/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working. 4. An ad hoc (a non-scheduled QA meeting) meeting regarding items in the IJ templates will be completed on 8/7/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 8/8/24. 6. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 8/8/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the facility plan of removal was as follows: In an interview on 08/09/24 at 9:30 a.m. with the Administrator in Training revealed he had been trained on 08/07/24 on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. In an interview on 08/09/24 at 9:35 a.m. with the Resource Nurse, revealed she had been trained on 08/07/24 on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. In an interview on 08/09/24 at 10:50 a.m. Resident #2 revealed she did feel safe in the facility, she stated a few weeks ago a facility staff came by to ask if there had been any issues with any CNA's and she told her there had not been any issues. She stated she knew she could notify the social worker or the administrator if she did not feel safe or was abused. In an interview on 08/09/24 at 11:23 a.m. with RN E revealed she had been in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident, the administrator was the abuse coordinator and should be notified if abuse was suspected. In an interview on 08/09/24 at 11:36 a.m. with Resident #3 revealed stated she did feel safe in the facility, she stated she had been asked by facility staff if she felt safe and if she had any issues with a CNA. She stated she had not had any issues. She stated if she did not feel safe or if she was abused she would tell her son or the administrator. In an interview on 08/09/24 at 11:41 a.m. with CNA F revealed he had been in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident, and the administrator was the abuse coordinator and should be notified if abuse was suspected. In an interview on 08/09/24 at 11:45 a.m. with MA G revealed she had been in-serviced that abuse was a willful act, it was never appropriate to have sexual contact with a resident, if she suspected abuse she would notify the abuse coordinator, the administrator, or the DON. In an interview on 08/09/24 at 12:07 p.m. with the Housekeeping Supervisor revealed she had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. She stated she would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. She stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 12:16 p.m. with CNA H revealed she was in-serviced that abuse was a willful act, it was not appropriate for an employee to have sexual contact with a resident. She stated if she suspected or saw abuse she should report to the administrator the abuse coordinator. In an interview on 08/09/24 at 12:22 p.m. with CNA I revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:28 p.m. with RN J revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:34 p.m. with visiting DON revealed she had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. She stated she would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. She stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 12:51 p.m. with CNA K revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:57 p.m. with CNA L revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:05 p.m. with the Director of Rehabilitation revealed he had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. He stated he would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. He stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:15 p.m. with Therapist N revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:23 p.m. with CNA O revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:27 p.m. with CNA P revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:31 p.m. with CNA Q revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:35 p.m. with Resident #4 revealed she stated she had not been touched inappropriately by anyone, she stated she received her medication on time. She stated facility staff asked her a few weeks ago if she was safe. She stated she felt safe living at the facility, she stated if she was abused she could tell her family or the administrator. In an interview on 08/09/24 at 1:42 p.m. with Resident #5 revealed she stated she did feel safe at the facility, she stated if she did not feel safe she could tell her family or the social worker. In an interview on 08/09/24 at 1:50 p.m. with Resident #6 revealed she felt safe in the facility, she stated she had not been touched inappropriately. She stated if she was abused she could notify the nurse or the administrator. In an interview on 08/09/24 at 2:30 p.m. with the Administrator revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated safety assessments had been completed on the residents. She stated Resident #1 had not returned to the facility since she was removed by the POA on 07/22/24. She stated CNA A was suspended 07/22/24 by phone and she was terminated on 07/25/24. Review of Facility train the trainer in-service dated 8/7/24 revealed the management staff had been in serviced on how to train the staff on Abuse: Prevention of and Prohibition Against by staff policy dated 10.2022 Review of Facility abuse and neglect in-service dated 8/7/24 revealed all facility staff had been in serviced on Abuse: Prevention of and Prohibition Against by staff policy dated 10.2022 Record review of Psych services evaluation for Resident's #7, #8, #9, #10, #11, #12, #13, and #14 dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of resident roster provided 08/07/24 reflected Resident #1 was no longer residing at the facility. Record review of Skills checklist-Perineal Care dated 07/22/24 and 07/23/24 reflected CNAs were re-evaluated to ensure they performed proper Perineal Care. Record review of Safe Interviews of facility residents dated 07/22/24 and 07/23/24 reflected residents were assessed for safety. Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. Record review of facility Termination Form dated 7/25/24 to CNA A reflected her last day of work was 07/21/24 and she was involuntary terminated for gross misconduct on 7/25/24. The administrator was informed the Immediate Jeopardy was removed on 08/09/2024 at 4:23 p.m. the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 11 residents (Resident #1) reviewed for abuse. The facility failed to implement policy that prohibited abuse of Resident #1 was sexually abused when a confidential interviewee provided video footage of CNA A undressing Resident #1 as Resident #1used her crossed arms to cover her breast and CNA A inserted her hands between the legs of Resident #1, moved her hands in a fast motion inside the vaginal area for eight (8) minutes and 2 (.02) seconds after the resident's clothes were taken off. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 08/09/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Record review of facility Abuse: Prevention of and Prohibition Against dated 11.2017 revised 12.2023 reflected, The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use technology that would infringe on the resident's right to personal privacy. Sexual abuse is non-consensual sexual contact of any type with a resident. Record review of Resident #1's admission record, dated 07/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] Resident #1 had diagnoses which included, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (trouble reasoning and making decisions while communicating), Dementia (a group of thinking and social symptoms that interferes with daily functioning), Psychotic Disorder with Delusions (an unshakeable belief in something untrue), Paranoid Schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly), Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Muscle Weakness (decreased strength in the muscles). Record review of Resident #1's Modified Admission MDS assessment, dated 02/12/24, reflected Resident #1 had no speech. She usually understood and comprehended most conversations. Resident #1 had severe cognitive impairment, the BIMS was not indicated, Resident #1 was unable to participate. Resident #1 was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 01/31/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected Resident #1 was totally dependent on staff for all her activities of daily living. Observation on 07/25/24 at 10:38 a.m. the State Surveyor received and reviewed the video provided by a confidential interviewee of the alleged incident involving CNA-A and Resident #1. The video revealed the following: Video dated 7/21/24 at (19:30:00) 7:30 PM, CNA-A entered the room with Resident #1, within camera view CNA-A began to remove the clothes off Resident #1, at (19:30:50) 7:30:50 PM the resident's blouse was completely removed, and CNA-A took the resident to her bed by grabbing her by the right arm. CNA-A used her right hand to turn back the cover on the bed. The resident was observed in the video using her left arm to cover her breast while CNA-A was walking her toward the bed. CNA-A stood the resident by the bed and pulled down the resident's pants before laying the resident on the bed, then reached to grab her feet from the floor and placed her feet in the bed. At (19:31:58) 7:30:58 PM CNA-A put the resident in bed and removed her pants leaving on the adult brief, during this time the resident was watching CNA-A while covering her breast with both of her arms. At (19:32:04) 7:32:04 PM CNA-A unfastened the adult brief of Resident #1 and walked away from the bed out of camera view, while the resident was lying on the bed covering her breast with both of her arms and the open adult brief was open exposing her vaginal area. CNA-A returned to the bedside of the resident at (19:32:38) 7:32:38 PM. When CNA-A returned to the bedside of the resident she returned with adult briefs and wipes. CNA-A was observed using the wipes to clean the resident. While CNA-A was cleaning the resident, Resident#1 was observed holding both of her arms in a bent position covering her breast while shaking her hands in a clasped position in front of her. CNA-A then turned the resident toward the wall and removed the soiled adult brief and bed pad. CNA-A stepped away from the bed again to dispose of the soiled items, as she left the resident lying on the bed completely naked. CNA-A returned to the bedside of the resident, and she placed two clean adult briefs under the resident by turning the resident from side to side. Once the open briefs were under Resident #1, CNA-A moved to the head of the bed and repositioned the pillow under the head of the resident before returning to the middle of the bed and grabbed the gown and shook the gown before she placed the gown over the head of the resident and put her arms inside the gown. At (19:35:19) 7:35:19 PM, while the resident's vaginal area was still uncovered CNA-A used her hands to open the bent legs of the resident and placed her hands in the vaginal area. The resident was observed raising up her right forearm and tapping the left arm of CNA-A while grimacing her face. The resident was observed stretching out her right leg and reaching her right hand toward CNA-A while looking at her. CNA-A was observed looking toward the resident while she had her hands in the open vaginal area of the resident. At (19:35:54) 7:35:54 PM Resident #1 was observed placing her shaking left hand in front of her face, while CNA-A was looking toward her. Resident #1 was observed raising her head slightly off the pillow and patting her left foot on the bed. At (19:36:17) 7:36:17 PM CNA-A continued to have her hands in the vaginal area of the resident when the resident raised her right arm and was moving it toward CNA-A, as CNA-A looked toward the resident. At (19:36:22) 7:36:22 PM CNA-A continued to have her hands in the vaginal area of Resident #1 as CNA-A's right arm was observed to be moving in a fast motion until the resident looked toward something behind CNA-A at (19:36:29) 7:36:29 PM. CNA-A then looked behind her, then she continued to keep her hands in the open vaginal area of the resident until the resident looked behind CNA-A again at (19:36:35) 7:36:35 PM. At (19:36:35) 7:36:35 PM CNA-A stood up as if she was talking to Resident #1. At (19:36:46) 7:36:46 PM CNA-A opened the legs of Resident #1 with her vaginal area still uncovered and then she walked away from the bed off camera. During this time Resident #1 used her hands to cover her open vaginal area. CNA-A returned to the bedside of Resident #1 at (19:36:52) 7:36:52 PM and she moved the hands of the resident, CNA-A leaned over and placed her right hand between the still bent legs of the resident at (19:37:02) 7:37:02 PM and the resident looked behind CNA-A and CNA-A looked at the resident. At (19:37:13) 7:37:13 PM the resident was observed moving her hand and looking behind CNA-A while CNA-A continued to have her hand moving it in a fast motion. At (19:37:24) 7:37:24 PM Resident#1's legs were stretched on the bed while CNA-A's hands were still moving fast in her vaginal area. This action continued in the open vaginal area of the resident until (19:37:32) 7:37:32 PM when CNA-A bent Resident #1's right leg back up before returning her hands to the open vaginal area. At (19:37:55) 7:37:55 PM, CNA-A moved her body closer to the head of the bed of the resident exposing her vaginal area more, CNA-A's right hand was observed on the vagina of Resident #1 moving in a fast motion until (19:38:02) 7:38:02 PM when CNA-A reached down and pulled up both adult briefs and fastened them at (19:38:21) 7:38:21 PM. At (19:38:30) 7:38:30 PM, CNA-A pulled down the gown of Resident #1 then repositioned her in bed. At (19:38:43) 7:38:43 PM, CNA-A covered Resident #1 with the bed covers, lowered the resident's bed, and repositioned her pillow at (19:39:26) 7:39:26 PM. A confidential interview revealed it was observed on 07/21/24 in the evening time, the confidential interviewee stated they were not sure of the specific time of the original viewing of the video. The confidential interviewee stated it was observed via video CNA-A was in the bedroom of Resident #1 putting Resident #1 in bed when they touched her inappropriately. The confidential interviewee stated Resident #1 was not verbal. The confidential interviewee stated there was audio on the camera, the interviewee stated when CNA-A entered the room with the resident CNA-A said, Let me lay you down. The confidential interviewee stated interviewee stated there was not much communication after that statement. The confidential interviewee stated after Resident #1's clothes were taken off, and the resident was put on the bed and the incident happened. The confidential interviewee stated the abuse was reported to the Administrator in Training, and law enforcement. The confidential interviewee stated Resident #1 was taken to the hospital for an exam. The confidential interviewee stated the hospital stated it would take several weeks to receive the results of the exam. The confidential interviewee stated Resident #1 was anxious when her adult brief was changed, and she grabbed the hand of the person who was changing her. The confidential interviewee stated it was hard to determine if the incident had caused the resident harm at this time. The confidential interviewee stated the family requested Resident #1 not be visited because she was non-verbal and could not contribute to the investigation. The confidential interviewee stated the video would be sent via text. In an interview with the Administrator in Training, acting abuse coordinator on 07/25/24 at 9:40 a.m. revealed he was notified of the abuse allegation on 07/22/24 late in the afternoon by the POA of Resident #1 . He stated the POA notified LE prior to coming to the facility. He stated he was told Resident #1 had been abused, he was not given specifics and was told there was a video, but he had not seen the video. He stated while LE and the POA was at the facility they removed Resident #1 from the facility when they left. He stated CNA A last worked 07/21/24 and was suspended on 07/22/24. He stated the facility's investigation was still ongoing at that time. He stated the facility was conducting safe surveys of all the residents and angel rounds (department heads are making rounds on assigned residents) and skin assessments on the two non-verbal residents. He stated the facility conducted an in-service with all staff on 07/22/24. He stated there was not any previous warnings or incidents regarding CNA-A at the facility. He stated CNA-A received the employee of the month for the month of June. He stated several families complimented her work. He stated at that time the facility was not able to verify if the incident had happened because the investigation was still ongoing. He stated the nursing staff was responsible to ensure the CNA's took proper care of the residents, the DON, and then the Administrator. During an interview on 07/25/24 at 12:20 p.m., LVN B said the abuse coordinator should be notified immediately after an allegation of abuse was made. She said she could tell the abuse coordinator, the administrator or administrator in training in person or call them . She said she could also tell the DON of an allegation of abuse. She said she was trained on abuse and neglect several times. She said the abuse policy was a topic that was trained frequently. She said when abuse allegedly occurred she would also need to ensure the resident and other residents were kept safe from the person who allegedly did the abuse. During an interview on 07/25/24 at 1:17 p.m., CNA C said if a resident alleged that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator who was the administrator, and/or the DON . She stated she would keep the resident safe and prevent the person who allegedly did the abuse away from other residents. She said she was in-serviced on all these principals' multiple times. During an interview on 07/25/24 at 2:47 p.m., CNA-D said she had been in-services on the facility abuse policy several times. She said if an allegation of abuse was made, they were to immediately report the allegation to the abuse coordinator , the administrator. She said she could also report to the charge nurse and the DON as well as call the abuse coordinator. She said she would also need to ensure the person who did the abuse did not have access to any resident and have them leave the building. In a follow-up interview with the Administrator in training on 07/25/24 at 3:43 p.m., he stated he interviewed CNA-A prior to the State Surveyor's entrance. He stated, CAN-A described and demonstrated the service she provided to Resident #1 as cleaning her and changing her bed and her brief. She stated she did not have any issues with Resident #1. He stated CAN-A did not provide a written statement of the services she provided to Resident #1. The Administrator in training stated the facility had psych services at the facility and they came and talked to the residents whom CNA-A had provided care . He stated psych services noted no concerns for other residents on Hall 500, where Resident #1 resided. He stated CNA-A would be terminated on 07/25/24, now that he knew the allegation was substantiated. He stated the facility became aware of the incident when the POA and police came to the facility on [DATE]. He stated the facility started in-services on abuse with the facility staff on 07/22/24. He stated their abuse and neglect policy required that all residents be protected after an allegation of abuse. He stated they ensured the protection of residents by conducting the safe surveys and angel rounds. He stated the residents were at risk of having their rights violated, risk of no longer being free from abuse, and risk of trauma. Record review of the facility's in-service, dated 03/26/24, revealed CNA A was in-serviced on the facility abuse policy. Abuse policy educated staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of residents by Psych services dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of the facility in-service, dated 07/22/24, reflected all staff signed they were in-serviced on facility abuse policy. Record review of Psych services evaluation for Resident's #7, #8, #9, #10, #11, #12, #13, and #14 dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of CNA A's Background check completed reflected: 01/04/2023-Federal Criminal National-clear, Healthcare Sanctions-clear, Sex Offender-clear 01/04/23-Criminal History Conviction Name Search with Department of Public Safety-No search results found 01/03/23-Texas Health and Human Services Not listed on the EMR, NAR: Active 07/15/23-Employability Status Check Search Results-Not listed on EMR-NAR status: Active; Certification expiration date: 07/03/2025 07/22/2024-Criminal History Conviction Name Search Results-No search results found 07/23/2024-Employability Status Check Search Results-Nurse Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. An IJ was identified on 08/07/24. The IJ template was provided to the Administrator on 08/07/24 at 1:30 p.m. and a Plan of Removal was requested. The POR was accepted on 08/08/24 at 4:23 p.m. The POR revealed the following: Develop and Implement Policy: Per the information provided in the IJ Template given on 8/7/2024, the facility has started but has not completed in-services with all staff as of 07/25/24. The facility received verbal information alleging that a staff member had touched a resident inappropriately. This allegation was given to the facility by the police and by an HHSC surveyor. The facility has not been given or reviewed the video where the alleged abuse may have occurred. 1. The Medical Director was notified of the IJ on 08/07/2024 at 2:10 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MOS Nurse and RN/ED Partners by the Clinical Resource. The training included regarding abuse to include resident rights to be free of sexual abuse. Started in-service training on 7/22/2024 on Abuse: Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. 3. Training and knowledge checks were completed with all staff regarding abuse to include resident rights to be free of sexual abuse. Skills check offs and skin assessments started on peri care 7/22/2024. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. This training was given by the ED, DON, ADON, MOS Nurse Clinical Resource and RN/ED Partners, was initiated on 8/7/24 will be completed on 8/8/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working. 4. An ad hoc (a non-scheduled QA meeting) meeting regarding items in the IJ templates will be completed on 8/7/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 8/8/24. 6. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 8/8/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 7. Monitoring of the facility plan of removal was as follows: In an interview on 08/09/24 at 9:30 a.m. with the Administrator in Training revealed he had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. He stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. He stated he was also trained on understanding behavioral symptoms of residents that may increase the risk of abuse was resistance to care, outburst, and difficulty in adjusting to new routines or staff. He stated he had been trained that if abuse or neglect involved an employee he should immediately remove the employee from care of any resident and suspend the employee during the investigation. In an interview on 08/09/24 at 9:35 a.m. with the Resource Nurse, revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated she was trained to recognize the signs of abuse of physical or psychosocial indicators, to inform staff they could report abuse they could do so without fear of reprisal. She stated she was trained to respond immediately to protect the alleged victim of abuse, and the victim should be examined for any injury, by physical examination or psychosocial assessment. In an interview on 08/09/24 at 11:23 a.m. with RN E revealed she was in-serviced on abuse policy that she should ensure all residents were free from neglect and abuse, to identify and assess behaviors that could indicate a resident had been abused was sexually aggressive behavior and saying sexual things. She sated some indicators of abuse would be sudden or unexplained changes in behaviors or activities, fear of a person providing care. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 11:41 a.m. with CNA F revealed his training included identifying and preventing abuse of a resident, how to report abuse and that he could report abuse without fear of retaliation. He sated he was re-in-serviced that they should not take photos of residents. He had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 11:45 a.m. with MA G revealed she stated abuse and neglect policy stated she should intervene in situations of abuse or neglect, she stated signs that a resident had been abused could be the resident acted different around a specific staff, the resident might be withdrawn or act ashamed when staff were providing care. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:07 p.m. with the Housekeeping Supervisor revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated abuse prevention policy included verbal aggression, physical aggression, sexual abuse. She stated some signs a resident had been abused would include injuries in an unusual location on the resident, sudden unexplained changes in the resident's behavior such as fear of a person or feeling shame or guilt. In an interview on 08/09/24 at 12:16 p.m. with CNA H revealed she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. She stated when she received additional in-service on the abuse policy she learned the abused resident should be kept safe from the employee, the resident should receive emotional support and counseling. She stated some signs of abuse would be sudden change in behavior or a resident who would normally participate in activities suddenly did not want to participate. In an interview on 08/09/24 at 12:22 p.m. with CAN I revealed she learned all abuse was not directly observed and possible indicators would be bruises, skin tears, injuries in an unusual location, and unexplained changes in behaviors. She stated she must protect the resident from the perpetrator. she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:28 p.m. with RN J revealed she stated regarding the facility policy on abuse and neglect all personnel, residents, and visitors were encouraged to report incidents and grievances without the fear of retribution, she would supervise the staff to identify and correct any inappropriate or unprofessional behaviors, she stated as a member of the staff she was responsible for ensuring residents were free from abuse, policy indicated that a resident with communication disorders or spoke a different language should be monitored for signs of abuse. She stated she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:34 p.m. with visiting DON revealed she had been trained on 08/09/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. In an interview on 08/09/24 at 12:51 p.m. with CNA K revealed she stated the abuse neglect policy was reviewed with her regarding recognizing signs of abuse, neglect, exploitation such as physical or psychosocial indicators, facility staff were prohibited from taking or keeping photographs of facility residents in any manner that demeaned or humiliated the resident. She stated she should report any reasonable suspicion of a crime against a resident, she should protect the resident. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:57 p.m. with CNA L revealed she stated she learned from abuse and neglect policy that she should ensure the residents were safe, she stated some types of abuse of a resident would be verbally aggressive behavior, screaming, cursing, insulting to their race, physically aggressive behavior. She stated a resident who has been abuse might also exhibit the same behaviors. she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she received additional training on the abuse policy regarding recognizing signs of abuse and neglect such as physical or psychosocial indicators, abuse and neglect should be reported to the administrator without fear of reprisal, she learned the facility staff was responsible for protecting the residents, they should not take or distribute photos of the residents, and that dementia residents are at a greater risk of abuse. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:05 p.m. with the Director of Rehabilitation revealed he would be responsible to protect all the residents, he stated the abuse and neglect policy indicated all personnel, residents, and visitors should be encouraged to report incidents without the fear of retribution, the facility would act to protect the resident and prevent further abuse, the facility should have structures and processes to provide needed care and services for all residents. Residents who require extensive nursing care or totally dependent on staff for provision of care are most vulnerable. He had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. In an interview on 08/09/24 at 1:15 p.m. with Therapist N revealed she was re-in-serviced on policy for identification of signs of abuse of a resident that included sudden or unexplained changes in behaviors or activities such as fear of a person or place, learning to identify different types of abuse such as mental/verbal, sexual, and physical, any act that would demean or humiliate a resident. