Every finding on record at Whispering Pines Lodge

Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 (Resident #1) reviewed for quality of life. The facility failed to ensure LVN A performed basic life support measures per AHA, BCLS guidelines when Resident #1 was in distress and choking on 2/7/26. The facility failed to ensure RN B performed basic life support per AHA guidelines for Resident #1 on 2/7/26. The facility failed to ensure MA C performed basic life support per AHA guidelines for Resident #1 on 2/7/26. The facility failed to ensure LVN A, RN B, and MA C, CPR trainings were up to date. These failures resulted in Resident #1 not receiving basic life support while choking on 2/7/26. While appropriate, back blows nor the Heimlich maneuver were performed for over a minute. The failure to follow AHA BCLS guidelines delayed initiation of CPR by a approximately 2 minutes. An Immediate Jeopardy (IJ) was identified on 2/19/26. The IJ template was provided to the facility on 2/19/26 at 4:13 p.m. While the IJ was removed on 2/20/26 at 4:18 p.m., the facility remained out of compliance at a scope of isolated and a severity level no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of their corrective systems.Findings included: Record review of Resident #1's face sheet, dated 2/18/26, indicated she was an [AGE] years old female admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, CHF (Congestive Heart Failure, a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently) type 2 diabetes and AFIB (atrial fibrillation is a serious irregular heart beat that can lead to complications such as blood clots, stroke and/or heart failure). Record review of the admission MDS, dated [DATE], indicated Resident #1 had clear speech, usually made herself understood and understood others. The MDS reported Resident #1 had severe cognitive impairment (BIMS of 03). The MDS indicated Resident #1 needed set up or clean-up assistance with meal and oral hygiene. The MDS indicated Resident #1 required partial/moderate assistance with toileting, sit to stand transfers and walking ten feet. The MDS reported Resident #1 required supervision or touching assistance with toilet transfers. The MDS indicated Resident #1 required partial/moderate assistance with locomotion in her manual wheelchair. The MDS indicated Resident #1 was frequently incontinent of bowel and always incontinent of bladder. The MDS reported Resident #1 had active diagnoses of senile degeneration of the brain, respiratory failure, muscle weakness and the presence of cardiac pacemaker. The MDS indicated Resident #1 had a mechanically altered diet while a Resident in the facility. Record review of Resident #1's care plan, dated 1/21/26, indicated Resident #1 had a diet other than a regular diet. The care plan did not address risk for choking. During an interview on 2/19/26 at approximately 10:00 a.m., the Administrator said the facility did have video of the incident on 2/7/26. During an interview on 2/19/26 at approximately 10:30 a.m., RN D (corporate compliance nurse) said while observing the video footage a timeline of events would be documented and then a copy supplied to the surveyor. During an observation on 2/19/26 at 10:40 a.m., with the Administrator and RN D (corporate compliance nurse) present, the video footage was observed. The Administrator and RN D confirmed the identification of Resident #1 on the video footage. During the footage Resident #1 sat in the dining room in her wheelchair. Resident #1 was served her breakfast tray. While she ate Resident #1 began to choke. LVN A responded promptly to Resident #1 and began to lightly tap her on her back repetitively after Resident #1 communicated by hand gesture to tap her back (occurred at 07:18:12 [7:18 am 12 second mark]). LVN A continued to lightly pat Resident #1 on the back as Resident #1 violently shook her head back and forth communicating a response of 'no' (occurred at 07:18:17).With the footage zoomed in on Resident #1, Resident #1 appeared to vomit (occurred at 07:18:48), then Resident #1 nods her head in up and down motion communicating 'yes' (occurred at 07:19:04). Resident LVN A appeared to be yelling for help and continuously lightly patting Resident #1 on the back (occurred at 07:19:10). Resident #1's body becomes limp and she was unresponsive (occurred at 07:19:25). LVN A walked to the edge of the dining room (occurred at 07:19:27) as Resident #1's limp body remained in her wheelchair. LVN A returned to Resident #1 (occurred at 07:19:34). RN B entered the dining room (occurred at 07:19:37). LVN A resumed lightly patting Resident #1 on the back as her limp body sat in the wheelchair, (occurred at 07:19:40). LVN A quickly assessed Resident #1 and then ran out of dining room (occurred at 07:19:44). LVN A positioned Resident #1's limp body forward (Resident #1's head appeared to rest on the dining table in front of her) and LVN A began to aggressively pat Resident #1 on the back (occurred at 07:19:53). MA C attempted the Heimlich maneuver (an emergency first-aid procedure used to attempt to clear a blocked airway in a choking conscious victim. The maneuver is performed by standing behind the victim, placing a fist just above their navel with the thumb side in, grasping it with the other hand, and delivering quick, upward thrusts to force air from the lungs) (occurred at 07:20:08). RN B returned to Resident #1's side and additional staff were noted in the dining room (CNA E and Housekeeper F). The staff moved Resident #1 away from the table (occurred at 07:20:18). After the wheelchair was moved away from the dining room table, RN B attempted the Heimlich maneuver (occurred at 07:20:22). Resident #1's body remains limp in the wheelchair. RN B attempted to shake Resident #1's shoulder while MA C appeared to perform a sternal rub (painful stimulus technique used by healthcare professionals to assess the neurological responsiveness of an unconscious or unresponsive person) occurred at 07:20:34. RN A began to push Resident #1 in the wheelchair but her (Resident #1's) feet began to drag on the floor impeding movement. CNA E immediately picked her feet up (Resident #1's) as RN B pushed the wheelchair out of the dining room. Resident #1 was out of video frame (out of the dining room) at 07:20:45. During an interview on 2/19/26 at 10:50 a.m., RN D said staff moved Resident #1 to the nearest empty room to initiate CPR. During an interview on 2/19/26 at 11:25 a.m., LVN A said when she saw Resident #1 raise her head in an upward motion, and initially thought Resident #1 was going to sneeze. LVN A said Resident #1 began coughing and went over to her. LVN A said she asked Resident #1 if she was ok and she shook her head no and asked her if she was choking and she nodded her head yes. LVN A said she started slapping Resident #1 on the back to get the object she was choking on loose. LVN A said she remembers she was trying to yell to get assistance from other staff. LVN A said when the resident went unconscious, she started to go out of the dining room to get help but RN B was on her way to the dining room. LVN A said it felt like an eternity and she was scared but felt hitting Resident #1 on the back was the right thing since she suspected she was choking. During an interview on 2/19/26 at 11:42 a.m., RN B said when she had gotten to the dining room Resident #1 was already blue and purple. RN B said Resident #1 was not responsive. RN B said she knew Resident #1 was gone and ran to check her code status. RN B said she noted Resident #1 was a full code and called 911, then ran back to the dining room. RN B said she remembered LVN A saying she (Resident #1) choked. RN B said she quickly attempted the Heimlich maneuver, but Resident #1 remained unresponsive. RN B said they (staff) moved Resident #1 to the nearest empty resident room to initiate CPR because she did not want to traumatize the other residents in the dining room. RN B said they (LVN A and RN B) continued CPR until EMS arrived. RN B said she knew that Heimlich maneuver was to be performed on a choking victim but that if the victim became unconscious CPR was to be initiated. RN B said she panicked and attempted the Heimlich maneuver even though Resident #1 was unconscious at that point. Record review of LVN A's BCLS certificate from the AHA, dated 11/9/2023, indicated her certification in BCLS had expired 11/30/25. Record review of RN B's BCLS certificate from the AHA, dated 12/18/23, indicated her certification in BCLS expired 12/31/25. During an interview on 2/19/26 at 11:50 a.m., RN D said MA C was not currently certified in BCLS. During an observation on 2/19/26 at approximately 2:50 p.m., the Administrator walked quickly from the left entrance of the dining room (where staff were observed to have exited with Resident #1) to the nearest resident room (identified as the room where Resident #1 was taken by staff to initiate CPR). RN B kept record of the time. Walking briskly to the room took the Administrator 15.51 seconds. Record review of the hospital emergency department note dated 2/7/26 at 8:16 am for Resident #1 stated chief complaint.Respiratory Arrest.per EMS, patient had lots of eggs in her mouth/throat-possible aspiration (inhaling foreign material [including food] into the airway and lungs instead of swallowing it into the esophagus). The emergency department note reported Resident #1 was shocked with defibrillator (a medical device that delivers a high-energy electric shock to the heart to stop dangerous, irregular rhythms (arrhythmias) or to restart the heart during cardiac arrest) five times and three rounds of epinephrine and amiodarone (critical drugs used together during advanced cardiovascular life support [ACLS] for cardiac arrest) were administered enroute to the Emergency Department. Record review of the Emergency Department diagnoses dated 2/7/26 at 8:17 am listed Cardiopulmonary arrest ( the sudden cessation of effective heart function and breathing, leading to an abrupt halt in blood circulation to the body and brain) Aspiration into airway, and Death. Record review of the Emergency Department provider note dated 2/7/26 at 8:20 a.m., stated .Patient pronounced with death at 8:11 AM with no respiratory effort and no pulse or heart sounds. Record review of the undated facility policy and procedure titled Choking/Aspiration indicated a Resident had four minutes to live and instructed signs a resident may be choking included hand on neck, cannot speak or breathe, turns blue, collapses. The policy and procedure indicated to perform Heimlich and also provided instruction for performing abdominal thrusts if the resident laid on their back. The policy and procedure did not address guidelines if the resident became unconscious or non-responsive. Record review of the undated facility policy and procedure titled Cardiopulmonary Resuscitation stated, Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth or providing breathing or providing air to the lungs via ambu bag (handheld, manual resuscitator device used to provide positive pressure ventilation to individuals who are not breathing or are breathing inadequately). The procedure is performed to prevent death. The procedure is performed to prevent death following cardiac or pulmonary arrest.The facility will have at least 1 (one) staff member who is trained in CPR/BCLS at all times in the facility. Trained staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in physical or virtual instructor-led setting in accordance with accepted national standards. The American Heart Association BCLS guidelines accessed at, https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001372 on 2/19/26, at 3:10 p.m., stated. Adult Basic Life Support Part 7 of the 2025 Guidelines, Adult Basic Life Support, provides recommendations for adults experiencing cardiac arrest, respiratory arrest, and FBAO ((foreign body obstruction of airway) .Significant New and Updated Recommendations-Foreign Body Airway Obstruction-Based on additional evidence of effectiveness and safety, the use of back blows is now recommended as the initial step for conscious adults with FBAO (foreign body obstruction [of airway]), followed by abdominal thrusts (Heimlich Manuever). As in 2020, once the person becomes unresponsive, the recommendation is to initiate CPR . with inspection of the mouth for presence of a foreign body prior to delivery of breaths . A new algorithm for treatment of FBAO ((foreign body obstruction of airway)for adults is included. The Administrator was notified on 2/19/26 at 4:10 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template via email on 2/19/26 at 4:13 p.m. The Plan of Removal was accepted on 2/19/26 at 7:00 p.m., and detailed the following: Interventions: 1. An audit was conducted on 2/19/26 by Regional Compliance Nurse on all residents that expired in the facility during the last 30 days, to ensure that CPR was performed according to AHA and BCLS guidelines to include the Heimlich Maneuver. No residents were identified. No additional findings were noted. 2. An audit was conducted on 2/19/26 by Human Resource of all charge nurses in facility for current CPR certifications. Completed 2/19/26. 3. Regional Compliance Nurse will conduct CPR classes for all charge nurses in the facility to ensure current certifications with return demonstration to include the Heimlich Maneuver. Completed 2/20/26. The Administrator and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 2/19/26 on the following and comprehension was verified by a post test a. Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that is unresponsive could be considered neglect. b. Cardio-Pulmonary Resuscitation - to include initiating CPR immediately when a resident is identified as unresponsive with no pulse. c. Choking- Heimlich Maneuver - to include the universal signs of choking and the Heimlich Maneuver according to the AHA and BCLS guidelines 1. LVN A, RN B, and MA C were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 2/19/26 on the following and comprehension was verified by posttest. a. Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that was unresponsive could be considered neglect. b. Cardio-Pulmonary Resuscitation - to include initiating CPR immediately when a resident is identified as unresponsive with no pulse. c. Choking- Heimlich Maneuver - to include the universal signs of choking and performing the Heimlich Maneuver according to the AHA and BCLS guidelines The Medical Director was notified of the immediate jeopardy citation on 2/19/26 by the Administrator. 1. An ADHOC QAPI meeting was completed on 2/19/26 to review the immediate jeopardy citations and subsequent plan of removal. In-services: 1. The Regional Compliance Nurse, ADO, Administrator, and ADON will in-service all medication aides and CNAs on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. Comprehension will be verified by a post-test. a. Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that is unresponsive could be considered neglect. b. Notification of a change in condition - including the universal signs of choking and the Heimlich maneuver to be completed immediately according to AHA and BCLS Guidelines. Staff should respond immediately and the nurse should be notified. 2. The Regional Compliance Nurse, ADO, Administrator, and ADON will in-service all charge nurses on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. Comprehension will be verified by a post test. a. Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that is unresponsive could be considered neglect. b. Notification of a change in condition - including the universal signs of choking and the Heimlich maneuver to be completed immediately according to AHA and BCLS Guidelines. Staff should respond immediately and the nurse should be notified. c. Cardio-Pulmonary Resuscitation - to include initiating CPR immediately when a resident is identified as unresponsive with no pulse. d. Choking-Heimlich Maneuver - to include the universal signs of choking and performing the Heimlich Maneuver according to the AHA and BCLS guidelines On 2/20/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the audit document dated 2/19/26 verified an audit was performed by the Regional Compliance Nurse (RN B) on all residents that expired in the facility during the last 30 days. Record review of the untitled audit record dated 2/19/26 found all facility nurses were audited by human resources for BCLS certification and 16 nurses were found with expired or missing BCLS certifications. During an interview on 2/20/26 at 9:19 a.m., RN B confirmed no residents in the facility required BCLS intervention prior to hospital transfer. RN B also said as a result of the audit performed by human resources many staff had expired BCLS certifications. RN B said she would be teaching BCLS per AHA guidelines to bring expired staff up to date in their certifications. RN B clarified all nurses would be required to have BCLS certification. RN B added that many CNAs and MAs will also be completing the class for certification. RN B stated she would be holding a class at 10:00 a.m. and 3:00 p.m on 2/20/26. During an observation on 2/20/26 at 10:57 a.m., RN B was conducting BCLS training course with AHA material. Record review of the Iin-service training reports dated 2/19/26 confirmed the Administrator and ADON were in-serviced over the following items: *Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that is unresponsive could be considered neglect. *Cardio-Pulmonary Resuscitation - to include initiating CPR immediately when a resident is identified as unresponsive with no pulse. *Choking- Heimlich Maneuver - to include the universal signs of choking and the Heimlich Maneuver according to the AHA and BCLS guidelines Record review of the posttests dated 2/20/26 confirmed the Administrator's and ADON's comprehension of the in-services listed above. Record review of the individual in-service training reports dated 2/19/26 confirmed LVN A, RN B, and MA C were in-serviced 1 on 1 by RN B over the following items: *Abuse and Neglect Policy: to include failure to perform the Heimlich maneuver according to AHA and BCLS guidelines or initiating CPR timely to a resident that is unresponsive could be considered neglect. *Cardio-Pulmonary Resuscitation - to include initiating CPR immediately when a resident is identified as unresponsive with no pulse. *Choking- Heimlich Maneuver - to include the universal signs of choking and the Heimlich Maneuver according to the AHA and BCLS guidelines. Record review of the posttests dated 2/20/26 confirmed LVN A's, RN B's, and MA C's comprehension of the in-services listed above. Record review of the facility document titled Off Cycle (ADHOC) QA Meeting Document confirmed the Medical Director was notified of the Immediate Jeopardy and attended by phone the ADHOC QAPI meeting on 2/19/26 addressing the identification of Immediate Jeopardy. The document outlined the facilities plan of removal and the plan for the Administrator and DON or ADON monitor weekly, with any identification during monitoring to be addressed for immediate change. During interviews on 2/20/26 from 1:20 p.m. to 4:10 p.m. The surveyor confirmed all direct care staff present on the evening shift or night shift of 2/19/26 (MAs worked 8- hour shifts, nurses and CNAs worked 12-hour shifts) and all clinical staff on the day shifts for 2/20/26 (MAs worked 8-hour shifts, nurses and CNAs worked 12-hour shifts) had received in-services as outlined in the Plan of Removal. Additional staff present for the 10am class that had completed the hands-on skills check-off portion of the AHA BCLS training were also interviewed. All staff interviewed (LVN A, RN B, MA C, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, RN T, CNA U, LVN V, MA W, MA X, MA Y, MA Z, MA AA, CNA AB) named signs a resident may be choking including the Universal Sign (clutching the throat with one or both hands; Coughing [forced, violent, or silent cough indicates a severe blockage]; Breathing - Noisy Breathing: High-pitched, squeaky, or wheezing noises, or absent breathing; Inability to Speak: The person cannot talk, or make sound; Panic: A panicked, terrified, or shocked facial expression. Color Change: Skin, lips, or fingernails turn blue, gray, or pale. The staff said they understood that a resident may not display all of these signs. They also said they understood resident vomiting did not mean the resident could breathe and was not necessarily reassuring. All staff said BCLS intervention would be initiated immediately for a choking resident, including immediate call to 911 for EMS services. The MAs and CNAs said if they saw these signs they would immediately call for the nurse but would attempt back blows five times alternated with Heimlich mauver 5 times. The MAs and CNAs said when the nurse arrived to take over, they would immediately call EMS if the nurse had not yet done so. The staff said failing to provide alternating back blows and Heimlich to a choking resident could be considered neglect. Nurses said choking residents would be administered BCLS intervention which included for a conscious victim, 5 blows to the back alternated with 5 attempts of Heimlich maneuver, until the item was dislodged or the victim became unresponsive. If the victim became unresponsive during these attempts, CPR was to be initiated immediately. The staff said failing to initiate CPR when a choking resident became unresponsive could be considered neglect. On 2/20/25 at 4:18 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of five residents (Resident #7, Anonymous Resident) reviewed for quality of life.The facility failed to report the Hall A water temperatures were cold and provided a bed bath to Resident # 7 with cold water during the winter storm.The facility failed to provide an anonymous resident with a warm, comfortable shower.This failure could place residents at risk for a decline in quality of life and health status.Findings included:Record review of Resident #7's face sheet, dated 1/29/2026, indicated she was a [AGE] year-old female, with diagnoses that included fracture of shaft of right tibia (a break in the shin bone), fracture of the right fibula (a break in one of the two long bones in the lower leg) and Chronic Diastolic heart failure (occurs when the left ventricle becomes stiff and cannot relax properly, leading to inadequate filling of blood).Record review of Resident #7's admission MDS assessment, dated 1/17/2026, indicated a BIMS score of 10, which indicated moderate cognitive impairment. She was able to make herself understood and she was able to understand others. Resident required substantial assistance with bathing and was dependent with dressing lower body.Record review of Resident #7's care plan undated, indicated she had ADL self-care performance deficits and required 2-staff for assistance for bathing, 2-person assistance with bed mobility and staff could provide a sponge bath when a full bath or shower could not be tolerated.During an interview on 1/29/2026 at 10:03 a.m., Resident #7 stated she took a cold bed bath during the winter storm. She said the facility lost power during the winter storm and did not have warm water. She said she wanted to feel clean, so she took a cold bed bath.During an interview on 1/29/2026 at 10:39 a.m., the SW said the Hall A shower was cold and the staff were working on it. The SW did not specify which staff were working on it. She said she discovered the water in the Hall A shower was cold when she stayed in the facility over the weekend on 1/27/2026 during the winter storm and went to take a shower. The SW said she did not think the facility was aware because she was not aware the water was running cold until she attempted to take a shower.During an observation on 1/29/2026 at 10:39 a.m., Hall A shower water ran for approximately three minutes, and the water temperature was 71 degrees Fahrenheit. The water did not rise above recommended temperature of 100-110 degrees Fahrenheit. During an interview on 1/29/2026 at 10:50 a.m., the SW said she did not think the facility was aware of the Hall A shower's water was cold because she was not. She said there were six residents currently residing on Hall A and using Hall B and D showers until the water was fixed. She did not indicate a projected time frame the repaired.During an interview at an undisclosed date and time, Anonymous Resident indicated they received a cold shower because the facility did not have hot water.During an interview on 1/29/2026 at 3:58 p.m., CNA D said she was aware the water in the shower room on Hall A was running cold. She said she reported it to maintenance and to the current DON. She said it was running cold for 1-2 months. CNA D said no one was taking a shower in Hall A shower room. She said maintenance told the staff he would fix it and the DON continued to remind him. CNA D said she had not received any complaints from residents that the shower was given to them on Hall A.During an interview and observation on 2/2/2026 at 10:30 a.m., Area Maintenance Specialist said he was not aware the water was running cold on Hall A. He said he let the maintenance man was terminated. The Area Maintenance Specialist went with surveyor to Hall A shower room and the water temperature measured with the facility's thermometer was 98.7degrees Fahrenheit. The sink temperature was also warm. He said somehow the hot water temperature was turned down. He said the facility performed weekly checks on the water temperature in each hall and he would provide the temperature logs for the facility.During an interview and record review on 2/2/2026 at 10:45 a.m., the Area Maintenance Specialist presented a folder with temperature logs. He said the temperature was supposed to be between 100-110 degrees Fahrenheit. He said the last recorded weekly temperature checks logged were on 12/22/2025. He said there had not been any temperature logs documented since. He said the maintenance man was recently terminated because of a recent inspection.During an interview on 2/2/2026 at 11:20 a.m., Housekeeper E said there was something going on with the showers. She said that Hall B's shower was flooding a couple of weeks ago and toilets were stopping up. She said the water temperatures would get temporarily fixed and then would get cold again. Housekeeper E said she overhead CNAs talking and complained about having to take residents to different halls to give showers. Housekeeper E said she did not think the residents enjoyed going to a different hall to get a shower. Housekeeper E said the CNA staff report on the QR code Maintenance Care app to alert for needs within the facility. She said the application was easy to use. Housekeeper E said not having a warm shower could make a resident feel neglected and uncomfortable and their needs not being met. She said a resident could get sick from cold water temperatures or refuse showers.During an interview on 2/2/2026 at 11:27 a.m., the Housekeeping Supervisor said the facility had problems with the hot water on Hall A and Hall B. She said she had not heard any residents complaining about the water temperatures, but she had overhead the CNAs complaining. She said they complained about the water being too cold and residents refusing showers. She said she heard staff were carrying hot water from one shower to another shower. The Housekeeping Supervisor said she had heard about it before the winter storm. She said she put a complaint in the QR app to report it. The Housekeeper Supervisor said a resident could get sick. She said she observed a resident crying over a year ago because the water was too cold. She said she would report it to the ADM if she continued to see it happen and stated the previous ADM was aware. The Housekeeping Supervisor said the previous ADM was aware of the issue. She said someone fixed it, but the water would get cold again.During an interview on 2/2/2026 at 11:35 a.m., CMA B said Hall A had issues with hot water, but she was not sure if it was fixed.During an interview on 2/2/2026 at 12:13 p.m., LVN C said Hall A did not have hot water. She said it was an on and off issue and she did not know how long it was out. She said she had reported it to maintenance. She said a couple of residents had complained a couple of weeks ago about not having hot water because they wanted a hot beverage or wanted to sponge off at their sink. LVN C said residents were taken to different halls to receive their shower. LVN C said the staff member who bathed the resident was responsible for ensuring the water temperatures were comfortable for the residents. She said a resident could refuse showers or baths if the water was too cold or it could make the resident uncomfortable.During an interview on 2/2/2026 at 1:15 p.m., the ADON said whoever noticed a change in the water temperature was responsible for reporting to the maintenance and maintenance supervisor. She said the staff could scan the QR code and the report would go to the maintenance care. She said it would need to be reported immediately. She said everyone wants a warm shower. The ADON said the lack of warm water could cause a resident to have poor hygiene if they refused showers. She said she expected the staff to report the issue immediately to supervisor.During an interview on 2/2/2026 at 1:30 p.m., the DON said she expected the water temperatures to be comfortable for the residents. She said the CNAs should checking the temperature of the water prior to showering the residents. She said if the water was not working properly, the facility needed to know. The DON said the facility was notified prior to the winter weather. She said they had to turn up the thermostat. She said there was only one resident on Hall A now and they took him to another unit for showers. She said she expected staff to take residents to another hall to get a warm shower. The DON said the maintenance was responsible for making sure the water temperatures were at a comfortable level and the CNAs should check.During an interview on 2/2/2026 at 2:45 p.m., the ADM said he knew the facility had concerns with water not getting as hot as it should be. He said it was brought up by the previous maintenance man, but he was terminated. The ADM said nobody wanted a cold shower. He said it could make a resident sick and uncomfortable. He said the maintenance man was responsible for ensuring the shower temperatures were appropriate and staff was responsible for reporting any issues. The ADM said he expected the residents to receive a warm bath/shower. The ADM said the staff could take the residents to other halls to get a shower. He said staff needed to report the problem.Record review of facility's grievances from 11/25/2026-1/6/2026 did not indicate any complaints of water temperature concerns in the facility.Record review of the facility's policy, Resident Rights, undated, stated: .The resident has a right to a dignified right to existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must 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.Record review of facility checklist titled Task # 39737850, dated 1/27/2026 indicated Water temperatures: Test and log the hot water temperatures in resident rooms and showers: 1. Ensure patient room water temperatures are between 100 degrees and 110 degrees Fahrenheit. Test temperatures in shower area, check resident rooms at the end of each wing on rotating basis. 2. Should be completed weekly to ensure patients' water is adequate.

Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 of 5 residents (Resident #21) reviewed for dignity.The facility failed to provide dignity and respect by allowing Resident #21 to remain in soiled clothing for two hours and taking resident to dining hall without changing his clothes on 1/29/2026.This failure could place residents at risk of embarrassment and low self-esteem.Findings included:Record review of Resident #21's Face Sheet, dated 1/29/2026, indicated a [AGE] year-old male, admitted [DATE], with diagnoses of unspecified dementia (memory loss), epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity), schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves), and major depression disorder (a mental disorder characterized by at least two weeks of pervasive low mood, self-esteem and loss of interest and pleasure), cerebrovascular disease (a group of conditions that affect blood flow to the brain, leading to serious health issues like strokes and transient ischemic attacks).Record review of Resident #21's Quarterly MDS, dated [DATE], indicated a BIMS score of 5 indicating the resident was severely cognitively impaired. Resident #21 was wheelchair bound and was dependent with bed mobility, transfers, dressing and toileting with 2-person assistance.Record review of Resident #21's Care Plan, dated 9/15/2025, indicated ADL self-care performance deficit and required assistance with ADLs. Interventions included assistance with personal hygiene as required: hair, shaving, oral care as needed, required 1 person assist for dressing, a lift for all transfers and required 1-2 person for assistance for toileting.During an observation on 1/29/2026 at 8:50 a.m., Resident #21 was seated in his wheelchair in front of the nurse's station in main area with a clear cup of white liquid spilled on his dark gray pants.During an observation on 1/29/2026 at 9:15 a.m., Resident #21 was seated in his wheelchair in front of the nurse's station in the main area with spilled white liquid on his dark gray pants and a small puddle of white substance located under his wheelchair. Resident #21 was slumped over in his wheelchair with his helmet on. Observed multiple staff members walked passed Resident #21 and were sitting at the nurse station.During an observation on 1/29/2026 at 9:23 a.m., Resident #21 was seated in his wheelchair in front of the nurse's station with absorbed white substance on black pants. Observed white substance under Resident #21's wheelchair.During an observation on 1/29/2026 at 9:51 a.m., Resident #21 remained at nurse's station seated in his wheelchair. Observation revealed the white substance below his wheelchair was cleaned up. Resident #21 remained seated in wheelchair with dark gray pants and black shirt with wet area on left upper thigh of pants.During an observation and interview on 1/29/2026 at 11:45 a.m., CNA D wheeled Resident #21 to the dining hall. CNA D said Resident #21's pants were dry but wheeled him to his room to change his clothing. Resident is non-verbal and unable to be interviewed.During an observation on 1/29/2026 at 11:55 a.m., observed CNA D transfer Resident #21 with a mechanical lift assistance of COTA F. Resident #21 was provided incontinent care and clothes were changed. Observed a white substance on the wheelchair and the sling for mechanical lift was wet. CNA D retrieved a clean sling to place under Resident #21 prior to transfer back to his wheelchair. Observed COTA F clean the wheelchair prior to transfer.During an interview on 1/29/2026 at 3:58 p.m., CNA D said she had gotten Resident #21 out of bed and dressed. She said he ate breakfast then she changed him before he returned to the nurse's station between 7:30 a.m. and 8:00 a.m. CNA D said she believed he had a health shake but did not observe that it spilled. She said he required assistance with eating. CNA D said the aides were responsible for ensuring he was clean and dry, and she was his assigned CNA. She said having spilled liquid could make Resident #21 feel nasty or gross. She said the morning was chaotic because she worked by herself until around 8:30 a.m. or 9:00 a.m.During an interview on 2/2/2026 at 11:35 a.m., CMA B said she would report to the charge nurse if she observed a resident who was disheveled or wearing dirty clothes. She said she would assist a resident to their room and let the staff know the resident needed to be changed. She said residents were not always able to verbalize what they needed or wanted. She said a resident could feel embarrassed or neglected if they were wearing dirty or soiled clothes. CMA B said it was the responsibility of all staff to ensure the residents were clean and dry. She said the charge nurse was responsible for ensuring the resident received the care needed and the DON should say something if she was aware the resident was wearing dirty clothes. During an interview on 2/2/2026 at 12:00 p.m., CNA G said she would change the resident if she observed a resident with soiled clothing. She said it could make a resident feel bad and was a dignity issue. CNA G said everyone was responsible for ensuring a resident was clean and dry.During an interview on 2/2/2026 at 12:13 p.m., LVN C said she would clean a resident or get someone to clean them up because they should be changed immediately if they were soiled with a liquid. She said it could make a resident feel cold and neglected if left in dirty clothing. LVN C said all staff were responsible for ensuring a resident was clean and dry, but the nurses and CNAs were primarily responsible.During an interview on 2/2/2026 at 1:15 p.m., the ADON said she expected the nurse to keep residents clean after a spill and keep the resident clean and dry. She said the nurse or staff should clean up a resident immediately if they are aware of it. She said it could make a resident feel bad about themselves and there could be a fall risk if there was a spill on the floor. The ADON said the nurse was responsible for ensuring the resident was clean and dry.During an interview on 2/2/2026 at 1:30 p.m., the DON said she expected the staff to keep residents clean and dry after a resident spilled liquids on their clothes. She said it was a dignity issue. The DON said, even if a resident was confused, they should be cleaned up. The DON said the CNA, charge nurse, and other staff can take a resident to their room and get someone to assist with changing the residents.During an interview on 2/2/2026 at 2:45 p.m., the ADM said he expected the staff to change the resident if they were soiled. He said he expected them to be changed in a reasonable time and after meals as well. He said it was everyone's responsibility to make sure residents were taken care of.Record review of facility policy titled Resident Rights, undated, indicated .the resident has the right to be treated with respect and dignity, including.3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 2 residents (Resident #14) reviewed for storage of medication.The facility failed to ensure that Resident #14's Fluticasone Propionate Nasal Spray (a synthetic corticosteroid that helps reduce inflammation in the body) were not left at her bedside.This failure could place residents at risk of not receiving medications as ordered or receiving too much medication.Findings included:Record review of Resident #14's face sheet, dated 1/29/2026, indicated an [AGE] year-old female, admitted [DATE]. Her diagnoses included Chronic Obstructive Pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), Acute respiratory failure (a condition where the lungs cannot adequately exchange gases, leading to insufficient oxygen in blood or excessive carbon dioxide), anxiety disorder (involves persistent, excessive worry that is mismatch to actual risk), and myopathy (a term that affect skeletal muscles, causing weakness, cramps and fatigue). Record review of Resident #14's admission MDS assessment, dated 11/18/2025, indicated she had a BIMS score of 9, which indicated moderate cognitive impairment. She was able to make herself understood and she was able to understand others. Record review of Resident #14's care plan, dated 11/13/2025, indicated she had potential for impaired cognitive function and impaired thought processes due to her oxygenation status secondary to COPD with shortness of breath. Interventions included, administer medications as ordered, engage the resident in simple, structured activities that avoid overly demanding task and review medications and record possible causes of cognitive deficit such as new medications or dosage increases, anticholinergics, opioids, benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Record review of Resident #14's physician's orders, dated 11/13/2025, indicated she was prescribed Fluticasone Propionate Suspension 50 mcg/ACT 1 spray each nostril one time a day for allergies. During an observation and interview on 1/29/2026 at 9:30 a.m., Resident #14 observed sitting up in chair in room with oxygen on. Resident #14 was observed to have a Fluticasone Propionate nasal spray 50 mcg on bedside tray table. Resident #14 said the staff normally keep the medication locked up. She did not know why the medication remained on her table.During an interview on 1/29/2026 at 3:39 p.m., CMA A said residents were not supposed to have medication in their room. She said she gave Resident #14 her nasal spray, but she left the room. CMA A said Resident #14 liked to administer her own nasal spray. CMA A said she realized she left the nasal spray in Resident #14's room at the end of her medication pass. She said she noticed the empty box and returned to Resident #14's room to retrieve it. CMA A said Resident #14 was able to self-administer her nasal spray. CMA A said a resident could take too much of the medication or a roommate could pick up the medication, knocking it over causing it to break. CMA A said she was responsible for ensuring the medication was placed back on the medication cart.During an interview on 2/2/2026 at 11:35 a.m., CMA B said residents should not have medications at bedside. CMA B said the nurses were responsible for ensuring medications were stored properly. She said there were no current residents who administered their own medications. CMA B said she would administer the nasal spray to a resident if prescribed. She said CMA B if medication were left in a resident room, another resident could come in the room and take the medication and have an allergic reaction to it. She said it would not be safe to leave medication in a resident's room.During an interview on 2/2/2026 at 12:13 p.m., LVN C said residents should not have medications in their room. She said currently she did not have any residents that administer own nasal sprays or eye drops. She said whoever catches medication in a room is responsible. She said someone could take the medication and use it incorrectly. She said if they used too much, it could make them sick.During an interview on 2/2/2026 at 1:15 p.m., the ADON said residents were not allowed to have medications in their rooms. She said the facility does not allow residents to self-administer medications. She said if another resident encountered the medication, they could use it and have an adverse reaction. The ADON said the nurse or medication aide were responsible for ensuring the medication was properly stored. She said she expected the nurses to keep the medications secured on the medication cart.During an interview on 2/2/2026 at 1:30 p.m., the DON said she expected the nurses and medication aides to not leave medications in a resident's room. The DON said if a staff member observes medication in a resident's room, they should notify the nurse. She said the staff member in charge of the medication cart was responsible for ensuring the medications were stored properly. She said it puts the resident at risk of overdose, or another resident could take the medication and cause a reaction.During an interview on 2/2/2026 at 2:45 p.m., the ADM said he expected the nursing staff to keep medications stored on the medication cart. He said a resident could take the medication inappropriately and it could create problems or make them sick. He said it could create issues with different organs depending on what the medication was. He said the nurse was responsible for making sure the medications were secure. He said a resident could self-administer medication if it was care planned. He said there was no one in the facility that were assigned to self-administer medication.Record review of the facility's policy, Medication Storage in the Facility, undated, stated: .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Record review of the facility policy titled Self-Administration of Medications by Residents Policy stated .each resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team and/or facility policy allows or has determined that the practice would be safe for the resident and other residents of the facility. Procedure: 1. Each resident is offered the opportunity to self-administer his or her during the routine assessment.2. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability.5. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer.The following conditions are met for bedside.a. The manner of storage prevents access by other residents.lockable drawers or cabinets are required.The medications provided to the resident for bedside storage are kept in the containers dispensed .6. All nurses and aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage.