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:27 p.m. with CNA O revealed she received addition training on how to prevent abuse or neglect of a resident how to recognize signs that a resident had been abused or neglected either physically or mentally. She stated she could report abuse without reprisal, and she should not take photos of any resident or distribute any resident to cause the resident to be demeaned or humiliated. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:15 p.m. with CNA P revealed she was re-in-serviced on the facility policy of how to recognize signs of abuse and neglect such as physical or psychosocial indicators, abuse and neglect should be reported without fear of retaliation, vulnerable residents usually had dementia or were cognitively impaired. She sated she learned that some residents with behavioral symptoms would be aggressive reactions outburst or yelling difficulty in adjusting to new routines or staff. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:31 p.m. with CNA Q revealed she had been re-trained on the abuse policy that all staff were encouraged to report incidents and abuse without fear of retribution, how to recognize signs of abuse and neglect which were physical or psychosocial, she should not take photos and distribute them of the residents, she stated she learned that residents with dementia or cognitively impaired residents were at greater risk of abuse. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 2:30 p.m. with the Administrator revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She s [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #4) of five residents reviewed for quality of care. The facility failed to retrieve results of an x-ray order of Resident #4's left hip in a timely manner, which resulted in delayed treatment of a dislocation for a period of approximately 28 hours. Resident #4 was found on the floor on 04/10/23 approximately 9:00 PM, STAT orders (referring to a diagnostic or therapeutic procedure that is to be performed immediately; prioritized in a lab, as the results have a potentially immediate impact on patient management) were submitted on 04/11/23 at approximately 4:56 AM, results retrieved on 04/12/23 at approximately 9:11 AM, by Physician I, and the resident was sent out to the hospital on 04/12/23 at approximately 11:21 AM. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. While the IJ was removed on 04/28/23, the facility remained out of compliance at a scope of actual harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. The facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. This failure placed residents at risk of a delay in medical evaluation, treatment and decrease in quality of care. Findings included: Review of Resident #4's face sheet dated 04/27/23 revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnosis included non-displaced intertrochanteric of fracture of left femur, unspecified fall, muscle weakness, difficulty in walking, abnormalities of gait and mobility, history of falling, lack of coordination, unsteadiness on feet. aphasia, major depressive disorder, vascular dementia with agitation. Review of Resident #4's quarterly MDS Assessment, dated 03/25/23, revealed Resident #4 was usually understood by others and was usually able to understand others; however, the resident's cognitive assessment/BIMS was not completed. Transferring between bed, chair, wheelchair, and standing position required extensive assistance with one person assist. Locomotion in the room required supervision with two person assist. Review of Resident #4's care plan, undated, revealed Resident #4 had ADL self-care performance deficit related to weakness, dementia, and transient ischemic accident. Goal: will maintain current level of function in transfers, toilet use and personal hygiene, Intervention: Toilet use: requires x1 staff to assist, Transfer requires x1 staff assist with transferring. Resident #4 at risk for falls related to weakness. Goal: will not sustain serious injury. Intervention: 1/1/23 Fall; due to drop in blood pressure, 1/19/23 Fall; educated resident to call for assistance when picking up things off the floor, 02/12/23 Fall; offer bathroom assistance when making rounds, 04/10/23 Fall; fall mat to beside at all times, be sure the call light is within reach and encourage to use it to call for assistance as needed, keep needed items, water, etc. in reach. Resident #4 had an actual fall with minor injury. Goal: Sutures x4 to be removed 02/19/23 will resolve without complication. Intervention: offer bathroom assistance when making rounds, Bed in lowest position, provide activities that promote exercise and strength building where possible. Review of Resident #4's progress notes dated 04/10/23 at 10:11 PM, documented by LVN A reflected: resident was noted sitting on the floor at the end of bed facing the door next to wheelchair. The roommate says she was trying to get out of bed, and she slid out and sat on the floor. Head to toe assessment done. Alert with no signs or symptoms of acute distress, no injuries noted at this time, vitals checked, staff helped back in bed, denies pain at this time. Bed placed in low position, MD, DON, and family notified, will continue to monitor. Review of medication notes dated 04/11/23 at 4:55 AM documented by LVN A reflected: Acetaminophen Tablet 650 mg. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Review of nurse's notes dated 04/11/23 at 4:56 AM documented by LVN A reflected: During routine rounds, this nurse noted Resident #4 holding left hip massaging it. Asked resident if she was in pain and resident nodded her head. Acetaminophen Tablet 650 MG Give 1 tablet by mouth was administered, MD notified, new order left hip x-ray to rule out fracture. X-ray order placed and waiting for the technician. Will continue to monitor. Review of medication notes dated 04/11/23 at 8:00 AM documented by the DON reflected: Acetaminophen Tablet 650 MG. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Follow up: PRN administration was: Effective, Pain scale was: 2. Review of nurse's notes dated 04/11/23 at 9:55 PM documented by LVN A reflected: Follow up follow day 1 of 2, no delayed injury noted, able to move all extremities without difficult. Denies pain to left hip. Bed placed in low position. Will continue to monitor. Review of nurse's notes dated 04/12/23 at 11:21 AM documented by the ADON reflected: Resident complained of pain to right hip. Pain management administered with acetaminophen. X-rays ordered. Results showed fracture to right hip (error in the facility note). Resident sent to hospital via city ambulance by stretcher. Review of Resident #4's lab results dated 04/11/23 at 11:21 AM revealed interpretation: significant findings: left hip x-ray unilateral 2-3 views show a fracture of the left proximal femur at the intertrochanteric region. Impression: Acute fracture of the left proximal femur at the intertrochanteric region. Reviewed by doctor on 04/12/23 9:11 AM. There was a delay (approximately 28 hours) in getting medical treatment for Resident #4 due to the facility not being aware x-ray results (which showed hip fracture) had been received and not promptly notifying the physician of the results. During an observation and interview on 04/27/23 at 11:48 AM with Resident #4 revealed communication was unclear. Resident #4 would nod head when asking her questions. Resident #4 stated she had some pain, she stated she fell , and she went to the hospital. Resident #4 was not able to say how the fall occurred. During an interview on 04/27/23 at 3:15 PM with CNA C revealed she was alerted to Resident #4's room by the roommate engaging the call light. CNA C stated she observed Resident #4 on the floor around 7:00 PM and called for the nurse to enter the room to assess. CNA C stated after the assessment Resident #4 was put in bed. CNA C stated she returned to check on Resident #4 and to complete incontinent care. CNA C stated Resident #4 was fighting with her and did not want me to change her. CNA C stated it was hard to tell if she was fighting or if she was displaying pain and alerted the nurse. CNA C stated Resident #4 usually did not talk too much but during her rounds the next day Resident #4 was crying. CNA C stated she informed the nurse Resident #4 was crying and appeared to be in pain, she stated the nurse then administered pain medication and ordered x-ray. CNA C stated Resident was not in the facility the following day when she arrived to work. During an interview on 04/27/23 at 3:48 PM with RN D revealed she was informed about Resident #4's fall. RN D stated she was not present when resident had fall or when the x-ray was completed. RN D stated it was protocol if a resident had a fall and complained of pain, nurses would contact the doctor, and the doctor would order an x-ray stat. RN D stated the x-ray techs would show up within the hour and would usually have the results returned the same day via fax. Upon the receipt of the result, nurses would send the results to the doctor, and wait on the doctor's new orders if any which could be pain management or send resident out to the hospital. If the doctor was busy the Nurse Practitioner would respond or would reach back out to the doctor if no response within 2-3 hours. It was the responsibility of all nurses to receive the x-ray results and alert the doctor of the results. RN D stated there was not one specific person who received the x-ray results; however, if you know your resident had an x-ray you should be looking for the results to come in so that you can alert the doctor. RN D stated not following up with x-ray results put the resident at risk of prolonged pain and not getting the services needed. On 04/27/23 at 4:10 PM an attempt to interview LVN A was unsuccessful. During an interview on 04/27/23 at 4:10 PM with the ADON revealed she was present on the day Resident #4 had a fall. ADON stated she and LVN A entered the room between 9:00 PM-9:30 PM after noting the call light was on and someone yelling. The ADON stated she found Resident #4 on the floor at the foot of the bed feet facing the door and head towards the wall. The ADON stated Resident #4's bed was observed to be at the lowest position. The ADON stated Resident #4 was assessed and back in the wheelchair. The ADON stated Resident #4 was crying and upset, you could tell she was in pain. According to the ADON, the next morning on 04/11/23 Resident #4 was hurting, in pain and grabbing her left side so she told the nurse to give pain medication and was told x-rays were already ordered. The ADON stated on 04/12/23 Resident #4 was showing signs of pain with crying and yelling. The ADON stated facility protocol would be to call out for mobile x-ray, when necessary, results were received pretty quick in the resident's chart and the nurse will contact the doctor immediately. The ADON stated she was not able to say who received Resident #4's x-ray results. The ADON stated any nurse on duty could review the x-ray results and contact the doctor. There was not one person responsible for following up with the doctor with the results. The ADON stated not getting the x-ray results in a timely manner could place residents at risk of getting proper medical care. On 04/27/23 at 4:48 PM an attempt to interview Physician I was unsuccessful. During an interview on 04/27/23 at 5:07 PM with the DON revealed she was notified by nursing staff on 04/10/23 at 8:00 PM that Resident #4 had a fall with no injuries. The DON stated LVN A stated during rounds he assessed Resident #4 and observed she was rubbing her hip, expressing that she was in pain. The DON stated LVN A contacted the doctor for an x-ray. The DON stated the x-ray was completed on 04/11/23 at 11:21 AM. The DON stated x-rays were returned the same day and were auto-posted into resident file. The DON stated there was no way to know when the results were uploaded to resident charts. The DON stated the charge nurse on duty for that resident would be the person to go into resident files to check for x-ray results, then contact the doctor. The DON stated in this case the doctor was the one that logged in, reviewed the results, and contacted us to send her out on 04/12/23. The DON stated Resident #4 was given Tylenol one time for pain and was sent to the hospital by stretcher. The DON stated without knowing what time the results came in it was hard to know the risk for Resident #4. During an interview on 04/28/23 at 12:26 PM with Physician I revealed he was reviewing all lab results and identified the results himself for Resident #4. Physician I stated he did not receive notification from the facility that the results were in. Physician I stated he notified the facility that Resident #4 needed to be sent out to the hospital right after revealing the results. Physician I stated he spoke to the DON to have the results sent directly to her so that she was aware when the results were in so she could notify the required authorities as soon as possible to prevent risk to the resident. During interview and record review it was revealed LVN A received a STAT order for an X-ray as of 04/11/23 at 4:56 AM. The x-ray was completed on 04/11/23 at 11:21 AM. Resident #4 was sent out to the hospital on 04/12/23 after the doctor reviewed the results on 04/12/23, he then notified the facility of the results. The ADON stated she did not follow up on the X-ray orders to see if they were received on 04/11/23 after the orders had been completed. ADON stated on 04/12/23 when she asked about orders for the X-ray on 04/12/23, she was notified the resident was being sent out to the hospital. Resident #4 had now been in pain during several shifts (10:00 PM-6:00 AM day 1 of 3, 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM day 2 of 3, and 6:00 AM-until sent to the hospital day 3 of 3) according to both LVN A and ADON. Review of the EMAR revealed she was administered pain medication once on 04/11/23 at 4:55 AM throughout all shifts after the fall. Hospital records revealed Resident #4 admitting diagnosis was severe left hip pain, left hip fracture, leukocytosis, acute cystitis without hematuria, fall, dementia. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. The IJ was removed on 04/28/23 because the facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. The facility submitted the following accepted Plan of Removal on 05/12/23: .Immediate Action: 1. ADON re-education was completed on 4/12/2023 was completed by DON. DON was educated by Clinical Resource .04/27/2023. 2. The Medical Director was notified of IJ on 5/11/2023 at 3:51 PM and read at 3:59 PM . 3. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party in the clinical record; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 4. Notified Medical Director of survey results on 4/28/23 and physician wrote a written statement of no harm or significant delay in care that we received on 5/1/23. (Relevance is that there is no harm or significant delay in care per the Medical Director). 5. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 6. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Identification of Others Affected: Residents who have ordered diagnostic and radiology services have the potential to be affected. Systemic Change to Prevent Re-occurrence: 1. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party with a progress note identifying results and notification made; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 2. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023. 3. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 4. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Monitoring: 1. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023, by Clinical IDT, daily, for 4 weeks, and then routinely monitored through the change of condition process. 2. Weekly clinical meetings will include review of laboratory orders and results. Meeting attendees will include the clinical IDT and the Administrator. Meeting minutes will be reported to monthly QA by DON/ADON/designee. During an interview on 05/11/23 at 4:11 PM with the ADON revealed when she entered the facility on 04/11/23 she received updated information from LVN A and the 24-hour report for Resident #4. The ADON stated she was told an x-ray had been ordered and waiting on x-ray techs arrival. The ADON stated you get busy doing other things and then she realized the next day on 04/12/23, they were sending Resident #4 out to the hospital. The ADON stated since she worked the floor on 04/11/23, she should have followed up with looking for the results by looking in the chart or contacting the x-ray company for results then contacting the physician and the family about Resident #4's results. The ADON stated she completed training and in-services pertaining to labs and radiology services on 04/28/23 the day after the initial HHSC visit on 04/27/23. The ADON stated the facility had implemented daily clinical meetings to review order listing reports and orders from the previous day to be checked by the interdisciplinary team. The ADON stated the team would then reach out to the nurse who created the order or charge nurse on the floor that day to see if they had reviewed orders, reached out to the doctor, and documented in the chart. The ADON stated lab results with significant findings would be sent directly to the DON, the DON would contact the charge nurse and the physician with the findings. The ADON stated the nurses would communicate verbally and through the 24-hour report, whether residents had labs, doctor appointments, anything noted on the 24-hour report, that shift nurse was now responsible to ensure the task was completed, followed-up on and documented in the resident chart. During interview on 05/11/23 at 6:11 PM with the DON revealed she received notification via text from LVN A on 04/10/23 the night of the fall after 9:00 PM. LVN A indicated Resident #4 had no apparent injury and no complaints of pain. The DON stated she returned to the facility on [DATE] about 5:45 AM and was verbally told by LVN A that Resident #4 started complaining of pain, and LVN A contacted the doctor and received an order for x-ray. The DON stated she would have expected x-ray to show up within 4-6 hours. The DON stated since LVN A's shift ended, the 24-hour report would alert the next shift nurse that Resident #4 was to complete x-ray. That shift nurse, which in this case was the ADON should have followed up to ensure the x-ray was completed and results given to the physician. The DON stated in-services were started on 04/28/23 with nurses to check lab results every 4 hours during 12-hour shift. The DON stated the facility had now implemented that after the morning stand-up meeting, the clinical team would review all orders from the previous day, check on the things that needed to be done, go over current orders, care plans, nurses' notes, documentation and calls to doctors and resident representatives. The DON stated she also contacted the imaging company to ensure they would send notification directly to her via text when there were significant findings with lab results. The DON stated the notifications came with a link so that she could access the results. The DON stated she would put in a progress note and notify the doctor, nurse, and resident representative. The DON stated for agency staff or as needed staff there would be a binder with in-services and test to complete to ensure all nursing staff were aware to check for laboratory, radiology, diagnostic result every 4 hours, and to call doctor and resident representatives with results, and to document in the resident chart. During interview on 05/11/23 at 6:46 PM with LVN A revealed the aide alerted him that Resident #4 had fallen on 04/10/23 between 8:00 PM-9:00 PM. LVN A stated when he entered the room Resident #4 was sitting down next to the bed legs straight out, the call light had been initiated by the roommate. LVN A stated the roommate stated Resident #4 was trying to get up off the bed and slid down to the floor. LVN A stated after his assessment her vitals were normal, no findings with range of motion and no indication of pain, Resident #4 was assisted to her bed. LVN A stated during his rounds at 12:00 AM Resident #4 was sleeping, during his rounds at 4:00 AM, Resident #4 was rubbing her left hip continuously. LVN A stated he asked her if she was in pain and the way she replied confirmed she was in pain. LVN A stated he provided her with pain medication which she has an order for use as needed. LVN A stated he contacted the physician and received order for X-ray, contacted the family and notified the DON. LVN A stated when the next shift nurse came, rounds were completed together, completed the 24-hour report so that she could follow up with X-ray. LVN A stated the next day when he entered the facility he completed rounds, Resident #4 was sleep, not showing signs of pain. LVN A stated he thought the results were received and the physician was notified. LVN A stated he did not think to look or ask about the x-ray results, LVN A stated he should have followed up on the results himself. LVN A stated he completed several in-service training about 2 weeks ago covering labs and x-ray results, checking for results every 4 hours during shift and if the results were critical to contact the physician and resident representative immediately, and document. During interview on 05/12/23 at 1:47 PM with Physician I revealed the reason he sent Resident #4 out to the hospital was due to her results of acute fracture of her left hip. Physician I stated Resident #4 did not have an emergency; however, it was urgent, and they needed to act with urgency. Physician I stated he was not sure when the results were sent or received and speaking with the x-ray company, they did not think the hip fracture was considered critical. Physician I stated communication was completed with them to have the understanding to contact the facility through phone call and fax with critical findings. It was discussed with the x-ray company that a hip fracture was a critical result and should have been called to the facility and not just faxed. Physician I stated some things were critical and needed action right away and this was one. Physiciani I stated even if the results came in the same day and she was sent to the hospital that night, the surgery would not have happened until 2-3 days later, and they were still in that window. During interview on 05/12/23 at 3:19 PM with a representative from the x-ray company revealed she had been communicating with the facility a number of ways to alert the facility when results came in. The x-ray company representative stated the results were automatically sent to the same number and emailed whether the findings were significant or not. The x-ray company representative stated after Resident #4's fall more functionality was provided to the alerts and as of 04/17/23 the facility would now be automatically emailed the findings and if there were significant results then the DON would also get a text notifying the DON of the critical result. The x-ray company representative confirmed monitoring and there had not been any further concerns. Review of in-services and interviews on 05/12/23 with nurses, ADON, DON, Clinical Resources revealed the facility implemented in-services on 04/28/23 on the following topics: 1. Notification to MD of abnormal results. Notification to responsible party (RP), progress notes, stating results and notification. 2. Reporting Lab results, check Lab & Radiology Q4 hours during a 12 hour shift. 3. Stop & Watch training with the Nurses, MAs, and CNAs. 4. Response on Resident call lights. Call light in reach of resident. 5. Fall Prevention Review of facility's Nursing Clinical policy and procedure, revised May 2007, reflected the following: Policy- It is the policy of this facility that the resident's attending physician will be notified of the results of diagnostic tests. Procedures: 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the physician of such test results .

Based on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #4) of five residents reviewed for radiology services. The facility failed to retrieve results of an x-ray order of Resident #4's left hip in a timely manner, which resulted in delayed treatment of a dislocation for a period of approximately 28 hours. Resident #4 was found on the floor on 04/10/23 approximately 9:00 PM, STAT orders (referring to a diagnostic or therapeutic procedure that is to be performed immediately; prioritized in a lab, as the results have a potentially immediate impact on patient management) were submitted on 04/11/23 at approximately 4:56 AM, results retrieved on 04/12/23 at approximately 9:11 AM, by Physician I, and the resident was sent out to the hospital on 04/12/23 at approximately 11:21 AM. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. While the IJ was removed on 04/28/23, the facility remained out of compliance at a scope of potential of actual harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. The facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. This failure placed residents at risk of a delay in medical evaluation, treatment and decrease in quality of care. Findings included: Review of Resident #4's face sheet dated 04/27/23 revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnosis included non-displaced intertrochanteric of fracture of left femur, unspecified fall, muscle weakness, difficulty in walking, abnormalities of gait and mobility, history of falling, lack of coordination, unsteadiness on feet. aphasia, major depressive disorder, vascular dementia with agitation. Review of Resident #4's quarterly MDS Assessment, dated 03/25/23, revealed Resident #4 was usually understood by others and was usually able to understand others; however, the resident's cognitive assessment/BIMS was not completed. Transferring between bed, chair, wheelchair, and standing position required extensive assistance with one person assist. Locomotion in the room required supervision with two person assist. Review of Resident #4's care plan, undated, revealed Resident #4 had ADL self-care performance deficit related to weakness, dementia, and transient ischemic accident. Goal: will maintain current level of function in transfers, toilet use and personal hygiene, Intervention: Toilet use: requires x1 staff to assist, Transfer requires x1 staff assist with transferring. Resident #4 at risk for falls related to weakness. Goal: will not sustain serious injury. Intervention: 1/1/23 Fall; due to drop in blood pressure, 1/19/23 Fall; educated resident to call for assistance when picking up things off the floor, 02/12/23 Fall; offer bathroom assistance when making rounds, 04/10/23 Fall; fall mat to beside at all times, be sure the call light is within reach and encourage to use it to call for assistance as needed, keep needed items, water, etc. in reach. Resident #4 had an actual fall with minor injury. Goal: Sutures x4 to be removed 02/19/23 will resolve without complication. Intervention: offer bathroom assistance when making rounds, Bed in lowest position, provide activities that promote exercise and strength building where possible. Review of Resident #4's progress notes dated 04/10/23 at 10:11 PM, documented by LVN A reflected: resident was noted sitting on the floor at the end of bed facing the door next to wheelchair. The roommate says she was trying to get out of bed, and she slid out and sat on the floor. Head to toe assessment done. Alert with no signs or symptoms of acute distress, no injuries noted at this time, vitals checked, staff helped back in bed, denies pain at this time. Bed placed in low position, MD, DON, and family notified, will continue to monitor. Review of medication notes dated 04/11/23 at 4:55 AM documented by LVN A reflected: Acetaminophen Tablet 650 mg. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Review of nurse's notes dated 04/11/23 at 4:56 AM documented by LVN A reflected: During routine rounds, this nurse noted Resident #4 holding left hip massaging it. Asked resident if she was in pain and resident nodded her head. Acetaminophen Tablet 650 MG Give 1 tablet by mouth was administered, MD notified, new order left hip x-ray to rule out fracture. X-ray order placed and waiting for the technician. Will continue to monitor. Review of medication notes dated 04/11/23 at 8:00 AM documented by the DON reflected: Acetaminophen Tablet 650 MG. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Follow up: PRN administration was: Effective, Pain scale was: 2. Review of nurse's notes dated 04/11/23 at 9:55 PM documented by LVN A reflected: Follow up follow day 1 of 2, no delayed injury noted, able to move all extremities without difficult. Denies pain to left hip. Bed placed in low position. Will continue to monitor. Review of nurse's notes dated 04/12/23 at 11:21 AM documented by the ADON reflected: Resident complained of pain to right hip. Pain management administered with acetaminophen. X-rays ordered. Results showed fracture to right hip (error in the facility note). Resident sent to hospital via city ambulance by stretcher. Review of Resident #4's lab results dated 04/11/23 at 11:21 AM revealed interpretation: significant findings: left hip x-ray unilateral 2-3 views show a fracture of the left proximal femur at the intertrochanteric region. Impression: Acute fracture of the left proximal femur at the intertrochanteric region. Reviewed by doctor on 04/12/23 9:11 AM. There was a delay (approximately 28 hours) in getting medical treatment for Resident #4 due to the facility not being aware x-ray results (which showed hip fracture) had been received and not promptly notifying the physician of the results. During an observation and interview on 04/27/23 at 11:48 AM with Resident #4 revealed communication was unclear. Resident #4 would nod head when asking her questions. Resident #4 stated she had some pain, she stated she fell , and she went to the hospital. Resident #4 was not able to say how the fall occurred. During an interview on 04/27/23 at 3:15 PM with CNA C revealed she was alerted to Resident #4's room by the roommate engaging the call light. CNA C stated she observed Resident #4 on the floor around 7:00 PM and called for the nurse to enter the room to assess. CNA C stated after the assessment Resident #4 was put in bed. CNA C stated she returned to check on Resident #4 and to complete incontinent care. CNA C stated Resident #4 was fighting with her and did not want me to change her. CNA C stated it was hard to tell if she was fighting or if she was displaying pain and alerted the nurse. CNA C stated Resident #4 usually did not talk too much but during her rounds the next day Resident #4 was crying. CNA C stated she informed the nurse Resident #4 was crying and appeared to be in pain, she stated the nurse then administered pain medication and ordered x-ray. CNA C stated Resident was not in the facility the following day when she arrived to work. During an interview on 04/27/23 at 3:48 PM with RN D revealed she was informed about Resident #4's fall. RN D stated she was not present when resident had fall or when the x-ray was completed. RN D stated it was protocol if a resident had a fall and complained of pain, nurses would contact the doctor, and the doctor would order an x-ray stat. RN D stated the x-ray techs would show up within the hour and would usually have the results returned the same day via fax. Upon the receipt of the result, nurses would send the results to the doctor, and wait on the doctor's new orders if any which could be pain management or send resident out to the hospital. If the doctor was busy the Nurse Practitioner would respond or would reach back out to the doctor if no response within 2-3 hours. It was the responsibility of all nurses to receive the x-ray results and alert the doctor of the results. RN D stated there was not one specific person who received the x-ray results; however, if you know your resident had an x-ray you should be looking for the results to come in so that you can alert the doctor. RN D stated not following up with x-ray results put the resident at risk of prolonged pain and not getting the services needed. On 04/27/23 at 4:10 PM an attempt to interview LVN A was unsuccessful. During an interview on 04/27/23 at 4:10 PM with the ADON revealed she was present on the day Resident #4 had a fall. ADON stated she and LVN A entered the room between 9:00 PM-9:30 PM after noting the call light was on and someone yelling. The ADON stated she found Resident #4 on the floor at the foot of the bed feet facing the door and head towards the wall. The ADON stated Resident #4's bed was observed to be at the lowest position. The ADON stated Resident #4 was assessed and back in the wheelchair. The ADON stated Resident #4 was crying and upset, you could tell she was in pain. According to the ADON, the next morning on 04/11/23 Resident #4 was hurting, in pain and grabbing her left side so she told the nurse to give pain medication and was told x-rays were already ordered. The ADON stated on 04/12/23 Resident #4 was showing signs of pain with crying and yelling. The ADON stated facility protocol would be to call out for mobile x-ray, when necessary, results were received pretty quick in the resident's chart and the nurse will contact the doctor immediately. The ADON stated she was not able to say who received Resident #4's x-ray results. The ADON stated any nurse on duty could review the x-ray results and contact the doctor. There was not one person responsible for following up with the doctor with the results. The ADON stated not getting the x-ray results in a timely manner could place residents at risk of getting proper medical care. On 04/27/23 at 4:48 PM an attempt to interview Physician I was unsuccessful. During an interview on 04/27/23 at 5:07 PM with the DON revealed she was notified by nursing staff on 04/10/23 at 8:00 PM that Resident #4 had a fall with no injuries. The DON stated LVN A stated during rounds he assessed Resident #4 and observed she was rubbing her hip, expressing that she was in pain. The DON stated LVN A contacted the doctor for an x-ray. The DON stated the x-ray was completed on 04/11/23 at 11:21 AM. The DON stated x-rays were returned the same day and were auto-posted into resident file. The DON stated there was no way to know when the results were uploaded to resident charts. The DON stated the charge nurse on duty for that resident would be the person to go into resident files to check for x-ray results, then contact the doctor. The DON stated in this case the doctor was the one that logged in, reviewed the results, and contacted us to send her out on 04/12/23. The DON stated Resident #4 was given Tylenol one time for pain and was sent to the hospital by stretcher. The DON stated without knowing what time the results came in it was hard to know the risk for Resident #4. During an interview on 04/28/23 at 12:26 PM with Physician I revealed he was reviewing all lab results and identified the results himself for Resident #4. Physician I stated he did not receive notification from the facility that the results were in. Physician I stated he notified the facility that Resident #4 needed to be sent out to the hospital right after revealing the results. Physician I stated he spoke to the DON to have the results sent directly to her so that she was aware when the results were in so she could notify the required authorities as soon as possible to prevent risk to the resident. During interview and record review it was revealed LVN A received a STAT order for an X-ray as of 04/11/23 at 4:56 AM. The X-ray was completed on 04/11/23 at 11:21 AM. Resident #4 was sent out to the hospital on 04/12/23 after the doctor reviewed the results on 04/12/23, he then notified the facility of the results. The ADON stated she did not follow up on the X-ray orders to see if they were received on 04/11/23 after the orders had been completed. ADON stated on 04/12/23 when she asked about orders for the X-ray on 04/12/23, she was notified the resident was being sent out to the hospital. Resident #4 had now been in pain during several shifts (10:00 PM-6:00 AM day 1 of 3, 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM day 2 of 3, and 6:00 AM-until sent to the hospital day 3 of 3) according to both LVN A and ADON. Review of the EMAR revealed she was administered pain medication once on 04/11/23 at 4:55 AM throughout all shifts after the fall. Hospital records revealed Resident #4 admitting diagnosis was severe left hip pain, left hip fracture, leukocytosis, acute cystitis without hematuria, fall, dementia. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. The IJ was removed on 04/28/23 because the facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. The facility submitted the following accepted Plan of Removal on 05/12/23: .Immediate Action: 1. ADON re-education was completed on 4/12/2023 was completed by DON. DON was educated by Clinical Resource .04/27/2023. 2. The Medical Director was notified of IJ on 5/11/2023 at 3:51 PM and read at 3:59 PM . 3. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party in the clinical record; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 4. Notified Medical Director of survey results on 4/28/23 and physician wrote a written statement of no harm or significant delay in care that we received on 5/1/23. (Relevance is that there is no harm or significant delay in care per the Medical Director). 5. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 6. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Identification of Others Affected: Residents who have ordered diagnostic and radiology services have the potential to be affected. Systemic Change to Prevent Re-occurrence: 1. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party with a progress note identifying results and notification made; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 2. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023. 3. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 4. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Monitoring: 1. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023, by Clinical IDT, daily, for 4 weeks, and then routinely monitored through the change of condition process. 2. Weekly clinical meetings will include review of laboratory orders and results. Meeting attendees will include the clinical IDT and the Administrator. Meeting minutes will be reported to monthly QA by DON/ADON/designee. During an interview on 05/11/23 at 4:11 PM with the ADON revealed when she entered the facility on 04/11/23 she received updated information from LVN A and the 24-hour report for Resident #4. The ADON stated she was told an x-ray had been ordered and waiting on x-ray techs arrival. The ADON stated you get busy doing other things and then she realized the next day on 04/12/23, they were sending Resident #4 out to the hospital. The ADON stated since she worked the floor on 04/11/23, she should have followed up with looking for the results by looking in the chart or contacting the x-ray company for results then contacting the physician and the family about Resident #4's results. The ADON stated she completed training and in-services pertaining to labs and radiology services on 04/28/23 the day after the initial HHSC visit on 04/27/23. The ADON stated the facility had implemented daily clinical meetings to review order listing reports and orders from the previous day to be checked by the interdisciplinary team. The ADON stated the team would then reach out to the nurse who created the order or charge nurse on the floor that day to see if they had reviewed orders, reached out to the doctor, and documented in the chart. The ADON stated lab results with significant findings would be sent directly to the DON, the DON would contact the charge nurse and the physician with the findings. The ADON stated the nurses would communicate verbally and through the 24-hour report, whether residents had labs, doctor appointments, anything noted on the 24-hour report, that shift nurse was now responsible to ensure the task was completed, followed-up on and documented in the resident chart. During interview on 05/11/23 at 6:11 PM with the DON revealed she received notification via text from LVN A on 04/10/23 the night of the fall after 9:00 PM. LVN A indicated Resident #4 had no apparent injury and no complaints of pain. The DON stated she returned to the facility on [DATE] about 5:45 AM and was verbally told by LVN A that Resident #4 started complaining of pain, and LVN A contacted the doctor and received an order for x-ray. The DON stated she would have expected x-ray to show up within 4-6 hours. The DON stated since LVN A's shift ended, the 24-hour report would alert the next shift nurse that Resident #4 was to complete x-ray. That shift nurse, which in this case was the ADON should have followed up to ensure the x-ray was completed and results given to the physician. The DON stated in-services were started on 04/28/23 with nurses to check lab results every 4 hours during 12-hour shift. The DON stated the facility had now implemented that after the morning stand-up meeting, the clinical team would review all orders from the previous day, check on the things that needed to be done, go over current orders, care plans, nurses' notes, documentation and calls to doctors and resident representatives. The DON stated she also contacted the imaging company to ensure they would send notification directly to her via text when there were significant findings with lab results. The DON stated the notifications came with a link so that she could access the results. The DON stated she would put in a progress note and notify the doctor, nurse, and resident representative. The DON stated for agency staff or as needed staff there would be a binder with in-services and test to complete to ensure all nursing staff were aware to check for laboratory, radiology, diagnostic result every 4 hours, and to call doctor and resident representatives with results, and to document in the resident chart. During interview on 05/11/23 at 6:46 PM with LVN A revealed the aide alerted him that Resident #4 had fallen on 04/10/23 between 8:00 PM-9:00 PM. LVN A stated when he entered the room Resident #4 was sitting down next to the bed legs straight out, the call light had been initiated by the roommate. LVN A stated the roommate stated Resident #4 was trying to get up off the bed and slid down to the floor. LVN A stated after his assessment her vitals were normal, no findings with range of motion and no indication of pain, Resident #4 was assisted to her bed. LVN A stated during his rounds at 12:00 AM Resident #4 was sleeping, during his rounds at 4:00 AM, Resident #4 was rubbing her left hip continuously. LVN A stated he asked her if she was in pain and the way she replied confirmed she was in pain. LVN A stated he provided her with pain medication which she has an order for use as needed. LVN A stated he contacted the physician and received order for X-ray, contacted the family and notified the DON. LVN A stated when the next shift nurse came, rounds were completed together, completed the 24-hour report so that she could follow up with X-ray. LVN A stated the next day when he entered the facility he completed rounds, Resident #4 was sleep, not showing signs of pain. LVN A stated he thought the results were received and the physician was notified. LVN A stated he did not think to look or ask about the x-ray results, LVN A stated he should have followed up on the results himself. LVN A stated he completed several in-service training about 2 weeks ago covering labs and x-ray results, checking for results every 4 hours during shift and if the results were critical to contact the physician and resident representative immediately, and document. During interview on 05/12/23 at 1:47 PM with Physician I revealed the reason he sent Resident #4 out to the hospital was due to her results of acute fracture of her left hip. Physician I stated Resident #4 did not have an emergency; however, it was urgent, and they needed to act with urgency. Physician I stated he was not sure when the results were sent or received and speaking with the x-ray company, they did not think the hip fracture was considered critical. Physician I stated communication was completed with them to have the understanding to contact the facility through phone call and fax with critical findings. It was discussed with the x-ray company that a hip fracture was a critical result and should have been called to the facility and not just faxed. Physician I stated some things were critical and needed action right away and this was one. Physician I stated even if the results came in the same day and she was sent to the hospital that night, the surgery would not have happened until 2-3 days later, and they were still in that window. During interview on 05/12/23 at 3:19 PM with a representative from the x-ray company revealed she had been communicating with the facility a number of ways to alert the facility when results came in. The x-ray company representative stated the results were automatically sent to the same number and emailed whether the findings were significant or not. The x-ray company representative stated after Resident #4's fall more functionality was provided to the alerts and as of 04/17/23 the facility would now be automatically emailed the findings and if there were significant results then the DON would also get a text notifying the DON of the critical result. The x-ray company representative confirmed monitoring and there had not been any further concerns. Review of in-services and interviews on 05/12/23 with nurses, ADON, DON, Clinical Resources revealed the facility implemented in-services on 04/28/23 on the following topics: 1. Notification to MD of abnormal results. Notification to responsible party (RP), progress notes, stating results and notification. 2. Reporting Lab results, check Lab & Radiology Q4 hours during a 12 hour shift. 3. Stop & Watch training with the Nurses, MAs, and CNAs. 4. Response on Resident call lights. Call light in reach of resident. 5. Fall Prevention Review of facility's Nursing Clinical policy and procedure, revised May 2007, reflected the following: Policy- It is the policy of this facility that the resident's attending physician will be notified of the results of diagnostic tests. Procedures: 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the physician of such test results .

Based on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of five residents reviewed for pain management. 1. MA A failed to apply a pain patch on Resident #1 as ordered, which resulted in the resident having pain at a level 8 out of 10. 2. MA A failed to report Resident #1's request for a PRN muscle relaxant to the nurse, which resulted in the resident having pain at a level 8 out of 10. These failures resulted in the resident experiencing preventable pain symptoms. Findings included: Review of Resident #1's EHR revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with emphysema, back pain, and difficulty swallowing. Resident #1 was hospitalized for her emphysema on 01/31/23 and incidental x-rays found fractures in her spine. The resident was diagnosed with compression fractures of the spine in her lower back. Review of Resident #1's admission MDS, dated [DATE], revealed her BIMS score had not been completed. Her Functional Status revealed she required limited assistance with most of her ADLs except her bed mobility and transfers for which she required extensive assistance. Review of Resident #1's care plan, dated 01/18/23, revealed she was at risk for self-care deficit related to back pain and for chronic pain related to back pain. Review of Resident #1's physician orders revealed the following orders written on 02/09/23: Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 8 hours as needed for Muscle spasm. Lidoderm Patch 5 % (Lidocaine) Apply to per additional directions topically in the morning for Pain on right shoulder and remove per schedule. Interview and observation on 02/22/23 at 11:50 AM, Resident #1 stated she had back pain for quite some time. She did not recall having any falls that would have caused her to have fractures in her back. Resident #1 stated she suffered from back pain and muscle spasms in her back that made it hard for her to sit up, get out of bed, and participate in her therapy. Resident #1 stated she had pain medication prescribed routinely that helped with the pain, and her muscle relaxant was prescribed every eight hours as needed. Resident #1 stated she really needed her muscle relaxant first thing in the morning to make the rest of the day bearable. Resident #1 stated she woke around 6:30 AM and had asked her medication aide (MA A) for a muscle relaxant when she was given her pain pill around 9:00 AM today and was told by the medication aide that she could not have a pain pill and a muscle relaxant at the same time. Resident #1 stated the medication aide only gave her the pain pill and moved on. She also wanted her pain patch applied; it was scheduled, but the medication aide had not applied it. Resident #1 stated her pain was an 8 out of 10 before receiving hydrocodone. Resident #1 stated she had had her pain pill and muscle relaxant at the same time in the past, and those were good days for her. Resident #1 stated she was not able to go to therapy because she was not able to get out of bed. At the time of the interview, Resident #1 was lying on her side and complaining of back spasms and requested the surveyor to ask her nurse for a muscle relaxant. The surveyor notified RN B of the resident's request for a muscle relaxant. Interview and observation on 02/22/23 at 12:05 PM, RN B stated she had not been made aware Resident #1 wanted a muscle relaxant. RN B proceeded to Resident #1's room to ask if she wanted a muscle relaxant, Resident #1 stated she did. RN B assessed Resident #1 for the presence of her lidocaine patch, the lidocaine patch was not observed. Resident #1's pain was 8 out of 10. RN B stated she would ask the medication aide about the patch. Interview on 02/22/23 at 12:30 PM, MA A stated when Resident #1 had asked for a muscle relaxant she thought the resident could not have the muscle relaxant and a pain pill at the same time. MA A stated she had not informed RN B about the muscle relaxant request because of that. MA A stated she had documented the lidocaine patch as being given, but she had been called away before she could apply it and forgot to come back. MA A stated she had not followed up with Resident #1 about her pain level after the resident received hydrocodone. Review of Resident #1's February 2023 MAR revealed the Lidocaine patch had been documented as being given at 8:00 AM on 02/22/23. The last documented time the muscle relaxant was administered was on 02/20/23, although it was a PRN order and could be administered as needed for muscle spasms. Interview on 02/22/23 at 12:32 PM, RN B stated she had not rounded on Resident #1 that morning to see if she had received her medications and if she had any needs. RN B stated if she had made rounds she would have known Resident #1 had been having pain and needed additional medications. RN B would not state if she normally conducted rounds on her residents. RN B stated medications prescribed as needed were administered by the nursing staff, and medication aides only administered routine medications. RN B stated as needed medications required a nurse's assessment to determine if the medication requested was appropriate for the resident's complaint. Interview on 02/22/23 at 12:55 PM, the DON stated all medications given were required to be documented in the resident's MAR at the time they were administered. The DON stated having an inaccurate MAR could lead to a resident being over medicated, missing a medication, and not receiving the therapeutic effects of a medication. The DON stated medication aides were expected to report a request for an as needed medication to the nurse so that the nurse could assess the resident for the appropriateness of the medication or find alternatives to medication. The DON stated MA A should have reported the request for a muscle relaxant by Resident #1 to RN B. She also stated MA A should not have documented she applied the lidocaine patch until she had actually placed it. Review of the facility's policy Administration of Medications, dated July 2017, reflected: .1. Only licensed medical and nursing personnel or any lawfully authorized staff member may prepare, administer, and record medication administration. 2. Medication must be administered in accordance with the resident's service plan. 3. Medications must be administered in accordance with the written orders of the attending physician. 8. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the resident's next medication.

Based on observation, interview, and record review, the facility failed to ensure that residents were free of any significant medication errors for one (Resident #1) of five residents reviewed for medications. 1. MA A failed to apply a pain patch on Resident #1 as ordered, which resulted in the resident having pain at a level 8 out of 10. 2. MA A failed to report Resident #1's request for a PRN muscle relaxant to the nurse, which resulted in the resident having pain at a level 8 out of 10. These failures resulted in the resident experiencing preventable pain symptoms. Findings included: Review of Resident #1's EHR revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with emphysema, back pain, and difficulty swallowing. Resident #1 was hospitalized for her emphysema on 01/31/23 and incidental x-rays found fractures in her spine. The resident was diagnosed with compression fractures of the spine in her lower back. Review of Resident #1's admission MDS, dated [DATE], revealed her BIMS score had not been completed. Her Functional Status revealed she required limited assistance with most of her ADLs except her bed mobility and transfers for which she required extensive assistance. Review of Resident #1's care plan, dated 01/18/23, revealed she was at risk for self-care deficit related to back pain and for chronic pain related to back pain. Review of Resident #1's physician orders revealed the following orders written on 02/09/23: Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 8 hours as needed for Muscle spasm. Lidoderm Patch 5 % (Lidocaine) Apply to per additional directions topically in the morning for Pain on right shoulder and remove per schedule. Interview and observation on 02/22/23 at 11:50 AM, Resident #1 stated she had back pain for quite some time. She did not recall having any falls that would have caused her to have fractures in her back. Resident #1 stated she suffered from back pain and muscle spasms in her back that made it hard for her to sit up, get out of bed, and participate in her therapy. Resident #1 stated she had pain medication prescribed routinely that helped with the pain, and her muscle relaxant was prescribed every eight hours as needed. Resident #1 stated she really needed her muscle relaxant first thing in the morning to make the rest of the day bearable. Resident #1 stated she woke around 6:30 AM and had asked her medication aide (MA A) for a muscle relaxant when she was given her pain pill around 9:00 AM today and was told by the medication aide that she could not have a pain pill and a muscle relaxant at the same time. Resident #1 stated the medication aide only gave her the pain pill and moved on. She also wanted her pain patch applied; it was scheduled, but the medication aide had not applied it. Resident #1 stated her pain was an 8 out of 10 before receiving hydrocodone. Resident #1 stated she had had her pain pill and muscle relaxant at the same time in the past, and those were good days for her. Resident #1 stated she was not able to go to therapy because she was not able to get out of bed. At the time of the interview, Resident #1 was lying on her side and complaining of back spasms and requested the surveyor to ask her nurse for a muscle relaxant. The surveyor notified RN B of the resident's request for a muscle relaxant. Interview and observation on 02/22/23 at 12:05 PM, RN B stated she had not been made aware Resident #1 wanted a muscle relaxant. RN B proceeded to Resident #1's room to ask if she wanted a muscle relaxant, Resident #1 stated she did. RN B assessed Resident #1 for the presence of her lidocaine patch, the lidocaine patch was not observed. Resident #1's pain was 8 out of 10. RN B stated she would ask the medication aide about the patch. Interview on 02/22/23 at 12:30 PM, MA A stated when Resident #1 had asked for a muscle relaxant she thought the resident could not have the muscle relaxant and a pain pill at the same time. MA A stated she had not informed RN B about the muscle relaxant request because of that. MA A stated she had documented the lidocaine patch as being given, but she had been called away before she could apply it and forgot to come back. MA A stated she had not followed up with Resident #1 about her pain level after the resident received hydrocodone. Review of Resident #1's February 2023 MAR revealed the Lidocaine patch had been documented as being given at 8:00 AM on 02/22/23. The last documented time the muscle relaxant was administered was on 02/20/23, although it was a PRN order and could be administered as needed for muscle spasms. Interview on 02/22/23 at 12:32 PM, RN B stated she had not rounded on Resident #1 that morning to see if she had received her medications and if she had any needs. RN B stated if she had made rounds she would have known Resident #1 had been having pain and needed additional medications. RN B would not state if she normally conducted rounds on her residents. RN B stated medications prescribed as needed were administered by the nursing staff, and medication aides only administered routine medications. RN B stated as needed medications required a nurse's assessment to determine if the medication requested was appropriate for the resident's complaint. Interview on 02/22/23 at 12:55 PM, the DON stated all medications given were required to be documented in the resident's MAR at the time they were administered. The DON stated having an inaccurate MAR could lead to a resident being over medicated, missing a medication, and not receiving the therapeutic effects of a medication. The DON stated medication aides were expected to report a request for an as needed medication to the nurse so that the nurse could assess the resident for the appropriateness of the medication or find alternatives to medication. The DON stated MA A should have reported the request for a muscle relaxant by Resident #1 to RN B. She also stated MA A should not have documented she applied the lidocaine patch until she had actually placed it. Review of the facility's policy Administration of Medications, dated July 2017, reflected: .1. Only licensed medical and nursing personnel or any lawfully authorized staff member may prepare, administer, and record medication administration. 2. Medication must be administered in accordance with the resident's service plan. 3. Medications must be administered in accordance with the written orders of the attending physician. 8. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the resident's next medication.