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Halls (Hall #2) and 2 of 4 showers (Shower #2 and Shower # 4) reviewed for infection control.The facility failed to ensure trash was properly stored for Shower #4 on 1/29/2026 at 9:44 a.m.The facility failed to ensure trash was properly stored and removed from Hall #2 on 2/2/2026 at 9:46 a.m.The facility failed to ensure dirty linens were properly stored in Shower #2 on 1/29/2026 at 10:24 a.m.These failures could affect residents and place them at risk of unsanitary and uncomfortable environment. Findings included:During an observation on 1/29/2026 at 9:44 a.m., Shower #4 had dirty linens on the floor and a bag of trash in a clear bag located behind the door.During an observation on 2/2/2026 at 9:46 a.m., two bags of trash in clear trash bags were on the floor in front of the shower room on Hall #2. Observed CNA G picked up the trash and placed it on a gray barrel and rolled it down the hall towards outside.During an observation and interview on 1/29/2026 at 9:44 a.m., Laundry E said the dirty linen should not be on the shower floor but kept in the linen barrel. Laundry E, not wearing gloves, picked up the dirty linens and placed them in the yellow barrel. Laundry E said she should have worn gloves when touching dirty linen.During an interview on 1/29/2026 at 3:15 p.m., the ADON said dirty linens go into a trash bag then placed in the gray barrel. The ADON said trash was placed in yellow barrels. The ADON said dirty linens should not be on the floor. She said it was an infection control issue and a fall risk. The ADON said the nurses were responsible for ensuring dirty linens were off the floor and in the proper barrels. She said the staff should not leave trash on the floor in the shower room. During an interview on 1/29/2026 at 3:58 p.m., CNA D said trash should be placed in the yellow barrel. She said the staff should place dirty linens in bags and place them in the gray barrel in the shower room. She said dirty linens should not be stored on the floor. CNA D said trash should not be placed on the floor in the shower room and should be placed in the yellow barrel in the shower room. CNA D said it was an infection control issue and could spread bacteria causing other people to get sick.During an observation on 2/2/2026 at 9:46 AM, observed 2 bags of trash located on Hall #2 in front of the shower room. There was a yellow barrel inside the doorway of the shower room propping the door open. CNA G observed placing 2 bags on top of the gray barrel and wheeling it down the hallway to go outside.During an interview on 2/2/2026 at 9:56 a.m., CMA H said she did not see the two trash bags on the floor in the hallway. CMA H said no trash should be left in the hallway on the floor. She said the aides were responsible for taking the trash out if the barrel was full. She said someone could trip over the bags or someone could take something out of the bags, eat something out of the trash, or spread germs.During an interview on 2/2/2026 at 11:20 a.m., Housekeeper E said trash should not be on the floor in the hallways and should be placed in the yellow barrel. She said trash should not be placed on the gray barrel and taken outside to dumpster. She said the staff would need to wipe down the gray barrels and disinfect the gray barrels that they return to the facility. Housekeeper E said dirty linens should not be picked up with bare hands and gloves should be worn. She said a person could get an infection if it touched their skin. She said the staff had been in-serviced on infection control. Housekeeper E said it was everyone's responsibility for infection control measures. She said a resident could get sick if infection control measures were not implemented. She said she would report to the ADM or supervisor if anyone was observed not properly using infection control measures.During an interview on 2/2/2026 at 11:27 a.m., the Housekeeping Supervisor said trash should not be in clear trash bags in the hallways or behind shower room doors. She said trash should not be placed on top of the gray barrels and rolled outside. She said it was an infection control issue with placing the trash on top of the barrels. She said the staff had to disinfect the barrels. She said residents could dig in the trash, wheel over the trash with their wheelchairs and drag trash on the floor if the trash was left on the floor. Housekeeper Supervisor said the floor technician was responsible for taking all trash out or the CNA could wheel the trash out to the dumpster.During an interview on 2/2/2026 at 11:35 a.m., CMA B said trash should not be placed outside in the hallway on the floor. She said it could cause cross contamination. She said a resident could cross through the trash in their wheelchair. She said it should be properly contained. She said dirty linens should be placed in the proper container and should be in a bag and never on the floor. She said a resident could trip over the dirty linens or get caught in a wheelchair. CMA B said the CNA and laundry staff were responsible for ensuring the linens were placed in clear bags and placed in gray barrels. She said if not properly placed, it could cause cross-contamination and spread germs to others.During an interview on 2/2/2026 at 12:00 p.m., CNA G said she was the one who placed the trash in the hallway on the floor. She said she thought she could place the trash on the floor if it was in a bag. She said she thought she could place trash with the dirty linens to transport outside. CNA G said dirty linens should not be left on the floor in a resident room. She said the dirty linens should be placed in a bag and taken to the laundry or placed in the laundry closet with the dirty linens. She said no trash should be left on the floor. She said it could contaminate the shower room. She said everyone was responsible for ensuring the trash and linens were taken out properly.During an interview on 2/2/2026 12:13 p.m., LVN C said linens should be placed in a bag and taken to the laundry or placed in a gray barrel. She said lines should not ideally be placed on the floor. She said it could contaminate the surface. LVN C said staff should not touch dirty linens with bare hands and gloves should be worn to prevent cross-contamination. She said it could cause contamination if someone touched resident or something a resident might touch. LVN C said everyone was responsible for ensuring staff were wearing gloves and not placing linens on the floor. LVN C said trash should not be in bags in the hallway and should be placed in yellow barrels.During an interview on 2/2/2026 at 1:15 p.m., the ADON said trash should be bagged and taken to the dumpster out back. She said the trash should not be placed on the floor or in hallways. She said it could be a fall risk and potential for spreading infection. She said she expected the staff to not place trash on the floor or hallways. She said the nurses were responsible for ensuring the trash was properly placed and not on the floors.During an interview on 2/2/2026 at 1:30 p.m., the DON said trash should not be stored in the hallways or left behind shower doors. She said the trash should be placed in the yellow barrel. The DON said she expected staff to wear gloves and properly bag linens and place them in gray barrels. She said trash should not be placed on the floor in the hallways. She said it was an infection control issue if the staff touched other surfaces or trash falls and contaminates other surfaces. The DON said all staff were responsible for ensuring trash and linens were stored properly.During an interview on 2/2/2026 at 2:45 p.m., the ADM said trash should be placed in the yellow barrels and linens go in the gray barrel. The ADM said staff should be wearing gloves while transferring dirty linens. He said it could cause cross-contamination if residents were provided care after touching dirty linens. He said he expected the staff to follow infection control policies.Record review of the facility's policy, Fundamentals of Infection Control Precautions, undated, stated: .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .1. Hand hygiene continues to be the primary means of preventing the transmission of infection.after handling soiled or used linens, dressings, bedpans, catheters or urinals.Gloving.to provide a protective barrier and prevent gross contamination of hands when touching blood, body fluids, secretions, excretions, mucous membranes and nonintact skin. 7. Linen and laundry.soiled linen may be contaminated with pathogenic microorganism, the risk for disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms. Hygienic and common-sense storage and processing of clean and soiled c=linens is recommended. 1. All soiled linen will be doubled bagged at the site that it was generated. All personnel will utilize all personal protective equipment. Soiled linen will be transported to the laundry site by cart.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 4 Halls (Hall #2) and 2 of 4 showers (Shower #2 and Shower #4) reviewed for environment.The facility failed to ensure trash was properly stored for Shower #4 on 1/29/2026 at 9:44 a.m.The facility failed to ensure trash was properly stored and removed from Hall #2 on 2/2/2026 at 9:46 a.m.The facility failed to ensure dirty linens were properly stored in Shower #2 on 1/29/2026 at 10:24 a.m.The facility failed to ensure toilet rim was intact without cracked porcelain on the back of the toilet on 1/29/2026 at 10:38 a.m These failures could place residents at risk in an unsanitary and uncomfortable environment.Findings included:During an observation on 1/29/2026 at 9:44 a.m., Shower #4 had dirty linens on the floor and a bag of trash in a clear bag located behind the door.During an observation and interview on 1/29/2026 at 9:44 a.m., Laundry E said the dirty linen should not be on the shower floor but kept in the linen barrel. Housekeeper E, not wearing gloves, picked up the dirty linens and placed them in the yellow barrel. Laundry E said she should have worn gloves when touching dirty linen.During an interview on 1/29/2026 at 3:15 p.m., the ADON said dirty linens go into a trash bag then placed in the gray barrel. The ADON said trash was placed in yellow barrels. The ADON said dirty linens should not be on the floor. She said it was an infection control issue and a fall risk. The ADON said the nurses were responsible for ensuring dirty linens were off the floor and in the proper barrels. She said the staff should not leave trash on the floor in the shower room. During an interview on 1/29/2026 at 3:58 p.m., CNA D said trash should be placed in the yellow barrel. She said the staff should place dirty linens in bags and place them in the gray barrel in the shower room. She said dirty linens should not be stored on the floor. CNA D said trash should not be placed on the floor in the shower room and should be placed in the yellow barrel in the shower room. CNA D said it was an infection control issue and could spread bacteria causing other people to get sick.During an observation on 2/2/2026 at 9:46 a.m., two bags of trash in clear trash bags were on the floor in front of the shower room on Hall #2. Observed CNA G picked up the trash and placed it on a gray barrel and rolled it down the hall.During an interview on 2/2/2026 at 9:56 a.m., CMA H said she did not see the two trash bags on the floor in the hallway. CMA H said no trash should be left in the hallway on the floor. She said the aides were responsible for taking the trash out if the barrel was full. She said someone could trip over the bags or someone could take something out of the bags, eat something out of the trash, or spread germs.During an interview on 2/2/2026 at 11:20 a.m., Housekeeper E said trash should not be on the floor in the hallways and should be placed in the yellow barrel. She said trash should not be placed on the gray barrel and taken outside to dumpster. She said the staff would need to wipe down the gray barrels and disinfect the gray barrels that they returned to the facility. Housekeeper E said dirty linens should not be picked up with bare hands and gloves should be worn. She said a person could get an infection if it touched their skin. She said the staff had been in-serviced on infection control. Housekeeper E said it was everyone's responsibility for infection control measures. She said a resident could get sick if infection control measures were not implemented. She said she would report to the ADM or supervisor if anyone was observed not properly using infection control measures.During an interview on 2/2/2026 at 11:27 a.m., the Housekeeping Supervisor said trash should not be in clear trash bags in the hallways or behind shower room doors. She said trash should not be placed on top of the gray barrels and rolled outside. She said it was an infection control issue with placing the trash on top of the barrels. She said the staff had to disinfect the barrels. She said residents could dig in the trash, wheel over the trash with their wheelchairs and drag trash on the floor if the trash was left on the floor. Housekeeper Supervisor said the floor technician was responsible for taking all trash out or the CNA could wheel the trash out to the dumpster.During an interview on 2/2/2026 at 11:35 a.m., CMA B said trash should not be placed outside in the hallway on the floor. She said it could cause cross contamination. She said a resident could come through the trash in their wheelchair. She said it should be properly contained. She said dirty linens should be placed in the proper container and should be in a bag and never on the floor. She said a resident could trip over the dirty linens or get caught in a wheelchair. CMA B said the CNA and laundry staff are responsible for ensuring the linens were placed in clear bags and placed in gray barrels. She said if not properly placed, it could cause cross-contamination and spread germs to others.During an interview on 2/2/2026 at 12:00 p.m., CNA G said she was the one who placed the trash in the hallway on the floor. She said she thought she could place the trash on the floor if it was in a bag. She said she thought she could place trash with the dirty linens to transport outside. CNA G said dirty linens should not be left on the floor in a resident room. She said the dirty linens should be placed in a bag and taken to the laundry or placed in the laundry closet with the dirty linens. She said no trash should be left on the floor. She said it could contaminate the shower room. She said everyone was responsible for ensuring the trash and linens were taken out properly.During an interview on 2/2/2026 at 12:13 p.m., LVN C said linens should be placed in a bag and taken to the laundry or placed in a gray barrel. She said lines should not ideally be placed on the floor. She said it could contaminate the surface. LVN C said staff should not touch dirty linens with bare hands and gloves should be worn to prevent cross-contamination. She said it could cause contamination if someone touched a resident or something a resident might touch. LVN C said everyone was responsible for ensuring staff were wearing gloves and not placing linens on the floor. LVN C said trash should not be in bags in the hallway and should be placed in yellow barrels.During an interview on 2/2/2026 at 1:15 p.m., the ADON said trash should be bagged and taken to the dumpster out back. She said the trash should not be placed on the floor or in hallways. She said it was a fall risk and potential risk for spreading infection. She said she expected the staff to not place trash on the floor or hallways. She said the nurses were responsible for ensuring the trash was properly placed and not on the floors.During an interview on 2/2/2026 at 1:30 p.m., the DON said trash should not be stored in the hallways or left behind shower doors. She said the trash should be placed in the yellow barrel. The DON said she expected staff to wear gloves and properly bag linens and place them in gray barrels. She said trash should not be placed on the floor in the hallways. She said it was an infection control issue if the staff touched other surfaces or trash fell and contaminated other surfaces. The DON said all staff were responsible for ensuring trash and linens were stored properly.During an interview on 2/2/2026 at 2:45 p.m., the ADM said trash should be placed in the yellow barrels and linens in the gray barrel. The ADM said staff should wear gloves while transferring dirty linens. He said it could cause cross-contamination if residents were provided care after touching dirty linens. He said he expected the staff to follow infection control policies.During an observation on 1/29/2026 at 10:36 a.m., Shower #2's toilet rim was broken on the back of the toilet with exposed rigid edges.During an observation and interview on 1/29/2026 at 3:30 p.m., the toilet rim in Shower # 2 was broken on the back of the toilet with exposed rigid edges and reported to the Corporate Nurse. She said she was not aware the porcelain was broken and would get it fixed immediately.During an interview on 2/2/2026 at 11:20 a.m., Housekeeper E said she reported the broken toilet to maintenance through the mobile QR application. She said she reported it in March 2025. She said the toilet rim was broken for a while and no one told her why it was not fixed. She said a resident could trip and fall or cut themselves on the porcelain. She said it should be reported immediately to maintenance or ADM when identified.During an interview on 2/2/2026 12:13 p.m., LVN C said she was not aware the toilet was broken in Shower #2. She said a resident could cut or hurt themselves if they fell or bumped into the broken porcelain.During an interview on 2/2/2026 at 1:15 p.m., the ADON said no one reported the porcelain broken on the toilet in Shower #2. She said whoever found it would be responsible for reporting it to maintenance. She said a resident could receive a skin injury from the broken porcelain.During an interview on 2/2/2026 at 1:30 p.m., the DON said she was not aware of the broken porcelain on the toilet in Shower #2. She said a report would need to be made immediately. She said a resident could have leaned back, fell or rubbed against it causing them to be injured or cut. She said all staff were responsible for ensuring equipment was intact. She said she would expect the staff to report immediately to prevent an injury.During an interview on 2/2/2026 at 2:45 p.m., the ADM said he expected the toilet to be fixed immediately due to resident safety. He said there was a possibility of an injury if a resident fell and hit the porcelain. He said everyone was responsible for ensuring the toilet was safe and operational.Record review of the facility's policy, Fundamentals of Infection Control Precautions, undated, stated, .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions .1. Hand hygiene continues to be the primary means of preventing the transmission of infection.after handling soiled or used linens, dressings, bedpans, catheters or urinals.Gloving.to provide a protective barrier and prevent gross contamination of hands when touching blood, body fluids, secretions, excretions, mucous membranes and nonintact skin. 7. Linen and laundry.soiled linen may be contaminated with pathogenic microorganism, the risk for disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms. Hygienic and common-sense storage and processing of clean and soiled c=linens is recommended. 1. All soiled linen will be doubled bagged at the site that it was generated. All personnel will utilize all personal protective equipment. Soiled linen will be transported to the laundry site by cart.Record review of the facility's policy, Resident Rights, undated, stated, .The resident has a right to a dignified right to existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must 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.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 4 of 21 residents (Resident #16, Resident #24, Resident #37 and Resident #60) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #16, Resident #24, Resident #37 and Resident #60 had a call light within reach on the memory care and secure unit. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.Findings include: Record review of Resident #16's face sheet dated 01/07/26 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: unspecified dementia, severe, with psychotic disturbances (describes a stage of dementia where cognitive decline is significant, and the person experiences severe behavioral issues like hallucinations), severe protein-calorie malnutrition, depression, and unilateral primary osteoarthritis, right knee (the cartilage in only your right knee is wearing down due to age or wear-and year, causing pain, stiffness, swelling, reduced motion and grinding sensations). Record review of Resident #16's MDS, dated [DATE], reflected Resident #16 was usually understood and usually understood by others. Resident #16's BIMs score was a 7, which indicated severe impaired cognition. Resident #16 was dependent on toileting and required partial or moderate assistance with all ADLs. Resident #16 was always incontinent to bowel and bladder. Record review of Resident #16's care plan dated 7/24/24 reflected Resident #16 was a high risk for falls due to her history of fall with fracture prior to admission. The interventions included anticipating and meeting resident's needs, to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review of Resident #24's face sheet dated 01/07/26 reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #24 had diagnoses which included: cerebral ischemia (a serious condition where blood flow and oxygen to the brain are reduced), dysphagia (difficulty swallowing), extrapyramidal movement disorder (medication-induced or disease-related movement disorder affecting the brain's motor system), convulsions (uncontrollable, rapid and repeated tightening and relaxing of muscles, causing body shaking) and vascular dementia (occurs when damaged blood vessels reduce oxygen and nutrient flow to the brain, causing cognitive decline). Record review of Resident #24's MDS, dated [DATE], reflected Resident #24 was understood and was understood by others. Resident #24's BIMs score was a 4, which indicated severe impaired cognition. Resident #24 was substantial or maximal assist on toileting and required partial or moderate assistance with ADLs. Resident #24 was always incontinent to bladder but was frequently incontinent to bowel. Record review of Resident #24's care plan dated 7/28/20 reflected Resident #24 was a risk for falls antipsychotic induced impaired mobility. The interventions included anticipating and meeting resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review of Resident #37's face sheet dated 01/07/26 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included: dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems and behavioral changes), malignant neoplasm of head, face and neck (a cancerous tumor) and major depressive disorder. Record review of Resident #37's MDS, dated [DATE], reflected Resident #37 was understood and was understood by others. Resident #37's BIMs score was a 3, which indicated severe impaired cognition. Resident #37 was independent with ADLs. Resident #37 was occasionally incontinent to bladder and bowel. Record review of Resident #37's care plan dated 10/06/25 reflected Resident #37 was a risk for falls due to his generalized weakness. The interventions included anticipating and meeting resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review of Resident #60's face sheet dated 01/07/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included: dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems and behavioral changes), chronic obstructive pulmonary disease (a progressive lung condition causing airflow obstruction, making breathing difficult) and overactive bladder. Record review of Resident #60's MDS, dated [DATE], reflected Resident #60 was usually understood and was usually understood by others. Resident #60's BIMs score was a 5, which indicated severe impaired cognition. Resident #60 required set-up or clean-up assistance with ADLs. Resident #60 was occasionally incontinent to bladder and bowel. Record review of Resident #60's care plan dated 09/10/25 reflected Resident #60 was at risk for falls due to unsteady gait and balance. The interventions included anticipating and meeting resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During observation and interview on 01/05/26 at 9:01 A.M., revealed Resident #37 was lying in bed watching television. He said he did not know where his call light was; when he needed something he went down the hall and asked the staff for what he needed. Resident #37's call light was on the side of his nightstand on the floor. During observation and interview on 01/05/26 at 9:15 A.M., revealed Resident #16 was lying in bed. Her call light was not within reach and it was tucked behind her nightstand on the opposite side of her bed. Resident #16 was asked if she could reach her call light. She said if she needed to call staff she could not because she could not reach her call light. During observation on 01/05/26 at 9:25 A.M., revealed Resident #60's call light was under her bed. During observation on 01/05/26 at 9:53 A.M., revealed Resident #24 was lying in bed asleep. His call light was on the floor on the other side of the nightstand opposite side of the bed. During observation on 01/06/26 at 9:23 A.M., Resident #37 was lying in bed resting. Her call light was not within reach. During observation on 01/06/26 at 9:27 A.M., revealed Resident #60 was lying in bed asleep. Her call light was not within reach. During observation on 01/06/26 at 9:28 A.M., revealed Resident #16 was not in her room. Her call light was not accessible to the bed. During observation on 01/06/26 at 9:33 A.M., revealed Resident #24 lying in bed asleep. His call light was not within reach; it was on the other side of his nightstand. During an interview on 01/06/26 3:21 P.M. CNA H said the call lights were a way for residents to notify staff if they needed something. She said Resident #37 never used his call light, but she knew the call lights needed to be accessible, so when the residents needed staff they could get a hold of them She said she agreed that a lot of the call lights on the secured unit were not accessible for the residents and she had put the call lights where the residents could get to them that morning. She said everyone was responsible for ensuring that the call lights were accessible for the residents. She said a negative effective of not having a call light accessible was if the residents fell, they could not get help. During an interview on 01/07/26 at 11:50 A.M. LVN G said the call light should be accessible for the residents to use in case of an emergency; the residents may need to contact staff. He said everyone was responsible for ensuring that the call lights were accessible for the residents. He said a negative effect of not having a call light accessible for a resident was that a resident could fall and cause an injury. He said a resident could even die and not be able to call for staff. During an interview on 01/07/2026 at 1:30 P.M., the Assistant Director of Nursing said the call light should be accessible for the residents to make their needs known. She said everyone was responsible for ensuring the call lights were accessible to the residents. She said negative effect of not having the call light accessible for the residents was potential falls. During an interview on 01/07/2026 at 2:41 P.M., the Director of Nursing said the call lights should be accessible and working properly for the residents so if they need help, they could get help when needed and not have to struggle to get to the call light. She said any of the staff that go into the residents' rooms were responsible for ensuring the call lights were accessible to the residents. She said negative effect of the call light not being accessible was if the resident needed assistance right away and they did not have a call light right away it could worsen the condition for the resident. During an interview on 01/07/2026 at 3:10 P.M., the Administrator said the call lights should be accessible for the residents if the resident needs help. He said all staff were responsible for ensuring the call lights were accessible for the residents and in working condition. He said a negative effect of the call light not being accessible was that a resident could potentially be in danger if they were not able to call for help. No Call light Policy was given per request.

Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed. The facility failed to employ a certified activities director who oversaw the activities program. This failure could place the residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings included: Record review of a personnel file for the Activity Director did not indicate an Activity Director Certification, that the Activity Director had 2 year of experience in a social or recreational program. During an interview on 01/07/2026 at 09:20 AM., the AD said she had been in the position as AD for approximately two months. The AD said she was not certified or completed the required activity director classes. The AD said she had not done any activity assessments, and she had just learned this morning that she was responsible for completing them. The AD said she was not aware of the frequency for completing the activity assessments because she was still learning. The AD said it was important to complete the activity assessments to know the residents and update their likes or dislikes and to prevent them from declining. The AD said, Another lady from a sister facility was going to train her but she had just found out she had a stroke and that is why she had not shown up for training. During an interview on 01/07/2026 at 4:18 PM, the Certified Occupational Therapist Assistant said she was a certified activity director and had volunteered to call bingo only. The Certified Occupational Therapist Assistant said she knew nothing about the assessment requirements, documenting activities and never said she would do those things for the AD or the facility. During an interview on 01/07/2026 at 4:26 PM, the Administrator said he expected the activity assessments to be done quarterly. The Administrator said the AD was responsible for completing the activity assessments. The Administrator said it was important for the activity assessments to be completed to learn the residents likes/dislikes, their religious preferences, and personalize information for them. The Administrator said it was important to have a qualified AD to ensure the residents did not have a decline in their quality of life. The Administrator said he was aware the Activity Director was hired without a certification. Record review of the facility's policy titled, Activity Programming dated 2011, indicated, The Activity Director determines the need for individual programming through the resident assessment process. Individual programs are coordinated by the Activity director and documented in the plan of care. Goals, type of interventions and response are documented and reflected in monthly or quarterly progress notes. The Activity Director and staff regularly (at least quarterly) assess the ability or the interest of the residents. The policy did not indicate the required qualifications for an Activity Director.

Based on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified or registered in accordance with applicable state laws for 1 (LVN A) of 4 licensed nursing staff reviewed for staff qualifications.The facility failed to ensure LVN A's license was valid in order to practice as a licensed vocational nurse from [DATE] through [DATE].This failure could place residents at risk of receiving nursing services by an unlicensed nurse.The findings included:Record review of LVN A's employee file revealed the facility verified her unencumbered (no restrictions) license with Nursys Quickconfirm (National database to verify nursing licensures) on [DATE] prior to her hire date of [DATE]. LVN A's employee file included a Job Description for Charge Nurse signed by LVN A on [DATE] acknowledging she had read the qualifications and requirements of the position of Charge Nurse which included being a RN or LVN in good standing. LVN A's employee file also included a handwritten letter from LVN A indicating she was turning in her notice on [DATE] and her last day performing as a charge nurse would be [DATE], but she was open to other positions within the facility.Record review of the website https://txbn.boardsofnursing.org/licenselookup accessed on [DATE], indicated LVN A was listed by the BON as having an expired license as of [DATE]. The verification report included a document with the title of Before the Texas Board of Nursing . in the matter of LVN A . Agreed Order . Terms of Order . it is therefore agreed and ordered that Vocational Nurse License Number . previously issued to LVN A, to practice nursing in the State of Texas is/are herby SUSPENDED and said suspension is ENFORCED until . Respondent's Certification . by my signature on this Order, I agree to the entry of this Order and all conditions of said Order . signed by LVN A on [DATE] . effective this 15th day of [DATE] . signed by the Executive Director on behalf of the BON .Record review of the facility's time punch report obtained [DATE] for LVN A indicated she worked 12.38 hours on [DATE], 11.52 hours on [DATE], 13.62 hours on [DATE], and 12.62 hours on [DATE].Record review of the facility's daily staffing sheets obtained [DATE] indicated LVN A was the Charge Nurse on the 6 AM to 6 PM for Halls C & D on [DATE], [DATE], [DATE], and [DATE].Record review of the facility's daily census obtained on [DATE] indicated the census was 66 on [DATE] with 14 residents on Hall C and 25 residents on Hall D; the census was 66 on [DATE] with 14 residents on Hall C and 25 residents on Hall D; the census was 65 on [DATE] with 14 residents on Hall C and 24 residents on Hall D; and the census was 66 on [DATE] with 14 residents on Hall C and 26 residents on Hall D.Record review of the website https://txbn.boardsofnursing.org/licenselookup of the BON report accessed on [DATE] indicated LVN A's licensed had an Enforced Suspension effective [DATE].During an interview on [DATE] at 5:36 PM, the DON said LVN A was a floor nurse and LVN A came to her in the middle of [DATE] and said she would have to put in her notice but would be able to work until end of December. The DON said LVN A said her past had caught up with her and she would have to do some TPAPN with the BON. The DON said she sent LVN A's written notice to their HR department after she received it. The DON said the week of Christmas, their Corporate HR contacted her via email and said LVN A's license was not good and they immediately removed LVN A from the nursing schedule. The DON said she did not check LVN A's license when she turned in her notice. The DON said she did look at an email LVN A showed her with the BON representative and LVN A had asked if she could work until the end of the month of December and LVN A said the BON representative told her she could work out her two week notice to the end of December. The DON said she did not actually see in the email the BON said LVN A could work until the end of December.During an interview on [DATE] at 10:30 AM, LVN A said her understanding of the form she signed for the BON on [DATE] was just saying she would not go to court. LVN A said she asked in the email to the BON representative if she could give a two week notice to her job and get another check to pay her fees to the BON. LVN A said the BON representative responded to the email and said as long as the form was signed by [DATE]th that would be fine. LVN A said she took it as the BON representative was saying she could work out her two week notice. LVN A said she did not realize her license was suspended effective [DATE] until the DON notified LVN A the week of Christmas and said HR had notified her that LVN A's license had expired [DATE]. LVN A said she was immediately told by the DON she could not work as a nurse or provide any type of patient care. LVN A said she knew she could not work as a nurse once her license was suspended, but she must have misinterpreted the email from the BON representative, because she thought she had approval to work out a two week notice to her job.During an interview on [DATE] beginning at 2:51 PM, the ADM said his understanding was LVN A had come to the DON and explained that her license was going to be suspended at the end of the year, and she turned in her notice. The ADM said then their Corporate HR person emailed them the week of Christmas and informed them LVN A's license expired on [DATE], so they immediately removed her from the schedule. The ADM said he would have expected LVN A to have communicated to them the status of her license. The ADM said the risk of LVN A working with a suspended license included she could get in trouble, it could create potential trouble for the facility, and it could create a potential safety issue for the residents; it was all about the safety of the residents. The ADM said they did not have a policy related to qualified staff and used the job descriptions as requirements for the position.Record review of the facility's Job Description for Charge Nurse dated from the Human Resources Manual 2014, provided by the ADM on [DATE], indicated . The following was a non-exhaustive criteria that relates to the job of a Charge Nurse . These were legitimate measures of the qualifications for a Charge Nurse and were related to the functions that were essential to the job of a Charge Nurse . Knowledge Base . Registered Nurse or Licensed/Vocational Nurse in good standing .

Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 6 residents (Resident #12) reviewed for call lights.The facility failed to ensure Resident #12's call light was functioning properly. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs. Findings include: 1.Record review of a face sheet dated 01/08/2026 revealed Resident #12 was [AGE] year-old male admitted on [DATE] with diagnoses including multiple sclerosis (chronic autoimmune disease where the immune system attacks the brain, spinal cord and optic nerves), hypertension (high blood pressure), and chronic pain. Record review of the quarterly MDS dated [DATE] revealed Resident #12 was understood by others and able to understand others. The MDS revealed Resident #12 had a BIMS of 15 which indicated cognitively intact. The MDS revealed Resident #12 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, transfer and bathing. Record review of Resident #12's care plan with revised date of 12/06/2025 indicated a chronic condition of multiple sclerosis with the following interventions: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments, encourage frequent rest periods to help conserve energy. During an observation and interview on 01/06/2025 at 08:45 AM, Resident #12 said he was waiting for the aide to assist him. He said he had pressed the call light button approximately 15 minutes ago but no one had come to answer the light. The Surveyor asked Resident #12 to press the call light button again. The Surveyor observed the light for the call button did not come on in the hallway area when Resident #12 pushed the call button. Student Nursing Aide B was notified and came into Resident #12's room and attempted turn on the call light without success. She stated that she was not aware the call light was not working. Student Nursing Aide B said she thought the call light was checked when the resident was relocated into the room the night before. Student Nursing Aide B said she was not aware the call light was not working. Student Nursing Aide B said it was important for the call light system to work properly to prevent potential injuries and to be notified of the residents' wants and needs. Student Nursing Aide B said she would notify the charge nurse and maintenance for repairs. During an interview on 01/07/2026 at 2:41 P.M., the Director of Nursing said the call lights should be accessible and working properly for the residents so if they need help, they could get help when needed and not have to struggle to get to the call light. She said any of the staff that go into the residents' rooms were responsible for ensuring the call lights were accessible to and properly working for the residents. She said negative effect of the call light not being accessible or functioning was if the resident needed assistance right away and they did not have a call light right away it could worsen the condition for the resident. During an interview on 01/07/2026 at 3:10 P.M., the Administrator said the call lights should be accessible and fully functioning for the residents if the resident needs help. He said all staff were responsible for ensuring the call lights were accessible to the residents and in working condition. He said a negative effect of the call light not being accessible and functioning were that a resident could potentially be in danger if they were not able to call for help. During an interview on 01/07/2024 at 04:30 PM., the Administrator said there was no policy to address the call light system.

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #2 and Resident #7) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #2. The facility failed to provide consistent and scheduled in-room activities for Resident #7 to meet her needs. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.Findings included: 1. Record review of a face sheet dated 01/08/2026 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included atherosclerotic heart disease (plaque buildup inside the arteries), malignant neoplasm of prostate (cancer tumor in the prostate gland) , cardiomegaly (enlarged hear), hypertension (high blood pressure), and back pain. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. Record review of the care plan with target date 02/17/2026 indicated Resident #2 needs out of room social, spiritual, and stimulus activities and mental stimulation with the following interventions: resident will attend activities of his/her choice, will watch TV, read and socialize with other residents at least 2 times weekly by next update, the activity director will encourage and remind the resident of current activities, the activity director will provide the resident reading material for mental stimulation, the activity director will praise the resident for attending activities of their choice. Record review of Resident #2's electronic health record indicated his last activity assessment was completed on 08/18/2025. During an interview on 01/07/2025 at 11:00 AM, Resident #2 stated he did not get out of his room for facility related activities. Resident #2 stated he enjoyed conversations in his room discussing the Bible. 2. Record review of a face sheet dated 01/08/2026 indicated Resident #7 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's disease (loss of memory and cognitive abilities), severe protein-calorie malnutrition, osteomyelitis (infection of the bone). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #7 was usually understood and usually understood others. The MDS assessment indicated Resident #7 had a BIMS score of 0, which indicated Resident #7 was severely cognitively impaired. Record review of Resident #7's care plan with a target date of 01/29/2026, indicated Resident #7 needed in room socialization and sensory stimulation with the following interventions: Resident will respond to one on one in room visits with sensory stimulation such as tactile, and visual in room activities, the Activity Director will provide the resident with one on one visits with sensory stimulation at least 3 times per week. During an observation on 01/06/2026 at 08:30 AM, revealed Resident #7 was lying in bed resting. During an observation on 01/06/2026 at 02:10 PM, revealed Resident #7 was lying in bed resting. During an observation on 01/06/2026 at 05:45 PM, revealed Resident #7 was laying bed resting. During an interview on 01/07/2026 at 08:10 AM the AD said she provided 1 on 1 activities to residents who were bedridden. The AD said some residents did better in small groups, and the more outgoing residents did better in larger groups. The AD said she had not documented in the computer charting system or on a log when a resident attended activities or refused to participate. The AD said she was not aware that she was supposed to be documenting who attended activities or when she did a 1:1 activity. The AD stated she was not certified as an AD at this time and was awaiting to take the class. During an interview on 01/07/2026 at 09:20 AM the AD said she had been in the position as AD for approximately two months. The AD said she had not done any activity assessments, and she had just learned this morning that she was responsible for completing them. The AD said she was not aware of the frequency for completing the activity assessments because she was still learning. The AD said it was important to complete the activity assessments to know the residents and update their likes or dislikes and to prevent them from declining. The AD said, Another lady from a sister facility was going to train her but she had just found out she had a stroke and that is why she had not shown up for training. During an interview on 01/07/2026 at 4:18 PM, the Certified Occupational Therapist Assistant said she was a certified activity director and had volunteered to call bingo only. The Certified Occupational Therapist Assistant said she knew nothing about the assessment requirements, documenting activities and never said she would do those things for the AD or the facility. Record review of the Certified Occupational Therapist Assistant's employee file indicated she had a Certificate of Completion for Nursing Home Activity Director dated November 28, 1994. During an interview on 01/07/2026 at 4:26 PM, the Administrator said he expected the activity assessments to be done quarterly. The Administrator said the AD was responsible for completing the activity assessments. The Administrator said it was important for the activity assessments to be completed to learn the residents likes/dislikes, their religious preferences, and personalize information for them. Record review of the facility's policy titled, Activity Programming dated 2011, indicated, The Activity Director determines the need for individual programming through the resident assessment process. Individual programs are coordinated by the Activity director and documented in the plan of care. Goals, type of interventions and response are documented and reflected in monthly or quarterly progress notes. The Activity Director and staff regularly (at least quarterly) assess the ability or the interest of the residents.

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed. (Nurse medication cart for the B Hall) LVN D failed to securely lock the nurse medication cart for the B Hall. This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions.Findings included: During an observation on 1/06/26 at 7:56 A.M. revealed the nurse medication cart sitting across the hall from room [ROOM NUMBER] was unlocked. The door was open to room [ROOM NUMBER] and the resident was in the room lying in bed. There was a resident standing at the nurse medication cart leaning on her walker. There were no staff present at the medication cart. The top drawer contained a tray of eye drops, lancets, alcohol pads, 3 insulin pens and a glucometer. The second drawer contained liquid G-tube medications, 34 cards of various medications (including Metoprolol, Metformin, Lisinopril, Keppra, Digoxin), Geri-Lanta, MiraLAX, Tums, Ready Care, 1 bottle of Liquid Protein and 1 bottle of Lactulose. Drawer 3 contained topical medications. Drawer 4 contained oxygen tubing and a supply of plastic cups. During an interview on 1/06/26 at 7:58 A.M. LVN D said the nurse cart was supposed to be in her possession, and the cart was supposed to be locked. She said she was called away by an aide. She said she normally kept the cart locked at all times. During an interview on 1/06/26 at 1:48 P.M. LVN D said she normally had the nursing cart locked when she walked away from it, but the aide caught her off guard by asking her to help her with a resident. The negative effect of leaving a medication cart unlocked was anyone can get into it. She stated she was not normally careless like that. During an interview on 1/07/26 at 10:45 A.M. RN J said when staff walked away from their cart it was always supposed to be locked. She said a negative effect of not locking a medication cart was someone could steal things off the cart and patient information could be exposed. During an interview on 1/07/26 at 1:30 P.M. the ADON said the person who opened the medication cart was responsible for ensuring the cart was locked when they stepped away from the cart. She said a negative effect of an unlocked nursing medication cart was that a resident could potentially get into the cart. During an interview on 1/07/26 at 2:41 P.M. the Director of Nursing said whoever was in charge of the medication cart was responsible for ensuring the medication cart was locked. She said a negative effect of an unlocked medication cart was residents could get in the cart and take something that does not belong to them, and they could be allergic to the item. During an interview on 1/07/26 at 3:10 P.M. the Administrator said he heard about the incident with the nurse leaving the medication cart unlocked. He said the nurses or medication aides were responsible for ensuring the medication carts were locked. He said the negative effect of unlocked medication carts had potential for a resident to pull out something that did not need to be pulled out of the cart. Review of an undated facility Medication Storage in the facility policy indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #12) reviewed for grievances. The facility failed to ensure a grievance was filed when Resident #12 reported to the DON his roommate was loud, and he could not sleep. This failure could place residents at risk for grievances not being addressed or resolved promptly resulting in frustration and sleep deprivation.Findings include: Record review of a face sheet dated 01/08/2026 revealed Resident #12 was [AGE] year-old male admitted on [DATE] with diagnoses including multiple sclerosis (chronic autoimmune disease where the immune system attacks the brain, spinal cord and optic nerves), hypertension (high blood pressure), and chronic pain. Record review of the quarterly MDS dated [DATE] revealed Resident #12 was understood by others and able to understand others. The MDS revealed Resident #12 had a BIMS of 15 which indicated cognitively intact. The MDS revealed Resident #12 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, transfer and bathing. Record review of Resident #12's care plan with revised date of 12/06/2025 indicated a chronic condition of multiple sclerosis with the following interventions: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments, encourage frequent rest periods to help conserve energy. During an interview on 01/05/2026 at 09:25 AM, Resident #12 stated he had spoken with the DON during the Christmas holidays regarding wanting a new roommate because his current roommate hollered out, moaned, and groaned throughout most of the day and night. Resident #12 stated he did not get any rest, and it was becoming very frustrating for him. Resident #12 stated the DON had not followed back up with him to date regarding this matter. During an observation on 01/05/2026 at 01:40 PM revealed while in Resident #12's room, Resident #12's roommate was heard hollering out and talking randomly. During an observation on 01/05/2026 at 02:45 PM revealed while in Resident #12's room, Resident #12's roommate was moaning loudly consistently and reached into the air while lying in bed. During an observation and interview on 01/05/2026 at 03:40 PM, revealed Resident #12 had his television very loud and stated he was trying to drown out the noise from his roommate. Resident #12 inquired about an update and stated he had spoken with the DON again today around lunch time regarding a change in roommate because he had grown more frustrated from lack of rest. During an interview on 01/05/2026 at 04:45 PM, Resident #12 stated he had not heard of any plan or resolution from the DON regarding a change in roommate. Record review of the grievance log dated 12/01/2025 - 01/05/2026 did not indicate any grievances filed by Resident #12. During an interview on 01/05/2026 at 5:01 PM, the DON stated she was aware of Resident #12's grievance of wanting a new roommate and him not being able to rest because of the constant moaning and groaning from his current roommate. The DON said Resident #12 had told her this morning, I am stuck in the mud! The DON explained that Resident #12 felt trapped with the situation of not being able to get another roommate. The DON said Resident #12 wanted a new roommate and she had been working on the matter. The DON stated she first learned of the complaint from Resident #12 during the holidays, probably a couple of weeks ago when she was working on the floor. The DON stated she thought she had made notes and provided them to the Social Worker for follow-up but was not able to locate the documentation. The DON said the Social Worker may have the notes regarding the grievance, but the Social Worker was off work the next few days. The DON said she needed to find a room for Resident #12 and would start working on a resolution with the Administrator at this time. The DON said it was important to log the grievances at the time of occurrence to ensure the timely response and follow up be appropriate to prevent any adverse effects to the residents such as lack of rest and increased frustrations. During an interview on 01/07/2026 at 04:00 PM, the Administrator stated that all grievances should be logged whether they were communicated verbally or written and followed up on timely to ensure an amicable resolution to provide the best possible outcome for the residents. The Administrator stated it was important for each resident to be able to rest in their own home. The Administrator said when a resident filed a grievance a resolution was developed and completed within 2-3 days at the very longest. He said if a resolution could not be completed in that time frame of 2-3 days a written update was provided. The Administrator said grievances should be addressed in a timely manner, so the residents delt like they were being heard. He said grievances not being addressed timely could cause residents to have unresolved complaints. The Administration said he was not aware of Resident #12's grievance until now. Record review of a facility Grievance Policy dated 11/02/2016 indicated .The resident had the right to, and the facility must make prompt efforts by the facility to resolve grievances that resident may have.Maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 6 residents reviewed for ADLs (Resident #2 and Resident 30). The facility did not provide scheduled showers for Resident #2 on 01/05/2026. The facility failed to provide assistance for Resident # 30 with the removal of facial hair on 01/05/2026. These failures could place residents at risk of not receiving services/care and decreased quality of life.Findings Include: 1. Record review of a face sheet dated 01/08/2026 indicated Resident # 2 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included atherosclerotic heart disease (plaque buildup inside the arteries), malignant neoplasm of prostate (cancer tumor in the prostate gland) , cardiomegaly (enlarged hear), hypertension (high blood pressure), and back pain. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS assessment indicated Resident #2 required supervision and partial assistance for all ADLs. Record review of the care plan with target date 02/17/2026 indicated Resident #2 had an activity of daily living (ADL) self-care performance deficit related to generalized weakness. The care plan indicated interventions included Resident #2 required limited assistance x1 staff for showering. During an interview and observation on 01/05/2026 at 08:30 AM, Resident #2 said he was waiting for the aide because it was his shower day. Resident #2 had a shower bag ready with his bath products inside. During an interview on 01/06/2026 at 08:15 AM, Resident #2 said he did not get a shower on yesterday's date. Resident #2 said the aide never came back to get him. Resident #2 was upset and stated it was important to get assistance with the shower when scheduled to decrease the chances of infection. Resident #2 said he had reminded the aide about the shower throughout the day yesterday, but no one appeared to have time. Record review of Resident #2's electronic health record indicated a completed bath was performed by Student Nursing Aide B on 01/05/2026. During an interview on 01/06/2026 at 08:30 AM, Student Nursing Aide B said she had been employed by the facility for a couple of weeks. Student Nursing Aide B said she was responsible for giving the residents their showers. Student Nursing Aide B said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. Student Nursing Aide B said it was important for residents to receive their showers so staff could observe their skin and to maintain the residents' cleanliness. Student Nursing Aide B said Resident #2 should have received a bath yesterday by the shower aide but the shower aide was pulled to work on another hall. Student Nursing Aide B said she had documented that she gave Resident #2 his shower on yesterday's date, but she must have made a mistake. Student Nursing Aide B said that she was assigned to Resident #2 but had failed to complete the shower as scheduled. Student Nursing Aide B said she would need to be re-educated to only document what task she had completed herself. 2. Record review of a face sheet dated 01/08/2026 indicated Resident #30 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's disease (decline in memory, thinking, reasoning and eventually hindering daily activities), chronic atrial fibrillation (irregular heartbeat) , subdural hemorrhage (brain bleed, hypertension (high blood pressure), and repeated falls. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and usually understood others. The MDS assessment indicated Resident #30 had a BIMS score of 05 which indicated severe cognitive impairment. The MDS assessment indicated Resident #30 required substantial and partial assistance for all ADLs. Record review of the care plan with target date 03/31/2026 indicated Resident #30 had an activity of daily living (ADL) self-care performance deficit related to limited range of motion of bilateral upper extremities. The care plan indicated interventions included Resident #2 required assistance with personal hygiene: hair, shaving and oral care. During an interview on 01/05/2026 at 01:45PM, Resident #30's family member said she had shaved Resident #30 on today's date. Resident #30's family member said she came to the facility on Resident #30's shower days and shaved him. Resident #30's family member said if she did not come to the facility to shave Resident #30, he would not get shaved and have hair stubble. Resident #30's family member said she would like for the facility to shave Resident #30 per the care plan. Resident #30's family member said Resident #30 would never want to have facial hair and appear unkept. During an interview on 01/06/2026 at 02:37 PM, CNA C said she gave Resident #30 a shower or on 01/05/2026. CNA C said she did not shave Resident #30 because she thought his family wanted to shave him. CNA C said Resident #30's family member always shaved him upon her arrival. CNA C said she had just assumed the family wanted to do the shaving and she had not inquired about it. CNA C said it was important to follow the plan of care to prevent infections and allow dignity with being appropriately dressed and groomed. During an interview on 01/07/2026 at 04:15PM, the DON said it was the CNAs responsibility to give the residents their showers and provide personal hygiene. The DON said there was a shower list that identified what resident received a shower on which day and shift. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to communicate with the charge nurses daily to ensure resident's needs were being met. The DON said if a resident refused she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of resident 's being bathed and showered appropriately according to the resident's Plan of Care. The DON said the importance of the residents receiving their scheduled showers was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. The DON said ultimately it was her responsibility to ensure the showers and personal hygiene were performed for the residents by the staff. The DON said a new system was implemented on yesterday's date to ensure no showers and hygiene were missed. During an interview 01/07/2026 at 4:39 PM, the Administrator said he expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff were responsible for making sure the baths/showers were provided for the residents. The Administrator said if the residents refused ADL care, the staff should educated the residents. The Administrator said if a resident refused, he expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, he expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers for hygiene according to the resident's plan of care to make the residents feel good, infection control and dignity. Record review of undated facility policy and procedure titled, Bath, Shower/Tub, Bathing by tub bath or shower is done to remove soil .Procedure.1. The resident will receive assistance with bathing according to their resident centered plan of care.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #22), reviewed for infection control practices.1. The facility failed to ensure SNA B and CNA C wore a gown while providing direct care to Resident #22, who was on EBP (infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities), while performing a mechanical lift transfer and incontinent care on 1/05/2026.2. The facility failed to ensure LVN D wore a gown and gloves while providing direct care to Resident #22's feeding tube (medical tube delivering liquid nutrition) and PEG tube (soft tube inserted through the skin and abdominal wall directly into the stomach) on 1/05/2026.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection. Findings included:Record review of Resident #22's face sheet dated 1/05/26 indicated he was [AGE] years old and was admitted to the facility on [DATE]. Resident #22 had diagnoses which included Alzheimer's disease (a progressive brain disorder causing irreversible decline in memory, thinking, and reasoning, interfering with daily life) and gastrostomy (also called PEG tube).Record review of Resident #22's quarterly MDS assessment dated [DATE] indicated he was rarely/never understood and was unable to complete the BIMS interview, which indicated he had severe cognitive impairment. Resident #22 was dependent on staff for most ADLs. Resident #22 was always incontinent of bowel and bladder. Resident #22 had a feeding tube/PEG tube.Record review of Resident #22's Care Plan indicated he was on enhanced barrier precautions with interventions of gloves and gown should be donned (put on) if any of the following activities were to occur . transfer . toileting/incontinent care . enteral feeding care . or other high-contact activity. Resident #22 had an ADL self-care performance deficit and was totally dependent on staff for toileting and he required a lift for all transfers. Resident #22 required tube feeding related advanced Alzheimer's and anorexia (not eating).Record review of Resident #22's Order Summary Report dated 1/05/2026 indicated an order for Enhanced Barrier Precautions related to PEG tube with an order date of 1/04/2026. There was also an order for Enteral (delivered directly into the stomach) Feed Order to check placement prior to feeding and medication administration with a start date of 5/13/2025.During an observation on 1/05/2026 beginning at 2:30 PM, LVN D entered Resident #22's room and put on gloves and then reached under the resident's shirt and disconnected the feeding tube from his PEG tube on his stomach. LVN D did not wear a gown as part of EBP. After the PEG tube was disconnected, CNA C and SNA B performed a mechanical lift transfer from the chair to the bed. SNA B leaned against Resident #22's bed, allowing the front of her clothing to come in contact with Resident #22's bedding and grabbed items from the bed and placed them on the bedside table. CNA C then moved Resident #22 to his bed and lowered to bed. CNA C then leaned over Resident #22 and his bed and pulled a blanket from under the resident on the opposite side away from her, allowing her clothing to come in contact with Resident #22 and his bed/bedding. SNA B leaned over bed and Resident #22 to unhook the straps from the mechanical lift, allowing her clothing to come in contact with Resident #22 and his bed/bedding. CNA C then began incontinent care, assisted by SNA B, and neither staff wore gowns as part of EBP while providing incontinent care. CNA C pushed Resident #22's brief down in between his legs, then used wipes to clean his front private area and CNA C was leaning against his bed. CNA C changed gloves, then both staff rolled Resident #22 away from them toward the wall and held him over on his side, removed his brief, then CNA C cleaned his back private area. CNA C changed her gloves, placed a new brief and pushed it and the lift pad under Resident #22, then pulled Resident #22 toward them as CNA C leaned over Resident #22 and pulled the lift pad out from under Resident #22 and pulled the new brief out from opposite side of the resident, allowing their clothing to touch the Resident #22 and his bed/bedding. CNA C then applied Resident #22's heel protectors. SNA B reached over Resident #22's head and grabbed his shoulders and pulled him over in bed and placed a neck pillow around his neck and pillows beside his head, then CNA C and SNA B pulled Resident #22 up in bed and repositioned. CNA C and SNA B did not wear a gown at any time while performing a mechanical lift transfer, incontinent care, or positioning Resident #22 as part of EBP. There was a red sign on the wall and a PPE cart outside of Resident #22's room by his door which indicated Resident #22 was on EBP and staff were required to wear a gown and gloves while providing direct resident care.During an interview on 1/05/2026 at 3:15 PM, Resident #22's RP said she came to the facility every day and watched the camera when she was not there. Resident #22's RP said the staff never wore a gown when providing care for Resident #22 and only wore gloves.During an observation on 1/05/2026 at 3:22 PM, LVN D entered Resident #22's room and lifted Resident #22's shirt and reconnected his feeding tube to his PEG tube. LVN D did not wear a gown or gloves while providing direct care.During an interview on 1/06/2026 at 4:36 PM, SNA B said she had worked at the facility since 9/2025. SNA B said she had been a SNA since 10/13/2025. SNA B said EBP meant the resident was fighting some kind of bacteria. SNA said a resident on EBP was any resident with a red sign on their door. SNA B said if the resident had a red sign that said they were on EBP, then staff should wear gloves, gown, mask, and a face shield, so not to transfer any infections back and forth from staff or other residents. SNA B said if the resident was on EBP, staff should wear the required gloves, gown, mask, and a face shield, anytime when entering the resident's room. SNA B said she and CNA C were not wearing PPE except gloves during Resident #22's mechanical lift transfer, incontinent care, or positioning on 1/5/2026 because it just slipped her mind. SNA B said by not wearing the gown, she could transfer anything from her clothing to another resident or to Resident #22 and they could get sick. SNA B said it would be an infection control issue.During an interview on 1/06/2026 at 4:48 PM, CNA C said she had worked at the facility for about five years.CNA C said she only knew to wear gloves with residents who had feeding tubes and urinary catheters. CNA C said she had received training on infection control. CNA C said the signs on the doors normally said whether the resident was on droplet or contact isolation and the sign said what type of protective equipment was needed. CNA C said she did not know she needed to wear a gown or what EBP was. CNA C said she agreed it could be an infection control issue to not wear the appropriate PPE.During an interview on 1/06/2026 at 5:04 PM, RN E said she had worked at the facility for about seven days. RN E said EBPs was to protect the resident from infections, and focused on residents with wounds, PICC lines, feeding tubes, urinary catheters, and any implanted device. RN E said staff should be wearing gowns and gloves for direct contact with the resident on EBP. RN E said staff should be wearing a gown and gloves to reconnect a feeding tube to a PEG tube to protect both resident and staff. RN E said by not wearing a gown and gloves when providing direct resident care to a resident on EBP, placed the resident at a higher instance of getting an infection.During an interview on 1/06/2026 at 5:10 PM, LVN D said she had worked at the facility for almost two years as a charge nurse. LVN D said EBP was to protect the resident from staff transferring germs/disease to residents with PEG tubes, Foley catheters, PICC lines, and wounds. LVN D said gloves, gown, and mask should be worn when providing direct patient care to a resident on EBP. LVN D said direct care would include touching a resident in any way, putting medications in PEG tube, providing any care, and would require gown and gloves to be worn. LVN D said with EBP, staff should wear gown and gloves during incontinent care and mechanical lift transfers. LVN D said staff should wear a gown and gloves when reconnecting a feeding tube to a PEG tube. LVN D said she was not wearing a gown but thought she was wearing gloves when she reconnected Resident #22's feeding tube to his PEG tube, because she usually did. LVN D said Resident #22 was on EBP. LVN D said by not wearing a gown and gloves while providing direct care, it could cause contamination and cause the resident an infection. During an interview on 1/06/2026 at 5:24 PM, RN F said the purpose of EBP was to prevent the spread of infection to residents with wounds, implanted devices, urinary catheters and to prevent staff from passing infections from a resident to other residents potentially. RN F said staff should wear gloves and a gown during direct resident care to residents on EBP. RN F said staff should wear a gown during mechanical lift transfers and incontinent care. RN F said a gown and gloves should have been worn during reconnection of a feeding tube to a PEG tube. RN F said the feeding tube/PEG tube would have been the reason the resident was on EBP. RN F said by staff not wearing the appropriate PPE with a resident on EBP, placed the resident at risk for infection. During an interview on 1/06/2026 at 5:36 PM, the DON said EBP was to prevent the spread infection especially with residents with catheters, PEG tubes, feeding tubes, IVs (intravenous- inserted into a vein), and wounds. The DON said staff should wear the appropriate gear when providing direct care to the resident to help prevent the spread of infection. The DON said staff should wear gown and gloves during mechanical lift transfers and incontinent care. The DON said staff should definitely wear a gown and gloves when reconnecting a feeding tube to a PEG tube. The DON said not wearing appropriate gear during direct care placed the resident at risk of infection. During an interview on 1/07/2026 at 2:51 PM, the ADM said he expected staff to follow the facility's policies for the safety of the residents and staff. The ADM said EBP was to ensure staff did not carry anything to the residents and vice versa. The ADM said he would absolutely expect staff to wear gown and gloves during direct care such as incontinent care, mechanical lifts and re-connecting a feeding tube to a PEG tube. The ADM said the resident could get something that makes them sick if staff were not wearing the appropriate PPE. Record review of the facility's undated policy titled Fundamentals of Infection Control Precautions received 1/07/2026 indicated . a variety of infection control measures were used for decreasing the risk of transmission of microorganisms in the facility . gloves were worn for three important reasons . 1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . 2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin. 3. To reduce likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these organisms to another resident . 5. Gowns and protective apparel . 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF (Longterm Care Facility) Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures . 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments .Record review of the facility's policy titled Enhanced Barrier Precautions dated 4/01/2024 indicated . Multidrug-resistant organism (MDRO) transmission is common in long-term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs . Enhanced Barrier Precautions (EBP) refer to infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used in conjunction with standard precautions and expand the use of PPE (personnel protective equipment) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . EBP are indicated for residents with any of the following: colonization with CDC (Centers of Disease Control and Prevention) targeted MDRO when Contact Precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . Indwelling medical device examples include central lines, urinary catheters, feeding tubes . Donning PPE for residents on EBP based on activity provided/assistance while in resident room . gown and gloves . for transfer a resident, changing briefs or assisting with toileting, turn and reposition or assist with bed mobility . device care or use: central line, urinary catheter, feeding tube .

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 20 of 25 (Resident's #2, #4, #5, #6, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for abuse and neglect. 1. The facility failed to ensure LVN D did not physically abuse Resident #4 when she picked her up from her wheelchair and threw her on to the mattress on the floor on 07/17/25. Resident #4 sustained a bruise to her right elbow and redness to the mid abdomen. 2. The facility failed to ensure LVN E did not verbally abuse Resident #9 when LVN E yelled and cursed at Resident #9 when she asked for pain medication on 08/17/25. 3. The facility failed to ensure Resident #12 did not physically abuse Resident #13 when he shoved her on 08/07/25 and on 08/23/25. On 08/23/25, Resident #13 sustained scratches to her face. 4. The facility failed to ensure Resident #5 was properly positioned during a tube feeding on 08/20/25. Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. 5. The facility failed to ensure sufficient staff were available to provide wound care treatment and documentation for Resident's #2, #16, #17, #18, #19, #20, #23 and #24 during August 2025 and September 2025. 6. The facility failed to ensure Resident's #4, #6, and #19 were provided feeding assistance during mealtimes. 7. The facility failed to ensure the secured unit was adequately staffed to prevent accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. 8. The facility failed to ensure Resident #7, Resident #8, Resident #14 Resident #21, and Resident #22 were provided supervision during the lunch meal on 09/08/25. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/13/25 at 12:49 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on abuse and neglect, notification of changes in condition, documentation policy, pain management policy, fall prevention policy, pressure prevention policy, medication administration policy, enteral feeding policy, and the bathing and showers policy. These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, decreased quality of life, serious harm, injury, impairment, and death.Findings included:1. Record review of a face sheet dated 09/17/25 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder), anxiety disorder, abnormal weight loss, dysphagia (difficulty swallowing foods or liquids). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #4 understood others and was never/rarely understood by others. The MDS indicated Resident #4 had a BIMS score of 0 which indicated Resident #4 was severely impaired and unable to complete the interview. The MDS indicated Resident #4 required supervision and touching assistance with eating, and dependent for showering, toileting, hygiene and transfers. Record review of Resident #4's care plan with a revised date of 09/08/25 indicated Resident #4 had a history of falls due to Huntington's disease and required staff times two for transfers. Record review of Resident #4's Order Summary Report dated 09/17/25 indicated an order for mattresses on floor with walls and floor surrounding mattresses padded every shift dated 07/12/25. Record review of a Provider Investigation Report dated 07/17/25 at 07:09 PM, indicated Resident #4's family member come to the facility and reported that she saw on the camera that a staff member had brought Resident #4 to her room in her wheelchair and threw her down on the mattress. The facility completed skin and pain assessment and order x-rays. Documented facility follow-up action was to in-service staff members with 1:1 education and physical therapy in-service regarding transfer of residents, police department notified, safe surveys conducted, trauma assessments for all residents. Record review of skin assessment completed on 07/17/25 by LVN CC indicated Resident #4 had bruising on right elbow and redness to lower abdomen. Record review of written statement by LVN D dated 07/17/25, indicated after Resident #4 had finished eating, she was slipping out of her chair. LVN D returned Resident #4 to her room in the wheelchair. LVN D stated when she stood up Resident #4 and she pulled against her, and she let her go before she knew it and had tried to grab her. LVN D stated she did not want to fall on her. LVN D wrote she saw Resident #4 was ok and left to clean up the wheelchair. During an observation on 09/09/25 at 09:32 AM, Resident # 4 was laying on the mattress in room. Resident #4 was non- interviewable. During an interview on 09/09/25 at 10:05 AM, Resident #4's family member stated she was very upset upon viewing the camera video of how LVN D threw Resident #4 on to the mattress during the transfer. Resident's 4's family member stated she immediately contacted the Administrator regarding the unnecessary roughness and lack of care used when providing care to Resident #4 on 07/17/2025. Resident #4's family member said she provided the Administrator with the video of the transfer. Resident #4's family member stated to her knowledge LVN D had not been back into Resident #4's room and was terminated. Resident #4's family member was tearful. Resident #4 's family member stated Resident #4 had a bruise to her right elbow and redness on her abdomen. During an observation on 09/09/25 at 1:27 PM of a video, date stamped 07/17/25 at 01:08 PM, LVN D wheeled Resident #4 into her room. Resident #4's bed mattress was located directly on the floor. LVN D lifted Resident #4 from the wheelchair and threw her onto the mattress. Resident #4 could be heard moaning and was rolling from side to side. LVN D turned and walked out of the room. Attempted telephone call to LVN D on 09/09/25 at 02:15 PM; left a voice message and requested a call back. During an interview on 09/09/25 at 04:30 PM, the Administrator stated she was the abuse coordinator for the facility and responsible to investigate and report any and all abuse allegations. The Administrator stated the importance of reporting and investigation timely was to prevent any further harm or harm to residents. The Administrator stated she had seen the video provided by Resident #4's family member on 07/17/25. The Administrator said the police were notified immediately. The Administrator said she did not report LVN D to the board of nursing because the police stated they could not get a good view to decide if LVN D had pushed or just lost her balance when Resident #4 was transferred. The Administrator stated LVN D was terminated on 07/18/25 and had not provided care to any residence after 07/17/25. The Administrator become tearful during the interview and said the care provided by LVN D during the video was abuse. Attempted telephone call to LVN D on 09/09/25 at 09:01 PM; left a voice message and requested a call back. Record review of the personnel chart of LVN D reflected she was terminated on 07/18/25. Record review of the personnel chart of LVN D reflected completion of Abuse and Neglect training upon hire date of 10/03/18 and yearly thereafter. The following Employee Disciplinary Memorandums for LVN D: 10/18/24 regarding failure to properly perform skin assessments. 2. Record review of a face sheet dated 09/11/25 indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute kidney failure, metabolic encephalopathy (imbalance in body's chemical processes leading to abnormal brain function), chronic obstructive pulmonary disease (progressive lung disease causing shortness of breath, cough, and airflow limitations), type 2 diabetes mellitus (excessive sugar in the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #9 understood others and was understood by others. The MDS indicated Resident #9 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #9 was independent with eating, required moderate assistance with showering and dressing, and dependent with toileting hygiene. Record review of Resident #9's care plan dated 08/06/25 indicated Resident #9 had a history of trauma related to being choked that may have a negative impact. The interventions included monitor for escalating anxiety, depression and sleep disturbances, perform de-escalation techniques as needed. Record review of Resident #9's Order Summary Report dated 09/11/25 indicated Acetaminophen-Codeine Tablet 300-30mg, give one tablet by mouth every 6 hours as needed for pain related to kidney failure dated 007/29/25 Record review of a Provider Investigation Report dated 08/18/25 at 08:17 AM, indicated Resident #9 alleged, [LVN E] refused to give her pain medications and hit the side of her mattress with her fist and told her she didn't need the pain medication. [Resident #9] alleged LVN E stormed out of the room cussing and yelling up and down the hall. LVN E was suspended pending investigation and safe surveys conducted, staff in services and trauma assessment completed on Resident #9. Record review of trauma assessment completed on 08/18/25 by the SW indicated Resident #9 had no trauma. Record review of written statement by LVN E dated 08/20/25 stated, whenever, Resident #9, asks for her medicine (pain meds) I always check the time, assess her pain and let her know whether it's time or not. Sometimes she agrees and sometimes she doesn't. She often states that she doesn't know why she turns her light on (forgets) or she just shrugs her shoulders. Most times she is easily redirected. Sunday, August 17th, 2025, I had the opportunity to meet and greet Resident #9's . I kneeled down in front of Resident #9 because she was in her wheelchair, took her left hand held it and greeted her and introduced myself to her family and thanked them for allowing me to be a part of her care. I stated it was my pride and privilege to take care of their loved one. The smiled, nodded and said, that is enough. It startled me just a bit, I stood up and apologized for interrupting their visit. He smiled and that was it. I empathically deny any allegations of cussing up and down the hall. First, profanity is verbal abuse. Second, there were CNA's present most of the night. I was the only one there at 02:30 AM. Third, I respect these elders home period. Attempted telephone call to LVN E on 09/09/25 at 11:40 AM left a voice message and requested a call back. During an interview on 09/09/25 at 12:25 PM, Resident #9's family member stated, he had received a call at approximately 03:00 AM on 08/17/25 from Resident #9. Resident #9's family member stated that Resident #9 complained that LVN E would not give her pain medications and was cussing and yelling at her. Resident #9 stated LVN E snatched up the blanket and slammed it back down on to her feet. Resident #9 family member stated he contacted the facility by phone and spoke with a nurse but could not recall the name and requested Resident #9's was checked on and pain medication administered appropriately. Resident #9's family member stated he did not hear anything more from Resident #9 or the facility the remainder of the night. Resident #9's family member stated that on 08/17/25 while visiting Resident #9, he had encountered LVN E. Resident #9's family member stated LVN E was talking to Resident #9 like she was a child and in a condescending manner. Resident #9's family member stated he told LVN E that was enough. Resident #9's family member stated, LVN E acted very peculiar as if she was on drugs. Resident #9's family member stated he received a call from the Administrator on 08/18/25 regarding Resident #9's previous allegations regarding LVN E. Resident #9's family member confirmed he had received the call from Resident #9. Resident #9's family member stated he also reported the incident wherein he had told LVN E to stop talking to Resident #9 in the childlike, condescending manner on 07/17/25 during a visit. Resident #9's family member stated he had requested LVN E not take care of Resident #9 due to her behaviors. Resident #9's family member stated that later perhaps the next day or so, he had received a call from the Administrator wherein she stated the allegations had been confirmed and LVN E was terminated from the facility. During an interview on 09/09/25 at 12:45 PM, Resident #9 stated she had used the call light button and waited on LVN E for a long time the night the incident occurred. Resident #9 stated upon LVN E entering her room she asked for her pain medication. Resident #9 stated LVN E began cussing and hitting the side of her bed and said she was not getting her pain medication, and she could not have it. Resident #9 said LVN E picked up her covers and slammed it back down over her feet. Resident #9 said LVN E then left her room yelling and cussing that she was not going to get the pain medication for her. Resident #9 stated she called her family member. Resident #9 stated she did not see LVN E for the remainder of the shift. Resident #9 said it was not very long before the day shift arrived, and she received her medication. Resident #9 said LVN E was always talking and moving around fast and rushed. Resident #9 stated she reported the incident to the one of the night shifts nurses the following evening. Resident #9 stated that later that evening after she told the nurse about the incident with LVN E, the Administrator spoke with her regarding the incident. During an interview on 09/09/25 at 12:55 PM, the Administrator stated Resident #9 had reported to RN T on 08/18/25 at approximately 07:00 PM that LVN E had grabbed her and thrown her into a chair and cursed her. The Administrator stated upon interviewing Resident #9, she stated she had used her call light and requested pain medication after waiting a long time. Resident #9 stated when LVN E walked into the room, she told Resident #9 she was not getting pain medication and begin hitting the side of the bed and slung the covers off her. The Administrator stated Resident #9 said she was not physically touched by LVN E. The Administrator stated Resident #9 left the room and was cussing and yelling in the halls. The Administrator stated when she contacted Resident #9's family member, she was told that LVN E had talked to Resident E in a condescending manner. The Administrator stated Resident #9's family member expressed concern and requested LVN E be kept away from Resident #9. The Administrator stated she had interviewed staff and confirmed LVN E had erratic behaviors such has yelling and cussing in front of the residents. The Administrator stated LVN E had only worked at the facility for about 2 weeks. The Administrator stated LVN E was terminated on 08/20/25. Attempted telephone call to LVN E on 09/09/25 at 01:15 PM; left a voice message and requested a call back. Attempted telephone call to RN T on 09/09/25 at 04:17 PM; sent a text message requesting call back per the voice mail message instructions. Attempted telephone call to RN T on 09/09/25 at 07:30 PM; sent a text message requesting call back per the voice mail message instructions Attempted telephone call to LVN E on 09/09/25 at 07:49 PM; left a voice message and requested a call back. During an interview on 09/09/25 at 07:50 PM, CNA F stated she had worked at the facility for 14 years. CNA F stated she currently worked the B hall. CNA F stated she had heard LVN E hollering before in the hallways. CNA F stated she did not know the situation of why LVN E was cussing and hollering but she had heard it. CNA F stated she had been reassigned to work B hall over the last month and had been working in the locked unit before. Attempted telephone call to LVN E on 09/10/25 at 02:30 PM; left a voice message and requested a call back. During an interview on 09/12/25 at 10:57 AM, the DON stated she had witnessed, on the night shift, LVN E holler and using profanity in the hallway while residents were present. The DON stated it was around the time of the incident with Resident #9. The DON stated she immediately addressed the issue with LVN E and had written up LVN E for those actions. The DON stated she expected the staff to treat the residents with respect and dignity. The DON stated all staff were responsible to report any suspicion or allegations of abuse to the abuse coordinator immediately. The DON stated the facility was the resident's home and no one appreciated being talked to or listening to that type of language in their own homes. The DON said using profanity to the residents was considered verbal abuse and could result in the residents feeling frightened, scared, degraded, or even humiliated. During an interview on 09/12/25 at 12:30 PM, the Administrator said she was the abuse coordinator. The Administrator said she expected all staff to report any type of abuse to her immediately. The Administrator said it was her responsibility to report and investigate allegations of abuse. The Administrator said the purpose of reporting timely and investigating properly was to prevent further abuse from occurring. The Administrator said LVN E was terminated following the investigation that involved Resident #9. Record review of the personnel chart of LVN E reflected she was terminated on 08/21/25. Record review of the personnel chart of LVN E reflected completion of Abuse and Neglect training upon hire date of 08/06/25 and yearly thereafter. The following Employee Disciplinary Memorandums for LVN E: 08/15/25 regarding hollering and using profanity in the hallways with residents present. 3. Record review of the face sheet, dated 09/11/25, reflected Resident #12 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss) psychosis (state of impaired reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the admission MDS assessment, dated 08/11/25, reflected Resident #12 had clear speech, was usually understood, and was usually able to understand others. Resident #12 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS reflected Resident #12 had physical behaviors directed toward others 1-3 days and wandering behaviors 4 to 6 days during the look-back period. Record review of Resident #12's comprehensive care plan, initiated on 08/06/25, reflected no care plan had been developed for behaviors. Record review of the order summary report, dated 09/11/25, reflected Resident #12 had an order, which started on 07/31/25, that indicated he may reside on the secured unit related to exit seeking behaviors. Record review of the behavior incident report, dated 08/07/25 at 7:25 AM, reflected CNA N reported that Resident #13 was in Resident #12's room looking at pictures on his nightstand when Resident #12 pushed Resident #13. There were no injuries. The report reflected Residents #12 and #13 were separated and the Administrator was notified. Record review of the behavior incident report, dated 08/23/25 at 6:20 AM, reflected Resident #12 pushed Resident #13 to the floor. Resident #12 reported Resident #13 tried to come into his room, so he stopped her. The incident was unwitnessed by staff. Record review of Resident #12's progress notes, reflected the following: On 09/06/25 at 12:41 PM, Resident #12 was transferred to another facility. Record review of the face sheet, dated 09/11/25, reflected Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and anxiety disorder. Record review of the quarterly MDS assessment, dated 05/29/25, reflected Resident #13 had clear speech, was usually understood, and was sometimes able to understand others. Resident #13 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #13 had no behaviors or refusal of care. Record review of the comprehensive care plan, last reviewed 06/05/25, reflected Resident #13 had the potential to demonstrate verbally and physically abusive behaviors. The care plan further revealed Resident #13 was at risk for elopement and resided on the secured unit. The interventions included: supervise closely and make regular compliance rounds whenever resident is in room. Record review of the order summary report, dated 08/23/25, reflected Resident #13 had an order, which started on 02/26/25, that she may reside on the secured unit related to exit seeking behaviors. Record review of Resident #13's progress notes, reflected the following: On 08/07/25 at 4:25 PM a trauma assessment was completed and was negative. On 08/08/25 at 9:02 PM, it was documented Resident #13 had no injury or adverse reaction from being pushed. On 08/23/25 at 6:20 AM, an event note was completed that reflected Resident #13 had 2 scratches on the right side of face and redness to side of left arm below the elbow. She reported that Resident #12 pushed her. X-rays were ordered of hips and elbows. On 08/23/25 at 9:11 AM, the Social Worker documented that she was notified Resident #13 was pushed by another male resident, which resulted in a fall to the floor. Resident #13 did not appear to be in distress, she was smiling and in a pleasant mood. On 08/26/25 at 12:04, Resident #13 was discharged to another facility. 4. Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the bodies demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision- making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeing related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, [Family member] or nurse to assist with feeding. The order started on 08/26/25. Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected [Resident #5]'s family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube is not definitely visualized.air distended stomach.left basilar airspace disease (condition in which the lower lungs of the left lung collapse, preventing air exchange), likely atelectasis (collapse of lung or part of lung from lack of air in the air sacs) given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. During an observation on 09/08/25 beginning at 1:25 PM of a video date and time stamped, 08/20/25 3:13 PM, revealed Resident #5 leaning over the left armrest of his Geri-chair. He was moaning and grunting, unable to lift his torso or head. At 3:16 PM, CNA G walked into the room, pulls his arm and ask him to sit up, and then walked out of the room. The interaction lasted approximately 45 seconds. Resident #5 returned to the same position within approximately 30 seconds after CNA G left the room. Resident #5 remained in the same position, where his head and torso were leaning over the left armrest for approximately 1 hour and 30 minutes. Resident #5 constantly moaned and grunted during the video until LVN L sets up him with pillows and positioned him comfortably at 4:26 PM. During an interview on 09/09/25 beginning at 2:38 PM, Resident #5's family member stated on 08/20/25 she had gone out to eat and did not watch the camera as she normally did. Resident #5's family member stated when she got home, she noticed a neck pillow was blocking the view of the camera, so she called the facility. Resident #5's family member stated she went back to review the video prior to the pillow blocking camera and noticed he had been leaning over his chair for about 2 hours. Resident #5's family member was concerned he may have aspirated so she requested a chest x-ray be performed. Resident #5's family member stated the chest x-ray showed aspiration pneumonia, and he was sent to the hospital. Resident #5's family member stated he was returned to the facility on antibiotics. Resident #5's family member stated the facility staff did not have enough help. Resident #5's family member stated she believed the incident would not have occurred if the facility had sufficient staffing because they would have been able to check on him more frequently. During an interview on 09/09/25 beginning at 10:55 AM, LVN M stated Resident #5's family member had requested that he go to the hospital because she was concerned about something that had occurred on the camera, and she believed he could have possibly aspirated. LVN M stated she notified the physician, and he was agreeable, so she sent Resident #5 to the hospital per the family member's request. LVN M stated Resident #5 had no signs or symptoms of aspiration, such as nasal drainage, shortness of breath, or wheezing. LVN M stated the facility had obtained the order for a chest x-ray, but it had not been completed before he was sent to the hospital, if she remembered correctly. LVN M stated Resident #5 did not return back from the hospital on her shift, so she was unaware of what he was treated for at the hospital. During an interview on 09/09/25 beginning at 11:50 AM, CNA G stated on 08/20/25 she was on the way to answer another resident's call light when she walked by Resident #5's room and noticed he was leaning over. CNA G stated she grabbed Resident #5 under the arm and elbow to sit him up. CNA G stated she sat Resident #5 up the best she could then proceeded to answer the call light. CNA G stated she was the only staff member assigned to her hallway and stated she never thought to check on him again because she had so much going through her mind. CNA G stated she was called later on to provide a statement of the incident. CNA G said she had just graduated CNA school about 4 months ago and was still learning things. CNA G stated grabbing someone by the arm was not the proper way to position them. CNA G stated the facility did provide her one-on-one education on proper positioning. CNA G stated looking back she should have checked on Resident #5 sooner, but it was hard to recognize in the moment because of the staffing concerns. CNA G stated Resident #5 should have been positioned in a Fowler's position (upright) during a tube feeding. CNA G stated improperly positioning a resident during a tube feeding could result in aspiration. CNA G stated she did help the nurse with wound care for Resident #2 because there was no one else to help. CNA G stated there were staffing concerns at the facility because no one wanted to work. CNA G stated the facility staff did not like the management staff. CNA G stated she had only worked at the facility since June 2025. CNA G stated at times she was the only CNA who was assigned to two halls, which was approximately 25 residents. CNA G stated she was unable to provide the care and services each resident required when she was scheduled alone. CNA G stated she felt rushed with the residents. CNA G stated management staff were aware of the staffing concerns, but felt like nothing was addressed. CNA G stated management did not consistently help out on the floor. CNA G stated the DON would provide assistance to one resident because of the camera in the room, but most of the time when she asked for help the DON would say Let me find someone to help you. CNA G stated she normally worked the C-Hall (the secured unit) and was the only staff member scheduled. Record review of Resident #2's face sheet dated 9/11/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnosis including acute posthemorrhagic anemia (is a condition that develops when you lose a large amount of blood quickly), heart failure (is a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pressure ulcer of left heel, stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and usually had the ability to understand others. Resident #2's had a BIMS score of 7 which indicated moderate cognitive impairment. Resident #2 required setup assistance for eating, supervision for oral hygiene, partial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #2 was always incontinent for urine and occasionally incontinent for bowel. Resident #2 had one, stage 3 unhealed pressure ulcers/injuries. Resident #2 had pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2's care plan, revised on 9/11/25, indicated Resident #2 had a pressure ulcer due to decreased mobility. Resident #2 had stage 3 pressure injury to left heel. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and administer medications as ordered. Record review of Resident #2's order summary report dated 9/11/25 indicated: Stage 3 pressure injury, cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Start date 8/25/25. Record review of Resident #2's wound administration record dated 8/1/25-8/31/25 indicated: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border ev

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 11 out of 25 (Resident's #4, #7, #8, #10, #11, #12, #13, #14, #19, #21, and #22) residents reviewed for accidents. 1. The facility failed to ensure adequate supervision on the secured unit to prevent two resident-to-resident physical altercations between Resident #12 and Resident #13 on 08/07/25, and 08/23/25, which resulted in scratches to Resident #13's face. 2. The facility failed to ensure the secured unit was adequately supervised to prevent unwitnessed fall accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. Resident #14 sustained a radius fracture and required 6 sutures to her left eye on 07/01/25. Resident #21 was sent to the ER after she hit her head and complained of pain on 07/03/25. Resident #10 sustained an abrasion to his left knee on 08/08/25. 3. The facility failed to ensure CNA H provided Resident #11 the correct level of assistance during toileting hygiene. On 07/14/25, CNA H provided incontinence care without assistance to Resident #11 which resulted in Resident #11 falling to the floor and hitting her head. Resident #11's fall mat had been moved for care, and she sustained a skin tear and facial bruising. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/13/25 at 12:49 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on abuse and neglect, notification of change in condition, fall prevention policy, and the Kardex. This failure could place residents at risk of serious injuries, harm, impairment, and death.The findings included: 1. Record review of the face sheet, dated 09/11/25, reflected Resident #12 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss) psychosis (state of impaired reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the admission MDS assessment, dated 08/11/25, reflected Resident #12 had clear speech, was usually understood, and was usually able to understand others. Resident #12 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS reflected Resident #12 had physical behaviors directed toward others 1-3 days and wandering behaviors 4 to 6 days during the look-back period. Record review of Resident #12's comprehensive care plan, initiated on 08/06/25, reflected no care plan had been developed for behaviors. Record review of the order summary report, dated 09/11/25, reflected Resident #12 had an order, which started on 07/31/25, that indicated he may reside on the secured unit related to exit seeking behaviors. Record review of the behavior incident report, dated 08/07/25 at 7:25 AM, reflected CNA N reported that Resident #13 was in Resident #12's room looking at pictures on his nightstand when Resident #12 pushed Resident #13. There were no injuries. The report reflected Resident #12 and #13 were separated and the Administrator was notified. Record review of the behavior incident report, dated 08/23/25 at 6:20 AM, reflected Resident #12 pushed Resident #13 to the floor. Resident #12 reported Resident #13 tried to come into his room, so he stopped her. The incident was unwitnessed by staff. Record review of Resident #12's progress notes, reflected the following: On 09/06/25 at 12:41 PM, Resident #12 was transferred to another facility. 2. Record review of the face sheet, dated 09/11/25, reflected Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and anxiety disorder. Record review of the quarterly MDS assessment, dated 05/29/25, reflected Resident #13 had clear speech, was usually understood, and was sometimes able to understand others. Resident #13 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS reflected Resident #13 had no behaviors or refusal of care. Record review of the comprehensive care plan, last reviewed 06/05/25, reflected Resident #13 had the potential to demonstrate verbally and physically abusive behaviors. The care plan further revealed Resident #13 was at risk for elopement and resided on the secured unit. The interventions included: supervise closely and make regular compliance rounds whenever resident is in room. Record review of the order summary report, dated 08/23/25, reflected Resident #13 had an order, which started on 02/26/25, that she may reside on the secured unit related to exit seeking behaviors. Record review of Resident #13's progress notes, reflected the following: On 08/07/25 at 4:25 PM a trauma assessment was completed and was negative. On 08/08/25 at 9:02 PM, it was documented Resident #13 had no injury or adverse reaction from being pushed. On 08/23/25 at 6:20 AM, an event note was completed that reflected Resident #13 had 2 scratches on the right side of face and redness to side of left arm below the elbow. She reported that Resident #12 pushed her. X-rays were ordered of hips and elbows. On 08/23/25 at 9:11 AM, the Social Worker documented that she was notified Resident #13 was pushed by another male resident, which resulted in a fall to the floor. Resident #13 did not appear to be in distress, she was smiling and in a pleasant mood. On 08/26/25 at 12:04, Resident #13 was discharged to another facility. 3. Record review of Resident #8's face sheet dated 9/11/25 indicated Resident #8 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had diagnoses including dementia with anxiety (a group of thinking disorders that interferes with activities of daily living with intense, excessive, and persistent worry and fear about everyday situations), chronic obstructive pulmonary disease (decrease airflow of the lungs), protein calorie malnutrition (when not enough protein calories are consumed to meet the body's needs), hypertension (high blood pressure). Record review of Resident #8's admission MDS assessment, dated 08/16/25, reflected Resident #8 was able to understand others and was understood by others. Resident #8 had a BIMS score of 4, which indicated her cognition was severely impaired. Resident #8 required setup and cleanup assistance with eating, and partial to moderate assistance with shower, toileting, and lower body dressing and personal hygiene. Record review of Resident #8's care plan, dated 09/11/2025, reflected Resident #8 had a significant unplanned weight loss. The care plan interventions were labs as ordered, monitor and record food intake, monitor and report any changes in residents eating habits, notify dietician, physician and family of any weight loss, Red Glass on meal tray to identify the resident and staff as possibly needing assistance, encouragement, and substitutes, weight the resident weekly for at least 4 weeks or until weight is stabilized. The care plan did not address risk of falls. Record review of Resident #8's Order Summary Report indicated Resident #8 had an order for regular diet dated 08/16/2025. Resident #8 had an order dated 09/10/2025 for Mirtazapine Tablet 7.5. mg give one tablet at bedtime for weight loss. Record review of the fall incident report, dated 09/06/25 at 3:05 PM, Resident #8 was found sitting on the floor in another resident's room without any bottoms on by the CNA. Resident #8 stated she was going to the bathroom and fell down when the other resident yelled at her for being in her room. The incident was unwitnessed and there were no injuries. 4. Record review of a face sheet dated 09/11/25 indicated Resident #10 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (progressive lung disease causing shortness of breath, cough, and airflow limitations), wandering, adult failure to thrive, and anxiety. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #10 usually understood others and was sometimes understood by others. The MDS indicated Resident #10 had a BIMS of 3 and was severely cognitively impaired. The MDS indicated Resident #10 had a history of falls. Record review of Resident #10's care plan dated 04/15/24 indicated a risk for falls related to dementia with generalized weakness. The interventions included anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, fall mat at bedside, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Record review of Resident #10's Order Summary Report dated 09/11/25 indicated the following: An order dated 04/12/24 to admit to the secure unit for exit seeking behaviors. An order dated 02/25/25 for bevel fall mat at bedside. Record review of the fall incident report, dated 08/08/25 at 7:05 AM, reflected Resident #10 had an unwitnessed fall. The report indicated Resident #10 was found in his room, beside the bed, sitting on the fall mat. Resident #10 reported he just sat down. There were no injuries. Record review of the fall incident report, dated 08/28/25at 5 PM, reflected Resident #10 was discovered in his room, sitting on the floor mat with legs stretched out and back leaning against the bed, smiling. The reported indicated the incident was unwitnessed and there were no identified injuries. Record review of the fall incident report, dated 09/04/25 at 8 AM, reflected Resident #10 was found on his knees, in a praying position, on the side of his bed. Resident #10 reported he got on his knees himself and did not fall. The incident was unwitnessed and there were no injuries identified. 5. Record review of the face sheet, dated 09/11/25, reflected Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and Parkinson's disease (a progressive movement disorder of the nervous system). Record review of the quarterly MDS assessment, dated 09/01/25, reflected Resident #14 had clear speech, was usually understood, and was usually able to understand others. Resident #14 had a BIMS score of 4, which indicated severely impaired cognition. Resident #14 had no behaviors or refusal of care. The MDS reflected Resident #14 was usually independent with eating, required partial/moderate assistance with shower/bathing, and independent with transfers and bed mobility. The MDS reflected Resident #14 had no recent falls. Resident #14 received a therapeutic diet while a resident. Record review of the comprehensive care plan, last reviewed on 05/21/25, reflected Resident #14 had an ADL self-care performance deficit and required supervision with bed mobility and walking. The care plan did not address assistance with meals. The care plan reflected Resident #14 was at risk for falls related to parkinsonism. Record review of the order summary report, dated 09/11/25, reflected Resident #14 had an order for no salt on tray diet with regular texture and regular consistency fluids. Lids on cups with hot liquids. The order started on 05/24/22. Record review of the fall incident report, dated 07/01/25 at 7:51 AM, reflected Resident #14 was found in the hallway sitting on the floor. Resident #14 was bleeding from a laceration over her left eye and glasses were lying beside her. Resident #14 stated she did not know what happened, she just fell. The fall was unwitnessed. Resident #14 was sent to the hospital with 8 out of 10 pain on the 0 - 10 pain scale and the deep laceration on her face. Record review of Resident #14's progress notes, reflected the following: On 07/01/25 at 12:56 PM, it was documented Resident #14 returned to the facility with a radius fracture, colitis, and the laceration she received from the fall. On 07/01/25 at 1:03 PM, it was documented Resident #14 returned with 6 sutures above her left eye and a splint to left arm. Record review of the fall incident report, dated 07/30/25 at 4:20 PM, reflected Resident #14 was found in the dining room on the ground. The incident was unwitnessed. Resident #14 stated she fell trying to pick up a pencil. There were no injuries. 6. Record review of the face sheet, dated 09/12/25, reflected Resident #19 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities). Record review of the significant change MDS assessment, dated 08/06/25, reflected Resident #19 had unclear speech, was sometimes understood, and was sometimes able to understand others. Resident #19 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #19 had a lower extremity impairment to both sides which interfered with daily function. Resident #19 was totally dependent on staff for ADLs, which included eating. The MDS reflected Resident #19 had a fall within the last month prior to admission. Resident #19 was checked for signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals. Resident #19 required a mechanically altered diet while a resident of the facility. Record review of Resident #19's comprehensive care plan, last reviewed 09/09/25, reflected the following: Resident #19 had an ADL self-care performance deficit and required staff assistance x 1 with eating and was resistive to eating at times. Resident #19 had a history of falls and the interventions included: fall mat beside bed, appropriate footwear, call light in reach, anticipate needs, and staff assistance x 2 with transfers. Record review of Resident #19's order summary report, dated 09/12/25, reflected an order, which started on 09/01/25 for a regular diet with pureed texture, and regular consistency liquids. Record review of Resident #19's fall incident report, dated 07/03/25, reflected LVN O was called to Resident #18's room by a CNA and found Resident #19 laying on the floor on her right side with wheelchair about 2 feet away. Resident #19 stated she was trying to walk around. The CNA reported to LVN O that Resident #19 had just returned from therapy where she was up walking with assistance. The incident was unwitnessed. No injuries were obtained. 7. Record review of Resident #21's face sheet dated 9/21/25 indicated Resident #21 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #21 had diagnoses including dementia (a group of thinking disorders that interferes with activities of daily living), chronic obstructive pulmonary disease (decrease airflow of the lungs), protein calorie malnutrition (when not enough protein calories are consumed to meet the body's needs), hypertension (high blood pressure). Record review of Resident #21's Quarterly MDS assessment, dated 06/20/25, reflected Resident #21 was able to usually understand others and was sometimes understood by others. Resident #21 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #21 required setup and cleanup with eating, supervision and touching with shower, toileting, upper and lower body dressing and personal hygiene. Record review of Resident 21's care plan, with a revised date 09/05/25, reflected Resident #21 had a diet order for fortified/enhanced mechanical soft texture with risk for unplanned weight loss. The care plan interventions for Resident #21 were determine food preferences and provide within dietary limitations, divided plate, broth with all meals, finger foods offered when available, add sandwich with meals, may have whole bacon with breakfast. Resident #21's care plan also addressed potential for malnutrition dated 05/24/23 with interventions that included monitor and document meal intake, monitor weights, labs, notify physician. The care plan indicated Resident #21 was also at risk for significant unplanned/unexpected weight loss dated 02/15/24 with 2 calorie/cc supplement with medication pass. The care plan indicated Resident #21 was at risk for falls. The interventions included: anticipate and meet the resident's needs, resident needs a safe environment with even floors free from spills, clutter, and proper footwear while ambulating or in wheelchair. Record review of Resident #21's Order Summary Report indicated Resident #21 had an order for Fortified/Enhanced Diet Mechanical Soft texture, regular consistency, Fortified/Enhanced Diet Mechanical Soft texture, preferences and provide within dietary limitations, divided plate, broth with all meals, finger foods offered when available, add sandwich with meals, may have whole bacon with breakfast dated 08/07/24, Health Shake two times a day, offer house shake two times a day with lunch and dinner dated and Readycare 2.0 four times a day to promote weight gain (60 ML four times daily) dated 05/20/24. Record review of the fall incident report, dated 07/03/25 at 9:45 AM, Resident #21 had an unwitnessed fall in the dining room. LVN O found Resident #21 in the dining room lying flat on her ack next to the table. Resident #21 reported she tried to sit in the chair and missed it. No injuries were indicated. Record review of the fall incident report, dated 08/20/25 at 2:20 PM, LVN L found Resident #21 on the floor in another resident's room. The fall was unwitnessed and there were no injuries noted. During an observation on 09/08/25 at 11:23 AM, Resident #21 walked out of the dining room to the secured unit doors. There was wet floor signs posted, and the floor was wet. There was no staff supervision. 8. Record review of the face sheet, dated 09/11/25, reflected Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills). Record review of the admission MDS assessment, dated 08/19/25, reflected Resident #7 had clear speech, was usually understood, and was usually able to understand other. Resident #7 had a BIMS score of 2, which indicated severe cognitive impairment. The MDS reflected Resident #7 wandered daily but had no refusal of care. The MDS reflected Resident #7 was independent with eating. Resident #7 required a mechanically altered diet while a resident and had no natural teeth or tooth fragments. Record review of the comprehensive care plan, revised on 09/09/25, reflected Resident #7 had an ADL self-care deficit the goal was to maintain her current level of functioning. There were no interventions. The care plan further reflected Resident #7 was at risk for malnutrition and the interventions included: monitor and document meal intake. Record review of the order summary report, dated 09/11/25, reflected Resident #7 had an order for regular diet with mechanical soft texture, regular consistency liquids, milk on all trays, which started on 08/24/25. During an observation on 09/08/25 at 10:48 AM, Resident #7 was wheeling herself around the facility. She was repeatedly asking for the time and when lunch would be served. 9. Record review of Resident #22's face sheet dated 09/12/25 indicated Resident #22 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #22 had diagnoses including dementia with anxiety a (a group of thinking disorders that interferes with activities of daily living), protein calorie malnutrition (when not enough protein calories are consumed to meet the body's needs), hypertension (high blood pressure), tremors, and weakness. Record review of Resident #22's Quarterly MDS assessment, dated 06/20/25, reflected Resident #22 was able to sometimes understand others and was sometimes understood by others. Resident #22 had a BIMS score of 7, which indicated her cognition was severely impaired. Resident #22 required supervision and touching with eating, moderate assistance with shower, and maximal assistance with toileting, upper and lower body dressing and personal hygiene. Record review of Resident 22's care plan, dated 09/19/25, reflected Resident #22 had a significant unplanned weight loss. The care plan interventions for Resident #22 were labs as ordered, monitor and record food intake, monitor and report any changes in residents eating habits, notify dietician, physician and family of any weight loss, Red Glass on meal tray to identify the resident and staff as possibly needing assistance, encouragement, and substitutes, weight the resident weekly for at least 4 weeks or until weight is stabilized, and praise resident for eating well. Record review of Resident #22's Order Summary Report indicated Resident #22 had an order for regular diet dated 04/24/25. During an interview on 09/08/25 at 10:25 AM, LVN A was on the secured unit. She stated she was the only one scheduled for the secured unit today. LVN A stated there were 11 residents on the secured unit and one person was not enough. LVN A stated she had to all the residents up and dressed, showered, and ready for breakfast. LVN A stated she was expected to pass all the trays and provide feeding assistance to the residents in their rooms. LVN A stated she was overwhelmed with the care needed for the residents most days and did not even get a bathroom break. LVN A stated she was unable to complete all her assigned duties regularly because of the insufficient staffing. LVN A stated she was unable to provide the residents with adequate supervision because she was unable to supervise the residents when she was providing care in other resident's room. During an observation on 09/08/25 at 10:45 AM, LVN A entered a resident room down the hallway on the secured unit. There were 3 resident's left in the dining room unsupervised. During an observation on 09/08/25 at 11:38 AM, Multiple residents were sitting in the dining room, unsupervised. LVN A was sitting outside the dining room in the hallway, unable to visualize the residents. A resident sitting in the dining room told another resident loudly to LEAVE IT ALONE. LVN A immediate stood up and walked to the dining room entrance to investigate and redirected the residents. During an observation on 09/08/25 at 12:12 PM, The Dietician left the dining room and secured unit. Resident #7, Resident #8, Resident #14 Resident #21, and Resident #22 were left in the dining room, unsupervised, for approximately 15 minutes. During an interview on 09/08/25 at 3:54 PM, the Regional Nurse Consultant stated the facility staff tried to schedule 2 staff members on the secured unit, but they were okay with only staff member on the secured unit. The Regional Nurse consultant stated the staffing needs were based on the census. During an interview on 09/08/25 at 4:22 PM, the ADON stated she had only worked at the facility for about 3 weeks. She stated it had been crazy with staffing. The ADON stated she had to work the floor this weekend and most days since she started at the facility. The ADON stated the facility just got approval to offer sign-on bonus for new applicants and shift-bonus for staff who pick up extra shifts. During an observation on 09/08/25 at 8:50 AM, Resident #21 was sitting in a chair in the hallway. Resident #21 was unsteadily bending over while sitting in the chair trying to put her drink on the ground. LVN A and Medical Records were down the hallway in a resident room. During an interview on 09/09/25 at 3:31 PM, LVN O stated she normally worked Hall C (secured unit) and Hall B. LVN O stated only one person, usually the CNA, was assigned to work the secured unit all shift. LVN O stated the nurse did not remain on the secured unit at all times. LVN O stated one person on the secured unit was not enough to provide adequate supervision. LVN O stated there should have been at least 2 staff members on the secured unit at all times. LVN O stated the residents on the secured unit required a lot of care and redirection. LVN O stated she was aware that CNAs assigned to the secured unit were unable to complete all their assigned tasks, such as showers. LVN O stated did not remember the exact details of every incident that happened on the secured unit. LVN O stated she was the nurse on duty for 6 of the 9 unwitnessed fall incidents. LVN O stated she believed the lack of supervision and insufficient staffing heavily contributed to the unwitnessed fall incidents and resident to resident altercations. LVN O stated lack of supervision and insufficient staffing could lead to injury from unwitnessed incidents and abuse or neglect. During an interview on 09/10/25 at 9:05 AM, CNA N stated she remembered the incident between Resident #12 and Resident #13. CNA N stated she was working on C-Hall and Resident #13 was doing her normal wandering and walking around. Resident #12 had a picture on the table in the dining room and Resident #13 stopped, picked up the photo, and started walking away. CNA N said No, put it back to Resident #13. Resident #13 started to put the photo back on the table, when Resident #12 got up and pushed her. CNA N stated she immediately separated the residents. CNA N stated Resident #13 was not hurt physically but she started crying. CNA N stated she explained to Resident #12 that he could not push other residents. CNA N stated Resident #12 then got up from his seat, started pacing the room, and talked about getting shot in the head. CNA N stated she tried to keep an eye of both of them the best she was able, and she reported the incident to the charge nurse. CNA G stated she was asked to write a statement. CNA N stated that was Resident #12's first or second day at the facility and he was scary. CNA N stated he was more aggressive than any other resident on the secured unit. CNA N said Resident #12 was particular about his space and did not want anyone touching his things. CNA N stated Resident #12 would become angry and upset when he would try to get off the hallway and it was locked. CNA N stated Resident #13 wandered up and down the hallways and would stare out the back windows. CNA N stated Resident #13 did not like to be told to put things back but would just stare at you and eventually say Okay, fine. CNA N stated she would be sassy at times, but she was not aggressive. CNA N stated she was the only staff member on the hallway during the incident. CNA N stated it was normal for her to be the only staff member assigned to the secured unit. CNA N stated it was impossible to complete all her assigned tasks, provide adequate supervision, and complete her documentation. CNA N stated she was unable to be at two places at one time and was unable to see what happening in the dining room or hallway when she was in a resident room. CNA N stated she had to prioritize eating and feeding, so she was unable to complete showers and provide adequate supervision most of the time. CNA N stated she had rush through rounds and was unable to provide the adequate care and services. During an interview on 09/10/25 beginning at 9:22 AM, LVN L stated she was the treatment nurse while employed at the facility, but she also worked as the charge nurse. LVN L stated she was the nurse assigned to C hall (secured unit) during several incidents on the secured unit. LVN L stated the resident to resident altercation on 08/07/25 between Resident #12 and Resident #13 was reported to her by CNA N. LVN L stated she completed the incident report on both residents and there were no injuries. LVN L stated Resident #12's medications were adjusted after the incident as he was new to the facility. LVN L stated she was unaware of any history of aggressive behaviors. LVN L stated Resident #13 was known to wander around the facility and pick up items. LVN L stated there were no further issues after that incident to her knowledge. LVN L stated she was unable to remember the details of the incidents that occurred on the secured unit, but she believed the inadequate supervision and insufficient staffing contributed to the unwitnessed incidents on the secure unit and could have possibly been prevented. LVN L stated usually one staff member was assigned the secured unit and then the nurse floated between the halls. LVN L stated the secured unit was not her only assignment, so she did not stay on the secured unit full time. LVN L stated management staff was aware of the staffing issues and would help occasionally but not most of the time. LVN L stated she felt like she was left without the resources needed to complete her job duties and that was why she was no longer working at the facility. During an interview on 09/10/25 at 10:27 AM, The Social Worker stated she was aware of two resident-to-resident altercations between Resident #12 and Resident #13. The Social Worker stated from her understanding Resident #13 was in Resident #12's personal space. The Social Worker stated if her memories were correct, the first incident had to do with photos. The Social Worker looking back on his stay at the facility, his brother was a trigger for him. The Social Worker stated Resident #12 kept brining up being shot in the head and Resident #13 kept going into his personal space. The Social Worker stated Resident #12 did not have any issues with any other resident on the secured unit. The Social Worker stated on the second incident Resident #12 shoved Resident #13 a little harder and she had some injuries. The Social Worker stated after the second incident he was placed on monitoring and sent to the behavioral hospital. The Social Worker stated once Resident #12 returned from the behavioral hospital, he was sent to a sister facility to be closer with his family. The Social Worker stated Resident #12 had no history of aggression. She said Resident #12 had been living with his father in another facility and when his father passed, he attempted to elope, which was why he needed the secured unit. The Social Worker stated after the first incident his medications were adjusted, he was provided a working television, and snacks. The Social Worker stated that kept Resident #12 happy. The Social Worker stated Resident #13 just liked to wander and ended up in Resident #12's room. During an interview on 09/11/25 at 11:15 AM, The DON stated she had been completing the staffing schedule the last few weeks. The DON stated she tried to schedule 2 nurses, 2 MAs, and 5 CNAs on the day shift. The DON stated she tried to schedule 2 MAs, 2 nurses, and 4 - 5 CNAs. The DON stated MAs worked 8 hour shifts, but the nurses and CNAs worked 12 hour shifts. The DON stated the facility has been unable to schedule what she needs since April 2025, when she started. The DON stated any time someone calls off and she was unable to get it covered, she has to work the floor. The DON stated she has tried to ask sister facilities for help, but she does not always get the help she requested. The DON stated she has received numerous complaints from residents, staff, and families about the care the residents receive and the inability to complete their assigned duties. The DON stated she has spoken with the Administrator, ADO, and Regional Compliance Nurse to let them know she needed help with staffing with no success. The DON stated the corporation has approved sign-on bonuses and extra shift bonuses for existing staff picking up extra shifts. The DON stated it was important to ensure the facility was sufficiently staffed so residents received good quality of care. The DON stated not receiving good quality of care could cause a decline the residents health and well-being. During an interview on 09/11/25 at 1:02 PM, The Administrator stated it was important to ensure the building was sufficiently staffed to ensure the residents were receiving the care they need. The Administrator stated if the residents were not receiving the care they needed it could have been harmful to them. The Administrator stated she had not received any complaints about one staff member being scheduled to the secured unit. The Administrator stated she was having complaints about the night shift on the secured unit and started havi