Based on observation, interview and record review the facility failed to ensure residents had the right to be from abuse, neglect, misappropriation of resident property, and exploitation for six of 16 residents (Residents #2, #3, #4, #5, #6 and #7) reviewed for abuse. The facility failed to protect Residents #2, #3, #4, #5, #6 and #7 from Resident #1, who had a known history of physical and verbal aggression towards residents. An Immediate Jeopardy (IJ) situation was identified on 01/05/23. The IJ began on 11/04/22 and removed on 12/22/22. While the IJ was removed on 12/22/22, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with alcohol induced persisting dementia (brain disorder that causes memory loss), alcoholic polyneuropathy (alcohol induced nerve disorder), aphasia (speech disorder), schizoaffective disorder (psychotic/mood disorder), major depressive disorder (mood disorder), and cognitive communication deficit. Record review of Resident #1's Quarterly MDS assessment, dated 11/28/22, reflected Resident #1 had a diagnosis which included non-Alzheimer's dementia. The resident had a BIMS score of 0, due to the BIMs not being completed due to cognitive deficits. The MDS reflected Resident #1 rarely had the ability to make himself clear and understand others. Resident #1 was severely impaired when it came to making decisions regarding tasks of daily life. The MDS reflected Resident #1 was short-tempered and easily annoyed. Record review of Resident #1's care plan, revised 11/07/22, revealed: Resident #1 was at risk for impaired cognitive function or impaired thought processes r/t dementia. Resident #1 had poor attention span, fidgety, unable to sit for a very long time and was constantly on the move. Goal: resident will maintain current level of cognitive function through review date. Interventions: administer Memantine as ordered, administer Thiamine as ordered, identify self at each interaction, and give step-by-step instructions one at a time as needed to support cognitive function. Resident #1 had the potential for psychosocial well-being problem r/t resident wandering into other residents' spaces, grabs their wrists, their items, food on trays in dining room, then other residents retaliate against him. Goals: resident will have no indications of psychosocial well-being problems through review date. Interventions: 1:1 supervision, monitor for injuries every shift for 3 days, monitor/document resident's feelings relative to the other residents. Resident #1 had the potential to demonstrate physical behaviors r/t Dementia, hitting, kicking at staff, unable to redirect behavior. Resident combative, verbally aggressive, going in and out of resident rooms, upset with redirection, cursing staff, and refusing care. Goals: resident will not harm self or other residents. Interventions: 1:1 supervision, administer Benadryl as ordered, provide physical and verbal cues to alleviate anxiety, document observed behaviors and attempted interventions, and give as many choices as possible regarding care and activities. Record review of Resident #2's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included age-related osteoporosis (weak bones), unspecified dementia without behavioral disturbances (brain disorder that causes memory loss), speech language deficits, and profound intellectual disabilities. Record review of Resident #2's Quarterly MDS assessment, dated 10/21/22, reflected a BIMS score of 06, which indicated severe impairment. Record review of Resident #2's care plan, dated 06/21/22, revealed the resident was to be monitored for re-traumatization r/t assault in 2013. The family complained of poor care at prior living situation. Resident noted to cry a lot, but not abnormal per guardian. Goals: resident will have no evidence of emotional, physical, and psychological problems by review date. Interventions: anticipate and meet needs, document behaviors and resident's response to interventions. Record review of Resident #3's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), unspecified dementia and essential hypertension (high blood pressure). Record review of Resident #3's Quarterly MDS assessment, dated 12/21/22, reflected a BIMS score of 0, due to the BIMs not being completed, due to cognitive deficits. Record review of Resident #3's care plan, dated 11/04/22, revealed the resident had potential for injury related to another resident hitting her in the chest, monitoring needed for injury. Interventions: Monitor res for pain, bruising chest area q shift. Resident #3 also had potential for pain and inability to communicate. Goal: If or when res shows signs of pain, pain med will be effective. Interventions: Anticipate need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #4's face sheet, dated 12/22/22, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), respiratory failure, anxiety disorder. Record review of Resident 4's Quarterly MDS assessment, dated 10/02/22, reflected the resident had a BIMS of 08, which indicated moderately impaired cognition. Record review of Resident #4's care plan, dated 01/22/20, revealed: Resident #4 had a terminal prognosis related to chronic obstructive pulmonary disease. Goal: to be free of depression and anxiety. Interventions: assess resident coping strategies and respect resident wishes, monitor significant changes in patients physical, mental, social, or emotional status and/or concerns including pain and uncomfortable situations. Record review of Resident #5's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), asthma, abnormalities of gait and mobility and major depressive disorder. Record review of Resident #5's Quarterly MDS assessment, dated 11/15/22, reflected the resident had a BIMS of 12, which indicated moderately impaired cognition. Record review of Resident #5's care plan, dated 04/01/22, revealed: Resident #5 was at risk for Re-traumatization related to history of alleged verbal abuse and history of alleged physical abuse. Goal: have no evidence of emotional, physical, and psychological problems. Interventions: monitoring behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Anticipate and meet needs. Record review of Resident #6's electronic face sheet, dated 12/22/22, revealed Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included moderate intellectual disabilities, manic episode without psychotic symptoms and cognitive communication deficit. Record review of Resident #6's Quarterly MDS assessment, dated 07/13/22, revealed Resident #6's BIMS score was 0, due to the BIMs not being completed due to cognitive deficits. Record review of Resident #6's care plan, dated 08/04/22, revealed Resident #6 had Anti-anxiety medication use related to anxiety disorder. Goal revealed resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included Lorazepam as ordered by physician. 8/3/2022 Increased Dosage. Record review of Resident #7's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), type II diabetes, aphasia (speech disorder), hemiplegia (severe or complete paralysis), hemiparesis (mild or partial weakness), osteoporosis (weak bones) and dementia (brain disorder that causes memory loss). Record review of Resident #7's Quarterly MDS assessment, dated 12/15/22, reflected the resident had a BIMS of 13, which indicated her cognition was intact. Record review of Resident #7's care plan, dated 06/08/22, revealed: Resident #7 had potential for aggressive behaviors and psychosocial well-being problem related to a resident-to-resident incident. Goal: resident will have no indications of psychosocial well-being problems and will identify coping mechanisms. Interventions: skin assessments, monitor for mood change, separate from other resident in incident, when conflict arises, remove Resident #7 to a calm safe environment and allow to vent/share feelings. Record review of Progress Notes, dated 12/11/2022, regarding Resident #1 revealed Resident was found in another resident's room scooting around. He took her picture frame and threw it and broke it. The other resident was pushing the seat of the wheelchair into his back over and over to scoot him out of her room. Resident removed from her room and avoiding glass on the floor, assisted back into wheelchair. Head to toe assessment shows no apparent injuries. Record review of Progress Notes, dated 12/12/2022, regarding Resident #1 revealed Resident remains on follow up related to resident-to-resident altercation with no other incidents observed or reported . Record review of Progress Notes, dated 12/13/2022, regarding Resident #1 revealed Resident wandering aimless into resident room with re-direction given . Record review of Progress Notes, dated 12/14/2022, regarding Resident #1 revealed Resident wandering aimless into resident room with re-direction given . Record review of Progress Notes, dated 12/21/2022, regarding Resident #1 revealed Resident agitated, moving from room to room waking up residents, resisting care Lorazepam Tablet 0.5 MG . Record review of Incident Report, dated 10/9/2022, regarding Resident #1 revealed Resident wheeled himself into room [ROOM NUMBER] and was found crawling around the floor there. Wheelchair was also knocked over. Left forearm skin tear noted. Range of motion per baseline. No signs of pain. Record review of Incident Report, dated 12/11/2022, regarding Resident #1 revealed Resident was in another residents' room and was bothering her things. He got out of his wheelchair and got onto the floor, found and broke a picture frame. An attempted interview and observation on 12/22/22 at 11:51 AM with Resident #1 revealed he was unable to participate in an interview due to cognitive deficits. When asked a question, the resident did not respond and was not aware of what was being said. Resident #1 was observed self-propelling around the facility in a wheelchair. He was seen entering a resident's room without any intervention. An interview and observation on 12/22/22 at 11:53 AM with RN C revealed she saw Resident #1 enter room [ROOM NUMBER]. RN C stated Resident #1 was always going into other rooms, and it was hard for staff to stop him because he would become angry. RN C stated she did not intervene because there were no residents in room [ROOM NUMBER], although Resident #1 was not supposed to be in that room. RN C proceeded to go into room [ROOM NUMBER] and redirected Resident #1 out. RN C stated Resident #1 went all over the facility and usually did not disturb anyone until he was redirected and unable to do what he wanted. RN C stated staff had been trained to do frequent checks on Resident #1 to prevent him from going into other resident rooms. An interview on 12/22/22 at 11:30 AM with Resident #2 revealed she was sitting in a wheelchair on the 200 Hall near her room. Resident #2 denied being abused or neglected by staff. When asked about other residents, Resident #2 stated she was afraid of Resident #1 and immediately became teary-eyed and hysterical. Resident #2 was so upset she could barely speak, but she was able to state Resident #1 was always coming into her room to take things and curse at her and her roommate. Resident #2 stated she was afraid Resident #1 was going to hurt her and her roommate. Resident #2 continued to cry and stated she had to protect her roommate from Resident #1. An attempted interview on 12/22/22 at 11:15 AM with Resident #3 revealed she was unable to participate in an interview due to cognitive deficits. Resident #3 was dressed and well-groomed with no visible marks or bruises. An interview on 12/22/22 at 11:55 AM with Resident #4 revealed she had recently relocated to another room because of having issues with another resident who she described as Resident #1. Resident #4 stated Resident #1 had just been in her room the previous night going through her personal items. Resident #4 stated Resident #1 liked to get close to her, in her personal space and this made her feel uncomfortable. Resident #4 stated Resident #1 needed to be in a different facility because staff were not able properly care for him because he liked to roam the facility, curse at residents, and cause problems with other residents. Resident #4 stated she always alerted staff to remove him from her room, but it sometimes took a long time to remove him. She stated she would use the saltshaker, telling him it was evil, to get Resident #1 away from her. Resident #4 denied ever being physically harmed by Resident #1 but stated she was afraid of him. An interview on 12/22/22 at 12:33 PM with Resident #5 revealed she had an encounter with Resident #1 while sitting in the dining room. She stated Resident #1 jumped on her. Resident #5 stated she was physically attacked but did not indicate having any pain or injuries from the incident. She stated she was nervous around Resident #1 since then. She stated Resident #1 would always come in her personal space as if he did not understand boundaries. Resident #5 stated when she saw Resident #1 getting too close, she would have to stop him to keep him from grabbing her. She stated he could have become very aggressive. Resident #5 stated Resident #1 needed to be at a different facility, because of the way he treated people and he could harm someone. Resident #5 stated she was scared he would cause harm to her again. An interview on 12/22/22 at 12:42 PM with Resident #6 revealed she was hit in the stomach by Resident #1 in the dining hall during lunch. Resident #6 stated she reported the altercation to the Speech Therapist. Resident #6 did not recall any pain or injuries after the altercation. Resident #6 stated she did not like Resident #1 and he was mean and made her feel uncomfortable. An interview on 12/22/22 at 2:45 PM with the Speech Therapist revealed on 11/07/22, he was walking in the dining area and Resident #6 reported to him she was hit in the stomach. When asked to identify the person who hit her, she pointed out Resident #1. The Speech Therapist stated he saw Resident #1 having aggressive behaviors towards staff and other residents on many occasions. The Speech Therapist stated he was told by several residents they were fearful of Resident #1. Residents stated they have woken to him being in their rooms throughout the night. The Speech Therapist stated he alerted the Administrator about all concerns that were brought to him by residents, and he would try to assist with redirecting Resident #1 as much as possible. An interview on 12/22/22 at 11:41 AM with Resident #7, revealed the only person she was afraid of at the facility was Resident #1. She stated, He's a pain in the butt! Resident #7 stated Resident #1 would always come in her room and take her personal belongings. She stated he was caught in her room about a week ago and when she broke a special picture frame of hers. Resident #7 stated staff would try to keep him out of her room, but he would find a way to get in. She stated she was recently moved to a different room to get away from Resident #1 and now felt safer. She denied ever being physically abused by Resident #1. An interview on 12/22/22 at 1:05 PM with CNA A, revealed she had worked at the facility since 2019. CNA A stated she worked on the 200 Hall with Resident #1. She stated Resident #1 would beat on the staff and other residents periodically since being admitted . CNA A stated he would sneak into other resident rooms and if staff were unable to catch him in a timely manner, he would grab or hit the residents. She stated if Resident #1 was seen going into another resident's room, staff would redirect and guide him out immediately. CNA A stated she last witnessed Resident #1 hit another resident about a month ago; however, he was constantly cursing and yelling at everyone. She stated Resident #1 was placed on 1:1 supervision after this incident, but she believed it was discontinued because he would attack the staff who were supervising him, and staff started refusing to work with him. This incident was reported and investigated on this date. CNA A stated Resident #1 was able to be redirected sometimes but most times he could not be due to his cognition. CNA A stated staff could not reason with Resident #1 or help him understand why he was unable to wander in other rooms or intrude on the space of other residents. She stated staff were told to check on Resident #1 more frequently, but it was hard to do so and care for all other residents. She stated most residents on the 200 Hall were afraid of Resident #1, and some had even been moved to different halls to get away from him. CNA A stated staff were trained on abuse, neglect and handling aggressive behaviors with the last training being about a month ago. An interview on 12/22/22 at 1:25 PM with RN B, revealed she had worked at the facility since 2017. RN B stated she worked on the 200 Hall with Resident #1. She stated Resident #1 was a difficult resident with aggressive behaviors. RN B stated most of the residents were afraid of him. She stated there were interventions in place to check on him every 15 mins and sometimes he was placed on 1:1 supervision. RN B stated she tried to keep Resident #1 close to her station, but it was hard because he liked to wander and go into other resident rooms. RN B stated Resident #1 had been on psychotropic medications to help control his behaviors; however, the family would have them adjusted or discontinued. RN B stated the medications Resident #1 was currently on, was not helping him. She stated the other residents were not safe with Resident #1 in the facility and she felt he belonged in a psychiatric hospital. An interview on 12/22/22 at 2:14 PM with the COTA revealed she worked at the facility for 5 months. She stated she witnessed a physical altercation between Resident #1 and Resident #3 on 11/4/22. The COTA stated she was standing in the dining room when she heard groans coming from the table where Resident #3 was sitting. The COTA stated she turned and saw Resident #1 trying to take food from one of the trays and when staff intervened, he became angry. The COTA stated Resident #1 was able to ball up his fist and reach across to punch Resident #3 in the chest twice before staff were able to pull him away. The COTA stated Resident #3 was assessed by the nurse and did not sustain any injuries to her knowledge. The COTA stated she saw Resident #1 become verbally aggressive and knock over things, but she denied ever seeing him physically harm any residents prior to that incident. The COTA stated the Administrator was immediately notified about the incident. An interview on 12/22/22 at 5:45 PM with the DON revealed she had been employed at the facility for about 5 months. The DON stated shortly after starting at the facility, she recommended Resident #1 be transferred to a memory care facility. However, he was Medicaid pending and the family would not provide the necessary documents for the application to be approved. The DON stated Resident #1 was not receiving proper care at their facility because he needed a more structured environment with staff who were trained to better handle his behaviors. The DON stated Resident #1 was in an advanced stage of dementia and his cognitive deficits was beyond what the facility was capable of managing. The DON stated Resident #1 would wander around the entire facility, going in other residents' rooms causing them to become upset. She stated there were incidents where Resident #1 would become physically aggressive towards other residents, break their personal items, and use profanity. She stated the physical aggression had not happened in about a month; however, the wandering and verbal aggression was continuous. The DON stated she was concerned with the safety of all residents but more so for Resident #1 because of his unawareness and the conflict he would cause. The DON stated she was concerned he would wander into another confused or aggressive resident's room. The DON stated Resident #1 was also physically and verbally aggressive towards staff, especially when care was being provided. The DON stated the MD placed Resident #1 on 1:1 supervision for about 2 weeks then discontinued after there were no new incidents. The DON stated he was then placed on 15-minute checks. The DON stated she could not say the interventions were effective, because Resident #1 was not suitable for the facility. She stated Resident #1 was previously on psychotropic medications that seemed to be working. However, the family decided to take him off and refused any other psychiatric services. The DON stated she was able to convince them to consent to low dose PRN psychotropic medications that were not as effective. The DON stated Resident #1's family would threaten to sue the facility if they transferred him or sent him out to be evaluated at a psychiatric hospital. The DON stated she was not sure what other options they had to protect everyone's safety and rights. Interview on 12/22/22 at 6:05 PM with the Administrator, revealed she had been employed at the facility since 12/01/22. The Administrator stated she was not yet familiar with all of Resident #1's history. However, he had presented many challenges since the start of her employment. She described Resident #1 as having extreme mood swings, presenting very friendly and happy at times and then frustrated and aggressive at other times. The Administrator stated Resident #1 was not easily redirected, and staff would have a hard time keeping him content. The Administrator stated Resident #1 required a higher level of care the facility could not provide due to not having a secured unit and because Resident #1's family would not consent to any psychiatric services, which included psychotropic medications and/or evaluations at a psychiatric hospital. The Administrator stated Resident #1's family also would not cooperate in providing documents to get him Medicare so he could be transferred to a more appropriate facility. She also stated Resident #1 had a balance of $60,000 owed to their facility, which made it even more difficult to find appropriate placement. The Administrator stated it was her responsibility to ensure the proper care and safety of all residents in the facility. However, she felt like there was not a simple solution and either way she would face a dilemma. The Administrator stated she knew it was best for Resident #1 to be discharged from the facility, but with his family not giving consent for him to be transferred or sent out to a psychiatric hospital, she would be at risk for an inappropriate discharge tag. The Administrator stated her hands were tied. She stated the facility had interventions in place for Resident #1's behaviors such as frequent redirection, checks every 15 minutes, and allowing him to self-redirect and have self-determination as much as possible; however, these interventions were not always effective. The Administrator stated the facility had decided to discharge Resident #1 to a psychiatric hospital and was in the process of doing so on this date. The Administrator stated keeping Resident #1 at the facility where he was not receiving the proper treatment was a risk to his safety as well as others; however, she did not know what else to do. Interview on 01/05/23 at 11:43 AM with CNA D revealed she had worked at the facility for 8 years and worked with Resident #1 until he was discharged on [DATE]. CNA D stated Resident #1 was a wanderer and was verbally and physically aggressive towards staff and other residents. CNA D stated she had not witnessed any incidents where Resident #1 was physically aggressive towards other residents; however, she witnessed him go throughout the halls yelling and cursing. CNA D stated residents were annoyed by Resident #1 and did not like for him to be in their space. CNA D stated she witnessed Resident #2 become visibly shaken and tearful in the presence of Resident #1. CNA D stated Resident #2's family informed staff Resident #1 resembled Resident #2's father, who abused her as a child, and Resident #1 triggered her post traumatic stress disorder. Interview on 01/05/23 at 12:10 PM with the Administrator and the DON revealed there were currently no other residents in the facility who exhibited similar aggressive behaviors as Resident #1. The DON stated Resident #1 was discharged from the facility on 12/22/22 and the facility put measures in place to prevent further abuse from occurring. The Administrator stated the facility already had interventions in place that would have been effective for Resident #1 had the family been cooperative and would still be effective for other residents who might exhibit similar aggressive behaviors. The DON further stated they hit many brick walls with the family by not allowing Resident #1 to get the assistance he required. The DON stated the family had requested Resident #1 be taken off all psychotropic medications 09/12/22 because they thought the resident appeared to be more confused. Two other nursing facilities had agreed to accept Resident #1, but only if they had the Medicaid application pending, but the POA was not assisting with the Medicaid application process by failing to produce the required documentation. They had also contacted the local ombudsman for assistance and the family kept making promises they would get the necessary paperwork for the Medicaid application, but they never received them. The Administrator stated that management had been in-serviced on the processes of discharges and transfers. The DON stated clinicals for potential residents would be screened closer for keywords such as agitation, aggression, and confusion to prevent the facility from admitting residents who may not receive appropriate services. The DON stated for current residents, the facility would continue to monitor for changes in conditions and a new onset of aggressive behaviors so appropriate interventions could be put in place immediately. The Administrator stated if interventions proved to be ineffective, the facility would meet with the resident and family to begin the process of discharge. Review of Resident #1's IDT meeting notes dated 12/23/22 reflected the following: Note Text: Discussed initial patient behaviors upon admission compared to most recent behaviors. The patient's behaviors have progressed to an increasingly difficult to manage level. POA previously requested termination of all pharmacological psychotropic interventions, which were initially prescribed to address diagnosis of dementia with agitation, schizoaffective disorder, alcohol induced persisting amnestic disorder, Wernicke's Korsakoff's syndrome, and major depression disorder. Team discussed how termination of psych meds has contributed to progressively increased behaviors and a higher risk of harm to self or others. Prior discussions have been had with POA regarding cooperative efforts needed to find alternative placement considering increased behaviors. POA and family continue to appear to be in denial regarding resident's disease process, resulting in unproductive discussions. Current non-pharmacological interventions currently in place: - Distract resident from wandering of offering pleasant diversions, structured activities, food, conversation, television, book. - Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - Monitor resident and redirect from entering other resident rooms. - Intervene as necessary to protect the rights and safety of others. - Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Give as many choices as possible about care and activities. - Q15 minute checks - D/t the increase progression of negative behaviors and barriers related to current POA allowed interventions becoming increasingly ineffective resident was transferred to an acute care hospital for higher level of care and assessment. Acute care hospital case manager advised that hospital has identified two facilities with memory care units that can provide increased level of care not available at this facility. Interview on 01/05/23 at 1:23 PM with the Physician revealed Resident #1 was under her care while he was at the facility. She stated when the resident was taken off of his psych medications, per family request, and it had a big impact on Resident #1's increased behaviors. The Physician said the facility kept in communication with her regarding his behaviors and the family later agreed for the resident to begin taking Zoloft and lorazepam because he was hitting staff and throwing things. She further stated she had given an order for Resident #1 to begin psych services but upon reading the psych notes, the resident remained agitated and combative. The Physician said there was nothing else the facility could do other than discharge him from the facility. Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against, revised 10/2022, revealed the following: Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Definitions: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances on abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Prevention: .2. The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: -Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: -Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; -Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; -Wandering into other's rooms/space . Protection: 1. If an allegation of abuse, neglect, misappropriat [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one Resident (Resident #1) of 2 residents reviewed for behavioral health. The facility failed to implement effective interventions and treatment to address Resident #1's aggressive behaviors. Resident #1 caused psychological harm to Resident #2 as evidenced by her becoming tearful and hysterical when his name was mentioned. Resident #1 caused physical harm to Resident #3 on 11/4/22 by punching her in the chest. Resident #1 caused psychological harm to Resident #4 as evidenced by her stating that she was afraid of him. Resident #1 caused psychological harm to Resident #5 as evidence by her stating that he made her nervous and fearful. Resident #1 caused physical harm to Resident #6 on 11/7/22 by hitting her in the stomach. Resident #1 caused psychological harm to Resident #7 as evidenced by her stating that she was afraid of him and developing aggressive behaviors of her own related to having conflicts with him. This failure could place all residents at risk for their medical, physical, and psychological needs not being met. The findings included: 1.Record review of Resident #1's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS dated , 11/28/22, reflected a BIMS score of 0, not completed due to cognitive deficits. Record review of Resident #1's care plan, revised 11/07/22, revealed: Resident #1 was at risk for impaired cognitive function or impaired thought processes r/t Dementia. Resident #1 had poor attention span, fidgety, unable to sit for very long time and constantly on the move. Goal: resident will maintain current level of cognitive function through review date. Interventions: administer [MEDICATION(S)] as ordered, administer [MEDICATION(S)] as ordered, identify self at each interaction, and give step-by-step instructions one at a time as needed to support cognitive function. Resident #1 had the potential for psychosocial well-being problem r/t resident wandering into other residents' spaces, grabs their wrists, their items, food on trays in dining room, then other residents retaliate against him. Goals: resident will have no indications of psychosocial well-being problems through review date. Interventions: 1:1 supervision, monitor for injuries every shift for 3 days, monitor/document resident's feelings relative to the other residents. Resident #1had the potential to demonstrate physical behaviors r/t Dementia, hitting, kicking at staff, unable to redirect behavior. Resident combative, verbally aggressive, going in and out of resident rooms, upset with redirection, cursing staff, and refusing care. Goals: resident will not harm self or other residents. Interventions: 1:1 supervision, administer Benadryl as ordered, provide physical and verbal cues to alleviate anxiety, document observed behaviors and attempted interventions, and give as many choices as possible regarding care and activities. Interview and observation on12/22/22 at 11:51 AM with Resident #1 revealed he was unable to participate in an interview due to cognitive deficits. When asked a question, resident did not respond and was not aware of what was being said. Resident #1 was observed self-propelling around the facility in a wheelchair. He was seen entering a resident's room without any intervention. Interview and observation on 12/22/22 at 11:53 AM with RN C, revealed that she saw Resident #1 enter room [ROOM NUMBER]. RN C stated that Resident #1 was always going into other rooms, and it was hard for staff to stop him because he would become angry. RN C stated that she did not intervene because there were no residents in room [ROOM NUMBER], although Resident #1 was not supposed to be in there. RN C proceeded to go into room [ROOM NUMBER] and redirect Resident #1 out. RN C stated that Resident #1 goes all over the facility and usually doesn't disturb anyone until he is redirected and unable to do what he wants. RN C stated that staff have been trained to do frequent checks on Resident #1 and prevent him from going into other resident rooms. 