Based on observations, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 19 of 25 resident's (Resident's #2, #4, #5, #6, #7, #8, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for sufficient staffing. 1. The facility failed to ensure sufficient facility staff were available to assist Resident #5 with positioning during a tube feeding on 08/20/25. Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. 2. The facility failed to ensure sufficient staff were available to provide wound care treatment and documentation for Resident's #2, #16, #17, #18, #19, #20, #23 and #24 during August 2025 and September 2025. 3. The facility failed to ensure the secured unit was adequately staffed to prevent accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. 4. The facility failed to ensure the secured unit was adequately staffed to provide supervision during mealtime for Resident's #7, #8, #14, #21, and #22 on 09/08/25. 5. The facility failed to follow the facility assessment for sufficient nurse staffing. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/13/25 at 12:49 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on abuse and neglect, notification of changes in condition, documentation policy, pain management policy, fall prevention policy, pressure prevention policy, medication administration policy, enteral feeding policy, and the bathing and showers policy. These failures placed residents at risk of inadequate supervision, an unsafe environment, decreased quality of care, increased risk of pressure ulcers, unwitnessed falls, risk for impaired nutrition, serious harm, injury, abuse, and death.The finding included: 1. Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the bodies demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeing related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, [family member] or nurse to assist with feeding. The order started on 08/26/25. Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected Resident #5's family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube [opening from the abdomen directly into the stomach] is not definitely visualized.air distended stomach.left basilar airspace disease [condition in which the lower lungs of the left lung collapse, preventing air exchange], likely atelectasis [collapse of lung or part of lung from lack of air in the air sacs] given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. 2. Record review of Resident #2's face sheet dated 9/11/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnosis including acute posthemorrhagic anemia (is a condition that develops when you lose a large amount of blood quickly), heart failure (is a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pressure ulcer of left heel, stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and usually had the ability to understand others. Resident #2's had a BIMS score of 7 which indicated moderate cognitive impairment. Resident #2 required setup assistance for eating, supervision for oral hygiene, partial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #2 was always incontinent for urine and occasionally incontinent for bowel. Resident #2 had one, stage 3 unhealed pressure ulcers/injuries. Resident #2 had pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2's care plan, revised on 9/11/25, indicated Resident #2 had a pressure ulcer due to decreased mobility. Resident #2 had stage 3 pressure injury to left heel. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and administer medications as ordered. Record review of Resident #2's order summary report dated 9/11/25 indicated: Stage 3 pressure injury, cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Start date 8/25/25. Record review of Resident #2's wound administration record dated 8/1/25-8/31/25 indicated: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Discontinued 8/24/25. Resident #2 did not have documentation for administration on 8/20/25, 8/21/25, 8/23/25, and 8/24/25. Resident #2 was in the hospital 8/3/25-8/13/25. Record review of Resident #2's wound administration record dated 9/1/25-9/30/25 indicated: Stage 3 pressure injury: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time a day for wound healing. Resident #2 did not have documentation for administration on 9/2/25, 9/5/25, 9/6/25, and 9/8/25. 3. Record review of the face sheet, dated 09/11/25, reflected Resident #16 was a [AGE] year-old female who initially admitted to the facility on [DATE] had diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), pressure ulcer of sacral region, stage 4 (wound created from pressure that is characterized by full-thickness skin loss that extends to muscle, tendon, and/or bone), and chronic osteomyelitis (bone infection). Record review of the significant change MDS assessment, dated 08/04/25, reflected Resident #16 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #16 had short-term and long-term memory problems, no memory recall ability, and severely impaired decision making skills. The MDS reflected Resident #16 had upper and lower extremity impairment to both sides that interfered with daily functions. Resident #16 was normally dependent on staff for all ADLs. Resident #16 had two stage 3 pressure ulcers and eight arterial wounds. The MDS reflected Resident #16 had a pressure reducing device for bed, nutrition or hydration interventions, pressure ulcer/injury care, application of non-surgical dressing, and application of dressings to feet. Record review of the comprehensive care plan, last reviewed 09/03/25, reflected the following: Resident #16 had an arterial wound to the right lateral ankle. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound to the right heel. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the left dorsal foot. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the left heel. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound of the right first toe. The interventions included: position and treat the wound per facility protocol. Resident #16 had a stage 3 pressure injury to her right upper back. The interventions included: follow facility protocol for treatment of injury, assist with turning and repositioning every 2 hours and as needed; low air loss mattress. Resident #16 had a stage 3 pressure ulcer to right upper back. The interventions included: Administer treatment and monitor for effectiveness, avoid positioning on injury, float heels, follow facility policies/protocols for prevention and treatment of skin issues, turn and reposition every 2 hours, cushion to wheelchair, bed as flat as possible, and use lifting devices, draw sheet, etc. to reduce friction. Resident #16 had a stage 3 pressure injury to sacrum. The interventions included: follow facility protocol for treatment of injury, assist with turning and repositioning every 2 hours and as needed; low air loss mattress. Resident #16 had an arterial wound to left shin. The interventions included: position and treat the wound per facility protocol. Resident #16 had an arterial wound to right shin. The interventions included: position and treat the wound per facility protocol. Resident #16 had a non-pressure wound to right chest. The interventions included: treat the wound per facility protocol. Record review of Resident #16's order summary report, dated 09/11/25, reflected the following: Arterial wound left heel. Apply skin prep three times a week and as needed until healed, every Monday, Wednesday, and Friday. Start date 08/11/25. Arterial wound of the left calf. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix, every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix, every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the right first toe. Apply skin prep 3 times a week on Monday, Wednesday, and Friday. Start date 09/08/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/06/25. Arterial wound of the right heel. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix 3 times a week and as needed if saturated, soiled, or dislodged. Start date 08/06/25. Arterial wound of the right lateral ankle. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Start date 09/05/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing three times per week and as needed if saturated, soiled, or dislodged every Monday, Wednesday, and Friday. Start date 08/06/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if saturated, soiled, or dislodged. Start date 08/05/25. Stage 3 pressure injury to upper back. Cleanse with normal saline, pat dry, apply calcium alginate, and cover with bordered dressing one time a day. Start date 08/25/25. Record review of Resident #16's wound administration record dated 8/1/25-8/31/25 indicated: Arterial wound left heel. Apply skin prep three times a week and as needed until healed, every Monday, Wednesday, and Friday. Resident #16 did not have documentation of administration on 08/11/25, 08/18/25, 08/20/25, and 08/29/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix once daily and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix once daily and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/06/25 and was missing documentation of administration for 08/05/25 and 08/06/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 09/05/25. Resident #16 was missing documentation of administration on 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged one time a day for wound healing. The order was stopped on 08/04/25 and was missing documentation of administration for 08/02/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply calcium alginate, wrap with kerlix every day and as needed if soiled or dislodged one time a day for wound healing. The order was stopped on 08/06/25 and was missing documentation of administration for 08/06/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing tree times per week and as needed if saturated, soiled, or dislodged one time a day every Monday, Wednesday, and Friday for wound healing. Resident #16 was missing documentation for 08/06/25, 08/11/25, 08/18/25, 08/20/25, and 08/29/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged one time a day for wound healing. Resident #16 was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, and 08/29/25. Pressure wound to upper back. Apply calcium alginate to wound bed and dry dressing one time a day for promote wound healing. The order was stopped on 08/24/25 and was missing documentation of administration for 08/09/25, 08/10/25, 08/11/25, 08/14/15, 8/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/21/25, 08/24/25, and 08/29/25. Stage 3 pressure injury to right upper back. Cleanse with normal saline, pat dry, apply Medi honey, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged, one time a day for wound healing. The order was stopped on 08/12/25 and was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, and 08/11/25. Stage 3 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every day and as needed if dressing is saturated, soiled or dislodged, one time a day for wound healing. The order was stopped on 08/28/25. Resident #16 was missing documentation of administration for 08/02/25, 08/05/25, 08/06/25, 08/09/25, 08/10/25, 08/11/25, 8/14/15, 8/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, and 08/21/25. Record review of Resident #16's wound administration record dated 9/1/25-9/30/25 indicated: Arterial wound of the left heel. Apply skin prep 3 times a week and as needed until healed one time a day every Monday, Wednesday, and Friday for promote wound healing. Resident #16 had missing documentation of administration for 09/03/25, 09/05/25, and 09/08/25. Arterial wound of the left calf. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Resident #16 had missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged for wound healing. The order was stopped on 09/05/25 and was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the left dorsal foot. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled or dislodged for wound healing. Resident #16 was missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. The order was stopped on 09/05/25 and was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the left shin. Cleanse with normal saline, pat dry, apply xeroform to wound bed, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. Resident #16 was missing documentation of administration for 09/08/25 and 09/09/25. Arterial wound of the right first toe. Apply skin prep three times a week on day shift on Monday, Wednesday, and Friday. Resident #16 was missing documentation of administration for 09/08/25. Arterial wound of the right foot. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. There was missing documentation of administration on 09/08/25 and 09/09/25. Arterial wound of the right heel. Cleanse with normal saline, pat dry, apply skin prep, wrap with kerlix three times a week and as needed is saturated, soiled, or dislodged one time a day every Monday, Wednesday, and Friday for wound healing. There was missing documentation of administration for 09/03/25 and 09/08/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. The order was stopped on 09/05/25 and there was missing documentation of administration for 09/02/25, 09/03/25, and 09/05/25. Arterial wound of the right lateral ankle. Cleanse wound with normal saline, pat dry, apply Medi honey to wound bed, apply alginate calcium, wrap with kerlix every day and as needed if saturated, soiled, or dislodged. There was missing documentation for 09/08/25 and 09/09/25. Arterial wound of the right shin. Cleanse with normal saline, pat dry, apply xeroform gauze, cover with dry border dressing three times per week and as needed if saturated, soiled, or dislodged. There was missing documentation of administration for 09/03/25 and 09/08/25. Non-pressure injury of the right chest. Cleanse with normal saline, pat dry, apply alginate calcium, cover with dry dressing every day and as needed if dressing is saturated, soiled, or dislodged for wound healing. There was missing documentation of administration for 09/02/25, 09/03/25, 09/08/25, and 09/09/25. Stage 3 pressure injury to upper back. Cleanse with normal saline, pat dry, apply alginate calcium, cover with bordered dressing one time a day for promote wound healing. There was missing documentation of administration for 09/02/25, 09/03/25, 09/08/25, and 09/09/25. 4. Record review of the face sheet, dated 09/11/25, reflected Resident #17 was an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills) and pressure ulcer of the sacral region, stage 4 (wound created from pressure that is characterized by full-thickness skin loss that extends to muscle, tendon, and/or bone). Record review of the significant change MDS assessment, dated 08/22/25, reflected Resident #17 had clear speech, was usually understood, and was usually able to understand others. Resident #17 had short-term and long-term memory problems, no recall ability, and severely impaired decision making skills. The MDS reflected Resident #17 had upper and lower extremity impairment to both sides that interfered with daily function. Resident #17 required total dependence with most ADLs. The MDS reflected Resident #17 had a stage 4 pressure ulcer. Resident #17 had a pressure reducing device for the bed and applications of nonsurgical dressings. Record review of the comprehensive care plan, last reviewed on 09/04/25, reflected Resident #17 had a stage 4 pressure injury to her sacrum. The interventions included: treatment as ordered and monitor effectiveness, turn and reposition every 2 hours, and air mattress. Record review of Resident #17's order summary report, dated 09/11/25, reflected the following: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. Start date of 07/25/25. Record review of Resident #17's wound administration record dated 8/1/25-8/31/25 indicated: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/15/25, 08/16,25, 08/17/25, 08/20/25, 08/21/25, and 08/24/25. Record review of Resident #17's wound administration record dated 9/1/25-9/30/25 indicated: Stage 4 pressure injury to sacrum. Cleanse with normal saline, pat dry, apply collagen powder, apply calcium alginate, cover with dry border dressing daily and as needed if soiled or dislodged. There was missing documentation of administration for 09/02/25, 09/05/25, 09/06/25, and 09/08/25. 5. Record review of the face sheet, dated 09/12/25, reflected Resident #18 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of brain bleed, peripheral vascular disease (refers to any disease or disorder of the circulatory system outside of the brain and heart), stroke, and a history of colon, lung, and testicular cancer. Record review of the significant change MDS assessment, dated 07/16/25, reflected Resident #18 had clear speech, was understood, and was able to understand others. Resident #18 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #18 had an upper extremity impairment to one side and a lower extremity impairment to both sides that interfered with daily function. The MDS reflected Resident #18 required total dependence with showers, toileting, and personal hygiene. Resident #18 required set-up help with eating and oral hygiene. Resident #18 required substantial/maximum assistance with dressing, bed mobility, and transfers. The MDS assessment reflected Resident #18 had a stage 4 pressure ulcer. Resident #18 had a pressure reducing device for bed and received pressure ulcer/injury care. Record review of the comprehensive care plan, last reviewed 07/14/25, reflected Resident #18 had a stage 4 pressure injury to right heel. The interventions included: treatment per orders and monitor for effectiveness, turn and reposition every 2 hours, and encourage the use of podus boot. Record review of Resident #18's order summary report, dated 09/12/25, reflected the following: Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgement to promote wound healing. Start date of 06/18/25. Record review of Resident #18's wound administration record dated 8/1/25-8/31/25 indicated: Apply collagen powder to wound bed, cover with calcium alginate and dry dressing one time a day for promote wound healing. The order was stopped on 09/07/25. There was missing documentation of administration for 08/12/25, 08/14/25, 08/16/25, 08/20/25, 08/21/25, 08/23/25, and 08/25/25. Dakin's (1/4 strength) external solution 0.125% (sodium hypochlorite) - apply to right heel topically once time a day for apply Dakin's soaked gauze to wound bed. The order was stopped on 09/07/25. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Lymphedemic wound to left heel. Apply skin prep daily one time a day for promote wound healing. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgment. There was missing documentation of administration for 08/06/25, 08/07/25, 08/12/25, 08/16/25, 08/20/25, 08/21/25, and 08/24/25. Record review of Resident #18's wound administration record dated 9/1/25-9/30/25 indicated: Apply collagen powder to wound bed, cover with calcium alginate and dry dressing one time a day for promote wound healing. The order was stopped on 09/07/25. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Dakin's (1/4 strength) external solution 0.125% (sodium hypochlorite) - apply to right heel topically one time a day for apply Daikin's soaked gauze to wound bed. The order was stopped on 09/07/25. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Lymphedemic wound to left heel. Apply skin prep daily one time a day for promote wound healing. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. Stage 4 pressure ulcer to right heel. Cleanse with normal saline, pat dry, apply collagen to wound bed, apply calcium alginate, and cover with dry dressing and wrap with kerlix daily and as needed related to soiling/dislodgement. There was missing documentation of administration for 09/02/25, 09/05/25, and 09/06/25. 6. Record review of the face sheet, dated 09/12/25, reflected Resident #19 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities). Record review of the significant change MDS assessment, dated 08/06/25, reflected Resident #19 had unclear speech, was sometimes understood, and was sometimes able to understand others. Resident #19 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #19 had a lower extremity impairment to both sides which interfered with daily function. Resident #19 was totally dependent on staff for ADLs, which included eating. The MDS reflected Resident #19 had a fall within the last month prior to admission. Resident #19 was checked for signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals. Resident #19 required a mechanically altered diet while a resident of the facility. The MDS reflected Resident #19 was at risk for developing pressure ulcers/injuries. Resident #19 had a pressure reducing device for the bed. Record review of Resident #19's comprehensive care plan, last reviewed 09/09/25, reflected the following: Resident #19 had an ADL self-care performance deficit and required staff assistance x 1 with eating and was resistive to eating at times. Resident #19 had a history of falls and the interventions included: fall mat beside bed, appropriate footwear, call light in reach, anticipate needs, and staff assistance x 2 with transfers. Resident #19 had a stage 2 pressure ulcer to her right buttocks. The interventions included: treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of pressure injuries. Record review of Resident #19's order summary report, dated 09/12/25, reflected the following: Regular diet with pureed texture, and regular c

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #5) reviewed for enteral nutrition. During a tube feeding on 08/20/25, Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. While the IJ was removed on 09/12/25 at 4:40 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy with the potential for more than minimal harm because all staff had not been provided education on abuse and neglect, notification of changes in condition, and enteral feeding tube management. This failure could place residents with gastrostomy tube at risk for complications from feeding tube administration such as aspiration and pneumonia, serious injury, harm, impairment, and death. The findings included: Record review of the face sheet, dated 09/11/25, reflected Resident #5 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), severe protein-calorie malnutrition (not getting enough protein or calories to meet the body's demands), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anorexia (loss of appetite), and dysphagia (difficulty swallowing). Record review of the quarterly MDS assessment, dated 07/30/25, reflected Resident #5 had unclear speech, was rarely/never understood, and was rarely/never able to understand others. Resident #5 had short-term and long-term memory problems. Resident #5 had no memory or recall ability and had severely impaired decision making skills. The MDS reflected Resident #5 had upper and lower extremity impairments to both sides which interfered with daily functions. The MDS reflected Resident #5 was dependent on staff for all his ADLs. Resident #5 used a feeding tube while a resident and also received a mechanically altered diet. The MDS reflected Resident #5 received 51% of more of his total calories through tube feeding. Record review of the comprehensive care plan, last reviewed 06/17/25, reflected Resident #5 required tube feeding related to anorexia and Alzheimer's disease. The interventions included: .the resident needs the head of bed elevated 30 degrees during and thirty minutes after tube feeding. The care plan further reflected Resident #5 had an ADL self-care deficit and required staff assistance x 1 with eating. Record review of the order summary report, dated 09/11/25, reflected Resident #5 had an order for regular diet and pureed texture with pudding consistency fluids, family member or nurse to assist with feeding. The order started on 08/26/25. During an observation of a video date and time stamped, 08/20/25 3:13 PM, revealed Resident #5 leaning over the left armrest of his Geri-chair. He was moaning and grunting, unable to lift his torso or head. At 3:16 PM, CNA G walks into the room, pulls his arm and ask him to sit up, and then walked out of the room. The interaction last approximately 45 seconds. Resident #5 returned to the same position within approximately 30 seconds after CNA G left the room. Resident #5 remained in the same position, where his head and torso were leaning over the left armrest for approximately 1 hour and 30 minutes. Resident #5 constantly moans and grunts during the video until LVN L sets up him with pillows and positioned him comfortably at 4:26 PM Record review of the progress notes reflected the following: On 08/21/25 at 4:03 AM, the note reflected Resident #5's family member requested a chest x-ray due to possible aspiration . due to positioning of resident in chair on previous shift.No signs or symptoms of aspiration [entry of solid or liquid material such as secretions, food, drink, or stomach contents from the mouth or stomach into the lungs] noted . head of bed elevated to 30 degrees. On 08/21/25 at 7:47 AM, the note reflected a response was received from the physician for a chest x-ray. On 08/22/25 at 3:29 AM, the note reflected Resident #5 was transferred to the hospital related to chest x-ray results findings indicated aspiration. Record review of Resident #5's diagnostic chest x-ray report, dated 08/21/25, reflected .reported gastrostomy tube [opening from the abdomen directly into the stomach] is not definitely visualized.air distended stomach.left basilar airspace disease [condition in which the lower lungs of the left lung collapse, preventing air exchange], likely atelectasis [collapse of lung or part of lung from lack of air in the air sacs] given elevation of the hemidiaphragm. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. During an interview on 09/09/25 beginning at 2:38 PM, Resident #5's family member stated on 08/20/25 she had gone out to eat and did not watch the camera as she normally did. Resident #5's family member stated when she got home, she noticed a neck pillow was blocking the view of the camera, so she called the facility. Resident #5's family member stated she went back to review the video prior to the pillow blocking camera and noticed he had been leaning over his chair for about 2 hours. Resident #5's family member was concerned he may have aspirated so she requested a chest x-ray be performed. Resident #5's family member stated the chest x-ray showed aspiration pneumonia, and he was sent to the hospital. Resident #5's family member stated he was returned to the facility on antibiotics. Resident #5's family member stated the facility staff did not have enough help. Resident #5's family member stated she believed the incident would not have occurred if the facility had sufficient staffing because they would have been able to check on him more frequently. During an interview on 09/09/25 beginning at 10:55 AM, LVN M stated Resident #5's family member had requested that he go to the hospital because she was concerned about something that had occurred on the camera, and she believed he could have possibly aspirated. LVN M stated she notified the physician, and he was agreeable, so she sent Resident #5 to the hospital per the family member's request. LVN M stated Resident #5 had no signs or symptoms of aspiration, such as nasal drainage, shortness of breath, or wheezing. LVN M stated the facility had obtained the order for a chest x-ray, but it had not been completed before he was sent to the hospital, if she remembered correctly. LVN M stated Resident #5 did not return back from the hospital on her shift, so she was unaware of what he was treated for at the hospital. During an interview on 09/09/25 beginning at 11:50 AM, CNA G stated on 08/20/25 she was on the way to answer another resident's call light when she walked by Resident #5's room and noticed he was leaning over. CNA G stated she grabbed Resident #5 under the arm and elbow to sit him up. CNA G stated she sat Resident #5 up the best she could then proceeded to answer the call light. CNA G stated she was the only staff member assigned to her hallway and stated she never thought to check on him again because she had so much going through her mind. CNA G stated she was called later on to provide a statement of the incident. CNA G said she had just graduated CNA school about 4 months ago and was still learning things. CNA G stated grabbing someone by the arm was not the proper way to position them. CNA G stated the facility did provide her one-on-one education on proper positioning. CNA G stated looking back now she should have checked on Resident #5 sooner, but it was hard to recognize in the moment because of the staffing concerns. CNA G stated Resident #5 should have been positioned in a Fowler's position (upright) during a tube feeding. CNA G stated improperly positioning a resident during a tube feeding could result in aspiration. CNA G stated there were staffing concerns at the facility because no one wanted to work. CNA G stated the facility staff did not like the management staff. CNA G stated she had only worked at the facility since June 2025. CNA G stated at times she was the only CNA who was assigned to two halls, which was approximately 25 residents. CNA G stated she was unable to provide the care and services each resident required when she was scheduled alone. CNA G stated she felt rushed with the residents. CNA G stated management staff were aware of the staffing concerns but felt like nothing was addressed. CNA G stated management did not consistently help out on the floor. CNA G stated the DON would provide assistance to one resident because of the camera in the room, but most of the time when she asked for help the DON would say Let me find someone to help you. CNA G stated she normally works C-Hall (the secured unit) and is the only staff member scheduled. During an interview on 09/10/25 beginning at 9:22 AM, LVN L stated on 08/20/25 she was acting as charge nurse. LVN L stated she was on the secured unit completing the medication pass and providing care as there was no CNA assigned to the secured unit. LVN L stated a little while later, she had someone relieve her on the secured unit and she was walking down B Hall when she noticed Resident #5 was slumped over. LVN L stated Resident #5 was repositioned and placed in the bed. LVN L stated CNA G had not reported he had been improperly positioned or slumped over. LVN L stated Resident #5 had a runny nose and snot was coming out of his nose. LVN L stated Resident #5's shirt was changed because the snot had made his shirt wet. LVN L stated Resident #5 had a slight runny nose after the incident but was not acting abnormal. LVN L stated Resident #5 had no signs or symptoms of respiratory distress. LVN L stated being improperly positioned during a tube feeding could have caused aspiration pneumonia. LVN L stated she expected the CNAs to notify her if they needed help. LVN L stated she believed if the facility was adequately staffed, this incident would not have occurred. During an interview on 09/11/25 beginning at 1:02 PM, The Administrator stated the charge nurse was responsible for monitoring to ensure residents who required a tube feeding were positioned properly. The Administrator stated the ADON was responsible for educating and overseeing the nurses and CNAs. The Administrator stated she was at a training on 08/20/25 when Resident #5 was left improperly positioned during a tube feeding. The Administrator stated the DON called her and explained what happened. The Administrator stated she was able to review the incident and the video that was obtained the next day. The Administrator stated in the video Resident #5 laid slumped over in his chair for approximately an hour and half. The Administrator stated she completed the self-report to HHSC and started 30 minute monitoring for Resident #5. The Administrator stated if any issues with positioning were observed, he was repositioned. The Administrator stated the DON provided 1:1 education with CNA G regarding proper positioning. The Administrator stated it was important to ensure residents were properly positioned during tube feedings to prevent aspiration. Record review of the Enteral Nutrition policy, undated, reflected .problems with the administration of the tube feeding are monitored and corrected by nursing. The policy did not address positioning. The Administrator was notified on 09/11/25 at 1:59 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 09/11/25 at 2:01 PM. The following plan of removal was submitted by the facility and accepted on 09/12/25 at 12:05 PM and included the following: Interventions:1. Resident #5 was assessed for proper positioning and signs of aspiration. No signs of a change in condition noted to any residents. Completed 9/11/25. 2. All residents on enteral feeds in the facility were assessed for proper positioning and signs of aspiration. All enteral feedings are in place according to orders. No additional changes in condition were noted that required notification to the MD. Charge Nurses, CNAs, and Med Aides will be responsible for monitoring the positioning of residents on enteral feedings throughout the shift at a minimum of every two hours. Clinical leadership will verify proper positioning of residents on enteral feedings during clinical rounds daily throughout the day. Clinical rounds will be documented on a monitoring tool. Completed 9/11/25. 3. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations.b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents.c. Enteral Feeding Policy to include adequate positioning- HOB elevated to prevent the risk of aspiration. If a resident is not positioned with the HOB elevated during enteral feedings, the charge nurse will be notified immediately. This in-service includes the signs and symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. 4. The medical director was notified of the immediate jeopardy citation by the administrator on 9/11/25. 5. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/11/25. In-services:1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 9/11/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 9/11/25.a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations.b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents.c. Enteral Feeding Policy to include adequate positioning- HOB elevated to prevent the risk of aspiration. If a resident is not positioned with the HOB elevated during enteral feedings, the charge nurse will be notified immediately. This in-service includes the signs and symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. On 09/12/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of the inpatient hospital record, dated 08/22/25, reflected Resident #5 arrived at the hospital at 4:04 AM via ambulance and was discharged back to the facility at 5:46 AM. The problems addressed was aspiration into airway, initial encounter. 2. Record review of Resident #5 Resident #16, Resident #20's progress notes, reflected an assessment was completed on 09/11/25 of the feeding tubes and no issues or concerns were identified. 3. During an observation on 09/12/25 at 12:33 PM, Resident #5 was positioned in semi-Fowlers (30 - 45-degree angle) position. No issues or concerns with feeding. No signs or symptoms of aspiration were observed. 4. During an observation on 09/12/25 at 12:34 PM, Resident #16 was positioned in semi-Fowlers position with sitter at bedside. No issues or concerns with feeding. No signs or symptoms of aspiration were observed. 5. During an observation on 09/12/25 at 12:35 PM, Resident #20 was positioned in semi-Fowlers position. No issues or concerns with feeding. No signs or symptoms of aspiration was observed. 6. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service training on abuse and neglect which included the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. It also included the abuse policy and procedure. 7. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. 8. Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on the enteral nutrition policy and procedure, which included: adequate positioning with the head of the bed elevated to prevent the risk of aspiration, notification of the charge nurse if a resident was improperly positioned, and signs or symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. 9. During an interview on 09/12/25 at 3:08 PM, the Medical Director stated he was notified of the immediate jeopardy situations at the facility. He said he was notified by the Regional Compliance Nurse on 09/11/25 and it was discussed with plans being implemented. 10. During an interview on 09/12/25 at 4:05 PM, the DON stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The DON stated that failure to provide care and services such as showers, wound treatments, adequate supervision, changing clothing, providing assistance with eating, and improper positioning with enteral feeding was considered neglect. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The DON stated a change in condition should be reported immediately. The DON stated the physician should be notified and an assessment completed. Enteral feeding policy to include adequate positioning. The DON stated residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The DON stated residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. The DON stated signs or symptoms of aspiration included: coughing, drooling, or wheezing. 11. During an interview on 09/12/25 at 4:14 PM, the Administrator stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The Administrator stated that failure to provide care and services such as showers, wound treatments, adequate supervision, changing clothing, providing assistance with eating, and improper positioning with enteral feeding was considered neglect. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The Administrator stated a change in condition should be reported immediately. The Administrator stated the physician should be notified and an assessment completed. Enteral feeding policy to include adequate positioning. The Administrator stated residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The Administrator stated residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. The Administrator stated signs or symptoms of aspiration included: coughing, drooling, or wheezing. 12. During an interview on 09/12/25 at 4:26 PM, the Regional Compliance Nurse stated she provided all the 1:1 in-service education for the DON and Administrator. 13. Record review of the AD HOC QAPI meeting dated 09/11/25, reflected 12 members were in attendance. 14. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to all staff on the abuse and neglect policy and procedure to include the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. There were 36 staff signatures. 15. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to all staff on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. There were 36 staff signatures. 16. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to direct care staff on the enteral nutrition policy and procedure, which included: adequate positioning with the head of the bed elevated to prevent the risk of aspiration, notification of the charge nurse if a resident was improperly positioned, and signs or symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. There were 22 staff signatures. 17. During interviews between 09/12/25 and 09/13/25, staff from all departments and all shifts to include: the AD, Medical Records, MDS Coordinator QQ, MDS Coordinator RR, [NAME] HH, [NAME] KK, [NAME] MM, Dietary LL, Dietary NN, DM, Housekeeper OO, Housekeeping Supervisor PP, RN P, RN T, LVN A, LVN M, LVN Q, MA B, MA Z, MA UU, CNA C, CNA G, CNA V, CNA SS, CNA TT, Speech Therapist VV, Director of Rehabilitation WW, COTA XX, COTA ZZ, and PTA YY were provided in-service education and were able to verbalize the following: Abuse and Neglect to include the types of abuse and examples of each. The staff were able to give examples of neglect which included: failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. The staff reported the Administrator was the abuse coordinator and any type of abuse should be reported immediately. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The staff were able to verbalize a change of condition should be reported to the charge nurse immediately. The charge nurses were able to verbalize the appropriate assessments and notifications of the physician and family during a change of condition. Enteral feeding policy to include adequate positioning. The facility staff reported residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses. The staff were able to verbalize residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. Staff reported if they noticed any residents were positioned improperly the charge nurse would be notified. The staff were able to verbalize the signs or symptoms of aspiration, which included: coughing, drooling, or wheezing. The Administrator was informed the IJ was removed on 09/12/25 at 4:40 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 residents (Resident #6) reviewed for quality of care.The facility failed to notify the physician when Resident #6 experienced low blood pressure, low heart rate and/or low blood pressure with an increased heart rate on 7/16/25, 7/18/25, 7/20/25, 7/21/25, 7/23/25, 7/25/25, 7/26/25, 7/27/25, 7/28/25,7/29/25, 7/30/25, and 8/1/25. On 8/1/25, Resident #6 had low hemoglobin 5.8 and low hematocrit 21.6. Resident #6 was sent to the ER due to critical lab values. Resident #6 was admitted and diagnosed with gastrointestinal hemorrhage. Resident #6 received a blood transfusion at the hospital. An Immediate Jeopardy (IJ) was identified on 9/11/25. The IJ Template was provided to the facility on 9/11/25 at 2:01 p.m. While the IJ was removed on 9/12/25 at 4:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to complete training in-services with all staff and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a decline in condition, delay in life-saving treatments, hospitalization, serious harm, and death. Findings included: Record review of Resident #6's face sheet dated 9/8/25 indicated Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including Dementia (is a general term describing a group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and judgment, which interfere with daily life), gastrointestinal hemorrhage (is when there is blood loss from any of the several organs included in your digestive system), iron deficiency anemia (is a common blood disorder that affects your red blood cells) secondary to blood loss (chronic), hypertension (is when the pressure in your blood vessels is too high (140/90 mmHg or higher)), and acute embolism and thrombosis of deep veins of right lower extremity (is a condition where a blood clot forms in a deep vein, often in the leg). Resident #6's most recent hospital stay was 8/1/25-8/5/25. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had a BIMS score of 2 which indicated severe cognitive impairment. Resident #6 required supervision for eating, substantial assistance for oral and personal hygiene, and dependent for toileting hygiene, shower/bathe self and dressing. Resident #6 was on an anticoagulant (is a medical treatment that prevents blood clots from forming). Record review of Resident #6's care plan dated 3/5/25 indicated: *Resident #6 was on an anticoagulant therapy. Intervention included monitor/document/report to MD signs/symptoms of anticoagulant complications such as lethargy, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. *Resident #6 had a diagnosis of hypertension. Intervention included give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (is a condition where blood pressure drops significantly upon standing up from a sitting or lying position) and increased heart rate and effectiveness. Record review of Resident #6's order summary dated 8/1/25 indicated: *Eliquis (anticoagulant) Oral Tablet 5 MG, give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right lower extremity. Start date 3/4/25. *Lisinopril (antihypertensive; treats high blood pressure) Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure (is the pressure when your heart beats to pump blood around your body) below 100, diastolic blood pressure (measures the pressure on blood vessel walls when your heart is relaxed between contractions) below 55 or heart rate less than 50. Start date 3/5/25. *Metoprolol Tartrate (antihypertensive; treats high blood pressure) Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Start date 3/5/25. Record review of Resident #6's medication administration record dated 7/1/25-7/31/25 indicated: *Eliquis (anticoagulant) Oral Tablet 5 MG, give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right lower extremity. Resident #6 received 61 out of 62 doses. *Lisinopril (antihypertensive; treats high blood pressure) Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. *Metoprolol Tartrate (antihypertensive; treats high blood pressure) Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. Resident #6's MAR indicated PM 7/18/25 (BP: 110/62, HR: 84) MA AA, 7/20/25 (BP: 115/76, HR: 60) MA AA, 7/21/25 (BP: 98/63, HR 79) MA X, 7/25/25 (BP: 90/70, HR: 100) MA X, 7/27/25 (BP: 90/41, HR: 116); Vitals Outside of Parameters, 7/29/25 (BP: 100/55, HR: 95) MA BB, 7/30/25 (Vitals Outside of Parameters) *Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Discontinued on 7/30/25. Resident #6's MAR indicated 7/16/25 (BP: 118/63, HR: 98) MA B, 7/18/25 (BP: 90/65, HR: 88) MA X; Vitals Outside of Parameters, 7/20/25 (BP: 96/56, HR: 56) MA Y, 7/21/25 (BP: 110/66, HR: 105) MA B, 7/23/25 (Hold see nurse notes) MA B, 7/25/25 (BP: 108/74, HR: 108) MA B, 7/26/25-7/28/25 (Hold see nurse notes) MA B, 7/29/25 (BP: 119/60, HR: 98) MA Z, and 7/30/25 (BP: 110/67, HR: 88) MA Z. Record review of Resident #6's MAR dated 8/1/25-8/31/25 indicated: *Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 8/1/25 (BP: 115/85, HR: 123) MA AA. *Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6's MAR indicated (AM) 8/1/25 (BP: 115/85, HR: 123) MA AA. Record review of Resident #6's progress notes dated 7/1/25-9/8/25 indicated: *7/23/25 at 12:44 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 127/51. *7/23/25 at 12:45 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/26/25 at 1:15 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/26/25 at 1:15 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 96/53 HR 101. *7/26/25 at 1:16 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/27/25 at 12:55 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 BP low 95/72 HR 58. *7/27/25 at 12:55 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/27/25 at 12:56 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 BP low. *7/28/25 at 12:48 p.m. by MA B: Amlodipine Besylate Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 110, diastolic blood pressure below 60 or heart rate less than 55. Resident #6 diastolic BP low 115/52 HR 101. *7/28/25 at 12:49 p.m. by MA B: Lisinopril Oral Tablet 5 MG, give 1 tablet by mouth one time a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 diastolic BP low 115/52 HR 101. *7/28/25 at 12:50 p.m. by MA B: Metoprolol Tartrate Oral Tablet 50 MG, give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure below 100, diastolic blood pressure below 55 or heart rate less than 50. Resident #6 diastolic BP low. *7/30/25 at 6:00 a.m. by LVN O: Neuro assessment BP 98/48, Pulse 93. Resident #6 had an unwitnessed fall in his room. *7/30/25 at 6:30 a.m. by LVN O: [NAME] assessment BP 87/45, Pulse 80. *7/30/25 at 6:45 a.m. by LVN O: [NAME] assessment BP 110/67, Pulse 88. *7/30/25 at 7:15 a.m. by LVN O: [NAME] assessment BP 100/56, Pulse 60. *7/30/25 at 7:45 a.m. by LVN O: [NAME] assessment BP 98/52, Pulse 87. *7/30/25 at 8:45 a.m. by LVN O: [NAME] assessment BP 92/59, Pulse 95. *7/30/25 at 9:45 a.m. by LVN O: [NAME] assessment BP 114/62, Pulse 82. *7/30/25 at 10:24 a.m. by LVN O: Notified MD K of family's concerns about the resident [Resident #6] being drowsy so much of the time. *7/30/25 at 11:45 a.m. by LVN O: [NAME] assessment BP 98/58, Pulse 82. *7/30/25 at 1:11 p.m. by LVN O: New order received from MD K to stop Amlodipine, Mirtazapine and Marinol. To get CBC (is a blood test that measures the number and types of various cells in the blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets), CMP (is a blood test that measures multiple substances in the body to assess overall health and identify potential medical conditions), and ammonia (measures the amount of ammonia in the blood) in AM. *7/30/25 at 1:45 p.m. by LVN O: Neuro assessment BP 94/54, Pulse 79. *7/30/25 at 9:45 p.m. by RN T: Neuro assessment BP 88/65, Pulse 71. *7/31/25 at 5:44 a.m. by RN T: Neuro assessment BP 108/64, Pulse 69. *7/31/25 at 1:08 p.m. by LVN L: When resident [Resident #6] was gotten up this morning his BP dropped to 75/62 and HR was 100. Resident #6 was laid back down and his BP and HR returned to normal. MD K notified and said to monitor. *7/31/25 at 7:20 p.m. by RN T: Neuro assessment BP 96/64, Pulse 76. *8/1/25 at 3:31 a.m. by RN T: Neuro assessment BP 93/56, Pulse 76. *8/1/25 at 11:18 a.m. by LVN L: Dr. lab called with critical labs. WBC 15.33 (The normal white blood cell count ranges between 4,000 and 11,000 cells per microliter), Hemoglobin (is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues; The normal Hb level for males is 14 to 18 g/dl (grams per deciliter)) 5.8, Hematocrit (is a blood test that measures the amount (percent) of your blood that is made up of red blood cells; The normal hematocrit for men is 40 to 54%) 21.6. *8/1/25 at 11:21 a.m. by LVN L: MD K notified about labs, no new orders. *8/1/25 at 5:08 p.m. by LVN L: Notified MD K of critical labs and he [MD K] recommended that we send him out to the hospital.Resident #6's progress note did not reflect any documented SBARs. Record review of Resident #6's hospital records dated 8/1/25 indicated, .brought in from nursing home after found to have some abnormal labs. he [Resident #6] does appear to be severely anemic with hemoglobin of 5.8.due to his anemia, a stool occult blood was checked in the ER which was positive though he [Resident #6] has not had an actual visible GI bleeding.impression.gastrointestinal hemorrhage. plan. transfuse PRBCs (packed red blood cells). Record review of Resident #6's hospital Discharge summary dated [DATE] indicated, .chief complaint.severe anemia. final diagnoses. iron deficiency anemia due to blood loss. gastrointestinal hemorrhage.hospital course.he [Resident #6] has been noted to be more fatigued recently, and blood work revealed severe anemia.he was found to be profoundly anemic initially with a hemoglobin of 5.8, and elevated creatinine 2.5.he received IV fluids and blood transfusion.he [Resident #6] was guaiac positive (a test result indicating the presence of occult (hidden) blood in the stool), and Gastroenterology (is the medical specialty that studies and treats diseases of the digestive system) was consulted.the plan was for the patient to undergo EGD (is a medical procedure used to examine the lining of the esophagus, stomach, and upper part of the small intestine (duodenum)) and colonoscopy (is an examination of the inside of your large intestine (colon)) yesterday, but he had episode of severe epistaxis (nosebleed), and it was felt the patient will not be able to tolerate an NG (nasogastric) tube.for the pre-op medication. On 9/9/25 at 9:40 a.m., attempted to contact MA Y by phone. Contact was unsuccessful. Unable to leave a message because the subscriber was not accepting calls. During an interview on 9/9/25 at 9:46 a.m., MA B said that she got the residents' vital signs for blood pressure medication. She said if the residents' vital signs were out of the parameters, she documented in the facility's charting system and held the medication. She said when she documented the medication was held due to the vital signs being out of range, it notified the charge nurse. She said the charge nurse received a notification in the facility's charting system. She said the held documentation, on the residents' MAR, flowed over to the progress notes. She said she also verbally notified the charge nurse when she held a blood pressure medication due to the vital signs being out of range. She said if she held a blood pressure medication on Resident #6, she probably reported to the charge nurse. She said if a resident had a low blood pressure (It is typically defined as a systolic pressure (the top number) below 90 mmHg and/or a diastolic pressure (the bottom number) below 60 mmHg) and high heart rate, it could mean the resident was in atrial fibrillation (is an irregular and often very rapid heart rhythm) or distress. She said it was important to notify the MDs if a blood pressure medication was held due to vital signs being out of range so they could make medication adjustments. On 9/9/25 at 10:27 a.m., attempted to contact LVN O by phone. Contact was unsuccessful and a message was left with callback phone number. During an interview on 9/9/25 at 11:37 a.m., the DON said the MAs were responsible for notifying the charge nurses when a blood pressure medication was held due to vital signs being outside of the parameters. She said the charges nurses were responsible for notifying the MD. She said the MD should be notified every time the blood pressure medication was held. She said the charges nurses documented in the residents' progress notes when they contacted the MD. She said if a resident had a low blood pressure and increased heart rate, it could indicate sepsis, dehydration, infection, and volume loss. She said the signs and symptoms of a GI bleed were low blood pressure, nosebleed, vomiting of blood, and tarry stools. She said when a resident's hemoglobin was low, they could experience low blood pressure, drowsiness, and fatigue. She said the ADON and DON should monitor this process by following up on vital sign alerts from the facility's charting system. She said she was not aware Resident #6 had several days of missed blood pressure medication and vital signs out of the parameters. During an interview on 9/9/25 at 2:52 p.m., RN P said the MAs were supposed to report to the charge nurses when a residents' vital signs were out of the parameters. She said the charge nurse should recheck the residents' vital signs. She said if the residents' vital signs were still out of range, then the charge nurse should notify the MD and family and do a SBAR. She said the facility's charting system did not notify the charge nurses when a medication was held due to vital signs being out of the parameters. She said if a resident had lower blood pressures it could indicate cardiac arrest and shock. She said the resident could need the emergency room. She said the charge nurses documented in a progress note when the physician was notified. She said it was important for the physician to be notified to receive orders. During an interview on 9/9/25 at 3:16 p.m., MD K said he could not recall what was reported to him on 7/31/25 in relation to Resident #6. He said he did not know if he would have changed his orders to only monitor Resident #6 if he knew about the other blood pressure and heart rate issues. He said he would have needed more information. He said he would have wanted to be notified of Resident #6's low blood pressures with lower (is a condition where the heart beats at a rate below 60 beats per minute (bpm) while resting) and higher heart rates (is a condition where the heart beats faster than normal, typically at a rate of over 100 beats per minute (bpm) at rest). He said he would have wanted to be notified when Resident #6's blood pressure medications were held due to vital signs being out of the parameters. He said a sign or symptom of a GI bleed was low blood pressure. During an interview on 9/9/25 at 3:38 p.m., LVN O said she did not remember being notified about Resident #6's low blood pressure readings and blood pressure medications being held. She said the MAs verbally notified the charge nurses about out-of-range vital signs and documented on the MAR. She said the charge nurses were responsible for notifying the physician. She said she did not recall doing a neuro assessment on Resident #6 after a fall in July 2025. She said if Resident #6's had a trend of low blood pressure readings then the MD should have been notified. She said signs or symptoms of a GI bleed were low blood pressure, tarry stool, and passing of blood. She said it was important to notify the physician because the resident could not need the prescribed blood pressure medication and so they could address the issue. During an interview on 9/10/25 at 9:45 a.m., LVN L said she was not aware Resident #6 had several days of low blood pressure readings with low and high heart rates prior to the incident on 7/31/25. She said when she called MD K about Resident #6 incident on 7/31/25, she did not report his previous low blood pressure readings with low and high heart rates. She said the MAs usually verbally told the charge nurses when the residents' vital signs were out of range and the medication was held. She said then the charge nurse could notify the MD. She said if the residents' blood pressure continued to be low, then the MD needed to be contacted for a medication adjustment. She said if the residents' blood pressure was low but the heart rate was high, then it could indicate anemia. She said if MD K had been given more information on 7/31/25, related to Resident #6's vital signs being out of normal range prior to the incident on 7/31/25, he may have done a different intervention. She said she wished she had known about Resident #6's previous vital signs so she could have reported it. She said the charge nurses documented on a progress note when the MD was notified and responded back. She said she did not know why there were two different notification entries on 8/1/25 to MD K about Resident #6 critical labs. During an interview on 9/11/25 at 1:03 p.m., the ADM said the charge nurses were responsible for notifying the physician when a resident had a change in condition. She said the charge nurses should also notify the ADON and DON. She said it was important to notify the physician in case the resident needed to be sent out to the ER or medication changed. She said the charge nurses documented the physician notification in a progress note. She said if the physician was not contacted, it could be detrimental to the resident. She said the nursing management should ensure the charge nurses responded to the residents' change of condition. She said the nursing management should ensure this process by doing in-services. Record review of an undated facility's Abuse/Neglect policy indicated, . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of a facility's Notifying the Physician of Change in Status policy revised 3/11/2013 indicated, .The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. Record review of a facility's Medication Administration and General Guidelines policy revised 3/2025 indicated, . Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized then the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials. The ADM and the Regional Compliance Nurse were notified of an IJ on 9/11/25 at 1:59 p.m. and a Plan of Removal (POR) was requested. The IJ template was emailed to the ADM on 9/11/25 at 2:01 p.m. The following plan of removal was submitted by the facility and accepted on 09/12/25 at 4:40 p.m. and included the following: Interventions: 1. Resident #6 no longer resides in the facility as of 9/11/25. 2. All residents in the facility had their blood pressures and heart rates reviewed for any abnormal readings. No additional changes in condition were noted that required notification to the MD. Completed 9/11/25. 3. The DON/ADON/Designee will review the 24hr report and PCC dashboard (is a customized, centralized view within the PointClickCare healthcare management platform that provides real-time, at-a-glance information relevant to a user's role, displaying clinical, financial, or administrative data to improve efficiency, decision-making, and patient care) daily for abnormal vital signs or changes in condition that need to be communicated to the MD. Completed 9/11/25 and will continue indefinitely. 4. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations. b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents. Med aides will report all abnormal vital signs during medication administration to charge nurse immediately. c. PCC Dashboard/24hr Report: Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician. 5. The medical director was notified of the immediate jeopardy citation by the administrator on 9/11/25. 6. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/11/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced as of 9/11/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Completion date 9/11/25. a. Abuse and Neglect: Examples include failure to provide assistance with showers, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following MD orders, treating pain, administer medication, notifying MD of change in condition, provide adequate supervision to prevent falls or resident to resident altercations. b. Notification of Change in Condition: notify a MD and RP of all changes in conditions such as abnormal vital signs, new onset or worsening pain or injuries from incidents. c. PCC Dashboard/24hr Report: Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician The surveyor verification of the Plan of Removal from 9/12/25 was as follows: *Record review of a resident roster provided on 9/8/25 indicated Resident #6 was not in the facility. *Record review of Resident #6's progress note dated 8/27/25 at 1:45 a.m., reflected Resident #6 was pronounced at 12:25 a.m. *Record review of the facility's Weights and Vitals Summary dated 9/8/25-9/30/25 indicated all residents, unit, and floors had been reviewed. The vital signs of blood pressure and pulse were targeted. Twenty-six residents had blood pressure and/or pulse that triggered a warning. RCN DD reviewed and signed the report on 9/12/25. *Record review of an email sent by RCN EE to MD K dated 9/11/25 at 7:09 p.m., indicated an attached list of residents with low pulse (5 residents), high pulse (3 residents), low blood pressure readings (7 residents), and high blood pressure readings (20 residents). *Record review of an email sent back from MD K to RCN EE dated 9/12/25 at 1:39 a.m., indicated MD K made medication adjustments for 2 residents. MD K acknowledged other vital signs and no new orders. *Record review of the facility's Daily Quality Assurance Meeting dated 9/11/25 at 9:00 a.m., indicated the 24-hour report, medication administration, and the facility's charting system dashboard had been reviewed by the DON. The clinical alerts had been reviewed. *Record review of the facility's 24-hour Summary report dated 9/11/25-9/12/25 indicated residents' vital signs and progress notes. Five residents had reported changes of conditions or new findings. The report indicated notifications to the MD, family, and hospice. *Record review of a provided document from the ADO on 9/12/25 indicated the Medical Director, MD K, was notified by the ADM on 9/11/25 at 3:55 p.m. of the immediate jeopardy citations. *Record review of a facility's AD Hoc QAPI Meeting dated 9/11/25 indicated the following members were in attendance: ADM, DON, ADON, Medical Director (via phone), Social Service, Dietary, RNC EE, Administrator in Training, MDS Coordinator RR and MDS Coordinator QQ. *Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service training on abuse and neglect which included the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. It also included the abuse/neglect policy and procedure. *Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as abnormal vital signs, pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. *Record review of the in-service training report dated 9/12/25, reflected the DON and Administrator signed and received in-service training on PCC Dashboard/ 24 Hour Report which included the following: the Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to the physician. *During an interview on 09/12/25 at 3:08 PM, the Medical Director stated he was notified of the immediate jeopardy situations at the facility. He said he was notified by the Regional Compliance Nurse on 09/11/25 and it was discussed with plans being implemented. *During an interview on 09/12/25 at 4:05 PM, the DON stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The DON stated that failure to provide care and services such as notifying the physician of change of condition, following physician orders,