2.Review of Resident #2's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS, dated [DATE], reflected a BIMS score of 06 indicating severe impairment. Review of Resident #2's care plan dated 06/21/2022, revealed resident to be monitored for re-traumatization r/t assault in 2013. Family complained of poor care at prior living situation. Resident noted to cry a lot, but not abnormal per guardian. Goals: resident will have no evidence of emotional, physical, and psychological problems by review date. Interventions: anticipate and meet needs, document behaviors and resident's response to interventions. Interview on 12/22/22 at 11:30 AM with Resident #2, revealed she was sitting in a wheelchair on the 200 Hall near her room. Resident #2 denied being abused or neglected by staff. When asked about other residents Resident #2 stated that she was afraid of Resident #1 and immediately became teary eyed and hysterical. Resident #2 was so upset that she could barely speak but she was able to state that Resident #1 was always coming into her room to take things and curse at them. Resident #2 stated she was afraid that Resident #1 was going to hurt her and her roommate, who she called Grandmother. Resident #2 continued to cry and stated that she had to protect her Grandmother from Resident #1. 3.Review of Resident #3's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 0, not completed due to cognitive deficits. Review of Resident #3's care plan dated 11/04/22, revealed resident had potential for injury r/t another Resident hit her in the chest, monitoring needed for injury. Interventions: Monitor res for pain, bruising chest area q shift. Resident #3 also had potential for pain and inability to communicate. Goal: If or when res shows signs of pain, pain med will be effective. Interventions: Anticipate need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Interview on 12/22/22 at 11:15 AM with Resident #3 revealed that she was unable to participate in an interview due to cognitive deficits. Resident #3 was dressed and well-groomed with no visible marks or bruises. 4.Record review of Resident #4's face sheet, dated 12/22/22, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 4's Quarterly MDS dated , 10/02/22 reflected resident had a BIMS of 08, indicating moderately impaired. Record review of Resident #4's care plan dated 01/22/20 revealed: Resident #4 had a terminal prognosis related to [CONDITION(S)]. Goal: to be free of depression and anxiety. Interventions: assess resident coping strategies and respect resident wishes, monitor significant changes in patients physical, mental, social, or emotional status and/or concerns including pain and uncomfortable situations. Interview on 12/22/22 at 11:55 AM with Resident #4 revealed she had recently relocated to room [ROOM NUMBER] because of having issues with another resident who she described as Resident #1. Resident #4 stated that Resident #1 had just been in her room the previous night going through her personal items. Resident #4 stated Resident #1 liked to get close to her, in her personal space and this made her feel uncomfortable. Resident #4 stated Resident #1 needed to be in a different facility because staff was not able properly care for him because he liked to roam the facility, curse at residents, and cause problems with other residents. Resident #4 stated she always alerted staff to remove him from her room, but it sometimes took a long time to remove him, she would use the saltshaker, telling him it was evil, to get Resident #1 away from her. Resident #4 denied ever being physically harmed by Resident #1 but stated that she was afraid of him. 5.Record review of Resident #5's face sheet, dated 12/22/22 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #5's Quarterly MDS dated , 11/15/22 reflected resident had a BIMS of 12 indicating cognitively intact. Record review of Resident #5's care plan dated 04/01/22 revealed: Resident #5 at risk for Re-traumatization related to history of alleged verbal abuse and history of alleged physical abuse. Goal: have no evidence of emotional, physical, and psychological problems. Interventions: monitoring behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Anticipate and meet needs. Interview on 12/22/22 at 12:33 PM with Resident #5 revealed she had an encounter with Resident #1 while sitting in the dining room. She stated Resident #1 Jumped on her. Resident #5 stated she was physically attacked but did not indicate having any pain or injuries from the incident. She stated she has been nervous around Resident #1 since then. She stated Resident #1 would always come in her personal space as if he did not understand boundaries. Resident #5 stated when she saw Resident #1 getting too close, she would have to stop him to keep him from grabbing her. She stated that he could become very aggressive. Resident #5 stated Resident #1 needed to be at a different facility, when asked why she stated because of the way he treated people and that he could harm someone. Resident #5 stated she was scared that he would cause harm to her again. 6.Record review of Resident #6's electronic face sheet, dated 12/22/22, revealed Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6's BIMS was 0, not completed due to cognitive deficits. Record review of Resident #6's care plan, dated 08/04/22, revealed Resident #6 had Anti-anxiety medication use related to anxiety disorder. Goal revealed resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included [MEDICATION(S)] as ordered by physician. 8/3/2022 Increased Dosage Interview on 12/22/22 at 12:42 PM with Resident #6 revealed she had been hit in the stomach by Resident #1 in the dining hall during lunch. Resident #6 stated she reported the altercation to the Speech Therapist. Resident #6 did not recall any pain or injuries after the altercation. Resident #6 stated she does not like Resident #1 that he is mean and makes her feel uncomfortable. Interview on 12/22/22 at 2:45 PM with Speech Therapist, revealed he was walking in the dining area and a Resident #6 reported to him that she had been hit in the stomach. When asked to identify the person who hit her, she pointed out Resident #1. Speech Therapist stated he had seen Resident #1 having aggressive behaviors towards staff and other residents on many occasions. Speech Therapist stated he had been told by several residents that they were fearful of Resident #1. Residents have stated they have woken to him being in their rooms throughout the night. Speech Therapist stated that he alerted the Administrator about all concerns that were brought to him by residents, and he would try to assist with redirecting Resident #1 as much as possible. 7.Record review of Resident #7's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's Quarterly MDS dated , 12/15/22, reflected resident had a BIMS of 13 indicating cognitively intact. Record review of Resident #7's care plan, dated 06/08/22, revealed: Resident #7 had potential for aggressive behaviors and psychosocial well-being problem r/t resident-to-resident incident. Goal: resident will have no indications of psychosocial well-being problems and will identify coping mechanisms. Interventions: skin assessments, monitor for mood change, separate from other resident in incident, when conflict arises, remove Resident #7 to a calm safe environment and allow to vent/share feelings. Interview on 12/22/22 at 11:41 AM with Resident #7, revealed that the only person she was afraid of at the facility was Resident #1. She stated, He's a pain in the butt! Resident #7 stated that Resident #1 would always come in her room and take her personal belongings. She stated he was caught in her room about a week ago and when she broke a special picture frame of hers. Resident #7 stated that staff would try to keep him out of her room, but he would find a way to get in. She stated that she was recently moved to a different room to get away from Resident #1 and now feels safer. She denied ever being physically abused by Resident #1. Interview on 12/22/22 at 1:05 PM with CNA A, revealed she had worked at the facility since 2019. CNA A stated that she worked on the 200 Hall with Resident #1. She stated that Resident #1 would beat on the staff and other residents. CNA A stated that he would sneak into other resident rooms and if staff were unable to catch him in a timely manner, he would grab or hit the residents. She stated if Resident #1 was seen going into another resident's room, staff would redirect and guide him out immediately. CNA A stated that she last witnessed Resident #1 hit another resident about a month ago; however, he was constantly cursing and yelling at everyone. She stated Resident #1 was placed on 1:1 supervision a few weeks ago but she believed it was discontinued because he would attack the staff who were supervising him, and staff started refusing work with him. CNA A stated that Resident #1 was able to be redirected sometimes but most times he was not. She stated that staff were told to check on Resident #1 more frequently, but it was hard to do so and care for all other residents. She stated that most residents on the 200 Hall were afraid of Resident #1 and some had even been moved to different halls to get away from him. CNA A stated that staff were trained on abuse, neglect and handling aggressive behaviors with the last training being about a month ago. Interview on 12/22/22 at 1:25 PM with RN B, revealed she had worked at the facility since 2017. RN B stated she worked on the 200 Hall with Resident #1. She stated that Resident #1 was a difficult resident with aggressive behaviors. RN B stated that most of the residents were afraid of him. She stated there were interventions in place to check on him every 15 mins and that sometimes he was placed on 1:1 supervision. RN B stated she tried to keep Resident #1 close to her station, but it was hard because he liked to wander and go into other resident rooms. RN B stated Resident #1 had been on [CONDITION(S)] medications to help control his behaviors; however, the family would have them adjusted or discontinued. RN B stated that the medications Resident #1 was currently on was not helping him. She stated the other residents were not safe with Resident #1 in the facility and that she felt he belonged in a psychiatric hospital. Interview on 12/22/22 at 2:14 PM with the Certified Occupational Therapy Assistant, revealed she had worked at the facility for 5 months. She stated she witnessed a physical altercation between Resident #1 and Resident #3 on 11/4/22. COTA stated she was standing in the dining room when she heard groans coming from the table where Resident #3 was sitting. COTA stated she turned and saw Resident #1 trying to take food from one of the trays and when staff intervened, he became angry. COTA stated Resident #1 was able to ball up his fist and reach across to punch Resident #3 in the chest twice before staff were able to pull him away. COTA stated Resident #3 was assessed by the nurse and did not sustain any injuries to her knowledge. COTA stated she had seen Resident #1 become verbally aggressive and knock over things, but she denied ever seeing him physically harm any residents prior to that incident. COTA stated the Administrator was immediately notified about the incident. Interview on 12/22/22 at 5:45 PM with the DON, revealed that she had been employed at the facility for about 5 months. The DON stated that shortly after starting at the facility, she recommended that Resident #1 be transferred to a memory care facility; however, he was Medicaid pending and the family would not provide the necessary documents for the application to be approved. The DON stated Resident #1 was not receiving proper care at their facility because he needed a more structured environment with staff who were trained to better handle his behaviors. The DON stated that Resident #1 would wander around the entire facility, going in other residents' rooms causing them to become upset. She stated there were incidents where Resident #1 would become physically aggressive towards other residents, break their personal items, and use profanity. The DON stated she was concerned with the safety of all residents but more so for Resident #1 because of the conflict he would cause. The DON stated she was concerned that he would wander into another confused or aggressive resident's room. The DON stated Resident #1 was also physically and verbally aggressive towards staff, especially when care was being provided. The DON stated the MD placed Resident #1 on 1:1 supervision for about 2 weeks then discontinued after there were no new incidents. The DON stated he was then placed on 15-minute checks. The DON stated that she could not say that the interventions were effective because Resident #1 was not suitable for the facility. She stated Resident #1 was previously on [CONDITION(S)] medications that seemed to be working; however, the family decided to take him off and refused any other psychiatric services. The DON stated she was able to convince them to consent to low dose PRN [CONDITION(S)] medications that were not as effective. The DON stated Resident #1's family would threaten to sue the facility if they transferred him or sent him out to be evaluated at a psychiatric hospital. The DON stated she was not sure what other options they had to protect everyone's safety and rights. Interview on 12/22/22 at 6:05 PM with the Administrator, revealed she had been employed at the facility since 12/01/22. The Administrator stated that she was not yet familiar with all of Resident #1's history; however, he had presented many challenges since the start of her employment. She described Resident #1 as having extreme mood swings, presenting very friendly and happy at times and then frustrated and aggressive at other times. The Administrator stated that Resident #1 was not easily redirected, and staff would have a hard time keeping him content. The Administrator stated that Resident #1 required a higher level of care that the facility could not provide due to not having a secured unit and because Resident #1's family would not consent to any psychiatric services, including [CONDITION(S)] medications and/or evaluations a psychiatric hospital. The Administrator stated that Resident #1's family also would not cooperate in providing documents to get him Medicare so that he could be transferred to a more appropriate facility. She also stated that Resident #1 had a balance of $60K owed to their facility, which made it even more difficulty to find appropriate placement. The Administrator stated it was her responsibility to ensure the proper care and safety of all residents in the facility; however, she felt like there was not a simple solution and that either way she would face a dilemma. The Administrator stated that she knew it was best for Resident #1 to be discharged from the facility but with his family not giving consent for him to be transferred or sent out to a psychiatric hospital, she would be at risk for an inappropriate discharge tag. The Administrator stated the facility had interventions in place for Resident #'s behaviors such as frequent redirection, checks every 15 minutes, and allowing him to self-redirect and have self-determination as much as possible; however, these interventions were not always effective. The Administrator stated that keeping Resident #1 at the facility where he was not receiving the proper treatment was a risk to his safety as well as others; however, she did not know what else to do. Record review of facility's policy titled Dementia Care Policy/Procedure, undated, revealed the following: It is the policy of this facility to provide residents who display or is diagnosed with Dementia with the appropriate treatment and services. Procedure: 1. Assess resident treatment and service needs through the Resident Assessment Instrument. 2. Develop and Implement care plans that include and support the dementia care needs. 3. On a quarterly and annual basis, the IDT shall review and revise care plans. 4. Modify the environment to accommodate resident care needs. 5. See other care planning elements under the Comprehensive Resident Centered IDT Care Planning Policy.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse of residents for 4 (Resident #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to implement a policy and process for immediately investigating, protecting the residents, and reporting allegations of abuse when: 1. Resident #3's responsible party made allegations of abuse to CNA E on 10/19/22 and she did not report it to the Administrator and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. Resident #12, #13, and #14 reported on 10/20/22 that CNA E verbally abused them, and the facility did not investigate or implement measures to protect the residents from further abuse. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's Admission Record dated 10/20/22 indicated the [AGE] year-old male resident was readmitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. The Interim Administrator, Clinical Resource RN, and DON were notified of the Immediate Jeopardy on 10/27/22 at 4:01 PM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 10/28/22 at 2:50 PM. Review of the Plan of Removal included: Immediate Action: 1. Administrator suspended on 10/26/22 pending the outcome of the investigation. 2. Medical Director / Resident's physician notified of IJ by Director of Nursing at 5:25 PM via phone. 3. In-service regarding Abuse: Prevention of and Prohibition Against was started on 10-27-22 for routinely scheduled facility staff, educated by Clinical Resource/designee. Inservice to be completed with routinely scheduled facility staff, by 4:30PM on 10-28-22. Remaining facility staff and agency staff will be required to be in-serviced on this policy upon start of their shift by the Director of Nursing/designee. 4. RN Clinical Resource will conduct education on the facility ANE policy with leadership team: a. Leadership Team: Administrator, Director of Nur [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide a safe environment free from abuse for 4 (Resident #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to protect and assure the safety of Residents #3, #12, #13, and #14 when verbal abuse was reported on 10/19/22 and 10/20/22. Resident #3 was verbally abused by staff (recorded on video footage) and Residents #12, #13, and #14 said they were verbally abused by CNA E. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish caused by fear. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's Admission Record dated 10/20/22 indicated the [AGE] year-old male resident was readmitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. The Administrator and DON were notified of the Immediate Jeopardy on 10/24/22 at 12:43 PM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 10/25/22 at 4:18 PM. Review of the Plan of Removal included: Immediate Action: 1. Medical Director / Resident's physician notified of IJ (Immediate Jeopardy) by the Administrator on 10/24/22 at 1:58 PM via phone. 2. In-service with quiz was started on 10-24-22 for employees, educated by Administrator, Clinical Resource, or Director of Nursing. Quiz and Inservice to be completed by all staff by end of day 10-25-22. Agency staff will be required to be in-serviced and quizzed prior to starting their shift on the floor. The in-service will include: a. Types of abuse with definitions, b. Contact and name of Abuse Coordinator and Grievance Coordinator, c. Timeframes for reporting, and the d. Seven components of abuse policy, which are: i. Screening - background checks on employee ii. Training - on hire, with any allegation of ANE, and annually iii. Prevention - identify, correcting, and intervening to ensure safe environment iv. Identification - identifying different types of abuse v. Investigation - complete and through investigative process and documentation of [TRUNCATED]

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including the State Agency, in accordance with State law through established procedures for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. 1) CNA E failed to report Resident #3's responsible party's allegation of abuse to the Administrator on 10/19/22. 2) The Administrator failed to report Resident #12, #13, and #14's allegations of verbal abuse on 10/20/22 to the State Agency; due to not reporting the residents continued to be exposed to the staff that had verbally abused them. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/14/22. While the IJ was removed on 11/14/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's Admission Record dated 10/20/22 indicated the [AGE] year-old male resident was readmitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. The Interim Administrator was notified of the Immediate Jeopardy on 11/14/22 at 10:55 AM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 11/14/22 at 12:56 PM. Review of the Plan of Removal included: Immediate Action 1. Administrator suspended on 10/26/22 pending the outcome of the investigation. 2. Medical Director/Resident's physician notified of IJ by Director of Nursing at 5:25 PM via phone. 3. In-service regarding Abuse: Prevention of and Prohibition Against was started on 10-27-22 for routinely scheduled facility staff, educated by Clinical Resource/designee. Inservice to be completed with routinely scheduled facility staff, by 4:30PM on 10-28-22. Remaining facility staff and [NAME] [TRUNCATED]

Based on observations, interview and record reviews the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further potential abuse, and mistreatment while the investigation was in process, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to immediately investigate, protect the residents, and report allegations of abuse when: 1. Resident #3's responsible party made allegations of abuse to CNA E on 10/19/22 and she did not report it to the Administrator and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. Resident #12, #13, and #14 reported on 10/20/22 that CNA E verbally abused them, and the facility did not investigate or implement measures to protect the residents from further abuse. These failures place all the residents, residing in the facility, at risk of abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's Admission Record dated 10/20/22 indicated the [AGE] year-old male resident was readmitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. The Interim Administrator, Clinical Resource RN, and DON were notified of the Immediate Jeopardy on 10/27/22 at 4:01 PM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 10/28/22 at 2:50 PM. Review of the Plan of Removal included: Immediate Action: 1. Administrator suspended on 10/26/22 pending the outcome of the investigation. 2. Medical Director/Resident's physician notified of IJ by Director of Nursing at 5:25 PM via phone. 3. In-service regarding Abuse: Prevention of and Prohibition Against was started on 10-27-22 for routinely scheduled facility staff,

Based on interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. 1) CNA E failed to report Resident #3's responsible party's allegation of abuse to the Administrator on 10/19/22. 2) The Administrator (the Abuse Coordinator) failed the residents by not implementing the Abuse Policy when he was informed, on 10/20/22, of Resident #12, #13, and #14's allegations that CNA E verbally abused them. CNA E continued to work after the Administrator was notified of the abuse. Safe Surveys conducted on 10/20/22, identified abuse and indicated additional residents were being abused. The Safe Surveys were not provided to the investigator until repeated inquiry and were found in the shred bin. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/14/22. While the IJ was removed on 11/14/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's Admission Record dated 10/20/22 indicated the [AGE] year-old male resident was readmitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's Admission Record dated 10/29/22 indicated the [AGE] year-old female resident was readmitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. The Interim Administrator was notified of the Immediate Jeopardy on 11/14/22 at 10:55 AM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 11/14/22 at 12:56 PM. Review of the Plan of Removal included: Immediate Action 1. Administrator suspended on 10/26/22 pending the outcome of the investigation. 2. Medical Director/Resident's physician notified of IJ by Director of Nursing at 5:25 PM via phone. 3. In-service regarding Abuse: Prevention of and Prohibition Against was started on 10-27-22 for routinely scheduled facility staff, educated by Clinical Resource/designee. Inservice to be completed with routinely scheduled facility staff, by 4:30PM on 10-28-22. Remaining facility staff and agency staff will be required to

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment of a resident, for one (Resident #1) of seven residents reviewed for injury resulting from a fall. The facility failed to ensure Resident #1 had a follow-up consultation with an Orthopedic Surgeon within a week of fracturing her third finger on her right hand as ordered by the hospital emergency room physician on 07/03/17 and failed to obtain treatment orders for the fractured finger until surveyor intervention on 07/27/17. As a result, Resident #1 had a decline in her ability to carry out her normal ADLs, experienced pain with movement, and had continued swelling of the finger. The failures placed the 18 residents, who were at high risk for falls, at risk for delayed treatment, diminished ability to carry out ADLs, and non-healing injuries with increased pain. Findings included: Resident #1's MDS assessment, dated 04/13/17, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired, she required supervision with locomotion on/off the unit, and she required extensive assistance with bed mobility and transfers. The resident did not have any functional limitation in range of motion in her bilateral upper extremities and had limited range of motion in her lower extremities on one side. Resident #1's Care Plan, dated 07/02/17, reflected focus areas that identified a fall with injury. Interventions included following-up as needed with orthopedics. Resident #1's July 2017 physician's orders [REDACTED]. Resident #1's Physician Orders, dated 07/02/17, reflected an order to transfer Resident #12 to the hospital for evaluation and treatment following a fall with injury to her right third finger. An incident report, dated 07/02/17, reflected Resident #1 sustained an injury to her right hand after falling, and she was sent to the hospital emergency room for evaluation and treatment. Resident #1's hospital ED Provider Notes report, dated 07/03/17, reflected Resident #1 admitted to the hospital due to a finger injury. The report reflected the hospital x-ray, completed on 07/03/17, revealed a minimally displaced oblique fracture extending through the base of the proximal phalanx of the third digit. The course of treatment reflected reduction and splinting at beside were done. The type of splint used was an ulnar gutter splint (aluminum) with cotton padding. The resident was discharged with orders to follow-up with an orthopedic surgeon in one week. Resident #1's Nurse's Notes, dated 07/03/17 at 3:45 a.m., reflected Resident #1 returned from the hospital where she was diagnosed with [REDACTED]. The DON and On-Call Physician were notified of the resident's return, and no new orders were received. Resident #1's Nurse's Notes reflected the following entries: 07/04/17 at 12:04 a.m. - Resident remains post fall day two of three, no delayed injuries noted .Right hand remains wrapped dressing, dressing was clean, dry and intact . 07/05/17 at 2:21 p.m. - Resident assessed denied pain states only hurts when someone touched it . 07/10/17 at 7:30 p.m. - Resident remains stable at the time, continue to monitor right hand third finger for signs and symptoms of infection. Dressing remained dry intact . 07/11/17 at 9:32 a.m. - Per restorative aid Resident can't walk in hallway restorative aid due to wrap on her hand . 07/14/17 at 5:56 a.m. and 07/18/17 at 4:02 p.m. - .Dressing to arm intact, clean and dry . No further documentation related to Resident #1's fractured right third finger were available in the nurse's notes. An observation of Resident #1's fractured right third finger with RN F on 07/27/17 at 1:58 p.m. revealed the resident's right hand was covered with an ace wrap dressing. RN F removed the ace wrap dressing, and Resident #1's third finger was swollen. The finger was malaligned, and the palmar aspect of the hand (palm) still had significant discoloration. When the dressing was removed, there also was a significant foul odor associated with the hand. RN F stated he was very new to the facility, and he had no history of providing care to the resident's fractured finger. He stated today was the first day he had removed the dressing. At the time of the observation, Resident #1 stated her hand hurt only with movement. An interview with the DON on 07/27/17 at 9:00 a.m. revealed Resident #1's discharge instructions from the hospital indicated she was to follow-up with an orthopedic surgeon in regards to the care of her fractured finger. The DON was not able to recall when or who she had seen in follow-up to her fracture. She stated the nursing staff at the facility were not treating the fractured finger, they did not remove the ace wrap, and did not treat her fracture in any fashion. An interview with the Administrator and DON on 07/27/17 at 10:00 a.m. revealed the Administrator indicated that Resident #1 had a follow-up appointment in with orthopedics today at 1:30 p.m. The Administrator stated the facility had attempted multiple times to schedule Resident #1 for a follow-up appointment with orthopedics, but the office did not return their calls and had no available appointments for Resident #1 to be seen. The DON stated today was the first available appointment for the resident to be evaluated orthopedist. An interview with the Orthopedic Surgeon's Office Manager on 07/27/17 at 11:43 a.m. revealed she had just spoken with the facility and scheduled an appointment for Resident #1 to be seen on 07/31/17 at 9:00 a.m. She stated there was no call received in the office from the facility for any question or direction for treatment of [REDACTED]. She stated she searched extensively and could find any indication any appointment was ever scheduled. She explained the facility told her that their scheduler that made all the appointments for the residents stated he had made an appointment for Resident #1 on 08/02/17 at 2:30 p.m.; however, the Office Manager stated there was no indication in the system that an appointment had ever been scheduled prior to today. She also stated there was nothing in their system reflecting that an appointment had been canceled or rescheduled for Resident #1. She stated it was their practice to always to follow-up on any emergency room visits involving fractures within seven to ten days. After seven to ten days, the Office Manager stated nothing could be done if there was a need for any surgical intervention or to correct any deformities. An interview with LVN B, who was Resident #1's charge nurse, on 07/37/17 at 12:11 p.m. revealed she had been removing the dressing and assessing Resident #1's fingers every day. She stated she assessed for movement, pain, and discoloration; however, she stated she did not document her assessments for Resident #1's fractured finger. She stated she only documented the wound care she provided, and assessments related to Resident #1's post-op amputated toe. LVN B stated there were no orders to remove the dressing from Resident #1's hand, and she could give no reason for not contacting the resident's Physician for clarification related to the care and treatment of [REDACTED]. LVN B stated when she assessed the resident she would check to make sure there was no contracture and if the resident could wiggle her fingers. She stated Resident #1 did not complain of pain when she moved her fingers. She stated she had no knowledge of Resident #1 having pain with movement, and she had no concerns with Resident #1's finger alignment. LVN B stated she did review the hospital emergency room discharge instructions, and she stated she was told the request for the consultation with the Orthopedic Surgeon had been made. She stated she did not recall who gave her that information. She stated she should have done follow-up on the resident's appointment. She stated she took full responsibility for not following-up on the care treatment of [REDACTED]. An interview with Resident #1's weekend charge nurse, LVN A, on 07/27/17 at 12:19 p.m. revealed she was the admitting nurse for Resident #1 upon her return from the hospital emergency roiagnom on [DATE] at 3:45 a.m. LVN A stated when Resident #1 returned to the facility, she had a very large bulky bandage on her right hand. LVN A stated she did not remove this dressing, she did not perform an assessment, and there were no orders for the care and treatment of [REDACTED]. LVN A stated usually a request for a consultation would be sent to the Social Worker, who would then schedule the appointment, but the Social Worker was no longer at the facility so the Van Driver was now the person responsible for scheduling the appointments. LVN A stated she always removed the Resident #1's dressings and assessed the resident's fractured finger. LVN A stated the alignment of the resident's finger was not as good as it was when she returned from the hospital, but she could not recall how long ago that change occurred. LVN A stated she had no reason why she did not document the assessment of Resident #1's fractured finger. An interview with the Administrator on 07/27/17 at 12:38 p.m. revealed his Scheduler informed him that Resident #1 had an appointment today with the Orthopedic Surgeon, but the Scheduler then informed him the appointment for today was with a different specialist and not with the Orthopedic Surgeon. He stated Resident #1's appointment to be seen by the Orthopedic Surgeon was scheduled for 08/02/17. The Administrator stated normally the Social Worker arranged these types of referral, but the facility no longer had a Social Worker. An interview with CNA C on 07/27/17 at 1:15 p.m. revealed he recalled Resident #1's right hand being wrapped in a splint from her mid arm to the tips of her fingers. He stated the splint remained in place until approximately one week ago. He stated prior to Resident #1's fall the resident was able to perform many tasks for herself including self-propelling her wheelchair, assisting with transfers, and oftentimes she only required supervision with her ADLs. Since the fall, the resident was now totally dependent on staff for assistance with all of her ADLs, and the resident was no longer willing to take showers, only sponge baths. CNA C stated the resident lost most of the independence she had prior to the fall. An interview with CNA D on 07/27/17 at 2:55 p.m. revealed Resident #1 had a fall in early July, and the resident had to wear a splint on her right forearm to her fingertips. CNA D stated prior to the fall Resident #1 was able to stand and do things for herself, but now she refused showers and was totally dependent upon staff for assistance with all of her ADLs with the exception of eating. An interview with CNA E on 07/27/17 at 3:35 p.m. revealed Resident #1 was able to do most everything for herself; however, since she fell , the resident was now totally reliant upon staff for assistance with all of her ADLs. CNA E stated prior to the fall Resident #1 enjoyed sweets and would self-propel in her wheelchair to the nurses' station looking for something sweet to eat, but now due to her hand injury, the resident was no longer able to self-propel in her wheelchair without great difficulty. The Orthopaedics Journal Principles of Hand Fracture Management, obtained on 08/03/17 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 12/, and published online on 02/23/12 reflected the following: .Hand function and in particular use of the fingers is vital for most daily tasks and virtually every profession, it is important that patients with phalangeal fracture receive appropriate management to restore their normal function. Management of phalangeal fractures is aimed at adequate anatomical reduction, maintaining fracture stability and early controlled mobilization. A period of immobility for 2-3 weeks is generally accepted for most phalangeal fractures, anything longer than 3 weeks has shown to increase long-term stiffness. The difficulty comes in finding techniques that give good stability at the fracture site, but also enable early mobilizations. Historically these fractures were treated conservatively with closed reduction and immobilization with splint or plaster of Paris cast . An undated resident roster, provided by the Administrator on 07/27/17, reflected there were a total of 18 residents identified as being at risk for falls.