Based on interview, and record review the facility failed to ensure that pain management was provided to that require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices of 2 of 11 residents reviewed for pain management. (Resident #6 and Resident #15) 1. The facility failed to ensure Resident #15 received her scheduled Oxycodone as ordered on [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #15 received her scheduled Gabapentin as ordered on [DATE]. The facility failed to notify Resident #15's physician when doses of the Oxycodone and Gabapentin, scheduled for 3pm and 4pm, were not administered on [DATE]. The facility failed to offer Resident #15 alternative prn pain medication options on [DATE] per the facility's policy. The facility failed to offer Resident #15 non-pharmacological interventions on [DATE] per the facility's policy. The facility failed to follow the Pain Management policy. 2. The facility failed to ensure Resident #6, who received scheduled opioid medications, had pain assessments at least every shift. The facility failed to ensure Resident #6, who displayed nonverbal signs of pain such as grimacing, hollering out and pushing staff away during ADL care, was administered prn medication. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 2:01 p.m. While the IJ was removed on [DATE] at 12:49 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to complete training in-services with all staff and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for unrealized pain, serious harm, decrease quality of life and decline in condition.Findings included: 1. Record review of Resident #15's face sheet dated [DATE] indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), low back pain, major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had clear speech, adequate hearing and vision. Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 15 which indicated intact cognition. Resident #15 was independent for eating, oral hygiene, and toilet hygiene, partial assistance for shower/bathe self and personal hygiene. Resident #15 received scheduled pain medication regimen. Resident #15 received opioids. Record review of Resident #15's care plan dated [DATE] indicated Resident #15 was on pain medication therapy related to fibromyalgia and wound. Intervention included administer medications as ordered. Record review of Resident #15's order summary report dated [DATE] indicated: *Tylenol Capsule 325 MG, give 2 capsules by mouth every 6 hours as needed for mild pain. Start date [DATE]. *Instant hot pack apply to affected area every hour as needed for pain, every 1 hour as needed for pain. Start date [DATE]. *Assess for pain each shift, every shift. Start date [DATE]. *Oxycodone Oral Tablet 10 MG (is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated), give 1 tablet by mouth five times a day for pain. Start date [DATE]. *Gabapentin Oral Capsule 300 MG (is an anticonvulsant medication used to treat nerve pain), give 1 capsule by mouth three times a day for pain for 5 days. Start dated [DATE]. Record review of Resident #15's Medication Administration Record dated [DATE]-[DATE] indicated: *Tylenol Capsule 325 MG, give 2 capsules by mouth every 6 hours as needed for mild pain. The MAR did not reflect an administration on [DATE]. This alternate prn pain medication was not administered on [DATE]. *Instant hot pack apply to affected area every hour as needed for pain, every 1 hour as needed for pain. The MAR did not reflect an administration on [DATE]. This non-pharmacological option was not administered on [DATE]. *Assess for pain each shift, every shift. The MAR did not reflect assessments on [DATE] (Nights), [DATE] (Nights), and [DATE] (Nights). *Oxycodone Oral Tablet 10 MG, give 1 tablet by mouth five times a day for pain. Times: 1am, 6am, 11am, 4pm, and 9pm. The MAR indicated on [DATE] at 1am administration was not given due to sleeping. The MAR did not reflect administration on [DATE] at 4pm. The MAR indicated on [DATE] administration at 9pm. The MAR indicated on [DATE] administration at 6am. *Gabapentin Oral Capsule 300 MG, give 1 capsule by mouth three times a day for pain for 5 days. The MAR did not reflect administration on [DATE] at 3pm. Record review of Resident #15's Individual Control Drug Record for Oxycodone 10 MG dated [DATE] indicated: *[DATE] at 6am, 1 pill given by RN S. *[DATE] at 11am, 1 pill given by MA B. *[DATE] at 9pm, 1 pill given by LVN M. *[DATE] at 11:55 p.m., 1 pill given by RN T. *[DATE] at 8am, 1 pill given by the DON. The Individual Control Drug Record did not reflect entries for [DATE] at 1am and 4pm. The Individual Control Drug Record did not reflect entries for [DATE] at 9pm. The Individual Control Drug Record did not reflect entries for [DATE] at 6am. Resident #15 scheduled doses are 1am, 6am, 11am, 4pm, and 9pm. Record review of Resident #15's e-MAR report dated [DATE] provided by RCN EE indicated: *[DATE] at 1am, code: 7 (sleeping), RN S. *[DATE] at 6am, 1 tablet, RN S. *[DATE] at 11am, 1 tablet, MA B. *[DATE] at 9pm, 1 tablet, LVN M. *[DATE] at 11:55pm (9pm), 1 tablet, RN T. *[DATE] at 8am (6am), 1 tablet, DON. The e-MAR did not reflect an entry for [DATE] at 4pm. Record review of Resident #15's progress notes dated [DATE]-[DATE] indicated: *[DATE] at 9:37 a.m. by LVN M, . CNA to this nurse that resident [Resident #15] was upset because she didn't get her 3pm Oxycodone. I [LVN M] entered the resident room with PM medications in hand. Resident #15 stated, 'I want to know why I didn't get my 3 o'clock pain medication'. I [LVN M] was not the nurse on duty at that time, apologized to her for her not receiving her 3 pm pain medication. I [LVN M] assured resident [Resident #15] am of what's going however at this time my hands are tied and the only thing I could do was give the medications that are due now. *[DATE] at 1:39 p.m., by the ADON, . Oxycodone Oral 10 MG.first oxycodone given late, so resident [Resident #15] refused this dose. *[DATE] at 8:00 a.m., by the DON, . Oxycodone Oral 10 MG.Resident #15 stated that she did not receive her medication at 6am. Resident state that she is in pain.This nurse [DON] administered medication and contacted NP. Record review of a PIR, Witness Statement by LVN M dated [DATE] indicated, . upon start of shift report is received off going nurse voiced she [RN P] can count with me [LVN M] but she didn't know what was going on either hall because she been all over the place and the ADON kept getting pulled off the floor so its gone be some stuff red cause I couldn't get to it. we [RN P & LVN M] then proceeded to count the nursing cart for A and D and the med aide cart for D. after counting the nurse [RN P] asked well do you want me to go ahead and catch up. I [LVN M] responded letting her know to do what she feels like she needed to do. Then she [RN P] asked for the keys to the cart back. Approx 15 min or so later she brought back the keys saying she has to go.This nurse [LVN M] to continue with only the scheduled medications for my shift. Record review of undated Customer Service Assessment submitted by a family member of Resident #15 indicated, .she [Resident #15] states that she received her 9:00 p.m. medications at 10:00 p.m., which technically not late. she [Resident #15] states that I called the desk at 5:00 about her 4:00 p.m. medications that did not come. she [Resident #15] saw no one until her nurse [LVN M] arrived at 10:00 p.m. Resident #15 states that she went 11 hours without pain medications. Resident #15 states that her medications have been more than two hours late many times, and no one addressed this.Resident #15 understands the window time frame of distributing medications however this window time frame is very extensive from the prior dose. Record review of Resident #15's grievance dated [DATE] indicated Resident #15 reported to Social Service regarding a grievance related to medications. Resident #15 stated that she did not receive her 6am oxycodone. The DON and ADM were assigned to take action. Resident #15 was provided with her oxycodone at 8am. The grievance was confirmed. During an interview on [DATE] at 5:04 p.m., Resident #15 said she did not get her Gabapentin and Oxycodone at 4 p.m. on [DATE]. She said she woke up around 5:30 p.m. in pain. She said her pain level was a 6 on scale from 1-10. She said she had called the front desk at 6:15 p.m. and 6:40 p.m., asking for her 4 p.m. medications. She said LVN M did not show up until almost 10:00 p.m. She said when LVN M finally showed up, her pain level was 7-8. She said LVN M did not offer to give a prn medication or non-pharmacological option to help with the pain. She said she had not had pain medication since 11am. She said she was so upset. She said her pain medications were given late a lot and they also missed doses. During an interview on [DATE] at 10:42 a.m., LVN M said she had been employed at the facility for about 30 days. She said she worked 6pm-6am shift. LVN M said Resident #15 was upset about not receiving her 4 p.m. pain medications. She said she arrived around 10 p.m. to give Resident #15 the evening medications. She said Resident #15 said she was in pain but did not tell her a specific number. She said Resident #15 said she was always in pain. She said CNA TT reported to her around 9:30 p.m. that Resident #15 was looking for her pain medications. She said she thought Resident #15 was looking for her pm medications, not her missed afternoon pain meds. She said when a resident did not receive their scheduled pain medication, it could affect their mood, sleep, and participation in therapy. She said the MAs and CNs were responsible for administering the residents' pain medication on schedule. She said the MAs and CNs documented pain medication administration in the facility's charting system and narcotic count sheet. She said the residents' pain assessment should be documented in the facility's charting system. She said the residents' pain should be assessed before and after administering pain medication and with complaints of pain. She said she did not go back and check on Resident #15's pain level until 1am. She said Resident #15 did not want her in her room after their disagreement. She said she received report from RN P on [DATE]. She said RN P, said she did not know if she gotten to everything due for the shift. She said RN P, said there were residents' medications left in red. She said she did not remember, if RN P specified, that Resident #15 did not get her scheduled medications. During an interview on [DATE] at 2:52 p.m., RN P said she started back at the facility recently and started orientation around [DATE]. RN P said on [DATE], she and the ADON were working the same medication cart. She said she did not know which residents got their medications or not. She said Resident #15 may have been one of the residents who did not get their medications on [DATE]. She said Resident #15 was in her right mind. She said if Resident #15 said she did not get her pain medications, then she did not. She said the facility was short staffed that day ([DATE]). She said the residents' needed their pain medications because they could become agitated and be in pain. She said the residents should get their scheduled medications because it was ordered that way. She said the residents could not be able to sleep, eat, or be bothered when in pain. She said the MAs and CNs documented pain medication administration in the facility's charting system on the MAR. She said they also charted on the residents' narcotic count sheet. During an interview on [DATE] at 12:42 p.m., Resident #15 said she would have wanted to be woken up on [DATE] at 1am for her pain medication. She said after she called the front desk several time for her pain medication on [DATE] and no one came; she was mad. She said she got changed before she received her 9pm pain medication on [DATE]. She said she was in a lot of pain during the changing. She said her pain ramped up her agitation. She said which did not help the situation with LVN M. She said LVN M did not offer to call the doctor, give her Tylenol, or a heating pad. She said LVN M, said it was not her responsibility to fix what another shift did not do. She said she was just screwed. She said when she got her pain medications late or missed doses, she was chasing her pain. She said her pain level was not going to get back level for a few days. On [DATE] at 5:31 p.m., attempted to contact LVN M by phone and sent text message. During an interview on [DATE] at 6:08 p.m., LVN M said she did not call the MD or NP when Resident #15 had a missed oxycodone dose on [DATE]. She said when she was counseled by the ADM and DON, they said she should have. She said she just did not think the MD or NP would let her have two doses of oxycodone. She said she did not offer Resident #15 any prn pain medication. She said when she previously offered Resident #15 the prn Tylenol for a headache, she said it did not work. She said she did not know Resident #15 had non-pharmacological options ordered. She said it was important to offer other option for pain to help with breakthrough pain. She said it helped keep the residents' pain under control. During an interview on [DATE] at 9:05 a.m., MA U said that scheduled medications were supposed to be given one hour before or after the scheduled time. She said that was the facility's policy. She said Resident #15's 6am oxycodone was administered late because of shift change. She said Resident #15 complained about her medications being late. She said when Resident #15's scheduled pain medications were given late or missed, it messed up the administration times for the next doses. She said Resident #15 could be in pain because of late or missed pain medications. During an interview on [DATE] at 5:03 p.m., CNA TT said Resident #15 called twice about her missed pain medications on [DATE]. She said she reported to LVN M, Resident #15 wanted her pain medications. She said Resident #15 was grimacing and red faced after the incident with LVN M. During an interview on [DATE] at 8:38 a.m., RN T said Resident #15 was not on her assigned hall. She said she had to administer Resident #15's medications because LVN M could not do it anymore. She said she may have given Resident #15's oxycodone late one night. She said she may have forgotten to pass medications to Resident #15 because she was not on her assigned hall. She said Resident #15 should get her scheduled medication on time so she did not hurt. She said it was also important because that was what Resident #15's body was used to. She said the residents' pain assessment were done each shift. She said it was important to do a pain assessment to make sure the pain medication was adequate for relief. During an interview on [DATE] at 10:45 a.m., the DON said she expected the nursing staff to wake the residents up to give medications. She said on [DATE], Resident #15's 6am oxycodone dose was not given. She said she notified the NP and administered the missed dose at 8am. She said she expected the nursing staff to assess the residents' pain every shift. She said it was important to do a pain assessment to address the residents' pain. She said if the residents' pain was not assessed and addressed, they could not be able to do ADLs and be uncomfortable. She said nursing staff should document medication administration when administered, not later. She said it was important to document the medications when administered so it would tell the actual time. She said the nursing staff should be following the 5 rights of medication administration. She said the ADON and DON oversaw the nursing staff to ensure pain assessments were done and timely medication administration. She said they should monitor this process by doing chart audits, reviewing the residents' MARs and TARs. She said she had not had a lot of time to do chart audits. She said morning meetings had not been happening to discuss the residents due to working the floor. 2. Record review of Resident #6's face sheet dated [DATE] indicated Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including Dementia (is a general term describing a group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking, reasoning, and judgment, which interfere with daily life), gastrointestinal hemorrhage (is when there is blood loss from any of the several organs included in your digestive system), and chronic pain. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes had the ability to understand others. Resident #6 had a BIMS score of 2 which indicated severe cognitive impairment. Resident #6 required supervision for eating, substantial assistance for oral and personal hygiene, and dependent for toileting hygiene, shower/bathe self and dressing. Resident #6 was always incontinent of urine and bowel continence was not rated. Resident #6 received scheduled pain medication. Resident #6 had not received prn pain medications or was offered and declined. Resident #6 had not received non-medication intervention for pain. Resident #6's occasionally experienced pain in last 5 days, made it hard to sleep at night, limited participation in rehabilitation therapy sessions, and limited day-to-day activities. Resident #6 rated his worst pain as a 3 over the last 5 days. Resident #6 received opioid medications. Record review of Resident #6's care plan dated [DATE] indicated: *Resident #6 had impaired cognitive function/dementia or impaired thought process related to diagnosis of dementia. Intervention included monitor/document/report to MD any change in cognitive function. *Resident #6 had ADL self-care performance deficit. Intervention included monitor/document/report to MD PRN any changes and declined in function. Record review of Resident #6's care plan dated [DATE] indicated Resident #6 was on routine pain medication therapy. Intervention included administer medication as ordered Record review of Resident #6's care plan dated [DATE] indicated: *Resident #6 had terminal prognosis and/or was receiving hospice services. Intervention included observe closely for signs of pain, administer pain medication as ordered, and notify physician immediately if there was breakthrough pain. Work with nursing staff to provide maximum comfort for the resident. *Resident #6 required hospice as evidence by terminal illness. Intervention included monitor for signs and symptoms of increased pain and discomfort. Give meds and treatments and monitor for relief. Assists with ADLs and provide comfort measures as needed. Record review of Resident #6's order summary dated [DATE]-[DATE] indicated: *Tramadol Oral Tablet 50 MG, give 2 tablets by mouth two times a day related to chronic pain. Start dated [DATE]. *Tylenol Oral Capsule 325 MG, give 2 capsules by mouth every 4 hours as needed for mild pain or fever. Start date [DATE]. *Tylenol with codeine #3 Tablet 300-30 MG (is a prescription combination pain medication containing acetaminophen and the opioid codeine), give 1 tablet by mouth every 8 hours as needed for pain. Start date [DATE]. *Lorazepam Tablet 0.5 MG (is used to treat anxiety disorders), give 1 tablet by mouth every 4 hours as needed for agitation. Start dated [DATE]. *Morphine Sulfate 10MG/5ML (is a powerful opioid analgesic used to treat moderate to severe pain), give 10 milligrams by mouth every 3 hours as needed for pain. Start date [DATE]. The order summary did not reflect a pain assessment every shift. Record review of Resident #6's MAR dated [DATE]-[DATE] indicated: *Tramadol Oral Tablet 50 MG, give 2 tablets by mouth two times a day related to chronic pain. Start dated [DATE]. The MAR indicated Resident #6 received 35 of 44 doses. *Tylenol Oral Capsule 325 MG, give 2 capsules by mouth every 4 hours as needed for mild pain or fever. The MAR indicated administration on [DATE] for pain level of 4. *Tylenol with codeine #3 Tablet 300-30 MG (is a prescription combination pain medication containing acetaminophen and the opioid codeine), give 1 tablet by mouth every 8 hours as needed for pain. The MAR did not reflect any administrations. *Lorazepam Tablet 0.5 MG (is used to treat anxiety disorders), give 1 tablet by mouth every 4 hours as needed for agitation. The MAR did not reflect any administrations. *Morphine Sulfate 10MG/5ML (is a powerful opioid analgesic used to treat moderate to severe pain), give 10 milligrams by mouth every 3 hours as needed for pain. The MAR did not reflect any administrations. Record review of Resident #6's Individual Control Drug Record for Morphine indicated the starting balance of 30 ML and destroyed quantity of 30 ML. The record did not reflect any administrations. Record review of Resident #6's progress notes dated [DATE]-[DATE] indicated: *[DATE] at 3:36 p.m. by LVN A, .Resident #6 has new order for Tylenol #3 for every 8 hours PRN for pain. Order to give before baths and wound care. *[DATE] at 9:08 p.m. by MD K, . Progress note.contractures, right knee.contracture, left knee. Stage 2 ulcers. administer Tylenol with codeine #3 as needed for pain.provide comfort care measures. he [Resident #6] exhibits signs of pain, particularly with movement. when attempting to place between his knees, even minimal movement of his left leg caused him to grimace and attempt to push the examiner's [MD K] hand away. *[DATE] at 11:48 a.m. by the DON, . family also informed that the resident [Resident #6] is being repositioned from side to side due to his knees being contracted upwards. Resident #6 moans and groans when turned and repositioned, and during incontinent care. Resident #6 continues to pull the pillow from between knees and pulls the wound care dressing off his knees and hip. Hospice Nurse spoke to the family about increasing routine pain medications. *[DATE] at 6:45 p.m. by the DON, . this nurse [DON] repositioned the resident [Resident #6] onto back, put pillow between his legs, and under his right side. Resident #6 moaning and groaning during repositioning. On [DATE] at 10:27 a.m., attempted to contact LVN O by phone. Contact was unsuccessful and a message was left with callback phone number. During an interview on [DATE] at 11:37 a.m., the DON said Resident #6 was in pain when he was admitted to hospice service. She said Resident #6 could not talk but vocalized pain by moaning. She said Resident #6 would moan when he was messed with. She said the residents' prn pain medications should be administered when the resident was in pain. She said if Resident #6 had prn pain medications ordered, she would have expected them to be used. She said it was important to administer prn pain medications to control pain, especially breakthrough pain. She said if a resident was in pain, it affected their ability to do ADLs or sleep more. She said a pain assessment should be documented in the facility's charting system. She said the nursing staff should document the pain assessment every shift and before prn pain medication was administered. During an interview on [DATE] at 1:20 p.m., the ADON said Resident #6 moaned when he was turned. She said Resident #6 screamed out in pain and grabbed at staff. She said Resident #6 was in pain and anxious when he pulled off his brief and clothes. She said she did not know if the CNs administered Resident #6 prn pain medication when he displayed signs of pain. She said she would have expected the CNs to administer Resident #6's ordered prn pain and anxiety medications when he was in pain. During an interview on [DATE] at 3:16 p.m., MD K said Resident #6 was severely contracted. He said Resident #6 was contracted into a fetal position. He said when he visited Resident #6, he moaned when moved. He said the staff would place a pillow between Resident #6's knees and he would start hollering out in pain. He said he would want the nursing staff to give prn pain medications if there were signs of distress. During an interview on [DATE] at 4:11 p.m., the hospice nurse said Resident #6 was admitted to the company on [DATE]. She said prn comfort medications were ordered for Resident #6. She said she saw Resident #6, two or three times before he expired on [DATE]. She said when the CNAs rolled Resident #6 for incontinence care or repositioning, he would say, stop or put his hand up. She said after Resident #6's care plan meeting on [DATE], she increased his scheduled pain medication. She said she increased Resident #6 scheduled pain medication because she knew he was guaranteed get it. She said Resident #6 was the most contracted man she had ever seen. She said she thought Resident #6 could not participant in therapy anymore because his contractures caused him so much pain. She said Resident #6 would have benefited from receiving prn pain medications. During an interview on [DATE] at 9:45 a.m., LVN L said she used to be the facility's treatment nurse. She said Resident #6 would wince when rolled over for wound care treatments. She said Resident #6 had 3 or 4 pressure ulcers. She said she wanted to say the nursing staff administered Resident #6 pain medication when he needed it. She said she could not remember though. She said if Resident #6 received prn pain medications, it would be documented on the MAR. She said the residents' pain level was assessed before and after administration. During an interview on [DATE] at 10:38 a.m., the Social Service said the facility had a care plan meeting with a family member of Resident #15. She said the family member of Resident #15 had reported, Resident #15 had been in pain on [DATE]. She said the family member of Resident #15 reported Resident #15 had waited an extended period for pain medication on [DATE]. She said the facility had a care plan meeting for Resident #6 on [DATE]. She said in the meeting, the DON and Hospice Nurse mentioned Resident #6 was in pain when touched or moved. She said they addressed the increased pain by scheduling Resident #6 pain medication. During an interview on [DATE] at 9:28 a.m., CNA AAA said Resident #6 pushed, grabbed, and held on to you when he was messed with. She said Resident #6 hollered out in pain when they would put a pillow between his knees, turned, and changed him. She said Resident #6 needed constant attention because he took off his gown and played in his feces. She said she reported it to the nurses and they gave Resident #6 pain medication. She said Resident #6 got pain medication before his bed baths, if it lined up with his scheduled dose times. She said when Resident #6 hollered out in pain, he was probably due for his scheduled pain medication. She said there may have been times she provided care to Resident #6 and he was in pain. She said the residents should receive pain medication to make them comfortable and easier to take care of. During an interview on [DATE] at 10:10 a.m., LVN O said Resident #6 moaned and groaned when he was turned and changed. She said Resident #6 stopped when they were done. She said she never gave prn pain medication before Resident #6's cares were done. She said she should have since it caused him so much pain. She said she did not premedicate him before wound care treatments. She said Resident #6 would holler out when his knees had to be separated for wound care. She said pain medications should be given to prevent or reduce pain. She said not providing pain medications when a resident displayed signs and symptoms could negatively affect them. During an interview on [DATE] at 1:03 p.m., the ADM said the CNs then the DON was responsible for the residents' pain management. She said the facility had a care plan meeting to address Resident #15's concerns. She said Resident #15 was given the ADON's phone number to contacted if she did not get her scheduled pain medications. She said LVN M should have notified Resident #15's physician when she found out she had missed doses of pain medications. She said LVN M was in-serviced on notifying the physician for missed doses of pain medications. She said LVN M should have offered Resident #15 prn pain medication and non-pharmacological options. She said she expected the nursing staff to follow the pain management policy. She said the staff were in-serviced on the pain management policy after the incident on [DATE] and probably before. She said it was important for the policy to be followed to take care of the residents and not to be in pain. She said Resident #6 was contracted. She said the few times she saw Resident #6; he was asleep. She said Resident #6 experienced pain when his contractures had to be pulled apart. She said she expected the nursing staff to give prn pain medication when needed. She said she expected the nursing staff to perform pain assessments. She said the CNs were responsible for administering prn pain medications. She said prn pain medication should be used when needed for comfort and pain management. She said when prn pain medication was not used, the residents could be uncomfortable, in pain, and decreased quality of life. She said the nursing management and hospice were responsible for Resident #6's pain management. She said they should review the residents' documentation to ensure prn medication were being used when needed. During an interview on [DATE] at 4:39 p.m., Resident #6's family member said Resident #6 moaned and groaned when he was touched. The family member of Resident #6 said they expressed this concern to the facility. During an interview on [DATE] at 12:18 p.m., CNA R said when she was assigned the hall Resident #6 was on, she was a Hospitality Aide. She said she could not provide ADL care on him. She said she never touched Resident #6 but noticed when other staff did, he would be in pain. She said Resident #6 would scream out in pain, push staff away, or say leave me alone. She said when he was in pain, she saw the CNAs tell the nurses. She said she never saw a nurse give Resident #6 pain medication before turning or changing him. She said Resident #6 would have benefited from prn pain medications if he got cares done before the next scheduled dose. Record review of an undated facility's Abuse/Neglect policy indicated, . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of an undated facility's Pain Management, Assessment Scale policy indicated, . Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological. or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. PRN-if the resident comp

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed for adequate supervision.The facility failed to prevent Resident #1 from causing a burn proximal red area 5CM x 9CM, distal red area with blister 3CM X 8CM herself with coffee on 4/23/25 while she was in bed and not providing a lid for her cup.The facility failed to keep coffee available to residents or served to residents at a safe temperature.These failures resulted in the identification of an Immediate Jeopardy (IJ) on 07/15/25 at 12:09 PM. While the IJ was removed on 07/16/25 at 08:47 AM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk for injury, harm, and impairment or death.Findings included: Record review of Resident #1's face sheet, dated 08/12/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Dementia (an umbrella term for a decline in mental abilities severe enough to interfere with daily life), Polyneuropathy (a condition where multiple peripheral nerves are damaged, causing a range of symptoms due to impaired nerve function), Muscle Weakness (a reduced ability to generate force). Record review of Resident #1's Annual MDS assessment, dated 04/11/25, indicated she had a BIMS score of 14, which indicated Resident #1 was cognitively intact. She was able to make herself understood and she was able to understand others. Resident #1's MDS reflected that she was independent on eating and drinking. Record review of Resident #1's care plan dated 6/6/2025 indicated that there was a focus area for Resident #1, risk of burns due to hot liquids and generalized weakness created on 11/1/2024. Furthermore, the care plan reflected the goal indicated that Resident #1 would not suffer any injury related to hot liquids, created on 11/1/2024. The care plan interventions were as follows: -Coffee and other hot liquids should not be served if over 140 degrees Fahrenheit Date Initiated: 11/01/2024Revision on: 11/04/2024.-DietIf hot liquid is spilled on self, staff should pour room temperature or lower templiquid on the affected area of the residentDate Initiated: 04/23/2025 -CNAResident to use a cup with a lid for hot liquids/coffeeDate Initiated: 11/01/2024Revision on: 11/06/2024 -CNAResident to use the dominant hand for drinkingDate Initiated: 04/23/2025Should be seated in upright position with table or overbed table when hot liquids arebeing consumedDate Initiated: 04/23/2025Record review of Resident #1's post incident assessment dated [DATE] revealed that Resident #1 had a burn proximal red area 5CM x 9 CM, distal red area with blister 3CM X 8CM. Shows that a new order was received to treat Resident #1's burn, Cleanse with normal saline, pat dry. Apply Silvadene ointment and cover with dry dressing. Change daily until resolved. Record review of Resident #1's progress note dated 4/23/25 revealed that Resident #1 told the Social Worker that she spilled coffee onto her abdomen and burned herself. Shows that the facility notified the resident's physician and the residents representative. Showed that the facility received new orders and updated Resident#1's care plan. Record review of facility provider investigation report dated 4/23/25 shows that the facility self-reported the incident, notified the resident's physician and received new orders, notified the resident representative, notified the incident to the Texas Health and Human Services Commission and the incident was investigated. The provider investigation report shows that Resident #1 was able to give a statement saying that she accidently burned herself when she spilled coffee into her stomach. Provider investigation report shows that the facility completed in-services regarding hot-liquids and residents at risk for burning themselves. Shows that the residents in the facility who were at risk were specifically named. Shows that staff across all disciplines were in-serviced. Record review of an undated written statement provided to the Administrator from the Social Worker, who first noticed the burn: On the morning of 4/23/25, I entered [Resident #1's] room to gather a box of hospice supplies that were left in her room. Upon entering her room, I noticed her glass of milk had been dropped on the floor and the milk was under her bed. I mentioned it to [Resident #1], and she told me she had spilled her milk and coffee when she tried to pull her overbed table closer to her. She was using her blanket to wipe the coffee off of her. I noticed that she was wiping her stomach with her blanket. I observed some redness to her stomach where the coffee had spilled. I immediately found her nurse and reported it to her, then went back to get some dry blankets on her. Record review of a written statement dated 4/23/25 provided to the Administrator from LVN B, who delivered the breakfast tray to Resident #1 On 4/23/25 at breakfast I [LVN B] TX Nurse delivered [Resident #1's] breakfast tray. [Resident #1] requested coffee. This nurse checked resident's meal tickets and noted no interventions regarding the coffee drinking on meal ticket. Signed by LVN B 4/23/25.During an interview and observation on 7/14/25 at 9:00 a.m., revealed the coffee available for residents to drink was temped using the surveyor's digital probe thermometer. The temperature of the coffee was 116F. The Dietary Manager said that he had brewed coffee that was in the kitchen. The temperature of the coffee inside the kitchen was measured by the investigator at 158F . He said the coffee was inside the kitchen which residents did not have access to but was to be served to residents in the hallways.During an interview on 7/14/25 at 9:33 a.m., Resident #1 was attempted to be interviewed. She was asked about the incident regarding her coffee burn that occurred on the morning 4/23/25. Resident #1 looked at the surveyor but did not respond with an appropriate answer to the question asked. Resident #1 was unintelligible during her interview and did not provide any relevant information. During an observation on 7/14/25 while touring the facility from 9:50 a.m., to 10:10 a.m., multiple residents were observed with lids on their coffee cups. During an observation on 7/14/25 at 12:15 p.m. it was observed that the coffee readily available for resident use in the dining room was measured at approximately 130F using the Dietary Manager's thermometer. The thermometer used by the Dietary Manager was an analog probe thermometer with hashmarks that read at 5-degree intervals. During an observation on 7/14/25 at 1:50 p.m. it was observed that the temperature of the coffee available to residents was 141.9F During an observation on 7/14/25 at 1:28 p.m. with an RN, revealed Resident #1's abdomen was observed. Her abdomen had healed, there was no open wounds, and her skin was clear and intact. Record review in Resident #1's meal ticket for 7/14/25 revealed that the ticked reflected, SPECIAL CUP FOR HER COFFEE WITH A LID During an observation on 7/15/25 at 7:55 a.m. while taking a temperature reading of a cup of coffee made available to residents in the dining room, the temperature of the coffee was 155.3F using a digital probe thermometer. During an interview on 7/15/25 at 9:40 a.m., with the Patient Care Coordinator, she said that Resident #1 ate her meals in her room. She said that a hall cart brought her food and coffee at the same time. She said that Resident #1 should have a lid on her cup of coffee since she was at risk of burning herself. She said that her coffee, since it had a lid, would be poured by the kitchen staff. She said that residents who were not at risk would have a regular open mug, and the coffee would be poured from a thermos that came with the hall cart provided by the kitchen. She said that CNAs and staff passing trays did not take the temperature of the coffee since it was the responsibility of kitchen staff to ensure that the coffee did not exceed the maximum of 140F. She said that no one should take the lid off Resident #1's coffee. During an interview on 7/15/25 at 10:17 a.m., the Director of Nurses said that CNAs or staff passing hall trays do not take the temperature of the coffee as it is passed out. She said that it is the responsibility of dietary staff to ensure the temperature does not exceed 140F. She said that meal tickets included hot liquid restrictions was added after the incident occurred. During an interview on 7/15/25 at 10:23 a.m., Dietary Aide A said that when coffee was served to the halls it would have been served in two different ways. She said that if the resident had a hot liquid risk it would be poured into a cup with a lid on the cup, then placed on the resident's tray . Or it would be poured into a regular coffee mug with no lid directly from a thermos that would be sent out with the hall cart. She said that only the kitchen staff took temperature readings of the coffee. She said that she knew who received a lid or not as they kept an updated list of residents at risk for hot liquids in the kitchen. During an interview on 7/15/25 at 11:00 a.m., the Social Worker said that she was the person who first noticed the burn on Resident #1's stomach. She said that Resident #1 told her that she tried to pull her bedside table closer to herself and when she did, she spilled coffee on the table, the floor, and herself. She said that Resident #1 had a regular coffee mug that came from the kitchen, and it did not have a lid on it. During an interview on 7/16/25 at 9:20 a.m., the Dietary Manager said he expects that his dietary staff follow facility policy regarding hot liquids and coffee. He said that he expected that hot liquids/coffee would not be served at a temperature that exceeds 140F and they are to log what the temperature was. He said that if the temperature exceeded 140F it would not be served until it had cooled down to 140F or below. He said that he expected that residents who require lids for their cups to be in place as it protected those who were at risk of burning themselves. He said that residents could be placed at risk for burning themselves if facility policy was not followed. He said that it was the responsibility of all dietary staff to ensure that residents that require a lid had one in place before the coffee left the kitchen. He said that they have a list of residents who are at risk for spilling hot liquids in the kitchen that is updated regularly. He said that after the incident that occurred on 4/23/25 he was in-serviced on all facility policies regarding residents handling hot liquids, who was at risk, abuse, and neglect. During an interview on 7/16/25 at 9:29 a.m., the Director of Nurses said she expected that staff follow facility policy for hot liquids which would include coffee. She said that staff were to ensure that coffee was served only once it had cooled to 140F or below, staff were taking the accurate temperature of the coffee or hot liquid, residents that required lids have a lid, and that all staff were responsible to ensure that facility policy was followed. She said that residents could be placed at risk for burning themselves if facility policy was not followed. She said that they knew who was at risk because they complete risk assessments for all residents, their care plan was updated if they were at risk, and the individuals at risk were also on their Kardex system. During an interview on 7/16/25 at 9:37 a.m., the Administrator said, she expected that all her staff follow facility policy regarding hot liquids or hot coffee. She said that staff were to take temperature readings of the coffee before it could be served, and it should not exceed 140F. She said that residents should be assessed for risk of handling hot liquids and those at risk of potentially burning themselves should have a lid. She said that all staff were ultimately responsible for ensuring the policies were followed. She said that residents had the potential to burn themselves if the facility policy was not followed. She said that every resident in the facility is assessed for various risks which included hot liquid assessments. Record review of a facility policy titled, Hot Liquid/Food Spills dated 2003 indicated that, Residents are at risk of having any hot liquid/food spilled on their person causing bums. Examples of hot liquids/food are: coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance.If any staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. The charge nurse is to be immediately notified so that an assessment of the resident can be completed. The charge nurse will report any injury to the attending physician and responsible patty and follow any further physician orders. Staff will assist with changing of clothes as needed an incident report and investigation will then be completed and determine if the resident needs further interventions to prevent future occurrences. The Administrator was notified of an IJ on 07/15/25 at 12:09PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 07/15/25 at 5:04 PM and included the following: Whispering Pines Lodge 07/15/25 Plan of Removal Problem : F689 Accidents and Hazards. All residents in the facility that consume coffee were assessed by DON/ADON/Charge Nurse for any signs of injuries from a burn. No coffee burns were assessed. The completion date will be 7/15/25. [Resident #1's] hot liquid assessment was completed as of 7/15/25 by the DON. [Resident #1] was provided with a coffee cup with a lid by the DON as of 7/15/25. [Resident #1's] care plan was updated with the coffee cup as of 7/15/25 by DON.The resident will be provided with her own personal coffee cup with a lid on 7/15/25. Hot liquid Assessments were updated on all residents that consume coffee in the facility by the DON on 7/15/25. Residents at high risk for coffee burns were assessed for the need for assistive devices if consuming hot liquids by the DON/ADON/Regional Compliance Nurse on 7/15/25. Care plans were updated as of 7/15/25 by the DON/ADON/Regional Compliance Nurse. Dietary slips were updated with specialized interventions such as lids, or specialized cups needed for hot liquids 7/15/25 All thermometers in the facility used for coffee temps were replaced with new digital thermometers by the administrator to ensure accuracy. Completed on 7/15/25. The administrator, dietary manager, or designee will be responsible daily for ensuring the coffee temperature will be checked and reading within 135-140 degrees [Fahrenheit] and logged prior to serving to residents. Coffee will not be served until the temperature is between 135- 140 degrees. The coffee temps will be logged by dietary staff prior to serving. The dietary manager and administrator will be responsible for ensuring temps are checked and logged daily prior to serving. This process and monitoring will be initiated by the administrator and start 7/15/25 The medical director was notified of the immediate jeopardy on 7/15/25 by the administrator. Residents will have access to coffee after it has been verified that the temperature is between 135-140 degrees. The coffee will be placed in the dining room for serving. The Dietary department and Administrator will be responsible for ensuring the temperatures are in range prior to serving. Start date 7/15/25 In-services: The ADO will in-service the Administrator and Dietary Manager 1:1 on the following topics on 7/15/25. Completion date will be 7/15/25. Abuse and Neglect- serving coffee above 140 degrees could result in neglect and cause injury to a resident. All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served at over 140 degrees. All brewed coffee will have the temperature logged before serving by dietary staff or designee. Hot liquid Spills Policy- Residents are at high risk for hot liquid spills. This policy explains the procedure following a hot liquid spill on a resident. Guidelines on serving coffee in a nursing facility policy- coffee will be served at temperature between 135- 140 degrees. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. Following care plans/interventions for residents requiring hot liquid interventions. The following in-services were initiated by Administrator, DON, ADON, on 7/15/25 for all staff. Any staff who are not present or in-serviced on 7/15/25, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced in orientation. All PRN and agency staff will be in-serviced prior to assuming shift. Completion date will be 7/15/25. Abuse and Neglect- serving coffee above 140 degree could result in neglect and cause injury to a resident. All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served at over 140 degrees. All brewed coffee will have the temperature logged before serving by dietary staff or designee. Hot liquid Spills Policy- Residents are at high risk for hot liquid spills. This policy explains the procedure following a hot liquid spill on a resident Guidelines on serving coffee in a nursing facility policy- coffee will be served at temperature between 135- 140 degrees. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. Following care plans/interventions for residents requiring hot liquid interventions. The surveyor verification of the Plan of Removal from 07/15/25 was as follows:During an observation on 7/16/25 at 7:57 a.m., it was observed that the Dietary Manager was temping the coffee in the kitchen. The dietary manager added ice until the coffee reached 116 Fahrenheit using a digital thermometer. He stated that they were not going to leave coffee out for anyone to get and that residents would need to ask for the coffee to be poured for them by the kitchen staff to ensure that no one received coffee that was too hot to be served. During an observation on 7/16/25 at 8:10 a.m., a walkthrough of the facility was completed and residents who were considered at risk had lids on their coffee cups. Resident #1 was observed with her own cup that had a tight fitting lid that she could drink her coffee from.During an observation on 7/16/25 at 8:15 a.m. Resident #1 was observed using her special cup for coffee with a lid on.Record review of five facility meal tickets with residents who were at risk for handling hot liquids on 7/15/25 at 11:23 a.m., revealed that residents who were at risk for handling hot liquids were notated on their meal ticket and it instructs dietary staff to place a lid on their coffee. During an interview on 7/16/25 at 9:00 a.m. the Dietary Manager stated that they had new digital thermometers so they could have more accurate readings rather than using the analog thermometers with the 5-degree hashmarks. He said that coffee would be given to residents when they asked kitchen staff, and a cup would be poured for them to ensure that no one received a cup of coffee that was over 140F.Record review of an undated AD Hoc (Spontaneous) QAPI Contributors sign in sheet revealed the Administrator, Director of Nurses, Medical Director, Dietary Supervisor, Activity Director. Record review of the facility's assessments of all residents revealed which residents were at risk of spilling hot liquids. Assessments were completed on 7/15/2025 by the DON and care plans were updated to reflect their risk for hot liquids.Record review of Resident #1's meal ticket dated 7/14/25 revealed that her ticket stated, SPECIAL CUP FOR COFFEE!!!! SPECIAL CUP FOR HER COFFEE REQUIRES LIDDuring interviews from 7/14/25 at 12:38 p.m. to 7/16/25 8:29 a.m. the following staff were interviewed: the Social Worker, Director of Nurses, Administrator, Assistant Director of Nurses, Dietary Manager, MDS Coordinator, Patient Care Coordinator, Activity Director, Dietary Aide A, LVN B, CNA C, LVN D, CMA E, Dietary Aide F, Dietary Aide G, CMA H, CNA I, Dietary Aide J, CMA K, LVN L, LVN M, LVN N, CNA O, RN P, CNA Q, LVN R, Dietary Aide S, Dietary Aide T, Certified Occupational Therapist U, Dietary Aide V The staff interviewed worked across various shifts including days, evenings, and nights. All staff said they were in-serviced on the Hot liquid Spills Policy, Guidelines on serving coffee in a nursing facility policy, and Abuse and Neglect. The dietary staff were able to articulate that coffee should not exceed 140F, to cool coffee down by using ice until it was below the 140F threshold. The dietary staff were in-serviced that dietary slips would notate if a resident was at risk for spilling hot liquids, abuse and neglect, and to log the temperature of coffee when it was made available to be given to residents. All other staff were able to articulate their in-service training on abuse and neglect and who to report to if they found that a resident had a burn, that 140F was the maximum temperature coffee could be served at, at risk residents needed a lid on their coffee, where to find which resident was at risk, and that each residents meal ticket would indicate if they had a special intervention for hot liquids. On 07/16/25 at 08:47AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents. (Resident #1). The facility did not prevent Resident #1, who resided on the secured unit, from leaving the facility unsupervised on 03/13/2025. Resident #1 was found at a local hospital emergency room where he had been taken by local police. The facility was not aware the resident was missing for approximately 4 hours until staff went to get him for his evening meal. The noncompliance was identified as PNC (past noncompliance). The IJ began on 03/13/2025 and ended on 03/14/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death. Findings included: Record review of a face sheet on 03/28/2025 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including: stroke, dysphagia (difficulty swallowing), alcohol abuse, cocaine use, and impaired cognitive function. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had clear speech, usually understood others and was usually understood, he had a BIMS score of 06 indicating severe cognitive impairment. He had a behavior of wandering daily. He required partial assistance with ADLs and could feed himself. He was incontinent of bladder and frequently incontinent of bowel. He was independent with mobility and walking unassisted. He had a feeding tube and also ate a mechanically altered diet. Record review of care plans for Resident #1 indicated he had a care plan initiated on 12/23/2024 and revised on 01/22/2025 indicating he was at risk for wandering. Goals included: The resident will not leave facility unattended and the resident's safety will be maintained through the next review period. He had another care plan initiated on 12/23/2024 and revised on 01/22/2025 which indicated he was at risk for elopement and required a secured unit. Care plan goals included: Will remain safe within the facility unless accompanied by staff or other authorized person through the next review date. Interventions included: Supervise closely and make regular compliance rounds whenever resident is in room. This care plan was updated on 03/14/2025 and indicated he had eloped from a window in an empty room on the secure unit and a new intervention initiated on 03/13/2025 indicated 1:1 monitoring was in use. Review of Resident #1's Progress Notes in the electronic record indicated the following: Notes dated 12/22/2024 at 1:20 PM indicated resident goes from room to room rummaging attempting to find something to eat. He takes other resident's clothing and packs and goes to the doors and attempts to leave.; Notes dated 12/30/2024 at 4:44 PM Resident continues to pace up and down the halls. He goes in and out of rooms taking food and other items. Resident must be monitored closely. Packs up his belongings and attempts to exit.; Notes dated 01/18/2025 at 11:50 AM Resident is extremely restless this shift. He is pacing the hallway and going in and out of other resident's rooms. Demanding to go home. Says he will walk if he has to. Not accepting direction well Interventions: Talked with him and explained his need for care at this point in his life. Talked about it being the winter season and bad weather expected.; Notes dated 1/19/2025 at 11:07 AM Resident continues the same behavior pattern as last shift. He is pacing up and down the hall and going in and out of other resident's rooms. Does not accept direction well. Is insistent that he is going home. Has packed his belongings and carried them with him in the hall. He has called his niece several times over the past two shifts. He does not get an answer. This nurse has left a message with the niece the last two shifts letting her know the resident wishes to speak with her if she has the time to call him. At this point, no return call. This nurse has advised the resident that he may speak with the social worker and/or administrator on Monday when they are in the facility regarding his wish to leave the facility. Resident is calm and accepting of that information at this time.; Progress notes continued with entries on 01/21/25 at 10:45 AM, 02/01/25 at 1:49 PM, 02/13/25 2:46 PM, and 02/21/25 9:51 AM regarding pacing and packing of clothes and wanting to go home; Progress Notes dated 2/28/2025 at 2:16 PM It was reported to this nurse just now that resident took the window alarm apart in room [ROOM NUMBER] yesterday (2-27-25). As I was just made aware I immediately reported it to the facility administrator. Resident was just in the room across the hall from his (room [ROOM NUMBER]) taking clothing that belongs to another resident from the closet. He also pulled the call light cord out of the wall and put it in his bag that he packs and carries around. Resident was directed into his own room and educated about taking other resident's belongings. He will not accept the direction. During an interview on 03/28/2025 at 9:25 AM, the DON said she was on vacation the week Resident #1 eloped from the facility and her ADON was the person the staff reported the incident to. She said Resident #1 had been transferred on the morning of 03/14/2025 to an inpatient psychiatric facility out of state. She said he had returned to the facility on the evening of 03/27/2025. She said he was on 1:1 monitoring before he transferred and was placed on 1:1 monitoring when he returned. During an interview on 03/28/2025 at 10:10 AM CNA A said she worked the memory care unit from 6AM-6 PM. She said she checked residents every hour to see if residents were in their rooms they are assigned to. She said residents wander in and out of each others rooms sometimes. She said they have to make sure every resident was present on the secure unit. She said she was working the day Resident #1 eloped. She said she saw him at lunch. She said lunch was over a little before 1:00 PM and she was going to start her showers assigned. She said Resident #1 was in front of the linen closet and she had to ask him to move so she could get towels for the showers. She said there was an LVN assigned to the unit but did not know if she was on the unit at the time of the elopement. She said the charge nurse came on and off the unit. She said she finished her showers about 2:00 PM. She said while in the shower area she could not hear anything happening on the unit. She said after the showers she was sitting at the dining room door where she could see the dining room residents and the hallway. She said there were 4 residents in the dining room that were almost 1:1 because they tended to stand and fall. She said she assumed Resident #1 was in his room taking a nap because that was what he usually did after lunch. She said Resident #1 did go in and out of other rooms and rummaged in the closets and drawers of other residents at times. She said it was about 4:30 PM and close to supper time and she went down to his room to bring him to the dining room. She said Resident #1 lived in room [ROOM NUMBER] and was not in his room. She said she opened the closed door on unoccupied room [ROOM NUMBER] and found the window broken. She said she immediately reported the broken window to the ADON. She said staff began an immediate sweep of the secure unit and Resident #1 was not found. She said Resident #1 was on 1:1 monitoring before he was transferred to the inpatient psychiatric facility. She said he had returned to the facility on [DATE] and had a staff member assigned to sit in the room with him 1:1 and document where he was and what he was doing every 15 minutes. She said he had been asleep most of the morning except he did get up and eat breakfast. During an interview and observation on 03/28/2025 at 10:45 AM, CNA B was sitting in room [ROOM NUMBER] at the foot of Resident #1's bed. Resident #1 was observed covered with a sheet and sleeping. She had a clipboard with log sheets with a check list for every 15 minute checks. She said they started the checks immediately upon Resident #1's return to the facility. She said she started her tour at 8:00 AM. She said the observation and documentation was to continue until they were told to stop. She said he had been sleeping except for getting up to eat breakfast. The toilet tank lid in the bathroom was secured with 2 zip-ties (0.25 wide) to keep the lid from being removed. The thumb locks and window alarms were present and intact on the window. During an observation on 03/28/2025 at 11:05 AM room [ROOM NUMBER] window secured with alarm and thumb locks. room [ROOM NUMBER], across the hall, window had been replaced and was secured with alarm and thumb locks. During an observation on 03/28/2025 at 11:06 AM the glass exit door at the end of the hall (adjacent to rooms [ROOM NUMBERS]) was observed to be a fenced in patio area for the secure unit's use. A construction site for homes being built was observed across the street with workmen present along with their personal vehicles. During an interview on 03/28/2025 at 11:10 AM CNA C said she had worked on the secure unit as well as other halls in the facility. She said she worked mostly the day shift (6AM-6PM). She said she was not working the day Resident #1 eloped. She said he had tried to leave through the doors on occasion but was always re-directed by staff. She said she had never seen him take any object and try to break the glass door or windows. She said when 2 aides are on the unit, while one is doing her showers the other one aide was on the hall and then they switch so the other aide can do her showers. She said when they had a nurse on the unit instead of an aide the nurse stayed on the hall while the aide did her showers. She said between breakfast and lunch she usually checked where residents were twice and then after lunch until supper she checked for residents 2-3 times. During an interview on 03/28/2025 at 11:20 AM the ADON said she had been the ADON for almost 3 years. She said she did not remember exact times but on 03/13/2025 CNA A told her Resident #1 was gone. She said it was about supper time. She told her the window had been broken out in room [ROOM NUMBER] on the secure unit. She said the toilet tank lid in room [ROOM NUMBER] had been placed neatly on the floor under the window and was not broken. She said they did an immediate head count in the general population areas of the facility and in the secure unit. Resident #1 was the only resident missing. She said she had staff start searching the grounds on foot and in cars while she notified the administrator, the medical director and the police. She said no one found the resident and when talking with persons living in the area no one had seen anyone fitting his description. She said there were no people or vehicles at the construction site at the time of the search. She said the first officer that responded made a tour in his vehicle around the immediate area. She said the second officer that responded recognized the resident from the picture provided. He said he was at one of the local hospitals. She said the medical director had called both hospitals to see if Resident #1 had been admitted and he had not been admitted . She said the police department had taken him to one of the hospitals and he was not admitted but still in the emergency room . She said the facility picked the resident up from the hospital and returned him to the facility. She said he was placed on 1:1 monitoring until he was transferred to inpatient psychiatric hospital the next day. She said the resident was assessed upon his return and he had no injuries other than 2 small scratches on his fingers. She said she had scheduled staff for 24-hour coverage to monitor Resident #1 through the weekend and would begin searching for coverage for Monday if it was needed. She said she was directed to schedule 1:1 monitoring and continue until she was told to stop. She said the facility was trying to secure alternate placement at the time. She said the usual rounding pattern was every 2 hours to account for residents. She said the expectation now was to make rounds and head count every 1 hour. She said all staff have been inserviced on elopement risk, elopement prevention and elopement drills have been conducted. She said she was told after the elopement Resident #1 knew how to remove the thumb locks and disable the window alarms. She did not say who told her this information. During an interview on 03/28/2025 at 12:25 PM the RN Compliance Nurse came to the facility when Resident #1 was reported missing on 03/13/2025. She said the ADON notified her at 5:09 PM. She said an administrator at another facility called and said Resident #1 was at the hospital. She said to her knowledge she did not know Resident #1 could disable the window alarms and remove the thumb locks on the windows. She said she saw the broken window and the toilet tank lid was placed under the window and was unbroken. During an interview on 03/28/2025 at 12:40 PM CNA A said she told the office (DON, ADON, Administrator) Resident #1 knew how to disable the alarms and knew how to undo the window thumb locks. She said she had seen him peel off the window alarms in one room and put it in his sock. She said she did not remember exactly when she told them but it had been a while ago. She said maintenance came every so often and checked the windows for the alarms and thumb locks. During an interview on 03/28/2025 at 12:45 PM the DON said she had never been told Resident #1 could disable the alarms and thumb locks on the windows. During an interview on 03/28/2025 at 12:50 PM the former administrator said she was informed Resident #1 was missing from the facility at 5:02 PM on 03/13/2025. She said at the time no one knew how long he had been gone from the facility. She said no one told her the resident knew how to disable the alarms on the windows and remove the thumb locks. She said the resident was found at the hospital where he had been taken by the police department at around 1:10 PM. She said the resident had got inside a pickup truck at a nearby construction site and the owner had called the police. She said she had put in her 30-day notice on 02/12/2025 and her last day had been 03/14/2025. She said before she left she made sure staff were inserviced on elopement and the toilet lids were secured. She said her expectation was to follow the facility policy on making rounds to check on residents but said the secure unit hall was short and took little time to round the hall. During an interview on 03/28/2025 at 1:15 PM LVN D said she was charge nurse for the secure unit and another hall the day Resident #1 eloped. She said she saw Resident #1 walking down the hall after lunch. She remembered he was wearing a gray shirt and gray pants. She said at that time he did not appear to be exit seeking, just going toward his room after eating lunch. She said she had just been on the unit for 2 days so did not know all the residents really well. She said around supper time she was notified the resident was missing. She said the facility was immediately searched. She said she was off duty but still at the facility when the resident returned, and he was placed on 1:1 monitoring. During an interview on 03/28/2025 at 3:05 PM the RN Compliance Nurse said the facility did not have a specific policy on making rounds on residents at the facility. She said after the elopement the expectation was to monitor every hour. She said initially there was a head count every 15 minutes from the evening of 03/13/2025 until the morning of 03/14/2025 when Resident #1 was transferred to the inpatient psychiatric facility. She said then the checks were to be made every hour on all residents. She said window checks were also done every hour to make sure they were intact. She said that has continued while he was gone and when he returned on 03/27/2025. She said the every hour rounding would continue until Resident #1 discharged . She said at the time of the elopement all residents in the facility were assessed for elopement risk and any resident that was high risk had their care plans updated with new interventions is needed. During interviews on 03/29/2025 at 10:30 AM CNAs A and C said they had been trained to check on residents every hour until they are told to stop. They said they had been trained on elopement risk and elopement protocol. CNA A said Resident #1 had been discharged from the facility around 6:00 PM on 03/28/2025. During observations on 03/29/2025 beginning at 10:40 AM the secure unit windows were all intact with alarms and thumb locks. All toilet tank lids were secured with 2 zip-ties. Residents asleep in bed were noted to have fall mats on the floor at bedside and beds were in the lowest position. A review of the facility investigation report indicated the incident occurred on 03/13/2025 and was reported to the state agency on 03/13/2025. Resident #1 was last seen at 12:54 PM on 03/13/2025 after lunch. He was reported missing at 5:02 PM. Resident had used toilet tank lid to break window in room [ROOM NUMBER]. Resident was seen getting into a pickup by construction worker and police was called. Police picked up resident around 1:11 PM and taken to a local hospital emergency room . Resident returned to facility at 6:20 PM with no injuries noted. Resident placed on 1:1 monitoring until transferred to inpatient psychiatric facility for further evaluation on 03/14/2025 at 10:45 AM. Review of typewritten note of previous administrator dated 03/13/2025 indicated she was notified of Resident #1's elopement by the ADON. She indicated the window had been broken with the toilet tank lid. Immediate search of the facility and grounds began and police were notified at 5:06 PM. Resident returned to facility at 6:20 PM. Resident on 1:1 monitoring, elopement risk assessments done, skin assessment done, all toilet lids were secured on secure unit, broken window was secured and hourly checks on residents and windows begun. Local police department informed former administrator Resident #1 was picked up at 1:11 PM. Former administrator went to construction site and found [NAME] who confirmed a black man had gotten into his pickup and he had called the police. Review of a handwritten statement dated 03/13/2025 the speech therapist had completed lunch observations and therapy with Resident #1 around 12:20 PM. The therapist continued therapy swallowing precautions training with the resident. Resident #1 was left in dining room after therapy session. Review of a handwritten statement dated 03/13/2025 indicated LVN D saw Resident #1 at approximately 12:54 PM Review of a handwritten statement dated 03/13/2025 indicated the occupational therapist returned Resident #3 (roommate) to his room about 3:30 PM and Resident #1 was not in his room. Review of handwritten statement dated 03/13/2025 CNA A indicated after picking up lunch trays around 12:50 PM she saw Resident #1 in front of the linen closet and asked him to step away so she could get some towels for showers. She thought she saw him later in the afternoon with a group of residents by the glass exit door. She said when searching rooms looking for him she found the broken window and reported him missing. Review of facility Elopement Prevention Policy dated 10/27/2010 indicated Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts.keypad exit magnetic locks, secured unit, .3.All exit devices will be maintained by the manufacturer's recommendations and function of each door device will be verified weekly and a log maintained. Staff Training: Staff will receive training during their orientation process and then annually regarding: elopement prevention, operation of all exit devices, and actions to take if elopement occurs. Review of facility Elopement Response Policy dated 10/27/2010 indicated Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.4. Should an employee discover a resident is missing from the facility, he/she should: A. report to the charge nurse .C. make a thorough search of the building and premises. If not located: D. notify Administrator and Director of Nursing; E. notify responsible party; F. notify attending physician; G. notify . Area Director of Operations . Facility took the following actions to correct the noncompliance prior to surveyor entrance: Review of documentation of training of all staff conducted beginning 03/13/2025 after the elopement for Elopement Prevention, Elopement Response, Abuse and Neglect. Review of electronic records indicated all residents were assessed for elopement risk on 03/13/2025. Elopement risks were identified and updated if necessary due to increased need for observation. Care plans were updated as necessary with additional interventions. Review of documentation beginning 03/13/2025 and ongoing for head count on residents every hour. Resident #1 and other secure unit residents on every 15 minute checks beginning 03/13/2025 at 6:30 PM and continuing until 03/14/2025 at 10:45 AM when Resident #1 discharged to inpatient psychiatric facility. Elopement drills to be conducted monthly on different shifts and random hours of the day. Review of elopement drill documentation indicated drills had been done. Surveyor verified the facility had corrected the noncompliance prior to survey entry through observations, record reviews and interviews.

Based on observation, interview, and record review the facility failed to ensure a resident had the right to be treated with dignity and respect and free from physical restraints for 1 of 3 residents (Resident #1) reviewed for resident rights. CNA D said she restrained Resident #1 on three occasions during the last month or so. She said about a month ago she had swaddled Resident #1 with a blanket by folding a blanket around Resident #1 to restrict her movements. CNA D said she had swaddled Resident #1 on the night of [DATE] to calm her down. On the morning of [DATE] CNA D said around 3:15 a.m. she had used a pair of leggings and tied Resident #1's legs to the bed to keep her from getting out of bed. Resident #1 was tied to the bed from 3:15 a.m. until around 8:00 a.m. on the morning of [DATE]. An IJ was identified on [DATE]. The IJ began on [DATE] and was removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on physical restraints, behaviors, fall prevention, and resident rights. This failure placed residents at risk of entrapment with serious injury or death. Findings included: The surveyor entered the facility on [DATE] at 1:15p.m. Record review of Resident #1's face sheet dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Huntington's Disease (disease that caused nerve cells in the brain to gradually break down-causing cognitive, psychiatric, thinking, and movement disorders), schizoaffective disorder ( mental health condition with mixed symptoms of hallucinations, delusions, mood disorders such as depression, or mania), anxiety disorder, and history of falling. Record review of Resident #1's significant change MDS dated [DATE] indicated she had long and short-term memory loss. She was not coded for any behaviors. She required supervision for eating and was dependent on staff for all other ADLs. Record review of Resident #1's care plan last revised on [DATE] indicated a Focused area of at risk for falls due to Huntington's Disease secondary to movement disorder. Some of the interventions were the resident was to be on a low bed with mattress on the floor beside her bed. The resident was able to and did crawl out of bed onto the mattress by herself. The resident needed activities that minimize the potential for falls while providing diversion and distraction. A Focused area of communication barrier secondary to Huntington's Disease. A Focused area of potential to demonstrate physical behaviors due to her poor impulse control such as crawling on the floor. Throwing her legs over the side of the bed, spastic movements caused her to come out of her bed or hit herself unintentionally. Some of the interventions were when the resident became agitated to intervene before the agitation escalated. Record review of Resident #1's active orders as of [DATE] indicated an order for a fall mat to floor at bedside dated [DATE]. An order that indicated she may have a scoop mattress to help establish bed boundaries dated [DATE]. An order dated [DATE] that indicated to admit to hospice. Record review of Resident #1's nursing notes dated [DATE] at 8:15 a.m. indicated Resident #1 was noted with legs tied together with a pair of leggings and tied to the bed. There was no signs and symptoms of distress noted. Investigation in progress. Signed by the ADON. Record review of Resident #1's Weekly skin check dated [DATE] indicated the resident had discoloration on her left and right arms. She had multiple scabs on her legs. Signed by treatment nurse. Record review Resident #1's Trauma Informed assessment dated [DATE] indicated the resident had a mental disorder and the questions were asked of the resident or responsible party. The assessment indicated they recently felt angry. Record review of CNA D's Proficiency Audit dated [DATE] indicated she had knowledge of the Abuse and Neglect Protocol. Record review of CNA D's personnel file indicated she began working at the facility on [DATE]. Her transcript details indicated she had a training on [DATE] regarding Creating a Restraint Free Environment, Fall Prevention, Preventing, Recognizing, and Reporting Abuse, and Essentials of Resident Rights. Record review of an in-service dated [DATE] regarding abuse and neglect indicated CNA D signed the training roster indicating she had received abuse training. Record review of a statement written and signed by CNA D indicated she said on the night of [DATE] she was taking care of Resident #1 and she took her leggings she was wearing off. She then tied one leg to the strap of the bed and put the other one through her legs. She stated she tied it to her gown to keep her from jumping out of the bed and hurting herself at about 3:15 a.m. She dated the statement [DATE]. She wrote another statement dated [DATE] that indicated in the past Resident #1 had two beds placed together and she kicked the mattress of the second bed and jumped on the metal frame. She put her back in the bed and she did it again. The aide wrote, So I swaddled her with blankets and she calmed down and went to sleep. During an interview on [DATE] at 2:06 p.m. RN A said she was on the unit working with a resident on the morning of [DATE]. She said CNA C came to her and said Resident #1 was tied up with a blanket or something to the bed frame. She said she told CNA C to get the ADON, because she was busy at that time. RN A said she did not actually see Resident #1 tied to the bed. She said Resident #1 had Huntington's with involuntary jerking movements of the arms and legs, and limited communication. RN A said Resident #1 communicated with gestures, was easily frustrated, and she could not walk. She said she did not know a lot about the incident as she was not really involved. During an interview on [DATE] at 2:10 a.m. CNA B said she heard Resident #1 was tied to the bed, but she did not see anything. She said she had written a statement saying she had not seen Resident #1 or any other resident restrained. During an observation and interview on [DATE] at 2:18 p.m. the ADON/LVN said CNA C called her to Resident #1's room. The ADON said when she arrived in the room Resident #1 had a pair of leggings (stretch pants) wrapped around her legs. She said Resident #1 had abnormal movements and it was hard to tell what was going on. The ADON said she first thought the pants were just pulled down until she looked closer. She said the leg part was wrapped around her leg and other leg was tied to the bed. She said the bed had straps that were used to keep the low air loss mattress in place. The pants were tied to the one of the bed straps at the foot of the bed. She said she had spoken with CNA D later and she said she did not want Resident #1 coming out of the bed. The ADON said the facility Administrator called the police, reported the incident, and suspended the aide. The ADON had a picture of Resident #1's legs tied to the bed. Review of the picture showed a black pair of pants wrapped around and through Resident #1's legs. The left leg looked like it may have still been in the appropriate pant leg. The other pant leg looked to be wrapped around the right leg and then tied to a strap on the side of the bed. The left side of the pants were below the knee, and the right side was at the knee joint. During an interview on [DATE] at 2:32 p.m. CNA C said on the morning of [DATE], she clocked in at 7:00 a.m. She said she had just finished passing trays, and she made Resident #1 her last resident because she required assistance with eating. CNA C said she was trying to assist Resident #1 to get up for her breakfast about 8:00 a.m. to 8:15 a.m. When she tried to get Resident #1 out of bed she could not. CNA C said Resident #1 ate her meals in her chair. She said Resident #1 could feed herself but must have staff to watch her. She said she could not get the resident out of bed and looked to see what was going on. CNA C said it looked like some pants wrapped around Resident #1's leg, connected to her leg somehow and tied to the bed. CNA C said she tried to untie the pants and she started to panic because she could not untie them. She said she had gotten the Housekeeper to come in and witness what was going on. She said she had gone and reported to RN A. She said RN A told her to report it immediately to the ADON. CNA C said the ADON came in and it took her a while to get Resident #1 untied. She said she did not know if Resident #1 was agitated or just having involuntary movements but she would not be still so she could be untied. CNA C said she came on shift and worked behind CNA D who was on the hall the night before. She said that was the first time she had seen any resident tied or restrained. She said Resident #1 would get agitated, she would crawl out of the bed, and she would jerk and move about. She said Resident #1 was mad and panicking because she could not get her up that morning. During an interview on [DATE] at 2:40 p.m. the Administrator, said she was notified by the ADON about 8:15 a.m. today, [DATE] of the incident. The Administrator said when she was notified Resident #1 was already untied. She said she was told CNA C found Resident #1's legs wrapped in a pair of pants or leggings and tied to the mattress. She said they had investigated and determined CNA D was the perpetrator. She said she called CNA D back to the facility and she had written statements. The Administrator said CNA D's justification for tying Resident #1 to the bed was, she had worked with a Huntington patent before, and they had fallen and died . The Administrator said CNA D said she was only trying to protect Resident #1 from hurting herself. The Administrator said they did a skin assessment, a pain assessment, the SW did a trauma informed assessment on Resident #1. She said they called the police and the family member. The Administrator said she had called the incident into the State this morning and they had started to conduct skin assessments on all the residents in the building and were in the process of interviewing all staff to determine if they had ever seen any type of restraint. She said they were doing safe surveys with all interview able residents to determine if any abuse was identified. She said they had also started in services. During an interview on [DATE] at 3:08 p.m. the DON said she was informed Resident #1 had been tied to the bed. She said she did not see the restraint, it had been removed when she arrived at the facility on today, [DATE]. She said she was present for the interview with CNA D who said she had tied Resident #1 to the bed because she was scared for Resident #1's safety. The DON said the aide told them Resident #1 was getting out bed, and her behaviors appeared worse on the night of [DATE] going into the morning of [DATE]. During a telephone interview on [DATE] at 3:14 p.m. CNA D said when she arrived at work on of [DATE] at 6:00 p.m. Resident #1 was agitated, she was hollering out, and could be heard at the nursing station. She said she had asked the nurse to give her something because she was so agitated. She said LVN E refused and said it would be a chemical restraint. CNA D said about a month ago she had swaddled Resident #1. She said swaddling was like when you swaddle a baby. She said she took her blanket tucked it under Resident #1 on one side, and then wrapped her in the blanket and tucked it under her on the other side. She said she did that about a month ago when there was an issue with her being in a bed that was too high. She said at that time Resident #1 calmed down and went to sleep. CNA D said Resident #1 was fighting with her demons last night. She said on the night of [DATE] Resident #1 would not calm down. CNA D said at first, she had swaddle Resident #1. She said Resident #1 kept fighting and squirming around trying to get out of the bed. She said around 3:15 a.m. she had tied Resident #1 to the bed. She said she had gotten busy with another resident and had left the facility without checking on her. CNA D said she tied Resident #1 to the bed because she did not want her to hurt herself. She said she tied her loosely she could still move but not jump out of the bed. CNA D said she thought Resident #1's disease had gotten worse, she felt she had a bond with Resident #1 and could calm her down. She said on that day Resident #1 would not calm down and kept trying to jump out of bed. During an interview on [DATE] at 3:25 p.m. with the ADON she said that she had difficult time getting the pants untied from around Resident #1's legs. She said she would not cooperate. She had spastic movements, or she may have been struggling it was hard to tell. She said once she got one leg straightened out the other one was bent. She said it did not take her too long, but it was not easy. She said when she had gone in the room the bed was in the lowest position and there was a mattress on the floor. During an observation on [DATE] at 3:50 p.m. showed Resident #1's room had a bed in the lowest position. There were two mattresses on the floor lying next to the bed and at the foot of the bed was a fall matt. Observation of the bed showed all corners, and any surface of the bed was wrapped with tape and a pool noodle. Resident #1 was laying on two mattresses. Her head was on the bed, and she was stretched parallel across the mattress. She was drinking from a cup and was making gestures with the cup. She made noises but she did not communicate except for gestures. During an interview on [DATE] at 9:00 a.m. the Administrator said she had not gotten a statement from the LVN E, but LVN E said Resident #1 was not agitated on the evening on [DATE] going into the night of [DATE]. The Administrator said when she talked to the Responsible Party on the phone, they were upset about the situation. During an interview and observation on [DATE] at 9:30 a.m. CNA B (who was more familiar with Resident #1) tried to ask her questions. Resident #1 was observed on a mattress on the floor. Observation showed there was a mattress on both sides of the low bed. When CNA B asked Resident #1 if anyone had hurt her, she shook her head no. Observation showed Resident #1's left eye was dark and discolored. CNA B asked Resident #1 about being tied up but Resident #1's responses were grunts and noises. Resident #1 would hide her face in the mattress and not respond. During an interview on [DATE] at 10:07 a.m. the SW said Resident #1's Responsible Party was mad in the beginning at the individual. She said the Responsible Party was given the option of pressing charges if he wanted to. The SW said Resident #1 liked to interact, but not too much social stimulation. She said she went to talk to Resident #1 but was unable to have a conversation about the incident. During an interview on [DATE] at 10:23 a.m. the Housekeeper said on the morning of [DATE] around 8:00 a.m. she was asked by CNA C to look at Resident #1. She said she observed Resident #1 with legging tied around her legs and to the bed. She said the pants were tied to a rail strap on the side of the bed. She said Resident #1 was making noises, grunting, and struggling to get united, it appeared. The Housekeeper said CNA C could not get Resident #1 untied and had gotten the ADON to assist. She said she had been in serviced on restraints, abuse, neglect, and if residents have behaviors, report immediately. She said she had not seen any residents restrained prior to this incident. During an interview on [DATE] at 11:25 a.m. RN A said Resident #1 could not stand up unassisted. She said she had a hip fracture that did not heal properly prior admission. There were several falls documented and RN A said Resident #1 would throw herself on the floor. She said she was very impatient if no one was there when she wanted something she would crawl to get across the room to what she wanted. RN A said it appeared sometimes Resident #1 just preferred to be on the floor. She said they would put her in the bed, and she would immediately roll back out on purpose. She said Resident #1 should not have been tied up. She said Resident #1 had jerking movements and could have hurt herself with spastic movements and getting tangled up more. She said Resident #1 would throw her body and, got easily frustrated when she could not have her way. She said, she picture Resident #1 behaving like an animal stuck in a fence struggling to get free. She said she could have hurt herself in the struggle to get free. RN A said Resident #1 crawled out of her broad chair this morning, she was found with her feet on the chair and her body on the floor. During an interview on [DATE] at 11:39 a.m. CNA B said Resident #1 would try to stand on her own, and could do so by pulling up on something, but she was not steady. She said Resident #1 could stand while in her chair but not from the bed. CNA B said she would get out of her chair, by leaning forward and rolling out of the chair. She said if Resident #1 wanted to get across the room she would figure out a way to get to her drawer to get a snack. CNA B said Resident #1 was easily frustrated when things did not go her way. She said if she were tied to the bed and could not move like she wanted Resident #1 could become frustrated quickly. CNA B said they could not leave Resident #1 in chair unattended, but she often wanted to sit in the chair. She said she was in serviced on abuse, restraints, Huntington's, and resident rights. CNA B said she was not aware of any staff tying residents to the bed and she knew not to do such a thing. During a telephone interview on [DATE] at 1:05 p.m. a family member said they had known Resident #1 all their life and if she was in her right mind or able to voice her frustrations, she would have been very upset to be treated like an animal. The family member said Resident #1 would have been cursing and likely trying to fight. The family member said there was no way Resident #1 would have stood for that kind of treatment, she would have been very upset. The family member said they were upset when they heard about the incident. They were trying to give the perpetrator the benefit of the doubt but had concerns about how many other residents had she done that to. They also had concerns that may not have been the first time she had tied Resident #1 to the bed because the staff was too busy. The family member said Resident #1 could not say how she felt but if she could not be happy. During a telephone interview on [DATE] at 3:36 a.m. LVN E said at the beginning of the shift on [DATE] at 6:00 p.m. Resident #1 was in her bed. She said when she passed the room her face was toward the door, and she appeared to be fine. LVN E said there was one mattress on the floor and the bed was in the lowest position. She said Resident #1 was not hollering or screaming. LVN E said CNA D did not come to her at any time during the night. She said Resident #1 was on hospice and she had as needed medications for anxiety. LVN E said if the resident had exhibited anxiety symptoms she would have given her medications as ordered. LVN E said she never saw Resident #1 swaddled, and she had no idea Resident #1 was tied to the bed. LVN E said the idea of her being tied up broke her heart. She said Resident #1 hurt herself all the time, by swinging her arms and legs around. She said sometimes she would hit herself in the face. LVN E said Resident #1, or anyone could hurt themselves worse by being tied up. She said she worked from 6p to 6 am and had a whole stack of in services on abuse and reporting, Huntington's disease, resident rights. She said she knew no one was to be tied to the bed. During an interview on [DATE] at 10:10 a.m. Resident #1's Responsible Party said the Administrator told him staff responsible for tying Resident #1 up was going to be fired. The Responsible Party said it was saddening and upsetting that someone would do that to a disabled person. The Responsible Party said Resident #1 had a cracked hip from 4-years ago, and it was not fixed, and she could not stand. The Responsible Party said if the staff did not want to be bothered, they did not have to tie Resident #1 up. He said the staff should consider their self-lucky that Resident #1 could not get up and untie herself. He said several years ago before her disease progressed, she would have wanted to fight that person for tying her up. The Responsible Party said it was hard to tell if Resident #1 had any reaction to the incident. They said they felt Resident #1 kind of clung to them more on that day. The Responsible Party said Resident #1 still had her mind but was unable to communicate. They said the most Resident #1 could do was roll out of bed and crawl all over the floor. The Responsible Party said she could pull herself up with the assistance of the chair. The Responsible Party said they tried to be sympathetic towards the person that treated Resident #1 that way, but that person did not take into consideration how his felt being tied down like she was not a human. The Responsible Party said for someone to tie Resident #1 up it took time, they would have had to tie the good leg first if not she would have kicked them. The Responsible Party said they were having a hard time dealing with the issue because they could only think that was not the first time the alleged perpetrator had tied Resident #1 up. The Responsible Party said that person should never be allowed to work in the healthcare field again because they may treat other residents the same way. The Responsible Party said staff should not tie someone up because they did not want to be bothered. Record review of the facility policy on Restraints revised [DATE] indicated it was the policy to ensure that residents are free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. Physical restrains are defined as any manual method or physical/mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restrict freedom of movement or normal access to one's body. Physical restrains include, but are not limited to leg restraints, arm restraints, that the resident cannot remove. Physical restraints for behavior control shall only be used in an emergency which threatens to bring immediate injury to the resident or others. Practices that are not to be used bed rails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. Tucking sheets so tightly that a bed bound resident cannot move. The facility had suspended CNA D and started putting corrective actions in place on [DATE] when the surveyor entered the building. They conducted skin assessments on Resident #1 and all residents in the facility. They conducted safe surveys on all interview able residents. They interviewed all staff to determine if any had noted any abuse or restraints in the facility. The facility in-serviced staff on Resident Rights, Restraints, Trauma Informed Care, Behaviors, Fall Prevention, and Abuse and Neglect During an interview on [DATE] 4:15 p.m. the Administrator said they had put corrective measures in place to ensure this type of thing does not occur again. She said they were a restraint free facility and had no idea why the staff member would tie Resident #1 to the bed. The Administrator said that she was infomed of the incident at 8:15 a.m. and immediately began to investigate. She called CNA D back to the facility and called the police. She said she suspended CNA D before she called the incident into the state agency into the State Agency around 10:00 a.m. on [DATE]. She said they had initiated skin assessments on all residents, safe surveys on interview able residents, initiated interviews with staff on restraints. She said they had in serviced on falls, behaviors, restraints, trauma informed care, abuse, and resident rights. The Administrator said they had suspended CNA D, and they were going to terminate her because the investigation was almost complete. She said the police had talked to CNA D, and said it was up to the family if they wanted to press charges. She said the family had not decided on what they wanted to do at the current time, but they did request a police report. Record review of CNA D's Employee Disciplinary Report dated [DATE] indicated she was placed on investigator suspension due to allegations of resident mistreatment. Record review of the facility Provider Self Reporting of Incidents indicated the Administrator was informed of the incident on [DATE] at 8:15 a.m. The State reporting system indicated they were notified at 10:04 a.m. on [DATE]. Record review of a payroll input /personnel action form for CNA D indicated she was terminated effective [DATE]. Record review of an in-service training dated [DATE] indicated training was provided to facility staff on the facility restraint policy. Record review of an in-service training dated [DATE] indicated staff were trained on Huntington's Disease with an attachment from the Mayo Clinic which indicated Huntington's Disease usually caused movement disorders. Movement disorders that cannot be controlled called Chorea. Chorea are involuntary movements affecting all muscles of the body, specifically the arms, legs, face, and tongue. Symptoms include involuntary jerking or writhing movements, muscle rigidity or contracture, slow eye movement, trouble walking or keeping posture and balance and trouble with speech or swallowing. Record review indicated an in-service conducted on [DATE] indicated staff were educated on Behavior management. Review of the attached Behavior Management Policy dated [DATE] indicated Behavior management included the management of anger, confusion and other behaviors that be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, or unmet needs. The utilization of physical restraints by a physician order only. Record review indicated facility staff were in-service was conducted on [DATE] on Fall Prevention Strategies, Trauma Informed Care and Abuse and neglect. Record review indicated facility staff were in-service dated [DATE] on Resident Rights dated [DATE] indicated the resident has the right to exercise their rights in the facility. the resident has a right to be treated with respect and dignity including: the right to be free from any physical or chemical restraints imposed for purpose of discipline or convenience and not required to treat the residents' medical symptoms. Record review witness statements indicated 41 staff had not seen any residents restrained all dated [DATE]. Record review of 22 resident safe surveys dated [DATE] revealed there were no concerns regarding restraints. Record review of Weekly Nursing Skin Checks dated [DATE] indicated all residents had skin assessments completed with no suspicious areas noted. Interviews were conducted with 4 CNAs and 3 LVNs, from [DATE] at 10:45 a.m. to [DATE] at 3:36 p.m., who were knowledgeable about the facility abuse policy and the restraints policy. They said they were in serviced on resident rights and when a resident said no that means do not force the resident to do something they did not want to do. They were in-service on the facility policy on restraints, behaviors, Huntington's, fall prevention, and resident rights. Those interviews are as follows. During an interview on [DATE] at 10:45 a.m. LVN F said he had received in services on Huntington's, restrains, abuse, trauma, behaviors, and resident rights. He said they were informed how residents may react, what are appropriate things to do, do not tie up a resident, give medications or speak with the doctors. During an interview on [DATE] at 2:20 p.m. CNA G said she worked from 7:30 a.m. to 3:30 p.m. as a restorative aide. She said she had in- services on abuse and neglect, restraints, Huntington's, behaviors, falls, and resident rights. She said she had not seen anyone tied up and that she knew better than to tie someone up. During an interview on [DATE] at 2:23 p.m. CNA K said she worked 6a to 2p. She said she had in- services on abuse and neglect, restraints, Huntington's, behaviors, falls, and resident rights. She said she had not seen anyone tied up and she knew better than to tie someone up. During an interview on [DATE] at 2:24 p.m. LVN H said she was she had in services on [DATE] but it was not over anything she did not already know. They had in-services on behaviors, falls, do not tie anyone up, and abuse. During an interview on [DATE] at 2:27 p.m. MA/CNA I said she worked from 6 a to 2p and on occasion would work 2p to 10 p. She said she had not seen anyone restrained and she would report it if she did. She said they had been in serviced on [DATE] about abuse, neglect, falls, behaviors, restraints, and Huntington's. During an interview on [DATE] at 2:30 p.m. CNA J said she worked from 6a to 6p. She said she was in-service on resident rights, and abuse. She said she knew you could not hit residents or tie them up. She said she had never seen anyone restrained. She was also in served on falls, restraints, Huntington's disease, and behaviors. During a telephone interview on [DATE] at 3:36 p.m. LVN E she worked from 6p to 6a and had a whole stack of in services on abuse and reporting, Huntington's disease, resident rights. She said she knew no one was to be tied to the bed. During an interview on [DATE] at 3:53 p.m. the facility Corporate Nurse said they were not going to allow CNA D to return to work, she had been terminated. She did not know how long it took the corporate HR to have the information in the system, but CNA D no longer worked for the facility. The immediate Jeopardy was determined after exit on [DATE] at 4:14 p.m. The facility Corporate Nurse was informed via phone. An IJ was identified on [DATE]. The IJ began on [DATE] and was removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on physical restraints, behaviors, fall prevention, and resident rights.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for quality of care. 1. The facility failed to ensure, on 1/16/25, HA B did not leave a spray bottle of cleaner, unattended in the dining room on the secured unit. a. The facility failed to ensure Resident #2 did not possibly ingest an unattended spray of bottle of cleaner on 1/16/25. b. The facility failed to follow their cleaning policy, on 1/16/25, and safely store chemicals in a locked area on the secured unit. 2. The facility failed to secure Resident #1's wheelchair with the floor straps which resulted in Resident #1 falling back in his wheelchair during transportation and sustaining two abrasions to the scalp on 1/23/25. a. The facility failed to train Transport CNA A on how to properly secure and transport residents in the facility's van before transporting Resident #1 to dialysis on 1/23/25. b. The facility failed to ensure Transport CNA A did not move Resident #1, after he fell back in his wheelchair, and sustained two abrasions to the scalp on 1/23/25. The noncompliance was identified as PNC. The IJ began on 01/23/25 and ended on 01/30/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death. Findings included: 1. Record review of Resident #2's face sheet dated 2/26/25 indicated Resident #2 was an [AGE] year-old, female admitted on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (is a condition caused by damage to the airways or other parts of the lung), and other symptoms and signs concerning food and fluid intake. Record review of Resident #2's significant change in status MDS assessment, dated 1/1/25 indicated Resident #2 was sometimes understood and sometimes had the ability to understand others. Resident #2 had impaired vision and no corrective lenses. Resident #2 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #2 wandered daily. Resident #2 did not use a mobility device. Resident #2 required setup or clean up assistance for eating. Record review of Resident #2's care plan dated 7/25/22 indicated Resident #2 had impaired cognitive function and impaired thought processes due to Alzheimer's/dementia. Intervention included the resident needs supervision assistance with all decision making. Record review of Resident #2's progress notes dated 1/7/25-2/26/25 indicated the following: *1/16/25 at 1:00 p.m., by the DON, indicated, .location of event: dining room .cognition/behavior at time of event: cognitive impairment and wanders . [Resident #2] was found with bottle of spray cleaner .sprayer lid removed and in her left hand and bottle in her right hand sitting on the table in front of her by RD D (dietary consultant) who removed it from [Resident #2] and called for this nurse [DON] .bottle and lid given to me at this time .I [DON] went over to check on resident and I asked her if she was ok, she nodded she was .I [DON] leaned in and smelled her mouth and could smell lemon scent which was the scent of the cleaning solution .immediately retrieved the ADM and ADON E .ADON E confirmed that she could smell the lemon smell in her [Resident #2] mouth as well .mouth rinsed and water given per Safety Data Sheet (is a document that contains information about the health and safety of a chemical) instructions .poison control number called as well for further instructions .sent to ER for evaluation .resident [Resident #2] gave no verbal response when questioned what happened .family representative called .any cleaning supplies not on facility approved list removed .verified that there was no other cleaning supplies located where residents could get them . *1/16/25 at 1:04 p.m., by the DON indicated, .call placed to MD V to make aware of possible ingestion of cleaner . *1/16/25 at 1:08 p.m., by the DON indicated, .call placed to emergency number/poison control number on back of cleaner bottle .located Safety Data sheet for the cleaner and began following instructions for ingestion .if resident had taken 2 swallows or equivalent of 60ml .60ml being the cut off .if had ingested more than 60mls send to ER due to being unaware of exact amount [Resident #2] to be sent to ER for evaluation . Record review of witness statement by RD D, dated 1/16/25, indicated .I [RD D] found an open bottle of cleaner during my noon rounds with Resident #2 .she [Resident #2] had the nozzle in her left hand and the bottle sitting on table in front of her with her right hand holding bottle .I [RD D] called for the DON speaking with the charge nurse .the DON arrived and took the cleaner bottle I [RD D] had retrieved from resident [Resident #2] . Record review of witness statement by HA B, dated 1/16/25, indicated .I [HA B] was serving lunch trays with LVN C .I [HA B] noticed .vomit up and spilled milk on the table and floor and I [HA B] went into the nurses room to grab a mop to clean it up because I did not want anyone to slip .I [HA B] grabbed the cleaner spray and mop and went back into the dining room .once I [HA B] was done I felt the spray bottle with cleaner was empty and at that time .I [HA B] sat the spray bottle on the table and helped .I [HA B] forgot to put the almost empty cleaner bottle away . Record review of a handwritten statement by LVN C, dated 1/16/25, indicated .an almost empty bottle of cleaner spray was left on dining room table after it was used to clean up a spill .a resident sitting at the table picked up and opened the bottle .it is unknown if the cleaner was ingested . During an interview on 2/26/25 at 10:00 a.m., LVN C said an almost empty bottle of cleaner was left on the dining room table. She said she was sitting at the nurse desk outside the dining room area. She said she had not witnessed the incident on 1/16/25. She said she had heard the nozzle on the bottle cleaner was unscrewed. She said she did not smell the cleaner on Resident #2 breath. She said the bottle of cleaner was an outside cleaner not provided by the facility. She said the bottle of cleaner and mop were in the nurse's room. She said it was a commonly known rule not to bring outside cleaners to the facility. She said she did not think the facility figured out who brought in the outside cleaner. She said she had not seen a staff use the outside cleaner before the incident on 1/16/25. She said outside cleaners were not allowed because they could not be compatible to patient care and the facility environment. She said outside cleaners should not be left unattended due to possible ingestion. She said ingesting cleaners could cause poisoning, vomiting, seizures and death. She said the hospital did not think Resident #2 ingested the outside cleaner. She said after the incident on 1/16/25, the facility in-serviced staff on not bringing outside cleaner to the facility, not to leave cleaners/chemicals unattended, and only use cleaners on the housekeeping cart, and where the SDS binders were located. She said she was also coached about the incident on 1/16/25. During an interview on 2/26/25 at 10:14 a.m., CNA K said she did not work on 1/16/25. She said she had not seen the outside bottle of cleaner or seen any staff using the bottle of cleaner before the incident. She said outside cleaners should not be brought to the facility and left unattended because the residents could drink or spray it their faces. She said the residents could get a chemical burn, sick, blindness, or death. She said before the incident, she had been told not to bring outside cleaner into the facility. She said after the incident on 1/16/25, she had been in-serviced on not to bring outside chemicals, where the SDS binders were located, and only use approved chemicals. She said the housekeeping carts, at that time, had a list of the approved cleaner stored in the carts and their use. On 2/26/25 at 1:37 p.m., called HA B and left a message. A phone call was not received before or after exit. During an interview on 2/26/25 at 2:02 p.m., ADON E said HA B called and told her about the incident involving Resident #2, on 1/16/25. She said HA B had poured some cleaner on the floor to clean up a mess. She said Resident #2 was found with the bottle of cleaner in her hands. She said she had smelled Resident #2's breath and it smelled like the lemon scented cleaner. She said it did not appear Resident #2 had ingested the cleaner. She said Resident #2 was sent to the ER for evaluation. She said HA B had gotten the outside cleaner from the storeroom near the nurse's desk. She said HA B had previously seen the outside cleaner in the storeroom and knew to find it in the storeroom. She said prior to the incident on 1/16/25, staff had not been in-serviced on not bringing outside cleaner into the facility. She said on admission, the residents and family were instructed not to bring the outside cleaners, into the facility. She said outside cleaners should not be used because the facility did not have the SDS listing. She said the facility also did not have the information on what to do if the cleaner/chemical was ingested. She said it was not a good thing for a cleaner/chemical to be ingested. During an interview on 2/27/25 at 8:36 a.m., RD D said she was making her lunch rounds on the secured unit when the incident on 1/16/25 happened. She said Resident #2 was sitting at a dining room table with the spray nozzle in one hand and the bottle in the other hand. She said she could not remember if there was any cleaner left in the bottle when she arrived. She said some of the nursing staff were at the nurse's desk. She said she could not remember if there were any CNAs in the dining room when she arrived. She said when saw Resident #2 with the bottle of cleaner, she immediately tried taking it away and called for help. She said she did not know what happened after the DON arrived and took over the situation. During an interview on 2/27/25 at 10:22 a.m., the DON said she was on the secured unit when Resident #2's incident happened. She said RD D called her into the dining room. She said Resident #2 had the sprayer in one hand and the bottle in her other hand. She said she and ADON E smelled the lemon scent on Resident #2's breath. She said the lemon scent bottle of cleaner did not have much left in it. She said HA B reported to her that the bottle of cleaner did not enough in it to use on the floor. She said she called poison control and looked the outside cleaner up in the SDS for what to do if ingested. She said MD V was notified. She said they could not determine how much Resident #2 ingested. She said they sent Resident #2 to the ER. She said the hospital did not believe Resident #2 had ingested any of the cleaner because she did not vomit, have redness in her throat, and tolerated water. She said before the incident on 1/16/25, she did not know if staff had been told not to bring outside cleaners into the facility. She said staff had required on-line training on handling chemicals which probably covered not leaving then unattended. She said it was important not to bring outside chemicals because the facility did not know how to treat exposure to them. She said the facility also did not have a readily available copy of the outside chemical/cleaner SDS sheet. She said when a chemical/cleaner was left unattended, there was a possibility of ingestion, skin burns, and getting in the resident's eyes. She said after the incident, the facility did a sweep for any other unapproved chemicals/cleaners in the building. During an interview on 2/27/25 at 11:13 a.m., the ADM said she started at the facility on 12/9/24. She said on 1/16/25, the DON and ADON E came and got her from the office. She said she was told RD D found a resident with a bottle of cleaner. She said the facility did not know if Resident #2 had ingested the cleaner or how much. She said poison control told them if Resident #2 had swallowed 60 mls or more, to send the ER. She said to be safe, the facility sent Resident #2 to the ER for evaluation. She said the hospital observed Resident #2 and sent her back to the facility. She said Resident #2 returned the same day (1/16/25). She said the hospital did not do any lab works while she was in the hospital. She said the facility drew labs the next day (1/17/25) on Resident #2. She said outside chemical/cleaners were not allowed because the facility did not have a SDS listing on them. She said the MD reviewed the labs and no new orders were received. She said if chemicals/cleaners were ingested, the resident could experience nausea, vomiting, and burning of the esophagus. She said she did not know if staff were aware outside cleaners were not allowed before 1/16/25. She said after the incident on 1/16/25, staff were in-serviced on outside cleaners and new hires were told upon hire. Record review of a facility conducted in-service, Cleaning Supplies/Chemicals dated 1/16/25 reflected training to all staff were provided education on the topic. Record review of a facility conducted in-service, MSDS Binders dated 1/16/25 reflected training to all staff were provided education on the topic. Record review of a facility conducted in-service, Personal Care Items/Chemicals on the Secured Unit dated 1/16/25 reflected training to all staff were provided education on the topic. Record review of a facility conducted in-service, Abuse/Neglect dated 1/16/25 reflected training to all staff were provided education on the topic. Record review of a facility conducted in-service, Chemicals dated 1/16/25 reflected training housekeeping and laundry staff were provided education on the topic. Record review of a facility conducted in-service, Hydration dated 1/16/25 reflected all nursing staff were provided education on the topic. Record review of HA B's Coaching Form dated 1/16/25, indicated . problem: outside chemicals/cleaning solutions being brought into facility and not being in a secured location .education: no outside cleaning chemicals can be brought into facility, we must use the chemicals housekeeping provides .all chemical/cleaning supplies must be locked up at all times .do not leave chemicals unattended at any time .Educator: DON .Student: HA B . Record review of LVN C's Coaching Form dated 1/16/25, indicated . problem: outside chemicals/cleaning solutions being brought into facility and not being in a secured location .education: no outside cleaning chemicals can be brought into facility, we must use the chemicals housekeeping provides .all chemical/cleaning supplies must be locked up at all times .do not leave chemicals unattended at any time .Educator: DON .Student: LVN C . Record review of HA B's Employee Disciplinary Report dated 1/16/25 indicated .Type of Disciplinary Action: Investigatory Suspension .TCNA A will be placed on an investigatory suspension pending an investigation into allegations of safety and security of the residents .ADON E .ADM . Record review of HA B's Employee Disciplinary Report Action Request dated 1/16/25 indicated .investigatory suspension .HA B left a non-approved cleaning agent within reach of a resident resulting in resident drinking the cleaning agent .ADON E .ADM .HR Coordinator . Record review the facility's letter to residents and family members indicated .we wanted to send a gentle reminder to everyone to please refrain from bringing any type of cleaning supply to the building .thank you . Record review of an undated facility's Daily Common Area Cleaning indicated .the goal is to keep facilities clean and odor free, while providing the resident .the safest environment possible .housekeeping carts/chemicals must be locked when not within eyesight of a staff member .use only approved pre-mixed chemicals provided by the supplier . 2. Record review of Resident #1's face sheet dated 2/25/25 indicated Resident #1 was a [AGE] year-old, male admitted on [DATE] and discharged from the facility on 2/1/25. Resident #1 had diagnoses including acquired absence of right leg above knee, end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and dependence on renal dialysis. Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had moderate difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #1 had functional limitation range of motion to the lower extremity on one side. Resident #1 used a cane/crutch and wheelchair for mobility. Resident #1 received dialysis within the last 14 days. Record review of Resident #1's care plan dated 02/13/25 indicated the following: *Resident #1 was at risk for falls. Intervention included the resident needed a safe environment. *Resident #1 needed dialysis. Intervention included encourage resident to go for the scheduled dialysis appointments. Resident #1 received dialysis. Record review of Resident #1 progress notes dated 01/22/25-02/26/25 indicated the following: *1/23/25 at 6:24 a.m., by LVN F indicated .at dialysis . *1/23/25 at 10:00 a.m., by LVN F indicated .[Resident #1] was transferred to a hospital on 01/23/25 at 10:15 a.m. related to had a fall in his wheelchair on the transportation van .sent out to ER for treatment and assessment due to receiving a head injury . *1/23/25 at 10:23 a.m., by LVN F indicated .resident had a fall .while on leave .unwitnessed, hit head, discovered on floor .oriented/no problem .the fall caused an abrasion to back of the head .size of abrasion 2 areas 1cmx1cm .scant bleeding to area .this nurse [LVN F] was called to facility van in the breezeway .upon arrival noted ADON [ADON E] and transportation staff [Transport CNA A] with resident [Resident #1] assisting resident .resident [Resident #1] noted seated up in wheelchair in the van with secured strap devices noted in place .resident [Resident #1] assessed for injuries .noted 2 abraised areas to back of head from hitting the lowering ramp to the van that was upright in the back of the van .Resident #1 states that all of a sudden the wheelchair went backwards .staff training . Record review of a fall incident report by LVN F, dated 01/23/25 at 9:55 a.m., indicated .[Resident #1] .out of facility/during transport .called to facility van per ADON E upon approaching the van was informed that [Resident #1] was in his wheelchair and the wheelchair had tipped backwards during transfer .[Resident #1] seated up in wheelchair at the current time .noted [Resident #1] to be safely secured in place with secured strap devices to flooring of the van . [Resident #1] stated that the wheelchair went backwards while he was riding in it and that his head hit the ramp flooring that was in position for transfer to the back of the van . [Resident #1] assessed for injuries .noted 2 small abrasions to top of head .to sent out to ER for evaluation . Record review of a staff member's statement by Transport CNA A dated 1/23/25 indicated .on January 23, 2025 after dropping a patient off for his 9:15 am appointment, I [Transport CNA A] left the wound care clinic to go to the dialysis center .I [Transport CNA A] arrived at the dialysis center around 9:25 am, patient [Resident #1] was sitting inside the center .I [Transport CNA A] rolled Resident #1 outside and proceeded to load him onto the transport van .once I got Resident #1 onto the van, I [Transport CNA A] proceeded to strap his wheelchair down .the front two wheels were strapped to the frame .the second or 1st back wheel (right side) was also strapped to the frame, the 2nd back wheel I [Transport CNA A] had trouble strapping to the frame, so I hooked it onto the wheel .I secured or tightened the straps of each wheel .I also secured the patient with the seat belts .I got back on the transport van and proceeded back to the facility .as soon as we crossed [a local road], Resident #1 said 'oww' .I looked back and his chair had flipped backwards .I pulled to the side of the road and grabbed the front arms of the patient's [Resident #1] wheelchair, and sat the patient back up .I asked Resident #1 was he hurt, he said his head kind of hurt .I restrapped the patient back down and proceeded to the facility . Record review of a staff member's statement by Transport CNA A dated 1/23/25 indicated .on January 23, 2025, I [Transport CNA A] was transporting Resident #1 back to the facility .we stopped at the red light on [a local road] and [a local road]. When the light changed, I proceeded through the light when Resident #1 said, 'oww' .I looked back and his wheelchair had flipped backwards .I immediately pulled over to the side of the road and went to see what had happened .he [Resident #1] said he just went back, I sat the wheelchair back up into its position and re-strapped the chair down, brought him back to the facility and immediately went inside and go the ADON [ADON E] to do a full assessment of the patient .he [Resident #1] only said he might have hit his head .my ADON [ADON E] and his nurse [LVN F] checked him out before I removed him from the van . On 2/25/25 at 11:00 a.m., called Resident #1, and his phone was no longer in service. During an interview on 2/25/25 at 11:07 a.m., LVN F said ADON E called him to come assess Resident #1 on 1/23/25. He said when Resident #1 arrived at the facility, his wheelchair was sitting up. He said all the hooks were attached to the wheelchair. He said Transport CNA A reported she looked back in the transport van and Resident #1 was gone. He said when he assessed Resident #1, there were two abrasions without bleeding to his scalp. He said Resident #1 hit his head on the bottom part of the lift in the back of the van. He said Resident #1 was a tall man with a standard size wheelchair. He said Resident #1 told him the incident scared the shit out of him. He said Resident #1 was sent to the ER for evaluation. He said Transport CNA A was the medical records staff but did transports. He said the Housekeeping Supervisor G used to do transports until Transport CNA A took over. He said he believed Transport CNA A started doing transports in December 2024 or January 2025. He said if a resident had a bad incident during transport, staff were supposed to call 911. He said Transport CNA A brought Resident #1 back to the facility after the fall incident on 1/23/25. He said as a nurse, if a resident had an incident during transport and was alert and oriented, he would transport the resident back to the facility. He said an MA or CNA could not properly assess a resident after an incident. He said if a resident had a fall incident during transport, they should not be moved before an assessment in case there was an injury or head injury. He said if a resident was moved, and had an injury or head injury, they could require emergent attention. During an interview on 2/25/25 at 11:25 a.m., ADON E said Transport CNA A came and got her when she arrived back at the facility on 1/23/25. She said Transport CNA A reported Resident #1 had fallen in the van. She said she went outside and Resident #1 was in an upright position. She said when she arrived to assess Resident #1, she did not look at the hooks and straps. She said she looked Resident #1 over, then LVN F arrived. She said Resident #1 was then removed from the van. She said Transport CNA A was the facility's designated van driver. She said Transport CNA A had not been the van driver for a long time. She said Transport CNA A said when they came across two local road, she heard something from the back of the van. She said Transport CNA A reported she looked in the rearview mirror and did not see Resident #1. She said Transport CNA A reported she turned around and saw Resident #1 had fallen. She said Transport CNA A reported Resident #1 had flipped backwards, but was still in the wheelchair. She said Transport CNA A reported she pulled over and got him in the upright position. She said Transport CNA A should have called an EMS, left Resident #1 on the floor of the van, and notified the facility of the incident. She said a resident with a fall should not be moved before an assessment because they potential could have an injury. She said the resident should also be assessed by a nurse. She said moving a resident with an injury could intensify the injury or make it worse. She said the corporate maintenance supervisor assessed the van after the incident. She said all the van drivers were retrained of van transportation. During an interview on 2/25/25 at 11:39 a.m., TCNA A said she was the medical record staff and van driver. She said she started being the van driver in November 2024. She said that was the first time she had been a van driver for the facility. She said the facility had not trained her on being the van driver. She said as a CNA, she used to ride with the residents on transports and sort of knew what to do. She said the facility had not trained her on how to properly secure straps or load the residents, until after the incident on 1/23/25. She said Resident #1's wheelchair brakes worked. She said Resident #1 was a tall man and his wheelchair back could have been a little taller. She said on 1/23/25, she put Resident #1 on the lift, locked the brakes, and put him in the van. She said Resident #1 was toward the back on the van near the ramp. She said she was not able to hook to the frame of Resident #1's wheelchair toward the 2nd back wheel. She said she placed the hook on the wheel of the wheelchair instead of the frame. She said she could not hook onto Resident #2's wheelchair frame toward the 2nd back wheel because there was a box in the way. She said she could not get her hand underneath the wheel to strap the frame. She said she attached and tightened the lap and arm band. She said after Resident #1 had fallen, the lap and arm band were still tight around him. She said she did not know what she was supposed to look for after she tightened and secured the straps and hooks. She said she was at a local streetlight, accelerated when the light changed colors. She said she heard oww and looked back towards Resident #1. She said when she looked back, Resident #1 was not there. She said she immediately pulled over. She said Resident #1 said he was not hurt so she pulled the wheelchair upright by pushing down on the front arm rests. She said after she pulled Resident #1 upright, she noticed one of the straps looked loose. She said she placed the strap on the frame instead of the wheel and retightened the loose wheel strap. She said Resident #1 answered her questions appropriately, so she felt it was okay to move him. She said she did not notice the abrasions on back of Resident #1's head. She said Resident #1 did not report the back of his head hurting until they arrived at the facility. She said if a resident was not properly secured during transport, an accident could happen. She said after the incident on 1/23/25, she was in-serviced to not move resident after a fall and to call EMS. She said she was trained on van transportation and then suspended. During an interview on 2/25/25 at 12:04 p.m., the Corporate Maintenance Supervisor said after the incident on 1/23/25, he inspected the van's tie downs, belt straps, locking system, wheelchair lift, safety switch, and hand pump. He said there were no rip or tears in the straps and tie downs. He said the belt straps and tie downs also locked in place. He said he could only assume Resident #1's incident was caused from the tie down being placed on the wheel not the wheelchair frame. During an interview on 2/25/25 at 1:30 p.m., the ADM said ADON E told her about Resident #1's incident on 1/23/25. She said during the facility's investigation, they put a corporate staff member, with a similar build as Resident #1, in a wheelchair and tried to simulate different scenarios of what could have caused the incident. She said the corporate staff member did not flip backwards in the wheelchair. She said Resident #1 was interviewed about the incident. She said Resident #1 denied TCNA A driving badly. She said Resident #1 reported all the straps were on his wheelchair. She said the facility pulled the driving report from the van's system and it did not show any erratic driving. She said the DOR assessed Resident #1's wheelchair and recommend a high back wheelchair. She said the facility changed Resident #1's wheelchair to prevent a reoccurrence. She said TCNA A was a CNA at the facility then promoted to the medical record staff and van driver. She said she did not know if TCNA A had been trained on van driver before she started. She said she did not know how often van drivers had to be trained but she would find out. She said TCNA A should have been trained on van driving so she knew what to do. During an interview on 2/25/25 at 2:41 p.m., the MS L said he was responsible for the van weekly inspections. He said the facility's van did not have an issue before or after the incident on 1/23/25. He said a resident needed to be properly secured for the safety of the resident. He said if a resident was not properly secured, it could cause the resident to flip over. He said if the resident flipped over, they could get bruises, or have falls and injuries. During an interview on 2/25/25 at 3:20 p.m., the DOR said Resident #1 was already on therapy service when his fall occurred in the transport van. He said the facility provided Resident #1 a standard size wheelchair after admission. He said the standard wheelchair was appropriate for him because he had good core strength and balance. He said he recommended changing Resident #1 to a high back wheelchair with anti-tippers as an intervention after the incident on 1/23/25. He said Resident #1 reported to him the wheelchair just tipped back on him unexpectedly during transport on 1/23/25. During an interview on 2/27/25 at 11:13 a.m., the ADM said TCNA A was already the van driver when she started on December 9th, 2024. She said she thought TCNA A was trained on being the facility's van driver. She said the van drivers were trained upon hire and after incidents involving the transport van. She said it was important for staff to be trained so they knew how to properly work the lift and strap residents in correctly. She said an incident could happen if the resident was not properly strapped on the transport van. She said TCNA A should have pulled over to a safe area and called an EMS when Resident #1 tipped over in the transport van. She said moving a resident after a fall without an assessment by a medical staff could cause an injury. She said she had received an in-service by corporate staff on No one is to drive the van unless they were checked off. Record review of a facility conducted in-service, No one is to drive the van unless they are checked off dated 1/23/25 reflected upper management were provided education on the topic. Record review of a facility conducted in-service, Wheelchair locks dated 1/23/25 reflected all nursing staff and therapy were provided education on the topic. Record review of a facility conducted in-service, Abuse/Neglect dated 1/23/25 reflected all staff were provided education on the topic. Record review of TCNA A's Employee Disciplinary Report dated 1/23/25 indicated .investigatory suspension .TCNA A will be placed [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident who used psychotropic drugs received gradual dose reduction and behavioral interventions, the medication was necessary to treat a specific condition as diagnosed and documented in the clinical records, and/or that PRN orders for psychotropic drugs were limited to 14 days unless the prescribing practitioner documented their rationale in the resident's medical records for 4 of 5 residents (Resident #34, Resident #53, Resident #22, and Resident #62) reviewed for unnecessary medications. 