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (or to commence a new form of treatment), for one resident (Resident #1) of seven residents reviewed for assistive devices. The facility failed to ensure Resident #1 had a follow-up consultation with an Orthopedic Surgeon within a week of fracturing her third finger on her right hand as ordered by the hospital emergency room physician on 07/03/17 and failed to obtain treatment orders for the fractured finger until surveyor intervention on 07/27/17. As a result, Resident #1 had a decline in her ability to carry out her normal ADLs, experienced pain with movement, and had continued swelling of the finger. The failures placed the 18 residents, who were at high risk for falls, at risk for delayed treatment, diminished ability to carry out ADLs, and non-healing injuries with increased pain. Findings included: Resident #1's MDS assessment, dated 04/13/17, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired, she required supervision with locomotion on/off the unit, and she required extensive assistance with bed mobility and transfers. The resident did not have any functional limitation in range of motion in her bilateral upper extremities and had limited range of motion in her lower extremities on one side. Resident #1's Care Plan, dated 07/02/17, reflected focus areas that identified a fall with injury. Interventions included following-up as needed with orthopedics. Resident #1's July 2017 physician's orders [REDACTED]. Resident #1's Physician Orders, dated 07/02/17, reflected an order to transfer Resident #12 to the hospital for evaluation and treatment following a fall with injury to her right third finger. An incident report, dated 07/02/17, reflected Resident #1 sustained an injury to her right hand after falling, and she was sent to the hospital emergency room for evaluation and treatment. Resident #1's hospital ED Provider Notes report, dated 07/03/17, reflected Resident #1 admitted to the hospital due to a finger injury. The report reflected the hospital x-ray, completed on 07/03/17, revealed a minimally displaced oblique fracture extending through the base of the proximal phalanx of the third digit. The course of treatment reflected reduction and splinting at beside were done. The type of splint used was an ulnar gutter splint (aluminum) with cotton padding. The resident was discharged with orders to follow-up with an orthopedic surgeon in one week. Resident #1's Nurse's Notes, dated 07/03/17 at 3:45 a.m., reflected Resident #1 returned from the hospital where she was diagnosed with [REDACTED]. The DON and On-Call Physician were notified of the resident's return, and no new orders were received. Resident #1's Nurse's Notes reflected the following entries: 07/04/17 at 12:04 a.m. - Resident remains post fall day two of three, no delayed injuries noted .Right hand remains wrapped dressing, dressing was clean, dry and intact . 07/05/17 at 2:21 p.m. - Resident assessed denied pain states only hurts when someone touched it . 07/10/17 at 7:30 p.m. - Resident remains stable at the time, continue to monitor right hand third finger for signs and symptoms of infection. Dressing remained dry intact . 07/11/17 at 9:32 a.m. - Per restorative aid Resident can't walk in hallway restorative aid due to wrap on her hand . 07/14/17 at 5:56 a.m. and 07/18/17 at 4:02 p.m. - .Dressing to arm intact, clean and dry . No further documentation related to Resident #1's fractured right third finger were available in the nurse's notes. An observation of Resident #1's fractured right third finger with RN F on 07/27/17 at 1:58 p.m. revealed the resident's right hand was covered with an ace wrap dressing. RN F removed the ace wrap dressing, and Resident #1's third finger was swollen. The finger was malaligned, and the palmar aspect of the hand (palm) still had significant discoloration. When the dressing was removed, there also was a significant foul odor associated with the hand. RN F stated he was very new to the facility, and he had no history of providing care to the resident's fractured finger. He stated today was the first day he had removed the dressing. At the time of the observation, Resident #1 stated her hand hurt only with movement. An interview with the DON on 07/27/17 at 9:00 a.m. revealed Resident #1's discharge instructions from the hospital indicated she was to follow-up with an orthopedic surgeon in regards to the care of her fractured finger. The DON was not able to recall when or who she had seen in follow-up to her fracture. She stated the nursing staff at the facility were not treating the fractured finger, they did not remove the ace wrap, and did not treat her fracture in any fashion. An interview with the Administrator and DON on 07/27/17 at 10:00 a.m. revealed the Administrator indicated that Resident #1 had a follow-up appointment in with orthopedics today at 1:30 p.m. The Administrator stated the facility had attempted multiple times to schedule Resident #1 for a follow-up appointment with orthopedics, but the office did not return their calls and had no available appointments for Resident #1 to be seen. The DON stated today was the first available appointment for the resident to be evaluated orthopedist. An interview with the Orthopedic Surgeon's Office Manager on 07/27/17 at 11:43 a.m. revealed she had just spoken with the facility and scheduled an appointment for Resident #1 to be seen on 07/31/17 at 9:00 a.m. She stated there was no call received in the office from the facility for any question or direction for treatment of [REDACTED]. She stated she searched extensively and could find any indication any appointment was ever scheduled. She explained the facility told her that their scheduler that made all the appointments for the residents stated he had made an appointment for Resident #1 on 08/02/17 at 2:30 p.m.; however, the Office Manager stated there was no indication in the system that an appointment had ever been scheduled prior to today. She also stated there was nothing in their system reflecting that an appointment had been canceled or rescheduled for Resident #1. She stated it was their practice to always to follow-up on any emergency room visits involving fractures within seven to ten days. After seven to ten days, the Office Manager stated nothing could be done if there was a need for any surgical intervention or to correct any deformities. An interview with LVN B, who was Resident #1's charge nurse, on 07/37/17 at 12:11 p.m. revealed she had been removing the dressing and assessing Resident #1's fingers every day. She stated she assessed for movement, pain, and discoloration; however, she stated she did not document her assessments for Resident #1's fractured finger. She stated she only documented the wound care she provided, and assessments related to Resident #1's post-op amputated toe. LVN B stated there were no orders to remove the dressing from Resident #1's hand, and she could give no reason for not contacting the resident's Physician for clarification related to the care and treatment of [REDACTED]. LVN B stated when she assessed the resident she would check to make sure there was no contracture and if the resident could wiggle her fingers. She stated Resident #1 did not complain of pain when she moved her fingers. She stated she had no knowledge of Resident #1 having pain with movement, and she had no concerns with Resident #1's finger alignment. LVN B stated she did review the hospital emergency room discharge instructions, and she stated she was told the request for the consultation with the Orthopedic Surgeon had been made. She stated she did not recall who gave her that information. She stated she should have done follow-up on the resident's appointment. She stated she took full responsibility for not following-up on the care treatment of [REDACTED]. An interview with Resident #1's weekend charge nurse, LVN A, on 07/27/17 at 12:19 p.m. revealed she was the admitting nurse for Resident #1 upon her return from the hospital emergency roiagnom on [DATE] at 3:45 a.m. LVN A stated when Resident #1 returned to the facility, she had a very large bulky bandage on her right hand. LVN A stated she did not remove this dressing, she did not perform an assessment, and there were no orders for the care and treatment of [REDACTED]. LVN A stated usually a request for a consultation would be sent to the Social Worker, who would then schedule the appointment, but the Social Worker was no longer at the facility so the Van Driver was now the person responsible for scheduling the appointments. LVN A stated she always removed the Resident #1's dressings and assessed the resident's fractured finger. LVN A stated the alignment of the resident's finger was not as good as it was when she returned from the hospital, but she could not recall how long ago that change occurred. LVN A stated she had no reason why she did not document the assessment of Resident #1's fractured finger. An interview with the Administrator on 07/27/17 at 12:38 p.m. revealed his Scheduler informed him that Resident #1 had an appointment today with the Orthopedic Surgeon, but the Scheduler then informed him the appointment for today was with a different specialist and not with the Orthopedic Surgeon. He stated Resident #1's appointment to be seen by the Orthopedic Surgeon was scheduled for 08/02/17. The Administrator stated normally the Social Worker arranged these types of referral, but the facility no longer had a Social Worker. An interview with CNA C on 07/27/17 at 1:15 p.m. revealed he recalled Resident #1's right hand being wrapped in a splint from her mid arm to the tips of her fingers. He stated the splint remained in place until approximately one week ago. He stated prior to Resident #1's fall the resident was able to perform many tasks for herself including self-propelling her wheelchair, assisting with transfers, and oftentimes she only required supervision with her ADLs. Since the fall, the resident was now totally dependent on staff for assistance with all of her ADLs, and the resident was no longer willing to take showers, only sponge baths. CNA C stated the resident lost most of the independence she had prior to the fall. An interview with CNA D on 07/27/17 at 2:55 p.m. revealed Resident #1 had a fall in early July, and the resident had to wear a splint on her right forearm to her fingertips. CNA D stated prior to the fall Resident #1 was able to stand and do things for herself, but now she refused showers and was totally dependent upon staff for assistance with all of her ADLs with the exception of eating. An interview with CNA E on 07/27/17 at 3:35 p.m. revealed Resident #1 was able to do most everything for herself; however, since she fell , the resident was now totally reliant upon staff for assistance with all of her ADLs. CNA E stated prior to the fall Resident #1 enjoyed sweets and would self-propel in her wheelchair to the nurses' station looking for something sweet to eat, but now due to her hand injury, the resident was no longer able to self-propel in her wheelchair without great difficulty. The Orthopaedics Journal Principles of Hand Fracture Management, obtained on 08/03/17 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 12/, and published online on 02/23/12 reflected the following: .Hand function and in particular use of the fingers is vital for most daily tasks and virtually every profession, it is important that patients with phalangeal fracture receive appropriate management to restore their normal function. Management of phalangeal fractures is aimed at adequate anatomical reduction, maintaining fracture stability and early controlled mobilization. A period of immobility for 2-3 weeks is generally accepted for most phalangeal fractures, anything longer than 3 weeks has shown to increase long-term stiffness. The difficulty comes in finding techniques that give good stability at the fracture site, but also enable early mobilizations. Historically these fractures were treated conservatively with closed reduction and immobilization with splint or plaster of Paris cast . An undated resident roster, provided by the Administrator on 07/27/17, reflected there were a total of 18 residents identified as being at risk for falls.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for one (Resident #1) of 12 wandering residents. Resident #1 exited the facility on 01/04/11 and rolled off the porch in his w/c, crashed on the sidewalk/curb, and fell on to the parking lot and sustained contusions, abrasions, bruises and broken ribs. After the fall, he was sent to the emergency room . The SW (southwest) corner exit door was not functioning properly at the time of the visit and the staff was not re-setting the alarm after it sounded. There was no railing on the porch/ramp at the SW corner of the building to prevent Resident #1 from rolling off in his w/c. The facility did not investigate how Resident #1 was able to exit the building and did not report the incident to the State agency. These failures resulted in Resident #1 being injured and having to go the hospital for treatment. These failures could affect the other 12 residents who were confused and wandered by placing them at risk of exiting the facility without staff knowledge and being injured. Findings included: 1. Review of the facility's current Abuse Prevention Manual with the effective date of January 2005 and most recent revision date of June 2009 revealed the following: The definition of Neglect was the, "Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness." The policy and procedures reflected, "Identification- The QA (Quality Assurance) Team investigates all occurrences,...that may indicate the presence of abuse, neglect or misappropriation...In addition the Medical Director, Director of Nurses and Administrator will review all unusual occurrences." The policy and procedure also reflected, "Reporting and Response- All allegations and substantiated occurrences of abuse, neglect and misappropriation of property are reported to the state agency and law enforcement officials as designated by state law." The investigation section of the policy reflected, "Investigations are conducted on all cases of alleged abuse/neglect...." Under the section of Prevention the policy and procedure reflected, "...Identifying, correcting and intervening in situations in which abuse, neglect and misappropriation of patient property is more likely to occur. This includes an analysis of: Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility...." 2. A review of Resident #1's Admission Face Sheet, un-dated, revealed he was a [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 01/04/11 and authored by LVN E revealed, "Found outside of bldg (building) on pavement lying on his (l) (left) side. Lg (large) amt (amount) blood noted on sidewalk. Covered c (with) blanket BP (blood pressure) 148/78 - 88 (heart rate) - 22 (respirations). 9-1-1 contacted. Compresses applied to gash over os (left eye). Unable to reach____(POA). Message left for ____(Resident's family member)." Review of Resident #1's Physician's Telephone Orders dated 01/04/11 with no noted time, revealed, "to _____(hospital name) via ambulance S/P (status [REDACTED]. Resident #1's Incident/Accident Report dated 01/04/11 reflected Resident #1 was located outside of the facility and experienced an unwitnessed fall. The report also reflected he suffered a contusion/hematoma to his head, a skin tear/laceration, and a bruise. The report further reflected Resident #1 was transferred to the ER. Further review of the report revealed, Resident #1 was found on the ground outside the exit door on the southwest corner of the building face down and positioned on his left side. The report reflected there was blood on the ground underneath his head and a large hematoma to his left eye with purple discoloration. The report indicated there was red drainage from area. The report also reflected there was purple discoloration and swelling to his upper lip and red fluid in his mouth. The report indicated Resident #1 was alert and talkative and he complained of pain to his face, his lower left shoulder. The report also indicated the w/c alarm was sounding and the w/c was upside down. Resident #1's Incident/Accident Report reflected was signed and dated on 01/07/11 by DON H (former DON.) DON H wrote on the report, "Staff inservices on reaction to door alarms. Also when find resident @ (at) door - need to walk out of building (and) look around. Head count needs to be completed. Safety fence is currently being contracted by administration. Bed alarm/chair alarms. Safety (check) completed." Note: There was no explanation or investigation about how Resident #1 got out of the facility documented on the report. Resident #1's Report also reflected no documented evidence the State agency was contacted. This last section had DON H's signature and a date of 01/07/11 and the Administrator's signature and date of 01/08/11, which indicate they had reviewed the report and signed it off as complete, even though there was no investigation of how Resident #1 got out of the facility. Review of Resident #1's hospital registration form dated 01/04/11 revealed an admission date of [DATE]. Resident #1's hospital Emergency Department Discharge Instructions dated 01/04/11 reflected [DIAGNOSES REDACTED]. Resident #1's Nurse's Notes dated 01/06/11 reflected, "Late entry for 1/5/11" in the margin and 01/06/11 ER nurse called yesterday and stated x-rays showed Resident #1 had right rib fractures to 5th and 6th ribs. Note: This was the only Nurse's Note or entry about broken ribs, which could be located in the clinical record until a chest x-ray study was done on 02/19/11. Observation on 03/01/11 at 10:07 a.m. revealed Resident #1 was fully dressed, but lying in bed. When questioned by the surveyor how he was feeling Resident #1 stated he was OK. On 03/01/11 at 3:55 p.m. the two surveyors went to the SW exit door where Resident #1 was reported to have gotten out of the building. The surveyors obtained the code to go out and exited the building. Once outside, the surveyors observed a porch area approximately 4 feet square with a railed ramp approximately 4 feet wide that went to the right for approximately 10 feet, turned to the left for approximately 6 feet then again turned to the left for approximately 8 feet ending on a sidewalk which paralleled the south side parking lot. The surveyors turned back around to go back through the exit door and were able to walk right through the SW exit door. (Note: The door was supposed to automatically lock after keying in the code and exiting the building.) Once back inside, the surveyors waited 30 seconds and re-tried the SW exit door and the door opened and no alarm sounded. The surveyors tried the door several times and were able to exit with no delay and no alarm sounding. An observation on 03/01/11 at 4:04 p.m. revealed a female resident in her w/c from the end of the 200 hall went to the SW exit door. The resident had a w/c alarm attached to her chair and self. The resident touched the push bar on the SW exit door, no alarm sounded. She touched the bar several times from right to left and then took her right foot and pushed the door which opened about two inches, then closed. The resident then appeared to lose interest and turned her w/c around and went back the way she had come. One surveyor asked a staff member to identify the resident was after she had made it back around to the PT department and they informed her it was Resident #2 and her room was on the 200 hall. On 03/01/11 at 4:06 p.m. the surveyors tried the South door leading to the inner courtyard area across from the PT department. The surveyors were able to push the door open and get outside into the courtyard without an alarm sounding. When the surveyors attempted to go back inside the facility the alarm sounded. On 03/01/11 at 4:15 p.m., the surveyors brought the Administrator and the Assistant Administrator to the SW exit door and asked them to try it. The Administrator pushed the door and it opened without an alarm sounding. He stated the door was not working. ADON B informed everyone that had happened on the previous night and she had re-set it and it had worked properly. ADON B pushed in a code and the alarm sounded for 15 seconds, while the Administrator pushed on the bar and then it opened and the alarm stopped. The Administrator then closed the door and the alarm sounded again and he stated, "It's working opposite how it should..." ADON B stated the door needed to be repaired and they needed to get an employee to sit and monitor the door until it was fixed as it was a very dangerous situation. The Administrator and Assistant Administrator agreed. On 03/01/11 at 4:30 p.m. the surveyor observed the Maintenance Director working on the SW exit door. The door was tested and appeared to be working at this time. An interview on 03/01/11 at 4:50 p.m. with the Administrator revealed the problem with the door was his staff was not re-setting the alarm after it sounded and therefore the door would not re-lock and the alarm would not sound when someone touched it. The Administrator stated and showed the surveyor a back-up alarm system the Maintenance Director had applied to the SW exit door. The Administrator demonstrated how it worked. An observation at that time revealed the back-up system alarmed whenever the door was opened. The surveyor asked the Administrator about Resident #1's incident. The Administrator stated there had been two residents at the SW exit door. He further stated when the staff got to the door they pulled one resident back and Resident #1 was able to get out of the door. He stated Resident #1 went straight off the porch. The Administrator also stated at that time, someone from corporate was driving around the building and saw Resident #1. The surveyor asked how he went off the porch with the railing there and the Administrator stated, "...The fence was not there when that happened...." The Administrator informed the surveyor when the new addition was first built the construction company said they did not need a railing on the ramp. He stated it was actually added, "...as an intervention...." after Resident #1's incident. The Administrator stated he probably still had a copy of the report and would get it for the surveyor. The surveyor went out the SW exit door and observed there was an approximately 3 ? foot drop off the porch area onto a 3 to 4 foot grassy slope, which ended at the edge of the sidewalk. The surveyor asked the Administrator if the camera, which was observed by the PT department and appeared to be pointing at the SW exit door, was a working camera. The Administrator replied it was a working camera and the monitor screen was at the Station II Nurse's Station. The Administrator took the surveyors to the Station II Nurse's Station, which was on the east end of the 500 hall. He showed the surveyors the re-set buttons for the SW exit door, as well as the camera monitor screen, which showed four different views, one of which was a view of the SW exit door. The Administrator informed the surveyor the re-set buttons were for the SE (southeast) and SW exit doors so the nurse would not have to go to the doors to re-set them. He stated the nurse was able to unlock the SE exit door as well from Station II Nurse's Station. He also stated there was no one to monitor the camera monitor and most of the time the Station II Nurse's Station was empty. The Administrator stated they did not report this incident to the State Agency. He stated the management team had discussed the incident in their morning stand-up meeting, called their corporate office, and because they knew how Resident #1 got injured, they felt it was not a reportable incident. During an interview with ADON A on 03/01/11 at 5:24 p.m., she revealed staff did not know Resident #1 was out of the building. She said she knew because, "I was the nurse that went out to assess him." She told the surveyor CNA J got one resident away from the door and did not realize Resident #1 had already gotten out and fallen off the ledge. ADON A said the person who had driven around the building was the one who discovered Resident #1 face down and he sent someone in and got her and that "...was the first time anyone inside realized he had gotten out...." A confidential interview revealed he/she heard the alarms. He/she said a family member looked out the window of his/her room and saw a big truck stop, a man get out and run over to a man on the ground and then a fire truck and ambulance came. He/she stated the alarm worked before and Resident #2 set it off and no one would come. He/she said it had happened several times the day before. Observation on 03/02/11 at 9:02 a.m. revealed Resident #1 was fully dressed, lying in bed. A Wanderguard was present to his right ankle. Further interview with ADON A on 03/02/11 at 9:17 a.m. revealed it was not CNA J who moved the other resident away from the door. She stated it was LVN K and she no longer worked at the facility. ADON A stated she would provide the surveyor with LVN K's phone number that the The surveyor asked ADON A who the second resident was and she stated Resident #3. ADON A also revealed she and the Administrator got statements from other employees the same night of the incident, but they had "...disappeared...." ADON A stated she would get a faxed statement from the SVP of Development who was the one who actually found the resident outside. During an interview with the Administrator on 03/02/11 at 9:20 a.m., he revealed he had placed the Administration Clerk at the Station II Nurse's Station to monitor the cameras. He stated if she saw a resident at the SW exit door, she would call someone to go get the resident and she would also go. He further stated the corporate office may put monitors in offices and/or hire a receptionist to monitor the cameras and answer telephones. On 03/02/11 at 10:30 a.m. the surveyor observed a staff member sitting at the Station II Nurse's Station beside the monitor. When the surveyor asked who she was, she replied she was the Administration Clerk. She stated she was going to sit and watch the SE or front entrance to the new wing (500 Hall), monitor for the SW exit door and answer telephones. She stated she started those duties that morning. Observation on 03/02/11 at 11:00 a.m. revealed Resident #1 was fully dressed, lying in bed with a Wanderguard on his right ankle. On 03/02/11 at 12:05 p.m. the Administrator brought the surveyor a Detailed Development Action Plan dated 03/02/11. The Plan reflected, "Back Door was not locking correctly" and the corrections they had already accomplished were listed. On 03/02/11 at 3:55 p.m. the SW exit door secondary alarm started sounding and the surveyor observed Resident #2 at the SW exit door and ADON B and one other employee getting the resident away from the exit and re-setting the door. The surveyor told ADON B that she had only heard the back-up or secondary alarm and not the programmed door alarm sound. ADON B tried the door and the programmed alarm sounded for 15 seconds, the door opened and the programmed alarm stopped and the back-up or secondary alarm sounded. The surveyor again told ADON B she did not hear the 15 second alarm sound before the back-up or secondary alarm sounded when Resident #2 opened the SW exit door. On 03/02/11 at 2:00 p.m., during a telephone interview with LVN K, she stated, "Yes I was there." when asked if she had been working hall 500 on the evening Resident #1 was injured. When asked about whether the SW door had alarmed she replied, "To be honest those doors sometimes work and sometimes don't, so I would always check them when I came on...." When asked if she had pulled a resident away from the door at the time of the incident she stated, "That was earlier in the day...