1. The facility failed to recognize the side effects of the medications Lorazepam (Ativan) and Risperidone (Risperdal) which caused Resident #34 to become lethargic, experience increased falls, had increased episodes of incontinence, behavioral symptoms not usual to the person, and weight loss. 2. The facility failed to notify Resident #34's physician of a weight loss of 9.8% or 15 lbs. in less than 30 days. 3. The facility failed to relay the correct behaviors to Resident #34's physician for increase dosage of Risperidone. Staff indicated Resident #34 was aggressive with staff and or other resident, instead of exhibiting wandering behaviors. 4. The facility failed to ensure Resident #34 had an appropriate diagnosis related to use of Trazadone. 5. The facility failed to ensure Resident #34 had an appropriate diagnosis related to use of Lorazepam. An IJ was identified on 10/02/04. The IJ template was provided to the facility on [DATE] at 12:03 p.m. While the IJ was removed on 10/03/24, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse, neglect, and exploitation prevention, resident weight, preventative strategies to reduce fall risk, notifying the physician of change in status, and psychotropic drugs. 6. The facility failed to ensure Resident #53's prescribed prn Lorazepam was limited to 14 days and the prescribing practitioner provided rationale for extended use. 7. The facility failed to ensure Resident #62 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders-feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record and a duration for the PRN order. 8. The facility failed to ensure Resident #22 had effective monitoring for her prescribed Lorazepam. The Lorazepam order was made for 180 days, and PRN psychotropic medications should be reevaluated every 14 days. These failures could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident #34's face sheet dated 09/30/24 indicated Resident #34 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning) with psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), paranoid schizophrenia (is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and acute embolism (is an obstruction or blockage in a blood vessel) and thrombosis (is a blood clot within blood vessels that limits the flow of blood). Record review of Resident #34's quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. Resident #34 had adequate hearing, clear speech, and adequate vision. Resident #34 had a BIMS score of 03 which indicated severe cognition impairment. Resident #34 did not exhibit behaviors of hallucinations or delusions. Resident #34 experienced other behavioral symptoms not direct toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, of verbal/vocal symptoms like screaming, disruptive sounds). Resident #34 experienced wandering that occurred daily. Resident #34 required setup for dressing, eating, and putting on footwear, supervision assistance for oral hygiene, partial assistance for shower/bathing self and personal hygiene, and dependent for toilet hygiene. Resident #34 required supervision for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Resident #34 did not have functional limitation in range of motion/impairments. Resident #34 used a wheelchair for mobility. Resident #34 was always incontinent of urine and frequently incontinent of bowel. Resident #34 had one fall with no injury since admission/entry or reentry or the prior assessment. Resident #34 had not experienced weight loss 5% or more in the last month or 10% or more in the last 6 months. The MDS indicated Resident #34 received an antianxiety, antipsychotic, and antidepressant during the last 7 days of the assessment period. Record review of Resident #34's care plan last review completed on 08/27/24 indicated: *Resident #34 required anti-psychotic medications due to her diagnosis of paranoid schizophrenia. Interventions included administer medication as ordered, monitor/record occurrence of target behavior symptoms, and monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: unsteady gait, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, fatigue, loss of appetite, weight loss, behavioral symptoms not usual to the person. Resident #34's care plan did not address antianxiety medication use. *Resident #34 resided in the secure care unit, related to diagnosis of dementia and risk of elopement. Intervention included notify MD of any changes. Resident #34's care plan did not reflect other behavioral symptoms coded on the MDS or behavior charted on the progress notes such as urinating on her and other resident's property. *Resident #34 was at risk for falls due to unsteady gait, generalized weakness to bilateral lower extremities, and use of psychotropic medications. Interventions included anticipate and meet the resident's needs, the resident needs activities that minimize the potential for falls while providing diversion and distraction, and review information on past falls and attempt to determine cause of falls. *Resident #34 had ADL self-care performance deficit. Intervention included bathing: requires staff x1 for assistance, bed mobility: requires staff x1 for assistance, dressing: requires staff x1 for assistance, eating: supervision as needed, resident uses a wheelchair, toileting: supervision as needed, encourage meal consumption and document amount consumed, and offer substitute. Record review of Resident #34's order summary report dated 08/01/24-08/31/24 indicated: *Lorazepam Oral Tablet 1mg (Lorazepam), give 1 tablet by mouth two times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. Start date 08/15/24. Discontinued. *Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth three times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. Start date 08/18/24. *Risperidone Oral Solution 1mg/ml (Risperidone), give 1.5ml by mouth two times a day related to paranoid schizophrenia. Start date 08/02/24. Discontinued. *Risperidone Oral Solution 1mg/ml (Risperidone), give 1.5ml by mouth three times a day related to paranoid schizophrenia. Start date 08/15/24. Discontinued. *Risperidone Oral Solution 1mg/ml (Risperidone), give 2ml by mouth three times a day related to paranoid schizophrenia. Start date 08/18/24. Discontinued. Record review of Resident #34's order summary report dated 08/31/24 indicated: *Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth three times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. Start date 08/18/24. *Risperidone Oral Solution 1mg/ml (Risperidone), give 2ml by mouth three times a day related to paranoid schizophrenia. Start date 08/18/24. *Trazodone HCL Oral Tablet 50mg, give 1 tablet by mouth one time a day related to paranoid schizophrenia. Start date 05/10/24. *Behavior Monitoring, enter the code- 0. None, 1. Panic, 2. Agitated, 3. Angry, 4. Anxiety, 5. Biting, 6. Compulsive, 7. Crying, 8. Pacing, 9. Screaming, 10. Pull IV line/tubes, 11. Poor eye contact, 12. Depressed, 13. Extreme fear, 14. False belief, 15. Fighting, 16. Finger painting feces, 17. Hallucinations/paranoia/delusion, 18. Head banging, 19. Insomnia, 20. Jittery, 21. Kicking, 22. Noisy, 23. Pinching, 24. Restless, 25. Scratching, 26. Slapping, 27. Suspiciousness, 28. Throwing objects, 29. Wandering, 30. Other see progress notes every day and night for Risperdal, Trazodone. If any behaviors are noted, document details in a progress note. Start date 05/11/24. *Side Effects- Enter the code- 0. None, 1. Dystonia (is a movement disorder that causes the muscles to contract), 2. Dry mouth, 3. Constipation/urinary retention, 4. Hypotension (low blood pressure), 5. Downiness, 6. Dizziness, 7. Arrythmias (irregular heart rhythm), 8. Tardive dyskinesia (are involuntary movements of the tongue, lips, face, trunk, and extremities), 9. Rash, 10. Headache, 11. Urine retention, 12. Weak, 13. Cogwheel (a type of rigidity that typically affects the limbs, causing them to move in small increments, similar to how gears move), 14. Tremors, 15. Appetite Changes, 16. Insomnia, 17. Confusion, 18. Sore throat, 19. Seizure, 20. Photosensitivity (a condition in which the skin becomes very sensitive to sunlight or other forms of ultraviolet light and may burn easily), 21. Suicidal ideations, 22. GI disturbance, 23. Ataxia (poor muscle control that causes clumsy movements) every day and night shift for Risperdal, Trazodone. If any side effects are noted, document details in a progress note. Start date 05/11/24. Record review of Resident #34's order summary report dated 09/30/24 indicated: *Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth three times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. Start date 08/18/24. *Risperidone Oral Solution 1mg/ml (Risperidone), give 2ml by mouth three times a day related to paranoid schizophrenia. Start date 08/18/24. *Trazodone HCL Oral Tablet 50mg, give 1 tablet by mouth one time a day related to paranoid schizophrenia. Start date 05/10/24. *Behavior Monitoring, enter the code- 0. None, 1. Panic, 2. Agitated, 3. Angry, 4. Anxiety, 5. Biting, 6. Compulsive, 7. Crying, 8. Pacing, 9. Screaming, 10. Pull IV line/tubes, 11. Poor eye contact, 12. Depressed, 13. Extreme fear, 14. False belief, 15. Fighting, 16. Finger painting feces, 17. Hallucinations/paranoia/delusion, 18. Head banging, 19. Insomnia, 20. Jittery, 21. Kicking, 22. Noisy, 23. Pinching, 24. Restless, 25. Scratching, 26. Slapping, 27. Suspiciousness, 28. Throwing objects, 29. Wandering, 30. Other see progress notes every day and night for Risperdal, Trazodone, Lorazepam. If any behaviors are noted, document details in a progress note. Start date 09/18/24. *Side Effects- Enter the code- 0. None, 1. Dystonia, 2. Dry mouth, 3. Constipation/urinary retention, 4. Hypotension, 5. Downiness, 6. Dizziness, 7. Arrythmias, 8. Tardive dyskinesia, 9. Rash, 10. Headache, 11. Urine retention, 12. Weak, 13. Cogwheel, 14. Tremors, 15. Appetite Changes, 16. Insomnia, 17. Confusion, 18. Sore throat, 19. Seizure, 20. Photosensitivity, 21. Suicidal ideations, 22. GI disturbance, 23. Ataxia every day and night shift for Risperdal, Trazodone, Lorazepam. If any side effects are noted, document details in a progress note. Start date 09/18/24. Record review of Resident #34's MAR dated 08/01/24-08/31/24, printed 10/08/24 indicated: * Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth one times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. The MAR indicated Resident #34 was administered 15/15 doses. Discontinued 08/15/24 at 12:56 p.m. *Lorazepam Oral Tablet 1mg (Lorazepam), give 1 tablet by mouth two times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. The MAR indicated Resident #34 was administered 6/6 doses. Discontinued 08/18/24 at 3:11 p.m. *Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth three times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. The MAR indicated Resident #34 was administered 35/40 doses. *Risperdal Oral Tablet 1mg (Risperidone), give 1 tablet by mouth two times a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 3/3 doses. Discontinued 08/02/24 at 5:22 p.m. *Risperidone Oral Solution 1mg/ml (Risperidone), give 1.5ml by mouth two times a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 26/26 doses. Discontinued 08/15/24 at 12:58 p.m. *Risperidone Oral Solution 1mg/ml (Risperidone), give 1.5ml by mouth three times a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 9/10 doses. Discontinued 08/18/24 at 3:09 p.m. *Risperidone Oral Solution 1mg/ml (Risperidone), give 2ml by mouth three times a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 38/40 doses. Discontinued 10/02/24 at 5:31 p.m. *Trazodone HCL Oral Tablet 50mg, give 1 tablet by mouth one time a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 31/31 doses. Discontinued 10/03/24 at 12:38 p.m. *Behavior Monitoring, enter the code- 0. None, 1. Panic, 2. Agitated, 3. Angry, 4. Anxiety, 5. Biting, 6. Compulsive, 7. Crying, 8. Pacing, 9. Screaming, 10. Pull IV line/tubes, 11. Poor eye contact, 12. Depressed, 13. Extreme fear, 14. False belief, 15. Fighting, 16. Finger painting feces, 17. Hallucinations/paranoia/delusion, 18. Head banging, 19. Insomnia, 20. Jittery, 21. Kicking, 22. Noisy, 23. Pinching, 24. Restless, 25. Scratching, 26. Slapping, 27. Suspiciousness, 28. Throwing objects, 29. Wandering, 30. Other see progress notes every day and night for Risperdal, Trazodone. If any behaviors are noted, document details in a progress note. Start date 05/11/24. Discontinued 09/18/24. The MAR indicated Resident #34 displayed behaviors of compulsive, anxiety, agitated, screaming/yelling, pacing, panic, wandering, and restlessness. The MAR did not indicate aggressive behaviors. Resident #34 did not display behaviors 21/62 shifts. *Side Effects- Enter the code- 0. None, 1. Dystonia, 2. Dry mouth, 3. Constipation/urinary retention, 4. Hypotension, 5. Downiness, 6. Dizziness, 7. Arrythmias, 8. Tardive dyskinesia, 9. Rash, 10. Headache, 11. Urine retention, 12. Weak, 13. Cogwheel, 14. Tremors, 15. Appetite Changes, 16. Insomnia, 17. Confusion, 18. Sore throat, 19. Seizure, 20. Photosensitivity, 21. Suicidal ideations, 22. GI disturbance, 23. Ataxia every day and night shift for Risperdal, Trazodone. If any side effects are noted, document details in a progress note. Start date 05/11/24. The MAR indicated Resident #34 did not experience side effects except for 08/03/24 (dry mouth). Record review of Resident #34's MAR dated 09/01/24-09/30/24 indicated: *Lorazepam Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth three times a day for anxiety/agitation related to unspecified dementia, moderate, with psychotic disturbance. The MAR indicated Resident #34 was administered 88/89 doses. *Risperidone Oral Solution 1mg/ml (Risperidone), give 2ml by mouth three times a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 88/89 doses. *Trazodone HCL Oral Tablet 50mg, give 1 tablet by mouth one time a day related to paranoid schizophrenia. The MAR indicated Resident #34 was administered 29/29 doses. *Behavior Monitoring, enter the code- 0. None, 1. Panic, 2. Agitated, 3. Angry, 4. Anxiety, 5. Biting, 6. Compulsive, 7. Crying, 8. Pacing, 9. Screaming, 10. Pull IV line/tubes, 11. Poor eye contact, 12. Depressed, 13. Extreme fear, 14. False belief, 15. Fighting, 16. Finger painting feces, 17. Hallucinations/paranoia/delusion, 18. Head banging, 19. Insomnia, 20. Jittery, 21. Kicking, 22. Noisy, 23. Pinching, 24. Restless, 25. Scratching, 26. Slapping, 27. Suspiciousness, 28. Throwing objects, 29. Wandering, 30. Other see progress notes every day and night for Risperdal, Trazodone, Lorazepam. If any behaviors are noted, document details in a progress note. The MAR indicated Resident #34 displayed behaviors of compulsive, anxiety, agitated, screaming/yelling, pacing, panic, wandering, restlessness, and other see progress note. The MAR did not indicate aggressive behaviors. Resident #34 did not display behaviors 16/59 shifts. *Side Effects- Enter the code- 0. None, 1. Dystonia, 2. Dry mouth, 3. Constipation/urinary retention, 4. Hypotension, 5. Downiness, 6. Dizziness, 7. Arrythmias, 8. Tardive dyskinesia, 9. Rash, 10. Headache, 11. Urine retention, 12. Weak, 13. Cogwheel, 14. Tremors, 15. Appetite Changes, 16. Insomnia, 17. Confusion, 18. Sore throat, 19. Seizure, 20. Photosensitivity, 21. Suicidal ideations, 22. GI disturbance, 23. Ataxia every day and night shift for Risperdal, Trazodone, Lorazepam. If any side effects are noted, document details in a progress note. The MAR indicated Resident #34 did not experience side effects. Record review of Resident #34's progress notes dated 05/29/24-09/30/24 indicated: *06/17/24 at 12:39 p.m. by LVN E, .day 6 follow room change from B hall to the C hall secure unit .resident has adjusted well . *07/07/24 at 9:09 a.m., by LVN E, .resident continues behaviors from previous shift .she will not accept redirection from staff .received order from MD T for Lorazepam 1mg every morning for anxiety . *07/08/24 at 8:58 a.m. by LVN R, .Day 2 Ativan 1mg every morning with no adverse reaction noted .less intrusive now than before Ativan was given . *07/16/24 at 8:44 a.m. by LVN E, .day 10/14 Lorazepam 1 mg every morning .Resident #34 cannot be redirected .attempts to walk .her gait is very unsteady a fall risk .resident is redirected many times during the shift . *07/19/24 at 10:51 a.m. by LVN E, .Day 13/14 Lorazepam 1 mg every morning .Resident #34 continues to be extremely difficult to redirect .she wanders in and out of rooms taking clothing that is not hers and urinating on other resident's beds and putting clothing between her legs for pads after takes her brief off . *07/24/24 at 1:35 p.m. by RN V, .Patient [Resident #34] having urinary frequency .MD T notified .new orders for urinalysis . *07/25/24 at 7:45 p.m. by LVN HH, .talked to MD T .reviewed the lab results . MD T recommended to start Cipro . *07/29/24 at 1:18 p.m. by LVN E, .Resident #34 continues to wander and pilfer thru other resident's things and their rooms . she will not accept any direction at all .goes into rooms and urinates on the floors and beds and clothing if she is allowed to wander alone . *08/02/24 at 6:01 p.m. by LVN E, .received order to increase Risperdal 1mg/ml to 1.5mg.ml .Resident #34 has been closely monitored by staff today to prevent behaviors .resident continues to repeat questions and behaviors with no regard for redirection . *08/05/24 at 10:40 p.m. by RN U, .resident cont. on Risperdal Elixir without s/s of adverse reactions noted .once resident in bed usually stays in bed without wandering . *08/07/24 at 4:23 p.m. by LVN E, .Day 5/14 Risperdal elixir .Resident #34 has rested some today but continues to be extremely difficult to redirect .continues to wander in and out of other rooms pulling out their clothing . *08/12/24 at 3:09 p.m., by LVN E, .Resident #34 has been extremely hard to redirect . she will not accept direction .she has had no adverse reaction related to the Risperdal Elixir but it does not seem to keep her calm and control the anxiety for very long periods of time . *08/13/24 at 5:07 p.m., by LVN E, .Day 10/14 Risperdal Elix [sic] .the medication is only effective for short periods of time .Resident #34 cannot be redirected and cannot be left without monitoring related to her unruly and destructive nature in the unit . *08/14/24 at 11:02 a.m. by LVN R, .Day 11/14 Risperdal Elixir .it is difficult to determine if medication is working as there is not a notable change in behavior . *08/15/24 at 2:45 p.m. by LVN E, .MD T in the facility today and gave the following new orders .1. Increase Risperidone Elixir 1.5ml from BID to TID .2. Increase Ativan 1mg every day to 1 mg BID . *08/18/24 at 3:19 p.m. by LVN E, .Resident #34 has been awake and have different behaviors during this shift .she will not be redirected and continues to attempt to go into other resident's rooms .MD T gave new order as follow 1. Increase Risperdal Elixir from 1.5 ml TID to 2ml TID . 2. Increase Ativan 1mg from BID to Ativan 1mg TID . *08/22/24 at 4:16 p.m. by LVN E, .Resident #34 is day 4/14 Risperdal elix [sic] increased to 2ml TID and Ativan increased to 1mg TID .she has been calm and quiet most of this shift . *08/22/24 at 4:21 p.m. by LVN E, .Resident #34 is day 3 post fall with injury to face and bridge of nose . *08/24/24 at 3:30 p.m. by LVN R, .Day 6/14 increase Risperdal 2ml TID and Ativan 1mg TID no benefit noticed from increase in medication .patient [Resident #34] is extremely difficult to redirect, is constantly trying to get up from her wheelchair and unlocks the chair, rolls and stands up .patient must be 1:1 at all times . *08/27/24 at 5:11 p.m. by LVN E, .Resident #34 was given 30ml milk of magnesium (is used for a short time to treat occasional constipation) per MD T's standing orders . *08/28/24 at 9:40 p.m. by LVN R, .Day 10/14 increase in Risperdal to 2ml TID and Ativan to 1 mg TID .Resident is very drowsy today, laying her head on dining room table and sleeping . *08/29/24 at 3:17 p.m. by LVN R, .Day 11/14 increase in Risperdal to 2ml TID and Ativan to 1 mg TID .Resident #34 moves slowly and when she does get up from wheelchair (against staff instruction) her gait is very unsteady and she stumbles around almost falling several times today . *08/30/24 at 2:19 p.m. by LVN E, .Resident #34 given 30 ml milk of magnesium .Resident #34 noted to be passing hard stool today with some straining noted . *08/30/24 at 6:19 p.m. by LVN E, .Resident #34 is day 12/14 increase .resident continues to be difficult to redirect and gets out of wheelchair and attempts to walk .she is unsteady on her feet .resident will ask same questions over and over and laugh .must be monitored at meal times to prevent her from taking food out of other trays . *09/01/24 at 4:45 p.m., by LVN E, .Resident #34 had urinated on the bed from pillow to foot .she had taken her pants and brief off and urinated on them on the floor . *09/04/24 at 3:37 p.m., by LVN E, .Resident #34 continues to have an extremely unsteady gait and leans forward when she walks .she cannot be redirected and must be monitored very closely .she continues to urinate on bedding and clothing when not monitored . *09/10/24 at 2:45 p.m. by LVN E, .Resident #34 continued to walk as I [LVN E] was trying to get to her .Resident #34 fell before I [LVN E] reached her .she fell on her side and did not hit her head . *09/10/24 at 4:41 p.m. by LVN E, .Resident #34 continues to be belligerent and impossible to redirect .Resident #34 gets out of chair and stumbles and wavers when she walks and has to be assisted back into the chair to keep her from falling . *09/15/24 at 7:45 a.m. by LVN E, .CNA called this nurse [LVN E] into resident's room .upon entering resident was laying on the floor on her left side .assessment revealed no injuries related to this fall . *09/15/24 at 10:09 a.m. by LVN E, .as Resident #34 turned and started to the other table she was bent forward and started falling into the table .the nurse [LVN E] attempted to keep her from falling unsuccessfully .I [LVN E] was able to break her fall but not prevent it . *09/16/24 at 10:03 a.m. by LVN R, .Day 1 post fall x2, Resident #34 seems to lean to the left when sitting in her wheelchair . no complaints pain or discomfort and no further post fall injuries noted at this time . *09/18/24 at 2:30 p.m. by LVN E, .Resident #34 is Day 3 post falls with no injuries noted at this time .the resident has been very restless this shift continuing to attempt to stand from a sitting position in her wheelchair .as she attempts this she leans forward with her face down causing her to stumble as she gets up .to prevent this the resident has been walking in the hallway holding to the handrail . *09/19/24 at 4:52 p.m. by LVN E, .Resident #34 is day 4 post fall with no injuries .Resident #34 has been restless this shift with numerous unsuccessful attempts to redirect her .she is extremely unsteady and is a fall risk when she rises from the chair bent over toward the floor . *09/20/24 at 8:25 a.m. by LVN R, .Resident #34 is day 5 post fall with no injuries .she is restless and getting up and down from wheelchair .very unsteady gait .nurse [LVN R] continues to try to redirect . *09/23/24 at 2:13 p.m. by LVN E, .Resident #34 is Day 1 follow up fall in resident room .resident has been alert and has been in dining room watching TV with other residents . *09/24/24 at 7:30 a.m. by LVN E, .Resident #34 was assessed this morning some light colored bruising noted to right hip and right chin .resident holding head to the left side .unable to assist this nurse and CNA get her from the commode to the wheelchair .resident answering questions .speaking slower than is her norm . informed administrative staff and informing MD T . *09/24/24 at 2:20 p.m. by LVN E, .Received a call from staff at [hospital] ER .she reported that our resident will be returning to the facility .she stated that imaging, labs, and UA had been completed .no fracture, no brain bleed were found .labs and UA are normal .hospital staff further states that the resident continues to be very lethargic and holds her head down and to the left .they can find no explanation for either even though it is evident and continuing at this time .the ER is returning her with no treatable condition . *09/27/24 at 3:22 p.m. by LVN E, .Resident #34 has been very tired today and has rested in bed most of this shift .she has been lethargic at times . Record review of Resident #34's physician progress note dated 08/15/24 at 9:10 p.m. by MD T indicated .Physician Progress Note .Assessment .Schizophrenia, Bipolar disorder, Pulmonary embolism (is a blockage in a lung artery caused by a blood clot or other substance that travels from another part of the body through the bloodstream), Generalized anxiety disorder, Hypertension (high blood pressure) .Plan: Increase risperidone to three times a daily, increase lorazepam to twice a daily, implement fall precautions, consider increasing medication as needed in the next few days if behavior issues persist .Subjective: Resident #34, a [AGE] year-old lady in the memory care unit, was seen due to increasing behavioral issues .she history of schizophrenia .the nurse staff report worsening behavioral issues despite current medication regimen of risperidone twice daily and lorazepam daily .during the visit, she appeared anxious, repeatedly attempting to stand from her chair without assistant despite instruction to remain seated .Psych: anxious, euthymic (is a normal, tranquil mental state or mood) . Record review of Resident #34's fall event notes reflected: *On 08/09/24, Resident #34 had a fall in the dining room. *On 09/10/24, Resident #34 had a fall in hallway. *On 09/15/24, Resident #34 had a fall in the resident's room. *On 09/15/24, Resident #34 had a fall in the dining room. *On 09/22/24, Resident #34 had a fall in the resident's room. Record review of Resident #34's hospital records dated 09/24/24 indicated .apparently the patient fell 2 days ago at the nursing home and was sent here for evaluation .we did call the nursing home and they said she has been acting more lethargic lately just not moving as much normally she will take a few steps but now she is not doing that no other abnormality .patient feels a little better now she is actually able to communicate more she is just repeating what I say she is more awake .the workup here was negative . Record review of Resident #34's weight record reviewed 10/02/24 indicated Resident #34 weighed 153 lbs. on 09/10/24 and 138 lbs. on 10/02/24. This was a 9.8% weight loss in less than one month. During an observation on 09/30/24 at 9:43 a.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and with her head down and eyes closed. During an observation and interview on 09/30/24 at 10:30 a.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and with her head down and eyes closed. CNA C brought a pillow to help prop Resident #34 more upright. Staff placed a snack and magazine in front of Resident #34, but she did not touch either item. Resident #34 smiled but did not respond when addressed by surveyor. Resident #34 was non interviewable. During an observation on 09/30/24 at 12:03 p.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and was asleep. Resident #34's lunch tray was in front of the resident untouched. Staff kept attempting to wake Resident #34 to eat her lunch. LVN R fed Resident #34 a few bites. During an observation on 09/30/24 at 4:04 p.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and was asleep. During an interview on 09/30/24 at 4:15 p.m., a family member of Resident #34 said Resident #34 was not on the secure unit when she was admitted . He said Resident #34 started wandering and going in other people's rooms. He said the facility placed her on the secured unit. He said Resident #34 had dealt with mental illness her whole life and did not take medications. He said Resident #34 did not like how the medications made her drowsy and sleepy. He said Resident #34 was on the medication she did not like and was very sleepy. During an observation on 10/01/24 at 8:14 a.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and appeared sleepy. Resident #34's breakfast tray was untouched in front of her. The DON encouraged Resident #34 to take a bit of her oatmeal. Resident #34 took one bite with the DON's assistance. During an observation on 10/01/24 at 11:04 a.m., Resident #34 was in the dining room in a wheelchair. Resident #34 was leaning to the left in her wheelchair and was asleep. During an interview on 10/02/24 at 9:03 a.m., LVN E said Resident #34 was in the general population then placed on the secured unit for wandering. She said Resident #34 never really walked very steady and liked to lean forward. She said Resident #34 had schizophrenia and was not redirectable. She said Resident #34 was a hard resident t[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible for 1 of 7 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure staff checked straps for damage prior to transferring Resident #1 which resulted in a laceration to Resident #1's forehead. This failure could place residents at risk for injury. Findings include: Record review of Resident #1's face sheet, dated 02/10/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (weakness on one side of your body) following cerebral infarction (Stroke) affecting the left dominant side. Record review of Resident #1''s MDS, dated [DATE], revealed Resident #1 required two-person assistance for transfers and had a BIMS score of 15, which indicated Resident #1 was cognitively intact, alert to person, place, and time. Resident #1 used a wheelchair to ambulate. Resident #1 required extensive assistance with most activities of daily living. Record review of Resident #1's care plan, dated 12/27/22, revealed Resident #1 required two-person assistance for transfers and required a mechanical lift due to a self-care performance deficit. Record review of Resident #1's nurse's note, dated 02/05/23 at 9:23 PM, by LVN B, revealed Resident #1 was kicking and yelling at staff. LVN B asked LVN A to assist in transferring Resident #1 from his wheelchair to his bed using a Mechanical lift. When LVN A and LVN B arrived in the room three of four straps were already attached to the lift. LVN A attached the last strap and proceeded with the transfer. During the transfer LVN B reported hearing a snap, and Resident #1 fell from the lift to the floor hitting his head causing a laceration. LVN B called 911 and Resident #1 was transferred to the hospital for evaluation and treatment. Record review of Resident #1's hospital records, dated 02/05/23, revealed Resident #1 arrived at the hospital with a facial laceration. The fall involved a lift chair assistance as the cause of accidental injury. The injury was repaired with stiches. CT scan (scans take a fast series of X-ray pictures, which are put together to create images of the area that was scanned.), showed no acute intercranial abnormalities, laceration to the soft tissue, swelling to the left frontal scalp and preorbital (around the eye) soft skin. There was mild soft tissue swelling to the left cheek. Resident #1 was released back to the facility after treatment. Observation of a video surveillance tape, date stamped on 02/05/22 at 8:48 PM, showed Resident #1 was being transferred from a wheelchair to a bed by LVN A and LVN B using a mechanical lift. The front left strap on the lift appeared to be frayed or damaged. During the transfer, the front left strap holding Resident #1, snapped and Resident #1 fell from the lift and hit his head on the floor. During an observation and interview on 02/10/23 at 1:20 PM revealed Resident #1 was in his bed. There was a bandage on his forehead, above his left eye with a date of 02/10/23. There was a Hoyer lift Sling under him. The sling appeared to be in good condition with no frayed edges. Resident #1 said he was doing okay. He said he fell while staff attempted to transfer him from his wheelchair to his bed. Resident #1 said he did not remember much about what happened. He said all he remembered was the strap broke and he hit the floor. He said the next thing he remembered was being at the hospital. He said he did not feel he had been abused or neglected and what happened was an accident. Resident #1 said he was not afraid to be transferred with the Hoyer Lift. During an interview on 01/17/23 at 1:20 PM, LVN A said he assisted LVN B with transferring Resident #1 with a Hoyer Lift on 02/05/23 around 8:30 PM. LVN A said while transferring Resident #1, a strap on the front left side of the lift snapped and Resident #1 fell to the floor and hit his head. LVN A said LVN B left the room and called 911 for assistance. LVN A said when he looked at Resident #1, there was blood on the floor coming from Resident #1's head. LVN A said she went and got a towel and applied pressure to the wound until EMS arrived and transported Resident #1 to the hospital for evaluation and treatment. LVN A said he did not realize the strip was damaged. LVN A said the cause of the accident was due to the defective strap. LVN A said he should have inspected the straps before he attempted to transfer Resident #1. LVN A said he was notified on 02/10/23 that he was suspended pending an investigation due to the incident. LVN A said he was scheduled to complete Mechanical Lift skills training before returning to work, but he had not yet received the training. During an interview on 01/17/23 at 1:45 PM, LVN B said she and LVN A was asked to assist in transferring Resident #1 from his wheelchair to his bed because staff reported Resident #1 was being verbally and physically aggressive toward staff who attempted to transfer him to his bed. LVN B said she asked LVN A to assist in the transfer. LVN B said when she arrived in the room, there were three straps already attached to the lift and LVN A attached the fourth strap to transfer Resident #1. LVN B said she was operating the lift and LVN A lowered the bed to the lowest position. LVN B said the bed caught on the edge of a trash can at the foot of the bed when the bed was lowered. LVN B said she raised Resident #1 out of the wheelchair and LVN A was moving the wheelchair out of the way when she heard a snap. LVN B said the strap on the front left side of the sling holding Resident #1 broke and Resident #1 fell to the floor hitting his head. LVN B said she went to the door and yelled for help. LVN B said she called 911 on her cell phone and LVN A went and got a towel to stop the bleeding. LVN B said she did not notice the strap was damaged and if so, she would have not used the defective sling to transfer Resident #1. LVN B said she was notified on 02/10/23 by the DON she was suspended pending an investigation into the incident. LVN B said she should have assessed the condition of the straps before she attempted to transfer Resident #1. LVN B said since the incident she had received skills training on transferring using a Mechanical lift on 02/15/23. During an interview on 02/10/23 at 12:12 PM, the DON said the first time she viewed the video was with the surveyor. DON said she had not reviewed the video of the incident with Resident #1 before this time. The DON said LVN A and LVN B failed to use proper technique when transferring Resident #1 with the Mechanical lift. The DON said staff should always assess the condition of the lift sling to ensure it was safe prior to use. The DON said it was obvious by viewing the video that the strap on the front left side was damaged and the sling should not have been used. The DON said after the incident she completed an assessment of all other lift slings in the building and found there were some that needed to be retired and new slings were ordered to replace the damaged slings. The DON said all staff received training to inspect the slings prior to use and if a sling showed signs of being defective or damaged the sling should not be used to transfer residents. The damaged sling should be reported to the charge nurse and the DON. The DON said the sling should be taken out of service and replaced with a new sling. The DON said all nursing staff would receive skills training with a check-off for each one on how to transfer a resident using a Mechanical lift. The DON said the skills training would be conducted by the DON and the Director of Rehabilitation. During an interview on 02/10/23 at 12:08 PM, the Administrator said she was notified Resident #1 had a fall from a Mechanical lift on 02/05/23 around 8:30 PM. The Administrator said the cause was a damaged strap that broke which caused injury to Resident #1. The Administrator said she reported the incident to the state on 02/05/23 at around 9:45 PM. The Administrator said all the slings and straps in the facility were assessed by the DON for possible damage and those found to be damaged were removed from service immediately. The Administrator said new slings were ordered to replace the damaged slings. The Administrator said on 02/06/23 an intervention plan was developed by QAPI regarding the Hoyer Lift issue. The Administrator said all staff were in-serviced on inspecting the straps and slings before use. The Administrator said the DON would monitor and inspect slings and straps weekly to ensure they were in good condition. The Administrator said any slings found to be damaged would be removed from service and replaced. The Administrator said all nursing staff would receive skills training on how to properly operate the Mechanical Lift. The Administrator said the skills training would be conducted by the DON and Director of Rehabilitation. An observation and interview on 02/10/23 at 1:45 PM revealed NA-A, NA-B and NA-C using a Hoyer lift to transfer Resident #1 from his bed to his wheelchair. NA A and NA B used proper technique in transporting the resident. Transfer was successfully completed with no concerns for Resident #1's safety. The equipment and sling were in good working order with no concerns. NA-A, NA-B and NA-C said they had recently received in-service training on safely using the Hoyer lift. They said they were to assess the condition of the sling and straps before using to transfer a resident. They said if the sling or straps were damaged, they were not to use them and report to the charge nurse and/or the DON. Interview on 02/10/23 at 1:30 PM, the Laundry Aide said she washed two to three Hoyer Lift slings daily. She said she followed the manufacturer's suggested care instructions. She said the slings were washed in cold to warm water, but never hot water. She said all slings were hung to air dry and slings were never dried in the dryer. She said heat could cause the material to stretch or become weak. Record review of Sling Laundry Instructions revealed .While the materials comply with applicable standards for strength, shrinkage and flammability, slings are subject to wear and tear, which increases with usage. Before each use check for fraying or cuts/tears in the straps and body of the sling. Slings that show wear or damage should be taken out of service . LAUNDRY INSTRUCTIONS: . Machine wash normal setting and at 140F/60C. Depending on the washing machine, this usually means on a medium temperature setting. Record review of in-service records from 02/06/23 through 02/17/23 revealed documentation that nursing staff received training on 10/17/22. Staff received in-service training on laundry instructions of Hoyer Lift Slings. The in-service was conducted by the Housekeeping Supervisor. After washing the Hoyer Lift sling, you cannot put heat on it. The sling needs to air dry or put in the dryer with no heat. The fabric when heated can stretch and snap! This will cause an injury. This will be an automatic [NAME]! Record review of in-service records revealed on 02/06/23 nursing staff received in-service training on Hoyer Lift transfer. o Must have 2 nursing staff (CNA, Nurse, Medication Aide) to use a Hoyer lift on a resident. o Always check sling and sling straps to verify they do not appear compromised. o If there is any question, have nurse verify it is okay to use. o DO NOT USE A DAMAGED SLING Under any circumstances. Record review of Mechanical lift Competency Evaluations dated 02/10/23 - 02/17/23, showed staff using a Hoyer life to transfer residents received a skills assessment on using a Mechanical Life to transfer residents safely. Record review of the facility's, undated, policy on Hydraulic lift revealed: . The resident will achieve safe transfer to bed or chair via mechanical lift device . The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift .23. Immediately remove any malfunctioning equipment from direct care use.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 24 residents reviewed for quality of care. (Resident #5 and Resident #33) The facility did not ensure -Resident #5 had care planned interventions in place to prevent wound deterioration due to the resident's noncompliance with treatment. -personal care items on the secured unit were stored securely, Resident #5 continued to obtain and apply restricting socks, lotions and shaving cream to his open wounds causing wound deterioration to the point a speacilist was sought for treatment. The facility did not assess and document skin changes for Resident #33 after she developed an open wound. These failures could place residents at risk for new development or worsening of existing wounds, infection, pain and decreased quality of life. Findings included: 1. An order summary report dated 5/21/2021, indicated Resident #5 was [AGE] years old, re admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The order summary report indicated Resident #5 was admitted to the secure unit due to history of exit seeking behavior. The report indicated Resident #5 had and arterial wound to the left distal third toe, an arterial wound to the left lateral fourth toe and the left lateral fifth toe. The MDS dated [DATE] indicated Resident #5 made himself understood and understood others. The MDS indicated Resident #5 required supervision for transfers, eating and personal hygiene . The MDS indicated Resident #5 did not reject care. The MDS did not address Resident #5's wounds. The care plan dated 2/13/2020 indicated Resident #5 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. The care plan indicated Resident #5 had a wound to the left fifth toe and the left third toe. The care plan did not address Resident #5's non-compliance of wearing tight restrictive socks or applying lotion and shaving cream to the open wounds on his left toes. A progress note dated 4/28/2021 at 2:42 p.m., completed by the wound care nurse, indicated Resident #5 was seen by the wound care physician due to a stage 4 pressure ulcer to the left medial fifth toe and a wound to the left plantar foot. The note indicated the wound to the fifth toe was deteriorating and an MRI had been ordered to rule out [CONDITION(S)]. The note indicated Resident #5 was noncompliant by removing treatments placed on wound, wearing tight socks that caused pressure and toes to be squished, and applied lotion to open wound areas. A progress note dated 4/29/2021 at 2:06 p.m., completed by the wound care nurse indicated Resident #5 said he did not know why he was removing the treatments and Resident #5 had dressing and foot covered with thick lotion. The note indicated the wound care nurse reeducated Resident #5 that the treatments had medications to help his wounds heal. A progress note dated 5/3/2021 at 2:07 p.m., completed by the wound care nurse indicated Resident #5 continued to be non-compliant with keeping his wound dressing in place and continued to apply lotion to the open area on his fifth toe wound. The note indicated Resident #5 had caked lotion between his toes and refused to allow the nurse to wash the lotion off. The note indicated Resident #5's toes were bright red in color. A progress noted dated 5/5/2021 11:36 a.m., indicated Resident #5 continued to be noncompliant by removing treatments placed, wearing tight socks causing pressure and toes to be squished and applying lotion to open area on the foot. A progress note dated 5/10/2021 at 1:18 p.m., completed by the wound care nurse indicated Resident #5 continued to be non-compliant with keeping dressings in place and continued to apply lotion to the open area on his fifth toe. A progress note dated 5/12/2021 at 9:30 a.m., written by LVN A indicated Resident #5 continued to be non-compliant with wearing compression stockings and keeping heavy shoes off. A progress note dated 5/12/2021 at 10:54 a.m., completed by the wound care nurse indicated Resident #5 continued to be non- compliant by removing treatments placed, wearing tight socks that caused pressure and toes to be squished and continued to apply lotion to open wound areas. A progress note dated 5/16/2021 at 9:12 p.m., completed by the wound care nurse indicated Resident #5 had a blackened area to the medial third toe. The note indicated toes remained reddish purple in color, hot, painful to touch and odorous. A progress note dated 5/17/2021 at 1:12 p.m., completed by the wound care nurse indicated Resident #5 continued to apply lotion to the wound. A progress note dated 5/19/2021 at 12:23 p.m., completed by the wound care nurse indicated Resident #5 continued to be non-compliant by removing treatments placed, wore tight socks and shoes that caused pressure and toes to be squished and applying lotion and shaving cream to open wound areas. A specialty physician wound evaluation and management summary dated 4/7/2021, 4/14/2021, 4/21/2021, 4/28/2021 and 5/19/2021 indicated, the wound on the left medial fifth toe had deteriorated. A Specialty physician wound evaluation and management summary dated 4/7/2021, indicated Resident #5 had a stage 4 pressure ulcer to the left, medial, fifth toe that measured 0.8 x 0.3 x 0.1 cm. The note indicated the wound had deteriorated. A Specialty physician wound evaluation and management summary dated 4/14/2021, indicated Resident #5 had a stage 4 pressure ulcer to the left, medial, fifth toe that measured 1 x 0.3 x 0.1 cm. The note indicated the wound had deteriorated. A Specialty physician wound evaluation and management summary dated 4/21/2021, indicated Resident #5 had a stage 4 pressure ulcer to the left, medial, fifth toe that measured 1.7 x 1 x 0.2 cm. The note indicated the wound had deteriorated. A Specialty physician wound evaluation and management summary dated 4/28/2021, indicated Resident #5 had a stage 4 pressure ulcer to the left, medial, fifth toe that measured 2.0 x 1.1 x 0.3 cm. The note indicated the wound had deteriorated. A Specialty physician wound evaluation and management summary dated 5/19/2021, indicated Resident #5 had an arterial wound (a very painful injury caused by poor circulation) to the left, medial, fifth toe that measured 2.0 x 1.4 x 0.2 cm. The note indicated the wound had deteriorated. During an observation on 5/18/2021 at 9:19 a.m., Resident #5 had a dressing to his left foot with the tops of his toes exposed. The tips of the toes appeared dark red and the third and fifth toes appeared black in color. During an interview on 5/20/2021 at 9:10 a.m., the wound care nurse said Resident #5 had arterial wounds to his left toes that were deteriorating due to his own non-compliance. The wound care nurse said he continued to wear tight and constricting socks and shoes and continued to apply lotion and shaving cream to the open wounds. The wound care nurse said they had taken away some socks, lotions and shaving creams but he continued to obtain these things. The wound care nurse said they had not gone through his personal belongings in the room to see if he had these things hidden in his room. The wound care nurse said Resident #5 had severe dementia and resided on the locked unit. The wound care nurse said Resident #5 had an appointment in June with a foot specialist to hopefully save his toes. During an interview on 5/20/2021 at 9:27 a.m., LVN C said Resident #5 had wounds on the left foot. She said it looked like Resident #5 was going to lose the small toe on the left foot. LVN C said Resident #5 would remove the dressings from his left foot and forget he did it. LVN C said he often caked lotion or shaving cream on the wounds and foot. During an interview on 5/20/2021 at 9:35 a.m., CNA B said Resident #5 was confused. CNA B said Resident #5 had wounds on his left foot that looked horrible. She said the wounds appeared to be getting worse. CNA B said Resident #5 often wore constricting socks and shoes. During an interview on 5/20/2021 at 9:40 a.m., CNA D said Resident #5 required supervision with ADLs but was somewhat independent . CNA D said Resident #5 had wounds on his foot that appeared to be getting worse. CNA D said Resident #5 wore constricting socks and shoes. CNA D said they removed some socks from his room, but he kept finding more to put on. CNA D said she was not sure where he found the socks. During an observation on 5/20/201 at 9:50 a.m., LVN C removed Resident #5's socks and shoes. There was no dressing on the left foot. There was a dried white substance on the foot and the toes. The fifth toe was black with a yellow drainage, no nail bed was able to be visualized, the base of the toe was open and had a yellow colored drainage. Resident #5's left third toe was black. During an observation on 5/20/2021 at 10:30 a.m., there was a small white and purple can labeled shaving cream noted on the residents bedside dresser. During an observation on 5/20/2021 at 10:46 a.m., a supply closet located next door to Resident #5's room was unlocked. Inside the storage room were small white and purple cans labeled shaving cream and small bottles labeled lotion. During an interview on 5/20/2021 at 10:50 a.m., CNA B said they did not keep the supply closet next to Resident #5's room locked. During an interview on 5/20/2021 at 10:53 a.m., LVN C said they did not keep the supply closet located next to Resident #5's room locked. During an interview on 5/20/2021 at 1:45 p.m., CNA D said she did not know how Resident #5 obtained lotion or shaving cream. CNA D said she had not seen him inside the supply closet or inside other resident room. CNA D said she had been instructed to watch Resident #5's room for shaving cream and lotion and report to charge nurse if any was found. During an interview on 5/20/2021 at 2:00 p.m., the wound care nurse said she believed Resident #5's wound was deteriorating due to his noncompliance including applying lotion and shaving cream to his open wounds and wearing tight constrictive footwear. The wound care nurse said Resident #5 had an appointment with a foot specialist next month to hopefully save his toes. During an interview at 5/20/2021 at 2:05 p.m., Resident #5's wound care physician said Resident #5 had vascular necrosis in his left toe with poor vascular supply. The wound care physician said anything constricting the circulation to the toes would cause worsening of the wound. The wound care physician said every time she saw the resident his left foot was caked in lotion or shaving cream both of which would cause worsening of the wound. During an interview on 5/20/2021 at 2:20 p.m., Resident #5 said he had shaving cream in his room and pulled out a large can of shaving cream from his bedside drawer. Resident #5 said he did not recall putting any shaving cream on his foot. Resident #5 said he put lotion on his foot because it made the pain go away. Resident #5 said he might have got the shaving cream and lotion from home he didn't know. During an interview on 5/20/2021 at 2:25 p.m., CNA E said shaving cream should not be kept in resident rooms on the secured unit. CNA E said he was not aware of any resident on the secured unit that should have shaving cream in their room for safety reasons. During an interview on 5/20/2021 at 2:52 p.m., the DON said the wounds on Resident #5's left foot had worsened due to his noncompliance. The DON said Resident #5 wore tight constrictive socks and shoes and applied lotion and shaving cream to the open wounds. The DON said she was not sure how Resident #5 kept getting the socks, shaving cream or lotion but he did seem to collect things. The DON said she expected staff to monitor for tight constrictive socks, lotion, and shaving cream in Resident #5's room and report to nursing or administrative staff if found so they could be removed from the room. The DON said they did not lock the supply closet door next to Resident #5's room on the secured unit because staff were frequently in and out of it all day long. The DON said Resident #5 had an appointment with a foot doctor on 6/1/2021 to hopefully save his toes. During an interview on 5/20/2021 at 3:29 p.m., CNA E said he had never seen Resident #5 in the supply closet but knew he got in there because he found shaving cream in his room just a few minutes ago. CNA E said he confiscated and disposed of the shaving cream. CNA E said he did not report this to the DON or charge nurse because he was not aware Resident #5 had been putting shaving cream on his wounds. CNA E said he took it away for safety reasons. During an interview on 5/20/2021 at 3:30 p.m., LVN C said Resident #5 can get in the supply closet if he wanted because it was not locked. LVN C said she had been instructed to monitor Resident #5's room for lotion and remove but was not aware of the need to monitor for and removing shaving cream. During an interview on 5/20/2021 at 3:33 p.m., CNA F said she had seen Resident #5 in the supply closet in the past. She said she redirected Resident #5 to his room During an interview on 5/21/2021 at 11:10 a.m., the administrator said supplies on the locked unit should be stored safely away from residents while still being accessible to the staff. The administrator said staff should remove any items from residents' rooms that could be unsafe for them to use or that may in any way impede wound healing. The administrator said she expected that if these items were found in a residents room it would also be reported to the charge nurse and administrative staff. During an interview on 5/21/2021 at 2:10 p.m., the DON said the charge nurses were responsible for checking the rooms for unsafe items and to remove them and report as necessary. 2. A face sheet with a print date of 5/21/21 indicated Resident #33, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated 12/9/20 indicated Resident #33 had skin impairments to her buttocks. She had a foley catheter with the intervention of ensuring the foley catheter tubing was anchored to the resident's leg or linens. The MDS dated [DATE] indicated Resident #33 had intact cognition. She required the extensive assistance of 2 staff members with bed mobility, the limited assistance of 2 staff members with dressing, and the extensive assistance of 1 staff member with toilet use and personal hygiene. The MDS addressed the resident's foley catheter and pressure ulcers to buttocks. The order summary report for May 2021 indicated Resident #33 had an order, with the start date of 5/20/21, to ensure catheter securement device in place. An order with the start date of 5/20/21, indicated the resident had a stage 2 pressure ulcer to her left inner thigh and to treat the ulcer with calcium alginate and a dry dressing. During an observation on 5/20/21 at 11:00 a.m., CNA G was providing catheter care for Resident #33 with the wound care nurse. When the resident's legs were spread apart, a wound was found on her left inner thigh, measuring 2 inches long and 1 inch wide. The wound care nurse said she did not know about the wound before today and was not sure if it was a pressure wound or a friction wound from the resident's catheter rubbing her leg. A specialty physician wound evaluation and management summary from 5/19/21, did not address the resident's wound to her inner left thigh. A weekly skin assessment form, completed on 5/19/21, by the wound care nurse, did not address the resident's wound to her inner left thigh. During an interview on 5/20/21 at 11:35 a.m., the wound care nurse said she did not see the area to the resident's inner left thigh yesterday because of the resident's positioning in her bed. She said she should have pulled the resident's legs further apart, but she did not. She said she did not think the area to the resident's thigh was pressure, but more of a friction wound from the resident's catheter rubbing her leg. During an interview on 5/20/21 at 11:45 a.m., CNA G said she was not aware of the area to Resident #33's inner thigh. She said the resident complained frequently of severe pain to her left knee, due to her arthritis. She said she provided catheter care to the resident with her legs closed, or semi-closed. She said she had not been notified of the area to the resident's inner thigh by any other aides during shift change. During an interview on 5/20/21 at 1:55 p.m., Resident #33 said she notified the wound care doctor of the sore spot on her leg yesterday while the doctor was in the facility. She said she called out to the doctor who was standing in the hallway. The doctor reentered the resident's room, observed the area, and told the resident the area looked fine and should resolve on its own. During an interview on 5/20/21 at 2:02 p.m., the wound care nurse said she talked to the wound care doctor who confirmed the resident did tell her about the area on her inner thigh. She said the doctor said it looked like an abrasion and she thought it would go away on its own. The wound care nurse said she was not present when the resident called the wound care doctor back into her room. A record review of the Skin Integrity Management policy with a revision date of 10/5/16 indicated the following: General Guidelines 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. 2. Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores etc. is to occur .