____ (Resident #2)...." She informed the surveyor she and one CNA were on the unit and they were in a room admitting a new resident. She stated they had not seen or heard anything until, "...someone came in and told us he was out...." She stated there was another nurse at the Station II Nurse's Station. She also stated, "...That door (SW exit door) has never worked, I kept telling them...." An interview on 03/03/11 at 11:10 a.m. with LVN E revealed she had been told by someone Resident #1 was outside and she went out there. LVN E stated ADON A and the Administrator were already out there with Resident #1, so she came back into the facility and, "...got gauze, B/P (blood pressure) cuff and everything, took it to ____ (ADON A) and came back in and filled out paper work to transfer him (Resident #1)." On 03/03/11 at 11:50 a.m. during an interview with ADON A she stated she discovered Resident #1 was outside on 01/04/11 when the SVP of Development's son came in and informed her there was someone outside bleeding. She stated the SVP of Development was out there and called 911 as soon as she arrived and she called the Administrator. An interview on 03/03/11 at 3:40 p.m. with CNA I revealed around 4:00 p.m. Resident #1 was confused and asking about his wife. She stated he set off for the front door and continued all over the building setting off the door alarms. She stated after dinner she saw him on the 100 hall going towards the 500 hall. CNA I stated after that she was on the 200 hall and heard the alarm. She stated another resident and another resident's family member pointed to Resident #1. CNA I stated she asked Resident #1 what he wanted and he told her he wanted to go home. She stated she took him back to his room on the 100 hall. CNA I said she went back to the 300 hall, which was her assigned hall. She stated about 20 minutes later she saw a couple staff members running and she went to see what was happening. CNA I stated she went to the 100 hall and looked in Resident #1's room and he was not there. She stated she went to the 500 hall and a couple of other CNA's ran down the 200 hall and they all met at the SW exit door. She stated she saw Resident #1 on the ground. CNA I stated since a nurse was with him, she went and helped LVN E make copies of his chart to transfer him. She stated she did not pull anyone else away from the SW exit door and the resident she was referring to in her written statement was Resident #1. She stated she had pulled him away from the SW door about 20 minutes before he actually got out. She re-read her statement, wrote the name of the resident she was referring to and dated it 03/03/11. The facility's WanderGuard Book (a binder located at the Station I Nurses' Station) contained a list of residents who had Wanderguards. The Resident Wanderguard List was updated on 12-1-10 and Resident #1 was not on this list. There were 12 residents on the list and four more residents, which had been added by hand. Two of the typed residents' names and two of the handwritten names had been crossed off and discharged was written beside them. The list also reflected the location of the wanderguard on the resident or on their equipment. The book also contained a page for each resident on the list with their picture and information about them. Resident #1 was not on any of the pages in the binder. Review of a handwritten statement from CNA L signed and dated 03/01/11 revealed, "On [DATE] I had just saw (sic) ____Resident #1 in dining room on 500 hall at 5:00 pm. Shortly after that I was notified that he had fallen outside." Review of a statement from the SVP of Development dated 03/02/11 revealed, "January 4, 2011 at approximately 5:15 PM I came to the facility and was driving around back of the building to pick up a compressor from the storage building. There was no one out back as I drove around. I picked up the compressor and locked the storage building. Then I turned around and drove back around the building, my headlights shined on a wheelchair that was lying on its side. It was dusk outside. I saw a gentleman wearing a grey sweatshirt and sweatpants, lying on the ground opposite his wheelchair. I stopped the truck in the fire lane and got out. The gentleman had a bloody nose and bloody face. I sent my son, who was with me, around the front of the building because the side door the gentleman had come out was locked. My son went around the front of the building to go and get a staff member. I dialed 911 on my cell phone and stayed with the gentleman until nursing staff arrived immediately along with the Administrator. The paramedics arrived shortly thereafter, assessed the gentleman and transported him to the emergency as a precaution to ensure residents safety. The Administrator and I then went inside and checked the doors. At this time all were working correctly. The staff members were then questioned and I was under the understanding that two residents had come to the door when the door alarm sounded. The staff members responded to the resident directly at the door and did not see the other resident who was already outside and/or around the corner. The door was relocked (sic)and the alarm was reengaged (sic) at that time." Resident #1's Comprehensive Plan of Care dated 12/12/10 reflected a problem of, "Resident is at Risk of Injury Due to Potential Elopement." Handwritten after "As Evidenced By:" was, "Attempting to leave facility/wants to go home." Under the heading "Goal" was, "Will be able to wander in a safe environment without the occurrence of injury and the resident's dignity will be maintained over next 90 days." The care plan reflected the following approaches: to monitor q one hour and prn to assure resident safety and re-direct when wandering un-safely. Resident #1's Elopement Risk Assessment was dated 12/03/10 and reflected a personal safety alarm device and frequent monitoring. Review of Resident #1's Care Summary dated 12/29/10 revealed that he was a "wanderer." 3. Review of the facility's CMS form 672 dated and signed by the Interim DON on 03/03/11 revealed there was a total census of 117 and 62 of those residents had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate an incident involving potential neglect and to report the incident to the State Agency for one (Resident #1) of 12 wandering residents. 1. The SW (southwest) corner exit door was not working properly on one day of the survey (03/01/11) and this was the door Resident #1 got out of undetected by staff in the facility. 2. The "Accident/Incident Report" filled out by ADON A and reviewed and signed by the former DON and the Administrator did not address how Resident #1 got out of the facility. 3. Resident #1's accident which resulted in contusions, abrasions and bruising of the head/face and fractured ribs that required medical attention was not reported to the Texas State Department of Aging and Disability Services (DADS.) These failures had the potential to affect the 12 residents in the facility on the "WanderGuard" list, and Resident #1, who wandered daily resulting in them exiting out the same door and possibly getting injured. Findings included: 1. A review of Resident #1's Admission Face Sheet, un-dated, revealed he was a [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 01/04/11 and authored by LVN E revealed, "Found outside of bldg (building) on pavement lying on his (l) (left) side. Lg (large) amt (amount) blood noted on sidewalk. Covered c (with) blanket BP (blood pressure) 148/78 - 88 (heart rate) - 22 (respirations). 9-1-1 contacted. Compresses applied to gash over os (left eye). Unable to reach____(POA). Message left for ____(Resident's family member)." Review of Resident #1's Physician's Telephone Orders dated 01/04/11 with no noted time, revealed, "to _____(hospital name) via ambulance S/P (status [REDACTED]. Resident #1's Incident/Accident Report dated 01/04/11 reflected Resident #1 was located outside of the facility and experienced an unwitnessed fall. The report also reflected he suffered a contusion/hematoma to his head, a skin tear/laceration, and a bruise. The report further reflected Resident #1 was transferred to the ER. Further review of the report revealed, Resident #1 was found on the ground outside the exit door on the southwest corner of the building face down and positioned on his left side. The report reflected there was blood on the ground underneath his head and a large hematoma to his left eye with purple discoloration. The report indicated there was red drainage from area. The report also reflected there was purple discoloration and swelling to his upper lip and red fluid in his mouth. The report indicated Resident #1 was alert and talkative and he complained of pain to his face, his lower left shoulder. The report also indicated the w/c alarm was sounding and the w/c was upside down. Resident #1's Incident/Accident Report reflected was signed and dated on 01/07/11 by DON H (former DON.) DON H wrote on the report, "Staff inservices on reaction to door alarms. Also when find resident @ (at) door - need to walk out of building (and) look around. Head count needs to be completed. Safety fence is currently being contracted by administration. Bed alarm/chair alarms. Safety (check) completed." Note: There was no explanation or investigation about how Resident #1 got out of the facility documented on the report. Resident #1's Report also reflected no documented evidence the State agency was contacted. This last section had DON H's signature and a date of 01/07/11 and the Administrator's signature and date of 01/08/11, which indicate they had reviewed the report and signed it off as complete, even though there was no investigation of how Resident #1 got out of the facility. Review of Resident #1's hospital registration form dated 01/04/11 revealed an admission date of [DATE]. Resident #1's hospital Emergency Department Discharge Instructions dated 01/04/11 reflected [DIAGNOSES REDACTED]. Resident #1's Nurse's Notes dated 01/06/11 reflected, "Late entry for 1/5/11" in the margin and 01/06/11 ER nurse called yesterday and stated x-rays showed Resident #1 had right rib fractures to 5th and 6th ribs. Note: This was the only Nurse's Note or entry about broken ribs, which could be located in the clinical record until a chest x-ray study was done on 02/19/11. Observation on 03/01/11 at 10:07 a.m. revealed Resident #1 was fully dressed, but lying in bed. When questioned by the surveyor how he was feeling Resident #1 stated he was OK. On 03/01/11 at 3:55 p.m. the two surveyors went to the SW exit door where Resident #1 was reported to have gotten out of the building. The surveyors obtained the code to go out and exited the building. Once outside, the surveyors observed a porch area approximately 4 feet square with a railed ramp approximately 4 feet wide that went to the right for approximately 10 feet, turned to the left for approximately 6 feet then again turned to the left for approximately 8 feet ending on a sidewalk which paralleled the south side parking lot. The surveyors turned back around to go back through the exit door and were able to walk right through the SW exit door. (Note: The door was supposed to automatically lock after keying in the code and exiting the building.) Once back inside, the surveyors waited 30 seconds and re-tried the SW exit door and the door opened and no alarm sounded. The surveyors tried the door several times and were able to exit with no delay and no alarm sounding. An observation on 03/01/11 at 4:04 p.m. revealed a female resident in her w/c from the end of the 200 hall went to the SW exit door. The resident had a w/c alarm attached to her chair and self. The resident touched the push bar on the SW exit door, no alarm sounded. She touched the bar several times from right to left and then took her right foot and pushed the door which opened about two inches, then closed. The resident then appeared to lose interest and turned her w/c around and went back the way she had come. One surveyor asked a staff member to identify the resident was after she had made it back around to the PT department and they informed her it was Resident #2 and her room was on the 200 hall. On 03/01/11 at 4:06 p.m. the surveyors tried the South door leading to the inner courtyard area across from the PT department. The surveyors were able to push the door open and get outside into the courtyard without an alarm sounding. When the surveyors attempted to go back inside the facility the alarm sounded. On 03/01/11 at 4:15 p.m., the surveyors brought the Administrator and the Assistant Administrator to the SW exit door and asked them to try it. The Administrator pushed the door and it opened without an alarm sounding. He stated the door was not working. ADON B informed everyone that had happened on the previous night and she had re-set it and it had worked properly. ADON B pushed in a code and the alarm sounded for 15 seconds, while the Administrator pushed on the bar and then it opened and the alarm stopped. The Administrator then closed the door and the alarm sounded again and he stated, "It's working opposite how it should..." ADON B stated the door needed to be repaired and they needed to get an employee to sit and monitor the door until it was fixed as it was a very dangerous situation. The Administrator and Assistant Administrator agreed. On 03/01/11 at 4:30 p.m. the surveyor observed the Maintenance Director working on the SW exit door. The door was tested and appeared to be working at this time. An interview on 03/01/11 at 4:50 p.m. with the Administrator revealed the problem with the door was his staff was not re-setting the alarm after it sounded and therefore the door would not re-lock and the alarm would not sound when someone touched it. The Administrator stated and showed the surveyor a back-up alarm system the Maintenance Director had applied to the SW exit door. The Administrator demonstrated how it worked. An observation at that time revealed the back-up system alarmed whenever the door was opened. The surveyor asked the Administrator about Resident #1's incident. The Administrator stated there had been two residents at the SW exit door. He further stated when the staff got to the door they pulled one resident back and Resident #1 was able to get out of the door. He stated Resident #1 went straight off the porch. The Administrator also stated at that time, someone from corporate was driving around the building and saw Resident #1. The surveyor asked how he went off the porch with the railing there and the Administrator stated, "...The fence was not there when that happened...." The Administrator informed the surveyor when the new addition was first built the construction company said they did not need a railing on the ramp. He stated it was actually added, "...as an intervention...." after Resident #1's incident. The Administrator stated he probably still had a copy of the report and would get it for the surveyor. The surveyor went out the SW exit door and observed there was an approximately 3 ? foot drop off the porch area onto a 3 to 4 foot grassy slope, which ended at the edge of the sidewalk. The surveyor asked the Administrator if the camera, which was observed by the PT department and appeared to be pointing at the SW exit door, was a working camera. The Administrator replied it was a working camera and the monitor screen was at the Station II Nurse's Station. The Administrator took the surveyors to the Station II Nurse's Station, which was on the east end of the 500 hall. He showed the surveyors the re-set buttons for the SW exit door, as well as the camera monitor screen, which showed four different views, one of which was a view of the SW exit door. The Administrator informed the surveyor the re-set buttons were for the SE (southeast) and SW exit doors so the nurse would not have to go to the doors to re-set them. He stated the nurse was able to unlock the SE exit door as well from Station II Nurse's Station. He also stated there was no one to monitor the camera monitor and most of the time the Station II Nurse's Station was empty. The Administrator stated they did not report this incident to the State Agency. He stated the management team had discussed the incident in their morning stand-up meeting, called their corporate office, and because they knew how Resident #1 got injured, they felt it was not a reportable incident. During an interview with ADON A on 03/01/11 at 5:24 p.m., she revealed staff did not know Resident #1 was out of the building. She said she knew because, "I was the nurse that went out to assess him." She told the surveyor CNA J got one resident away from the door and did not realize Resident #1 had already gotten out and fallen off the ledge. ADON A said the person who had driven around the building was the one who discovered Resident #1 face down and he sent someone in and got her and that "...was the first time anyone inside realized he had gotten out...." A confidential interview revealed he/she heard the alarms. He/she said a family member looked out the window of his/her room and saw a big truck stop, a man get out and run over to a man on the ground and then a fire truck and ambulance came. He/she stated the alarm worked before and Resident #2 set it off and no one would come. He/she said it had happened several times the day before. Observation on 03/02/11 at 9:02 a.m. revealed Resident #1 was fully dressed, lying in bed. A Wanderguard was present to his right ankle. Further interview with ADON A on 03/02/11 at 9:17 a.m. revealed it was not CNA J who moved the other resident away from the door. She stated it was LVN K and she no longer worked at the facility. ADON A stated she would provide the surveyor with LVN K's phone number that the The surveyor asked ADON A who the second resident was and she stated Resident #3. ADON A also revealed she and the Administrator got statements from other employees the same night of the incident, but they had "...disappeared...." ADON A stated she would get a faxed statement from the SVP of Development who was the one who actually found the resident outside. During an interview with the Administrator on 03/02/11 at 9:20 a.m., he revealed he had placed the Administration Clerk at the Station II Nurse's Station to monitor the cameras. He stated if she saw a resident at the SW exit door, she would call someone to go get the resident and she would also go. He further stated the corporate office may put monitors in offices and/or hire a receptionist to monitor the cameras and answer telephones. On 03/02/11 at 10:30 a.m. the surveyor observed a staff member sitting at the Station II Nurse's Station beside the monitor. When the surveyor asked who she was, she replied she was the Administration Clerk. She stated she was going to sit and watch the SE or front entrance to the new wing (500 Hall), monitor for the SW exit door and answer telephones. She stated she started those duties that morning. Observation on 03/02/11 at 11:00 a.m. revealed Resident #1 was fully dressed, lying in bed with a Wanderguard on his right ankle. On 03/02/11 at 12:05 p.m. the Administrator brought the surveyor a Detailed Development Action Plan dated 03/02/11. The Plan reflected, "Back Door was not locking correctly" and the corrections they had already accomplished were listed. On 03/02/11 at 3:55 p.m. the SW exit door secondary alarm started sounding and the surveyor observed Resident #2 at the SW exit door and ADON B and one other employee getting the resident away from the exit and re-setting the door. The surveyor told ADON B that she had only heard the back-up or secondary alarm and not the programmed door alarm sound. ADON B tried the door and the programmed alarm sounded for 15 seconds, the door opened and the programmed alarm stopped and the back-up or secondary alarm sounded. The surveyor again told ADON B she did not hear the 15 second alarm sound before the back-up or secondary alarm sounded when Resident #2 opened the SW exit door. On 03/02/11 at 2:00 p.m., during a telephone interview with LVN K, she stated, "Yes I was there." when asked if she had been working hall 500 on the evening Resident #1 was injured. When asked about whether the SW door had alarmed she replied, "To be honest those doors sometimes work and sometimes don't, so I would always check them when I came on...." When asked if she had pulled a resident away from the door at the time of the incident she stated, "That was earlier in the day...____ (Resident #2)...." She informed the surveyor she and one CNA were on the unit and they were in a room admitting a new resident. She stated they had not seen or heard anything until, "...someone came in and told us he was out...." She stated there was another nurse at the Station II Nurse's Station. She also stated, "...That door (SW exit door) has never worked, I kept telling them...." An interview on 03/03/11 at 11:10 a.m. with LVN E revealed she had been told by someone Resident #1 was outside and she went out there. LVN E stated ADON A and the Administrator were already out there with Resident #1, so she came back into the facility and, "...got gauze, B/P (blood pressure) cuff and everything, took it to ____ (ADON A) and came back in and filled out paper work to transfer him (Resident #1)." On 03/03/11 at 11:50 a.m. during an interview with ADON A she stated she discovered Resident #1 was outside on 01/04/11 when the SVP of Development's son came in and informed her there was someone outside bleeding. She stated the SVP of Development was out there and called 911 as soon as she arrived and she called the Administrator. An interview on 03/03/11 at 3:40 p.m. with CNA I revealed around 4:00 p.m. Resident #1 was confused and asking about his wife. She stated he set off for the front door and continued all over the building setting off the door alarms. She stated after dinner she saw him on the 100 hall going towards the 500 hall. CNA I stated after that she was on the 200 hall and heard the alarm. She stated another resident and another resident's family member pointed to Resident #1. CNA I stated she asked Resident #1 what he wanted and he told her he wanted to go home. She stated she took him back to his room on the 100 hall. CNA I said she went back to the 300 hall, which was her assigned hall. She stated about 20 minutes later she saw a couple staff members running and she went to see what was happening. CNA I stated she went to the 100 hall and looked in Resident #1's room and he was not there. She stated she went to the 500 hall and a couple of other CNA's ran down the 200 hall and they all met at the SW exit door. She stated she saw Resident #1 on the ground. CNA I stated since a nurse was with him, she went and helped LVN E make copies of his chart to transfer him. She stated she did not pull anyone else away from the SW exit door and the resident she was referring to in her written statement was Resident #1. She stated she had pulled him away from the SW door about 20 minutes before he actually got out. She re-read her statement, wrote the name of the resident she was referring to and dated it 03/03/11. The facility's WanderGuard Book (a binder located at the Station I Nurses' Station) contained a list of residents who had Wanderguards. The Resident Wanderguard List was updated on 12-1-10 and Resident #1 was not on this list. There were 12 residents on the list and four more residents, which had been added by hand. Two of the typed residents' names and two of the handwritten names had been crossed off and discharged was written beside them. The list also reflected the location of the wanderguard on the resident or on their equipment. The book also contained a page for each resident on the list with their picture and information about them. Resident #1 was not on any of the pages in the binder. Review of a handwritten statement from CNA L signed and dated 03/01/11 revealed, "On [DATE] I had just saw (sic) ____Resident #1 in dining room on 500 hall at 5:00 pm. Shortly after that I was notified that he had fallen outside." Review of a statement from the SVP of Development dated 03/02/11 revealed, "January 4, 2011 at approximately 5:15 PM I came to the facility and was driving around back of the building to pick up a compressor from the storage building. There was no one out back as I drove around. I picked up the compressor and locked the storage building. Then I turned around and drove back around the building, my headlights shined on a wheelchair that was lying on its side. It was dusk outside. I saw a gentleman wearing a grey sweatshirt and sweatpants, lying on the ground opposite his wheelchair. I stopped the truck in the fire lane and got out. The gentleman had a bloody nose and bloody face. I sent my son, who was with me, around the front of the building because the side door the gentleman had come out was locked. My son went around the front of the building to go and get a staff member. I dialed 911 on my cell phone and stayed with the gentleman until nursing staff arrived immediately along with the Administrator. The paramedics arrived shortly thereafter, assessed the gentleman and transported him to the emergency as a precaution to ensure residents safety. The Administrator and I then went inside and checked the doors. At this time all were working correctly. The staff members were then questioned and I was under the understanding that two residents had come to the door when the door alarm sounded. The staff members responded to the resident directly at the door and did not see the other resident who was already outside and/or around the corner. The door was relocked (sic)and the alarm was reengaged (sic) at that time." Resident #1's Comprehensive Plan of Care dated 12/12/10 reflected a problem of, "Resident is at Risk of Injury Due to Potential Elopement." Handwritten after "As Evidenced By:" was, "Attempting to leave facility/wants to go home." Under the heading "Goal" was, "Will be able to wander in a safe environment without the occurrence of injury and the resident's dignity will be maintained over next 90 days." The care plan reflected the following approaches: to monitor q one hour and prn to assure resident safety and re-direct when wandering un-safely. Resident #1's Elopement Risk Assessment was dated 12/03/10 and reflected a personal safety alarm device and frequent monitoring. Review of Resident #1's Care Summary dated 12/29/10 revealed that he was a "wanderer." 2. Review of the facility's current Abuse Prevention Manual with the effective date of January 2005 and most recent revision date of June 2009 revealed the following: The definition of Neglect was the, "Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness." The policy and procedures reflected, "Identification- The QA (Quality Assurance) Team investigates all occurrences,...that may indicate the presence of abuse, neglect or misappropriation...In addition the Medical Director, Director of Nurses and Administrator will review all unusual occurrences." The policy and procedure also reflected, "Reporting and Response- All allegations and substantiated occurrences of abuse, neglect and misappropriation of property are reported to the state agency and law enforcement officials as designated by state law." The investigation section of the policy reflected, "Investigations are conducted on all cases of alleged abuse/neglect...." Under the section of Prevention the policy and procedure reflected, "...Identifying, correcting and intervening in situations in which abuse, neglect and misappropriation of patient property is more likely to occur. This includes an analysis of: Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility...." 3. Review of the facility's CMS form 672 dated and signed by the Interim DON on 03/03/11 revealed there was a total census of 117 and 62 of those residents had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, it was determined the facility failed to implement it's written polices and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for one (Resident #1) of 12 wandering residents. 1. Resident #1 was able to exit the facility undetected on 01/04/11, roll off a porch in his w/c and sustain injuries, which required going to the emergency room for treatment. 2. The SW (southwest) corner exit door was not working properly when tested by the surveyors on 03/01/11 and the facility failed to ensure the SW corner exit door was re-set each time the alarm sounded and there fore it was left unsecured, allowing residents to go out the door without alarming. 3. There were no railings on the porch or exit ramp leading from the outside of the SW exit at the time of Resident #1's accident. These failures had the potential to affect the 12 residents and Resident #1 who wandered daily. Findings included: 1. Review of the facility's current Abuse Prevention Manual with the effective date of January 2005 and most recent revision date of June 2009 revealed the following: The definition of Neglect was the, "Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness." The policy and procedures reflected, "Identification- The QA (Quality Assurance) Team investigates all occurrences,...that may indicate the presence of abuse, neglect or misappropriation...In addition the Medical Director, Director of Nurses and Administrator will review all unusual occurrences." The policy and procedure also reflected, "Reporting and Response- All allegations and substantiated occurrences of abuse, neglect and misappropriation of property are reported to the state agency and law enforcement officials as designated by state law." The investigation section of the policy reflected, "Investigations are conducted on all cases of alleged abuse/neglect...." Under the section of Prevention the policy and procedure reflected, "...Identifying, correcting and intervening in situations in which abuse, neglect and misappropriation of patient property is more likely to occur. This includes an analysis of: Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility...." 2. A review of Resident #1's Admission Face Sheet, un-dated, revealed he was a [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 01/04/11 and authored by LVN E revealed, "Found outside of bldg (building) on pavement lying on his (l) (left) side. Lg (large) amt (amount) blood noted on sidewalk. Covered c (with) blanket BP (blood pressure) 148/78 - 88 (heart rate) - 22 (respirations). 9-1-1 contacted. Compresses applied to gash over os (left eye). Unable to reach____(POA). Message left for ____(Resident's family member)." Review of Resident #1's Physician's Telephone Orders dated 01/04/11 with no noted time, revealed, "to _____(hospital name) via ambulance S/P (status [REDACTED]. Resident #1's Incident/Accident Report dated 01/04/11 reflected Resident #1 was located outside of the facility and experienced an unwitnessed fall. The report also reflected he suffered a contusion/hematoma to his head, a skin tear/laceration, and a bruise. The report further reflected Resident #1 was transferred to the ER. Further review of the report revealed, Resident #1 was found on the ground outside the exit door on the southwest corner of the building face down and positioned on his left side. The report reflected there was blood on the ground underneath his head and a large hematoma to his left eye with purple discoloration. The report indicated there was red drainage from area. The report also reflected there was purple discoloration and swelling to his upper lip and red fluid in his mouth. The report indicated Resident #1 was alert and talkative and he complained of pain to his face, his lower left shoulder. The report also indicated the w/c alarm was sounding and the w/c was upside down. Resident #1's Incident/Accident Report reflected was signed and dated on 01/07/11 by DON H (former DON.) DON H wrote on the report, "Staff inservices on reaction to door alarms. Also when find resident @ (at) door - need to walk out of building (and) look around. Head count needs to be completed. Safety fence is currently being contracted by administration. Bed alarm/chair alarms. Safety (check) completed." Note: There was no explanation or investigation about how Resident #1 got out of the facility documented on the report. Resident #1's Report also reflected no documented evidence the State agency was contacted. This last section had DON H's signature and a date of 01/07/11 and the Administrator's signature and date of 01/08/11, which indicate they had reviewed the report and signed it off as complete, even though there was no investigation of how Resident #1 got out of the facility. Review of Resident #1's hospital registration form dated 01/04/11 revealed an admission date of [DATE]. Resident #1's hospital Emergency Department Discharge Instructions dated 01/04/11 reflected [DIAGNOSES REDACTED]. Resident #1's Nurse's Notes dated 01/06/11 reflected, "Late entry for 1/5/11" in the margin and 01/06/11 ER nurse called yesterday and stated x-rays showed Resident #1 had right rib fractures to 5th and 6th ribs. Note: This was the only Nurse's Note or entry about broken ribs, which could be located in the clinical record until a chest x-ray study was done on 02/19/11. Observation on 03/01/11 at 10:07 a.m. revealed Resident #1 was fully dressed, but lying in bed. When questioned by the surveyor how he was feeling Resident #1 stated he was OK. On 03/01/11 at 3:55 p.m. the two surveyors went to the SW exit door where Resident #1 was reported to have gotten out of the building. The surveyors obtained the code to go out and exited the building. Once outside, the surveyors observed a porch area approximately 4 feet square with a railed ramp approximately 4 feet wide that went to the right for approximately 10 feet, turned to the left for approximately 6 feet then again turned to the left for approximately 8 feet ending on a sidewalk which paralleled the south side parking lot. The surveyors turned back around to go back through the exit door and were able to walk right through the SW exit door. (Note: The door was supposed to automatically lock after keying in the code and exiting the building.) Once back inside, the surveyors waited 30 seconds and re-tried the SW exit door and the door opened and no alarm sounded. The surveyors tried the door several times and were able to exit with no delay and no alarm sounding. An observation on 03/01/11 at 4:04 p.m. revealed a female resident in her w/c from the end of the 200 hall went to the SW exit door. The resident had a w/c alarm attached to her chair and self. The resident touched the push bar on the SW exit door, no alarm sounded. She touched the bar several times from right to left and then took her right foot and pushed the door which opened about two inches, then closed. The resident then appeared to lose interest and turned her w/c around and went back the way she had come. One surveyor asked a staff member to identify the resident was after she had made it back around to the PT department and they informed her it was Resident #2 and her room was on the 200 hall. On 03/01/11 at 4:06 p.m. the surveyors tried the South door leading to the inner courtyard area across from the PT department. The surveyors were able to push the door open and get outside into the courtyard without an alarm sounding. When the surveyors attempted to go back inside the facility the alarm sounded. On 03/01/11 at 4:15 p.m., the surveyors brought the Administrator and the Assistant Administrator to the SW exit door and asked them to try it. The Administrator pushed the door and it opened without an alarm sounding. He stated the door was not working. ADON B informed everyone that had happened on the previous night and she had re-set it and it had worked properly. ADON B pushed in a code and the alarm sounded for 15 seconds, while the Administrator pushed on the bar and then it opened and the alarm stopped. The Administrator then closed the door and the alarm sounded again and he stated, "It's working opposite how it should..." ADON B stated the door needed to be repaired and they needed to get an employee to sit and monitor the door until it was fixed as it was a very dangerous situation. The Administrator and Assistant Administrator agreed. On 03/01/11 at 4:30 p.m. the surveyor observed the Maintenance Director working on the SW exit door. The door was tested and appeared to be working at this time. An interview on 03/01/11 at 4:50 p.m. with the Administrator revealed the problem with the door was his staff was not re-setting the alarm after it sounded and therefore the door would not re-lock and the alarm would not sound when someone touched it. The Administrator stated and showed the surveyor a back-up alarm system the Maintenance Director had applied to the SW exit door. The Administrator demonstrated how it worked. An observation at that time revealed the back-up system alarmed whenever the door was opened. The surveyor asked the Administrator about Resident #1's incident. The Administrator stated there had been two residents at the SW exit door. He further stated when the staff got to the door they pulled one resident back and Resident #1 was able to get out of the door. He stated Resident #1 went straight off the porch. The Administrator also stated at that time, someone from corporate was driving around the building and saw Resident #1. The surveyor asked how he went off the porch with the railing there and the Administrator stated, "...The fence was not there when that happened...." The Administrator informed the surveyor when the new addition was first built the construction company said they did not need a railing on the ramp. He stated it was actually added, "...as an intervention...." after Resident #1's incident. The Administrator stated he probably still had a copy of the report and would get it for the surveyor. The surveyor went out the SW exit door and observed there was an approximately 3 ? foot drop off the porch area onto a 3 to 4 foot grassy slope, which ended at the edge of the sidewalk. The surveyor asked the Administrator if the camera, which was observed by the PT department and appeared to be pointing at the SW exit door, was a working camera. The Administrator replied it was a working camera and the monitor screen was at the Station II Nurse's Station. The Administrator took the surveyors to the Station II Nurse's Station, which was on the east end of the 500 hall. He showed the surveyors the re-set buttons for the SW exit door, as well as the camera monitor screen, which showed four different views, one of which was a view of the SW exit door. The Administrator informed the surveyor the re-set buttons were for the SE (southeast) and SW exit doors so the nurse would not have to go to the doors to re-set them. He stated the nurse was able to unlock the SE exit door as well from Station II Nurse's Station. He also stated there was no one to monitor the camera monitor and most of the time the Station II Nurse's Station was empty. The Administrator stated they did not report this incident to the State Agency. He stated the management team had discussed the incident in their morning stand-up meeting, called their corporate office, and because they knew how Resident #1 got injured, they felt it was not a reportable incident. During an interview with ADON A on 03/01/11 at 5:24 p.m., she revealed staff did not know Resident #1 was out of the building. She said she knew because, "I was the nurse that went out to assess him." She told the surveyor CNA J got one resident away from the door and did not realize Resident #1 had already gotten out and fallen off the ledge. ADON A said the person who had driven around the building was the one who discovered Resident #1 face down and he sent someone in and got her and that "...was the first time anyone inside realized he had gotten out...." A confidential interview revealed he/she heard the alarms. He/she said a family member looked out the window of his/her room and saw a big truck stop, a man get out and run over to a man on the ground and then a fire truck and ambulance came. He/she stated the alarm worked before and Resident #2 set it off and no one would come. He/she said it had happened several times the day before. Observation on 03/02/11 at 9:02 a.m. revealed Resident #1 was fully dressed, lying in bed. A Wanderguard was present to his right ankle. Further interview with ADON A on 03/02/11 at 9:17 a.m. revealed it was not CNA J who moved the other resident away from the door. She stated it was LVN K and she no longer worked at the facility. ADON A stated she would provide the surveyor with LVN K's phone number that the The surveyor asked ADON A who the second resident was and she stated Resident #3. ADON A also revealed she and the Administrator got statements from other employees the same night of the incident, but they had "...disappeared...." ADON A stated she would get a faxed statement from the SVP of Development who was the one who actually found the resident outside. During an interview with the Administrator on 03/02/11 at 9:20 a.m., he revealed he had placed the Administration Clerk at the Station II Nurse's Station to monitor the cameras. He stated if she saw a resident at the SW exit door, she would call someone to go get the resident and she would also go. He further stated the corporate office may put monitors in offices and/or hire a receptionist to monitor the cameras and answer telephones. On 03/02/11 at 10:30 a.m. the surveyor observed a staff member sitting at the Station II Nurse's Station beside the monitor. When the surveyor asked who she was, she replied she was the Administration Clerk. She stated she was going to sit and watch the SE or front entrance to the new wing (500 Hall), monitor for the SW exit door and answer telephones. She stated she started those duties that morning. Observation on 03/02/11 at 11:00 a.m. revealed Resident #1 was fully dressed, lying in bed with a Wanderguard on his right ankle. On 03/02/11 at 12:05 p.m. the Administrator brought the surveyor a Detailed Development Action Plan dated 03/02/11. The Plan reflected, "Back Door was not locking correctly" and the corrections they had already accomplished were listed. On 03/02/11 at 3:55 p.m. the SW exit door secondary alarm started sounding and the surveyor observed Resident #2 at the SW exit door and ADON B and one other employee getting the resident away from the exit and re-setting the door. The surveyor told ADON B that she had only heard the back-up or secondary alarm and not the programmed door alarm sound. ADON B tried the door and the programmed alarm sounded for 15 seconds, the door opened and the programmed alarm stopped and the back-up or secondary alarm sounded. The surveyor again told ADON B she did not hear the 15 second alarm sound before the back-up or secondary alarm sounded when Resident #2 opened the SW exit door. On 03/02/11 at 2:00 p.m., during a telephone interview with LVN K, she stated, "Yes I was there." when asked if she had been working hall 500 on the evening Resident #1 was injured. When asked about whether the SW door had alarmed she replied, "To be honest those doors sometimes work and sometimes don't, so I would always check them when I came on...." When asked if she had pulled a resident away from the door at the time of the incident she stated, "That was earlier in the day...____ (Resident #2)...." She informed the surveyor she and one CNA were on the unit and they were in a room admitting a new resident. She stated they had not seen or heard anything until, "...someone came in and told us he was out...." She stated there was another nurse at the Station II Nurse's Station. She also stated, "...That door (SW exit door) has never worked, I kept telling them...." An interview on 03/03/11 at 11:10 a.m. with LVN E revealed she had been told by someone Resident #1 was outside and she went out there. LVN E stated ADON A and the Administrator were already out there with Resident #1, so she came back into the facility and, "...got gauze, B/P (blood pressure) cuff and everything, took it to ____ (ADON A) and came back in and filled out paper work to transfer him (Resident #1)." On 03/03/11 at 11:50 a.m. during an interview with ADON A she stated she discovered Resident #1 was outside on 01/04/11 when the SVP of Development's son came in and informed her there was someone outside bleeding. She stated the SVP of Development was out there and called 911 as soon as she arrived and she called the Administrator. An interview on 03/03/11 at 3:40 p.m. with CNA I revealed around 4:00 p.m. Resident #1 was confused and asking about his wife. She stated he set off for the front door and continued all over the building setting off the door alarms. She stated after dinner she saw him on the 100 hall going towards the 500 hall. CNA I stated after that she was on the 200 hall and heard the alarm. She stated another resident and another resident's family member pointed to Resident #1. CNA I stated she asked Resident #1 what he wanted and he told her he wanted to go home. She stated she took him back to his room on the 100 hall. CNA I said she went back to the 300 hall, which was her assigned hall. She stated about 20 minutes later she saw a couple staff members running and she went to see what was happening. CNA I stated she went to the 100 hall and looked in Resident #1's room and he was not there. She stated she went to the 500 hall and a couple of other CNA's ran down the 200 hall and they all met at the SW exit door. She stated she saw Resident #1 on the ground. CNA I stated since a nurse was with him, she went and helped LVN E make copies of his chart to transfer him. She stated she did not pull anyone else away from the SW exit door and the resident she was referring to in her written statement was Resident #1. She stated she had pulled him away from the SW door about 20 minutes before he actually got out. She re-read her statement, wrote the name of the resident she was referring to and dated it 03/03/11. The facility's WanderGuard Book (a binder located at the Station I Nurses' Station) contained a list of residents who had Wanderguards. The Resident Wanderguard List was updated on 12-1-10 and Resident #1 was not on this list. There were 12 residents on the list and four more residents, which had been added by hand. Two of the typed residents' names and two of the handwritten names had been crossed off and discharged was written beside them. The list also reflected the location of the wanderguard on the resident or on their equipment. The book also contained a page for each resident on the list with their picture and information about them. Resident #1 was not on any of the pages in the binder. Review of a handwritten statement from CNA L signed and dated 03/01/11 revealed, "On [DATE] I had just saw (sic) ____Resident #1 in dining room on 500 hall at 5:00 pm. Shortly after that I was notified that he had fallen outside." Review of a statement from the SVP of Development dated 03/02/11 revealed, "January 4, 2011 at approximately 5:15 PM I came to the facility and was driving around back of the building to pick up a compressor from the storage building. There was no one out back as I drove around. I picked up the compressor and locked the storage building. Then I turned around and drove back around the building, my headlights shined on a wheelchair that was lying on its side. It was dusk outside. I saw a gentleman wearing a grey sweatshirt and sweatpants, lying on the ground opposite his wheelchair. I stopped the truck in the fire lane and got out. The gentleman had a bloody nose and bloody face. I sent my son, who was with me, around the front of the building because the side door the gentleman had come out was locked. My son went around the front of the building to go and get a staff member. I dialed 911 on my cell phone and stayed with the gentleman until nursing staff arrived immediately along with the Administrator. The paramedics arrived shortly thereafter, assessed the gentleman and transported him to the emergency as a precaution to ensure residents safety. The Administrator and I then went inside and checked the doors. At this time all were working correctly. The staff members were then questioned and I was under the understanding that two residents had come to the door when the door alarm sounded. The staff members responded to the resident directly at the door and did not see the other resident who was already outside and/or around the corner. The door was relocked (sic)and the alarm was reengaged (sic) at that time." Resident #1's Comprehensive Plan of Care dated 12/12/10 reflected a problem of, "Resident is at Risk of Injury Due to Potential Elopement." Handwritten after "As Evidenced By:" was, "Attempting to leave facility/wants to go home." Under the heading "Goal" was, "Will be able to wander in a safe environment without the occurrence of injury and the resident's dignity will be maintained over next 90 days." The care plan reflected the following approaches: to monitor q one hour and prn to assure resident safety and re-direct when wandering un-safely. Resident #1's Elopement Risk Assessment was dated 12/03/10 and reflected a personal safety alarm device and frequent monitoring. Review of Resident #1's Care Summary dated 12/29/10 revealed that he was a "wanderer." 3. Review of the facility's CMS form 672 dated and signed by the Interim DON on 03/03/11 revealed there was a total census of 117 and 62 of those residents had a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 12 wandering residents. 1. Resident #1 exited the facility without staff's knowledge on 01/04/11 and rolled off the porch in his w/c, then crashed on the sidewalk/curb and fell on to the parking lot and sustained contusions, abrasions, bruises and broken ribs. His injuries required treatment in the emergency room . 2. Resident #1 was not listed on the facility's WanderGuard list at the time of the accident. 3. The facility failed to ensure the SW (southwest) corner exit door was properly re-set after each time the alarm was set off thus possibly enabling a resident to get out. 4. There was no railing on the porch/ramp at the SW corner of the building to prevent Resident #1 from rolling off in his w/c at the time of the accident. These failures had the potential to affect the 12 residents and Resident #1 who wandered daily resulting in them exiting out the same door and possibly getting injured. Findings included: 1. A review of Resident #1's Admission Face Sheet, un-dated, revealed he was a [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 01/04/11 and authored by LVN E revealed, "Found outside of bldg (building) on pavement lying on his (l) (left) side. Lg (large) amt (amount) blood noted on sidewalk. Covered c (with) blanket BP (blood pressure) 148/78 - 88 (heart rate) - 22 (respirations). 9-1-1 contacted. Compresses applied to gash over os (left eye). Unable to reach____(POA). Message left for ____(Resident's family member)." Review of Resident #1's Physician's Telephone Orders dated 01/04/11 with no noted time, revealed, "to _____(hospital name) via ambulance S/P (status [REDACTED]. Resident #1's Incident/Accident Report dated 01/04/11 reflected Resident #1 was located outside of the facility and experienced an unwitnessed fall. The report also reflected he suffered a contusion/hematoma to his head, a skin tear/laceration, and a bruise. The report further reflected Resident #1 was transferred to the ER. Further review of the report revealed, Resident #1 was found on the ground outside the exit door on the southwest corner of the building face down and positioned on his left side. The report reflected there was blood on the ground underneath his head and a large hematoma to his left eye with purple discoloration. The report indicated there was red drainage from area. The report also reflected there was purple discoloration and swelling to his upper lip and red fluid in his mouth. The report indicated Resident #1 was alert and talkative and he complained of pain to his face, his lower left shoulder. The report also indicated the w/c alarm was sounding and the w/c was upside down. Resident #1's Incident/Accident Report reflected was signed and dated on 01/07/11 by DON H (former DON.) DON H wrote on the report, "Staff inservices on reaction to door alarms. Also when find resident @ (at) door - need to walk out of building (and) look around. Head count needs to be completed. Safety fence is currently being contracted by administration. Bed alarm/chair alarms. Safety (check) completed." Note: There was no explanation or investigation about how Resident #1 got out of the facility documented on the report. Review of Resident #1's hospital registration form dated 01/04/11 revealed an admission date of [DATE]. Resident #1's hospital Emergency Department Discharge Instructions dated 01/04/11 reflected [DIAGNOSES REDACTED]. Resident #1's Nurse's Notes dated 01/06/11 reflected, "Late entry for 1/5/11" in the margin and 01/06/11 ER nurse called yesterday and stated x-rays showed Resident #1 had right rib fractures to 5th and 6th ribs. Note: This was the only Nurse's Note or entry about broken ribs, which could be located in the clinical record until a chest x-ray study was done on 02/19/11. Observation on 03/01/11 at 10:07 a.m. revealed Resident #1 was fully dressed, but lying in bed. When questioned by the surveyor how he was feeling Resident #1 stated he was OK. On 03/01/11 at 3:55 p.m. the two surveyors went to the SW exit door where Resident #1 was reported to have gotten out of the building. The surveyors obtained the code to go out and exited the building. Once outside, the surveyors observed a porch area approximately 4 feet square with a railed ramp approximately 4 feet wide that went to the right for approximately 10 feet, turned to the left for approximately 6 feet then again turned to the left for approximately 8 feet ending on a sidewalk which paralleled the south side parking lot. The surveyors turned back around to go back through the exit door and were able to walk right through the SW exit door. (Note: The door was supposed to automatically lock after keying in the code and exiting the building.) Once back inside, the surveyors waited 30 seconds and re-tried the SW exit door and the door opened and no alarm sounded. The surveyors tried the door several times and were able to exit with no delay and no alarm sounding. An observation on 03/01/11 at 4:04 p.m. revealed a female resident in her w/c from the end of the 200 hall went to the SW exit door. The resident had a w/c alarm attached to her chair and self. The resident touched the push bar on the SW exit door, no alarm sounded. She touched the bar several times from right to left and then took her right foot and pushed the door which opened about two inches, then closed. The resident then appeared to lose interest and turned her w/c around and went back the way she had come. One surveyor asked a staff member to identify the resident was after she had made it back around to the PT department and they informed her it was Resident #2 and her room was on the 200 hall. On 03/01/11 at 4:06 p.m. the surveyors tried the South door leading to the inner courtyard area across from the PT department. The surveyors were able to push the door open and get outside into the courtyard without an alarm sounding. When the surveyors attempted to go back inside the facility the alarm sounded. On 03/01/11 at 4:15 p.m., the surveyors brought the Administrator and the Assistant Administrator to the SW exit door and asked them to try it. The Administrator pushed the door and it opened without an alarm sounding. He stated the door was not working. ADON B informed everyone that had happened on the previous night and she had re-set it and it had worked properly. ADON B pushed in a code and the alarm sounded for 15 seconds, while the Administrator pushed on the bar and then it opened and the alarm stopped. The Administrator then closed the door and the alarm sounded again and he stated, "It's working opposite how it should..." ADON B stated the door needed to be repaired and they needed to get an employee to sit and monitor the door until it was fixed as it was a very dangerous situation. The Administrator and Assistant Administrator agreed. On 03/01/11 at 4:30 p.m. the surveyor observed the Maintenance Director working on the SW exit door. The door was tested and appeared to be working at this time. An interview on 03/01/11 at 4:50 p.m. with the Administrator revealed the problem with the door was his staff was not re-setting the alarm after it sounded and therefore the door would not re-lock and the alarm would not sound when someone touched it. The Administrator stated and showed the surveyor a back-up alarm system the Maintenance Director had applied to the SW exit door. The Administrator demonstrated how it worked. An observation at that time revealed the back-up system alarmed whenever the door was opened. The surveyor asked the Administrator about Resident #1's accident. The Administrator stated there had been two residents at the SW exit door. He further stated when the staff got to the door they pulled one resident back and Resident #1 was able to get out of the door. He stated Resident #1 went straight off the porch. The Administrator also stated at that time, someone from corporate was driving around the building and saw Resident #1. The surveyor asked how he went off the porch with the railing there and the Administrator stated, "...The fence was not there when that happened...." The Administrator informed the surveyor when the new addition was first built the construction company said they did not need a railing on the ramp. He stated it was actually added, "...as an intervention...." after Resident #1's accident. The Administrator stated he probably still had a copy of the report and would get it for the surveyor. The surveyor went out the SW exit door and observed there was an approximately 3 ? foot drop off the porch area onto a 3 to 4 foot grassy slope, which ended at the edge of the sidewalk. The surveyor asked the Administrator if the camera, which was observed by the PT department and appeared to be pointing at the SW exit door, was a working camera. The Administrator replied it was a working camera and the monitor screen was at the Station II Nurse's Station. The Administrator took the surveyors to the Station II Nurse's Station, which was on the east end of the 500 hall. He showed the surveyors the re-set buttons for the SW exit door, as well as the camera monitor screen, which showed four different views, one of which was a view of the SW exit door. The Administrator informed the surveyor the re-set buttons were for the SE (southeast) and SW exit doors so the nurse would not have to go to the doors to re-set them. He stated the nurse was able to unlock the SE exit door as well from Station II Nurse's Station. He also stated there was no one to monitor the camera monitor and most of the time the Station II Nurse's Station was empty. During an interview with ADON A on 03/01/11 at 5:24 p.m., she revealed staff did not know Resident #1 was out of the building. She said she knew because, "I was the nurse that went out to assess him." She told the surveyor CNA J got one resident away from the door and did not realize Resident #1 had already gotten out and fallen off the ledge. ADON A said the person who had driven around the building was the one who discovered Resident #1 face down and he sent someone in and got her and that "...was the first time anyone inside realized he had gotten out...." A confidential interview revealed he/she heard the alarms. He/she said a family member looked out the window of his/her room and saw a big truck stop, a man get out and run over to a man on the ground and then a fire truck and ambulance came. He/she stated the alarm worked before and Resident #2 set it off and no one would come. He/she said it had happened several times the day before. Observation on 03/02/11 at 9:02 a.m. revealed Resident #1 was fully dressed, lying in bed. A Wanderguard was present to his right ankle. Further interview with ADON A on 03/02/11 at 9:17 a.m. revealed it was not CNA J who moved the other resident away from the door. She stated it was LVN K and she no longer worked at the facility. ADON A stated she would provide the surveyor with LVN K's phone number that the The surveyor asked ADON A who the second resident was and she stated Resident #3. ADON A also revealed she and the Administrator got statements from other employees the same night of the accident, but they had "...disappeared...." ADON A stated she would get a faxed statement from the SVP of Development who was the one who actually found the resident outside. During an interview with the Administrator on 03/02/11 at 9:20 a.m., he revealed he had placed the Administration Clerk at the Station II Nurse's Station to monitor the cameras. He stated if she saw a resident at the SW exit door, she would call someone to go get the resident and she would also go. He further stated the corporate office may put monitors in offices and/or hire a receptionist to monitor the cameras and answer telephones. On 03/02/11 at 10:30 a.m. the surveyor observed a staff member sitting at the Station II Nurse's Station beside the monitor. When the surveyor asked who she was, she replied she was the Administration Clerk. She stated she was going to sit and watch the SE or front entrance to the new wing (500 Hall), monitor for the SW exit door and answer telephones. She stated she started those duties that morning. Observation on 03/02/11 at 11:00 a.m. revealed Resident #1 was fully dressed, lying in bed with a Wanderguard on his right ankle. On 03/02/11 at 12:05 p.m. the Administrator brought the surveyor a Detailed Development Action Plan dated 03/02/11. The Plan reflected, "Back Door was not locking correctly" and the corrections they had already accomplished were listed. On 03/02/11 at 3:55 p.m. the SW exit door secondary alarm started sounding and the surveyor observed Resident #2 at the SW exit door and ADON B and one other employee getting the resident away from the exit and re-setting the door. The surveyor told ADON B that she had only heard the back-up or secondary alarm and not the programmed door alarm sound. ADON B tried the door and the programmed alarm sounded for 15 seconds, the door opened and the programmed alarm stopped and the back-up or secondary alarm sounded. The surveyor again told ADON B she did not hear the 15 second alarm sound before the back-up or secondary alarm sounded when Resident #2 opened the SW exit door. On 03/02/11 at 2:00 p.m., during a telephone interview with LVN K, she stated, "Yes I was there." when asked if she had been working hall 500 on the evening Resident #1 was injured. When asked about whether the SW door had alarmed she replied, "To be honest those doors sometimes work and sometimes don't, so I would always check them when I came on...." When asked if she had pulled a resident away from the door at the time of the accident she stated, "That was earlier in the day...____ (Resident #2)...." She informed the surveyor she and one CNA were on the unit and they were in a room admitting a new resident. She stated they had not seen or heard anything until, "...someone came in and told us he was out...." She stated there was another nurse at the Station II Nurse's Station. She also stated, "...That door (SW exit door) has never worked, I kept telling them...." An interview on 03/03/11 at 11:10 a.m. with LVN E revealed she had been told by someone Resident #1 was outside and she went out there. LVN E stated ADON A and the Administrator were already out there with Resident #1, so she came back into the facility and, "...got gauze, B/P (blood pressure) cuff and everything, took it to ____ (ADON A) and came back in and filled out paper work to transfer him (Resident #1)." On 03/03/11 at 11:50 a.m. during an interview with ADON A she stated she discovered Resident #1 was outside on 01/04/11 when the SVP of Development's son came in and informed her there was someone outside bleeding. She stated the SVP of Development was out there and called 911 as soon as she arrived and she called the Administrator. An interview on 03/03/11 at 3:40 p.m. with CNA I revealed around 4:00 p.m. Resident #1 was confused and asking about his wife. She stated he set off for the front door and continued all over the building setting off the door alarms. She stated after dinner she saw him on the 100 hall going towards the 500 hall. CNA I stated after that she was on the 200 hall and heard the alarm. She stated another resident and another resident's family member pointed to Resident #1. CNA I stated she asked Resident #1 what he wanted and he told her he wanted to go home. She stated she took him back to his room on the 100 hall. CNA I said she went back to the 300 hall, which was her assigned hall. She stated about 20 minutes later she saw a couple staff members running and she went to see what was happening. CNA I stated she went to the 100 hall and looked in Resident #1's room and he was not there. She stated she went to the 500 hall and a couple of other CNA's ran down the 200 hall and they all met at the SW exit door. She stated she saw Resident #1 on the ground. CNA I stated since a nurse was with him, she went and helped LVN E make copies of his chart to transfer him. She stated she did not pull anyone else away from the SW exit door and the resident she was referring to in her written statement was Resident #1. She stated she had pulled him away from the SW door about 20 minutes before he actually got out. She re-read her statement, wrote the name of the resident she was referring to and dated it 03/03/11. The facility's WanderGuard Book (a binder located at the Station I Nurses' Station) contained a list of residents who had Wanderguards. The Resident Wanderguard List was updated on 12-1-10 and Resident #1 was not on this list. There were 12 residents on the list and four more residents, which had been added by hand. Two of the typed residents' names and two of the handwritten names had been crossed off and discharged was written beside them. The list also reflected the location of the wanderguard on the resident or on their equipment. The book also contained a page for each resident on the list with their picture and information about them. Resident #1 was not on any of the pages in the binder. Review of a handwritten statement from CNA L signed and dated 03/01/11 revealed, "On [DATE] I had just saw (sic) ____Resident #1 in dining room on 500 hall at 5:00 pm. Shortly after that I was notified that he had fallen outside." Review of a statement from the SVP of Development dated 03/02/11 revealed, "January 4, 2011 at approximately 5:15 PM I came to the facility and was driving around back of the building to pick up a compressor from the storage building. There was no one out back as I drove around. I picked up the compressor and locked the storage building. Then I turned around and drove back around the building, my headlights shined on a wheelchair that was lying on its side. It was dusk outside. I saw a gentleman wearing a grey sweatshirt and sweatpants, lying on the ground opposite his wheelchair. I stopped the truck in the fire lane and got out. The gentleman had a bloody nose and bloody face. I sent my son, who was with me, around the front of the building because the side door the gentleman had come out was locked. My son went around the front of the building to go and get a staff member. I dialed 911 on my cell phone and stayed with the gentleman until nursing staff arrived immediately along with the Administrator. The paramedics arrived shortly thereafter, assessed the gentleman and transported him to the emergency as a precaution to ensure residents safety. The Administrator and I then went inside and checked the doors. At this time all were working correctly. The staff members were then questioned and I was under the understanding that two residents had come to the door when the door alarm sounded. The staff members responded to the resident directly at the door and did not see the other resident who was already outside and/or around the corner. The door was relocked (sic)and the alarm was reengaged (sic) at that time." Resident #1's Comprehensive Plan of Care dated 12/12/10 reflected a problem of, "Resident is at Risk of Injury Due to Potential Elopement." Handwritten after "As Evidenced By:" was, "Attempting to leave facility/wants to go home." Under the heading "Goal" was, "Will be able to wander in a safe environment without the occurrence of injury and the resident's dignity will be maintained over next 90 days." The care plan reflected the following approaches: to monitor q one hour and prn to assure resident safety and re-direct when wandering un-safely. The care plan also reflected a goal for Resident #1 to be free of injury related to disease process. The approaches included to re-orient as needed and to maintain the environment free from clutter and hazard. Resident #1's Elopement Risk Assessment was dated 12/03/10 and reflected a personal safety alarm device and frequent monitoring. Review of Resident #1's Care Summary dated 12/29/10 revealed that he was a "wanderer." 2. Review of the facility's CMS form 672 dated and signed by the Interim DON on 03/03/11 revealed there was a total census of 117 and 62 of those residents had a [DIAGNOSES REDACTED].