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 10 residents reviewed for abuse. (Resident #1) The facility did not prevent Resident #1 from being sexually abused. Resident #1 alleged she was raped after she was found with a vaginal injury consistent with a sexual assault. Resident #1 was afraid and had a torn labia that required surgical repair. CNA B was the last known staff member to provide any care for Resident #1. This was determined to be past non-compliance Immediate Jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The past non-compliance existed from 5/13/19 to 5/14/19. This failure could place other residents whom CNA B cared for at risk for sexual abuse and fear. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A face sheet dated 5/16/19 indicated Resident #1's original admitted was 10/12/16 and the resident had a [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and was sometimes understood and her cognition was severely impaired. The MDS indicated Resident #1 had no behaviors, received extensive to total assistance with most ADLs and was always incontinent of bowel and bladder. A care plan dated 1/14/19 indicated Resident #1 required extensive assistance of one staff member for bathing and toileting. The care plan indicated the resident had contractures, but the location of the contractures was not specified. A hospital history and physical dated 5/13/19 completed by Resident #1's primary care physician, who was the facility's medical director indicated Resident #1 was noted to have some vaginal bleeding with clots after receiving a bath. The report indicated the resident stated she was raped and was transferred to the emergency department for further evaluation. The report indicated the resident was noted to have a labial tear and underwent surgical repair. The report indicated Resident #1 was nonverbal during the visit and did not answer any questions. During an observation and interview on 5/16/19 at 2:08 p.m., Resident #1 was lying in a hospital bed. She had dark bruising to her left upper arm, and scratches to the bottom of her left breast. Resident #1 had limited mobility in both arms and the nail on the middle finger of her right hand was broken off at the quick. Resident #1 was able to say her name and consistently answered simple yes and no questions. Resident #1 said yes when asked if someone hurt her. Resident #1 looked terrified when asked how someone hurt her. Resident #1 said he (indistinct word) me .he (indistinct word) me .he (indistinct word) me. The resident did not indicate what the indistinct word was and did not answer further questions. During a telephone interview on 5/17/19 at 11:26 a.m., CNA B said 5/13/19 was the first time he ever worked B hall where Resident #1 resided. CNA B said he arrived to work around 6 a.m. on 5/13/19. CNA B said he went into Resident #1's room once between 8:00 a.m. and 8:20 a.m. He said he gave Resident #1 a bed bath, provided peri care because her brief was wet, and changed her sheets because the sheets were dirty. He said he was not rough with the resident in any way and the resident did not have blood in her brief. He said he did not go back into Resident #1's room after that. CNA B said while he was providing care for Resident #1, someone came into the room and immediately left the room and he did not see who entered the room. CNA B said between 11:30 a.m. and 12:00 p.m., the ADON told him he needed to talk to the DON. He said the DON asked him about the care he provided to Resident #1 that morning and told him the resident was bleeding from her vagina and he was suspended. He said he told the DON what she was accusing him of was disgusting. CNA B said she did not verbally say what she was accusing him of, but it was obvious from her questioning the facility blamed him for the bleeding and he had been fired. CNA B said the police questioned him that night and the police told him if he was the one who caused the residents injury to her vagina, they did not feel he did it intentionally. He said he provided the police with his DNA and scrubs. During a telephone interview on 5/19/19 at 8:21 p.m., LVN G said Resident #1 readmitted to the facility from the hospital on [DATE] around 10:30 p.m. LVN G said Resident #1 had been in the hospital with a urinary tract infection and hypothermia. LVN G said she removed Resident #1's catheter between 10:30 p.m. and 11:00 p.m. on 5/12/19 and the resident had no signs of pain or bleeding when she removed the catheter. LVN G said she assessed Resident #1 from head to toe and Resident #1 had a bruise on each hand and upper right arm from IVs she had during her hospital stay. LVN G said aside from those bruises, Resident #1's skin looked great. LVN G said she checked on the resident every hour and saw the resident at the end of her shift at 6:00 a.m. on 5/13/19. LVN G said when she last saw Resident #1 on the morning of 5/13/19 she was sitting up in her bed and was in a good mood. LVN G said she had never known Resident #1 to resist incontinent care or appear scared. During a telephone interview on 5/19/19 at 7:55 p.m., CNA F said the last time she went into Resident #1's room on 5/13/19 was 4 a.m. She said she checked the resident for incontinence and the resident was dry. She said her bed was kind of wet because of the resident's formula from her feeding tube, so she changed her sheets. CNA F said the resident had no blood in her brief, was not combative, was not in pain, and did not appear to be scared. CNA F said that was her first time to work with Resident #1. During an interview on 5/16/19 at 10:13 a.m., CNA D said on 5/13/19 around 10:00 a.m., she knocked on Resident #1's door and opened it looking for CNA E. She said when she opened the door, she saw the privacy curtain was closed around Resident #1. She said she did not see Resident #1 and did not hear anything. She said she could see the foot of Resident #1's bed and saw CNA B adjusting Resident #1's covers. During an interview on 5/16/19 at 10:22 a.m., CNA [NAME] said she worked the hall with CNA B on 5/13/19. She said she and CNA D went outside to go smoke just before 10:00 a.m., and CNA D opened Resident #1's door. CNA D said CNA B came to her between 10:00 a.m. and 10:30 a.m. and asked her which resident was Resident #2, and CNA D told him Resident #2 was in the A bed. CNA D said CNA B said oh, I gave the wrong person a bath. CNA [NAME] said she was surprised to learn Resident #1 had blood in her brief and alleged that someone raped her. CNA [NAME] said she had not seen anyone in Resident #1's room, and the only person who was seen in Resident #1's room according to other staff was CNA B. During an interview on 5/17/19 at 9:05 a.m., RN A said when she went in to Resident #1's room between 8:15 a.m. to 8:30 a.m. on 5/13/19, Resident #1 was behaving normally and was in a cheerful mood. She said around 8:30 a.m., CNA B asked her who needed showers and she referred him to his pocket worksheet and she circled the names of the residents requiring showers on his pocket worksheet. She said she told him to give Resident #2 (Resident #1's roommate) a bed bath. RN A said between 9:15 a.m. and 9:30 a.m., she went back into Resident #1's room to administer medications to Resident #1 and did not notice anything out of the normal. RN A said Resident #1's sheets were dirty, her hair had not yet been brushed, and her linens had not been changed at that time. RN A said the linens were not soaked with urine and did not have blood on them, but just appeared unclean. RN A said after 10:00 a.m., CNA B came to her and reported he gave the wrong resident a bath. RN A said CNA B indicated he gave Resident #1 a bath instead of Resident #2. RN A said she asked CNA B why he did that, and CNA B did not give an explanation. RN A said she went back into Resident #1's room around 11:45 a.m. and Resident #1's eyes were closed, and her brief was saturated with blood. RN A said she immediately went to Resident #1 and touched her shoulder to wake her up and Resident #1 became very agitated and started swinging her arms. RN A said Resident #1 had never done that before. RN A said Resident #1 was screaming no, no, no, no and seemed scared. RN A said it took about 30 seconds to one minute to get the resident to calm down. She said she tried to get Resident #1 to spread her legs open, and the resident clenched her legs tightly together and kept screaming no. RN A said Resident #1 screaming no was unusual. RN A said she left and got CNA C to help her. She said she asked Resident #1 what happened, and Resident #1 asked If I tell you, will you make me leave? RN A said she assured Resident #1 they would not make her leave, but the resident did not tell them what happened. RN A said Resident #1's entire brief and sheets were saturated with blood. RN A said the resident was actively bleeding, but she could not see where the resident was bleeding from. RN A said she started playing back in her mind that CNA B said he had mistakenly given Resident #1 a bath. RN A said she left the room and went to the social worker and told him Resident #1 was bleeding and told him she suspected CNA B had something to do with it. She said her, and the social worker went to the DON's office and reported it to the DON and ADON. She said the ADON immediately pulled CNA B from the hall and the DON talked to him and asked him to leave. She said the ADON went to Resident #1's room to assess her. The ADON asked Resident #1 what happened to her and Resident #1 repeated I got raped, I got raped, I got raped. RN A said the words were clear and there was no doubt what she was saying. RN A said she had known Resident #1 since she was first admitted to the facility and Resident #1 never had any self-inflicted injuries and was never known to scratch or dig in her brief. She said Resident #1's hands were kept closed and were contracted, and she did not think Resident #1 was capable of scratching her vaginal area to the point of injuring herself. RN A said Resident #1 was observed with blood under her nails and blood on the top of her hand. RN A said she would have expected the blood to be on the bottom of her hand if the resident had caused any injury to herself. RN A said prior to the incident, she thought CNA B was weird, but he was always nice and did his work. RN A said she suspected CNA B sexually assaulted Resident #1 because he was the only person who had been in the room, and Resident #1 acted scared when she was normally smiling and making jokes. During a telephone interview on 5/17/19 at 11:04 a.m., CNA C said on 5/13/19 around 11:15 a.m., she was across the hall from Resident #1's room assisting another resident. CNA C said when she exited the other resident's room, she looked across the hall and Resident #1 appeared to be falling asleep. She said Resident #1 did not appear to be in any distress but Resident #1 did not respond when she spoke to her. CNA C said Resident #1 usually smiled and waved at her when she talked to her, and CNA C assumed the resident did not respond this time because she was falling asleep. CNA C said about 10 minutes later, RN A came to her and said she needed assistance cleaning Resident #1. CNA C said Resident #1 was bleeding and her brief was blood-soaked. CNA C said she used towels soaked with water to clean Resident #1, but as soon as she would wipe, more blood would quickly reappear. She said it appeared Resident #1 was bleeding from her clitoris area. She said she had never known the resident to have menstrual cycles and she told the nurse the bleeding did not appear to be from a cycle because she was bleeding near her clitoris area. CNA C said she stayed in the room when RN A left to get the social worker. She said RN A returned with the ADON and the ADON asked Resident #1 what happened and Resident #1 asked do you want me to tell you the truth? and promise you won't make me leave?. CNA C said Resident #1 was swinging her arms and said I was raped. I was raped. I was raped. CNA C said something had to have happened to Resident #1 for her to bleed that bad. CNA C said all three towels she used to clean Resident #1 up were saturated with the resident's blood. CNA C said she suspected CNA B did something to Resident #1. CNA C said CNA B was the CNA assigned to Resident #1 at the time and he reported to RN A that he had accidentally given Resident #1 a bed bath when she was not scheduled to receive one. During an interview on 5/16/19 at 9:20 a.m., the ADON said on 5/13/19 she went to Resident #1's room and asked Resident #1 what happened, and it sounded like Resident #1 said I was raped. The ADON said Resident #1 was excited and seemed upset. Resident #1 asked the ADON if she wanted her to tell her the truth. The ADON said Resident #1 asked If I tell you, will you take me outside? The ADON said Resident #1 indicated she wanted CNA C and RN A to leave the room, but would not answer any further questions after they left the room. A nursing note dated 5/13/19 written by the DON indicated the DON entered Resident #1's room in response to being notified of the resident bleeding in her peri area. The note indicated the resident was on a low bed and was laying back with the upper half of her body on the bed and her legs on the floor. The resident was wearing a hospital gown and had a towel over her peri area. The note indicated the resident was minimally verbal but was resistive to care. The note indicated the towel was removed and a there was a gross amount of bright red bleeding with a few small clots. The note indicated the DON was unable to determine if the bleeding was vaginally, but it appeared to be so. The note indicated the brief had a large amount of bright red blood and a tear was noted on the front left side of the brief. The note indicated blood was noted on and under the resident's right hand and nails, and the resident's nail on her middle finger was broken. The note indicated Resident #1 was not able to clearly state what happened but answered no when asked if someone hurt her. The note indicated 911 was called and the resident was transported to the emergency department. During an interview on 5/16/19 at 9:10 a.m., the DON said on 5/13/19 RN A reported she was in Resident #1's room and saw she had blood in her brief. She said RN A reported she approached Resident #1 and touched her the resident screamed no, no, no and was swinging her arms. The DON said Resident #1 had a history of [REDACTED]. The DON said Resident #1 said to RN A what sounded like I was raped. The DON said Resident #1 clenched her legs together when RN A tried to assess where Resident #1 was bleeding. She said after RN A took Resident #1's brief down, a significant amount of bleeding was observed but it could not be determined from where. She said RN A cleaned the resident up as well as she could, and RN A and the social worker reported the bleeding to the DON between 11:30 a.m. and 11:45 a.m. The DON said CNA B was assigned to Resident #1 during the shift and he indicated to RN A prior to the discovery of the bleeding that he had accidentally given Resident #1 a bed bath when he was supposed to have given Resident #1's roommate a bed bath. The DON said she pulled CNA B into the office to question him. The DON said CNA B said he gave Resident #1 a bed bath and provided Resident #1 with peri-care and there was nothing unusual. CNA B reported there was no bleeding noticed during the peri care. The DON said she informed CNA B he was suspended because he was the last person known to provide care for Resident #1 prior to her being found with unusual bleeding. The DON said CNA B said, that's just sick. She said CNA B wrote a statement and was immediately suspended and left the facility. The DON said she went to see Resident #1 and she had a significant amount of bright red bleeding from her vaginal area. The DON said she asked Resident #1 what happened, and the resident did not answer. She said she asked Resident #1 if she was hurt, and Resident #1 nodded yes. The DON said Resident #1 had jagged fingernails, her middle fingernail was missing, and she had blood on her hand and under her fingernails, and her brief was torn. The DON said she immediately suspected Resident #1 may have caused the injury to herself from itching due to a yeast infection or that the injury was possibly related to the removal of Resident #1's Foley catheter the day prior. The DON said Resident #1 was sent to the emergency room for further evaluation. The DON said there were no witnesses and the police came to the facility around 6:00 p.m. that night. She said it was at that time she learned the injury was likely a result of a sexual assault. The DON said they narrowed down a two-hour window when the injury likely occurred, and during that time CNA B was the only known staff member to provide care for Resident #1. During an interview on 5/16/19 at 10:51 a.m., the administrator said she received a call on 5/13/19 indicating Resident #1 was bleeding from her vaginal area. She said she immediately returned to the facility and CNA B had already been suspended. The administrator said she asked Resident #1 if anyone hurt her and the resident only said ouch. She said they interviewed all the staff who were at the facility and made a timeline and she was told the last person to have any contact with Resident #1 was CNA B. The administrator said if the hospital determined Resident #1 was raped, CNA B would have been the only one who could have done it. An ambulance patient care report dated 5/13/19 indicated EMS was dispatched to the facility a 12:40 p.m. and arrived at the scene at 12:54 p.m. The report indicated dried blood was noted on Resident #1's sheets and bed, and there was a clear trash bag full of blood-soaked towels and one blood-soaked adult diaper. The report said Resident #1 was unable to answer any questions, which was normal for the resident per nursing home staff. The emergency department nurse documentation indicated Resident #1 presented to the emergency department on 5/13/19 at 1:14 p.m. The note indicated EMS stated the resident had vaginal bleeding, and staff were concerned about a possible sexual assault. A sexual assault forensic examination report dated 5/13/19 indicated Resident #1 was brought in to the emergency department with genital bleeding. Resident #1 was assessed with [REDACTED]. The report indicated there was a laceration to Resident #1's right labia majora. The report indicated Resident #1 was not menstruating and it was unknown if there was penetration. The report indicated Resident #1 was minimally verbal and stated I don't know when asked the gender or race of the assailant. An operative report from the treating gynecologist/surgeon dated 5/13/19 indicated Resident #1 was examined under anesthesia on the operating table. The right labia were lacerated at the distance of approximately 7 cm with active bleeding noted at the inferior portion. The report indicated the surgeon was unable to identify the urethra, so another physician was consulted. The surgeon repaired the right labia laceration with mattress stitches. The report indicated it was estimated the resident lost 100 mls of blood. During an interview on 5/16/19 at 2:45 p.m., the gynecologist surgeon said she was called to the emergency room to evaluate Resident #1 because Resident #1 verbalized she was raped. The surgeon said she did not examine Resident #1 until she was in the operating room. The surgeon said she had to do a surgery to repair Resident #1's labia. She said Resident #1 was wearing a blood saturated brief, and there was so much blood and active bleeding, she could not find Resident #1's urethra without consulting a physician to assist her. The surgeon said specimens were collected as part of a rape kit to send to the state forensics department. The surgeon said Resident #1 was only able to answer yes and no questions and answered I don't know to every question to identify an assailant. The surgeon said she could not tell if Resident #1 was penetrated because there were no lacerations in her vagina and the injuries were only to her labia. The surgeon said Resident #1's injuries were consistent with a sexual assault, and said the resident also had scratch marks on her left breast. The surgeon said she did not feel the injury was self-inflicted because it was too deep, and the injury could not have been related to the removal of Resident #1's catheter the night before. The surgeon said, someone had to have done something to her. During an interview on 5/17/19 at 1:57 p.m., the police investigator said CNA B had been cooperative with the police investigation. The investigator said CNA B offered a DNA sample, his scrubs, and to take a polygraph test without hesitation. He said CNA B admitted to doing a[***]y job with Resident #1 and said he tripped and fell on to Resident #1 when he was preparing to give Resident #1 a bed bath between 8:00 a.m. and 8:30 a.m. He said CNA B referred to the bed bath as PTA, which CNA B informed the officer meant that he cleaned Resident #1's pits, tits, and ass. The investigator said CNA B said he did not go into Resident #1's room after that. The investigator said based on the information he currently had, there was not enough evidence to obtain a warrant for CNA B. The investigator said his main concern regarding how the facility handled the situation was they did not call the police when the allegation of rape was first made. The investigator said the hospital notified the police just before 5 p.m. on 5/13/19 and CNA B was not questioned by the police until 6:30 p.m. to 7:00 p.m. The investigator said it did not look as if CNA B cleaned himself up, but that amount of time gave CNA B the opportunity to possibly destroy evidence or wash his scrubs before they were collected by the police. During an interview on 5/17/19 at 3:18 p.m. with the vice president of clinical services, the administrator, the area director of operations, and the DON, the vice president of clinical services said the facility in-serviced after this incident to immediately notify the police of any incident reportable to the state agency. The administrator and DON said in hindsight, the police should have been contacted after it was suspected that Resident #1 alleged she was raped. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 5/13/19 through 5/14/19. The facility took the following actions to correct the non-compliance: After Resident #1 was found with unusual bleeding to her vaginal area, the facility implemented the following interventions: *Resident #1 was assessed, the resident's physician was notified, and the resident was transferred to the hospital on [DATE]. *CNA B was suspended pending the outcome of the investigation and later terminated as he was the last CNA to care for Resident #1 prior to the discovery of the bleeding. *Head to toe assessments were completed on all residents on B hall, the hall where Resident #1 resided. *All staff were in-serviced on abuse and neglect starting 5/13/19. *All staff were in-serviced regarding signs of sexual abuse starting 5/14/19. *The DON and Administrator were in-serviced on 5/14/19 that the physician and police were to be notified of any potential sexual abuse immediately. *All interviewable residents were interviewed. *All staff were interviewed. *All current staff were checked to see if they were on the misconduct registry and their criminal history was checked on 5/14/19. *All residents were checked to determine if any resident was on the Texas sexual offender list on 5/14/19. An Abuse/Neglect policy revised 11/7/16 indicated .the facility will provide the residents, families, and staff an environment free from abuse and neglect . The policy defined abuse as the willful infliction of injury .with resulting physical harm, pain or mental anguish and defined sexual abuse as non-consensual sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to implement written policies that prevent abuse for 1 of 10 residents reviewed for abuse. (Resident # 1) The facility did not follow their internal policies to protect Resident #1 from sexual abuse. Resident #1 alleged she was raped after she was found with a vaginal injury consistent with a sexual assault. Resident #1 was afraid and had a torn labia that required surgical repair. CNA B was the last known staff member to provide any care for Resident #1. This was determined to be past non-compliance immediate jeopardy (IJ) due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The past non-compliance existed from 5/13/19 to 5/14/19. This failure could place other residents whom CNA B cared for at risk for sexual abuse and fear. Findings included: An Abuse/Neglect policy revised 11/7/16 indicated .the facility will provide the residents, families, and staff an environment free from abuse and neglect . The policy defined abuse as the willful infliction of injury .with resulting physical harm, pain or mental anguish and defined sexual abuse as non-consensual sexual contact of any type with a resident. Physician orders [REDACTED].#1 was [AGE] years old, was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A face sheet dated 5/16/19 indicated Resident #1's original admitted was 10/12/16 and the resident had a [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and was sometimes understood and her cognition was severely impaired. The MDS indicated Resident #1 had no behaviors, received extensive to total assistance with most ADLs and was always incontinent of bowel and bladder. A care plan dated 1/14/19 indicated Resident #1 required extensive assistance of one staff member for bathing and toileting. The care plan indicated the resident had contractures, but the location of the contractures was not specified. A hospital history and physical dated 5/13/19 completed by Resident #1's primary care physician, who was the facility's medical director indicated Resident #1 was noted to have some vaginal bleeding with clots after receiving a bath. The report indicated the resident stated she was raped and was transferred to the emergency department for further evaluation. The report indicated the resident was noted to have a labial tear and underwent surgical repair. The report indicated Resident #1 was nonverbal during the visit and did not answer any questions. During an observation and interview on 5/16/19 at 2:08 p.m., Resident #1 was lying in a hospital bed. She had dark bruising to her left upper arm, and scratches to the bottom of her left breast. Resident #1 had limited mobility in both arms and the nail on the middle finger of her right hand was broken off at the quick. Resident #1 was able to say her name and consistently answered simple yes and no questions. Resident #1 said yes when asked if someone hurt her. Resident #1 looked terrified when asked how someone hurt her. Resident #1 said he (indistinct word) me .he (indistinct word) me .he (indistinct word) me. The resident did not indicate what the indistinct word was and did not answer further questions. During a telephone interview on 5/17/19 at 11:26 a.m., CNA B said 5/13/19 was the first time he ever worked B hall where Resident #1 resided. CNA B said he arrived to work around 6 a.m. on 5/13/19. CNA B said he went into Resident #1's room once between 8:00 a.m. and 8:20 a.m. He said he gave Resident #1 a bed bath, provided peri care because her brief was wet, and changed her sheets because the sheets were dirty. He said he was not rough with the resident in any way and the resident did not have blood in her brief. He said he did not go back into Resident #1's room after that. CNA B said while he was providing care for Resident #1, someone came into the room and immediately left the room and he did not see who entered the room. CNA B said between 11:30 a.m. and 12:00 p.m., the ADON told him he needed to talk to the DON. He said the DON asked him about the care he provided to Resident #1 that morning and told him the resident was bleeding from her vagina and he was suspended. He said he told the DON what she was accusing him of was disgusting. CNA B said she did not verbally say what she was accusing him of, but it was obvious from her questioning the facility blamed him for the bleeding and he had been fired. CNA B said the police questioned him that night and the police told him if he was the one who caused the residents injury to her vagina, they did not feel he did it intentionally. He said he provided the police with his DNA and scrubs. During a telephone interview on 5/19/19 at 8:21 p.m., LVN G said Resident #1 readmitted to the facility from the hospital on [DATE] around 10:30 p.m. LVN G said Resident #1 had been in the hospital with a urinary tract infection and hypothermia. LVN G said she removed Resident #1's catheter between 10:30 p.m. and 11:00 p.m. on 5/12/19 and the resident had no signs of pain or bleeding when she removed the catheter. LVN G said she assessed Resident #1 from head to toe and Resident #1 had a bruise on each hand and upper right arm from IVs she had during her hospital stay. LVN G said aside from those bruises, Resident #1's skin looked great. LVN G said she checked on the resident every hour and saw the resident at the end of her shift at 6:00 a.m. on 5/13/19. LVN G said when she last saw Resident #1 on the morning of 5/13/19 she was sitting up in her bed and was in a good mood. LVN G said she had never known Resident #1 to resist incontinent care or appear scared. During a telephone interview on 5/19/19 at 7:55 p.m., CNA F said the last time she went into Resident #1's room on 5/13/19 was 4 a.m. She said she checked the resident for incontinence and the resident was dry. She said her bed was kind of wet because of the resident's formula from her feeding tube, so she changed her sheets. CNA F said the resident had no blood in her brief, was not combative, was not in pain, and did not appear to be scared. CNA F said that was her first time to work with Resident #1. During an interview on 5/16/19 at 10:13 a.m., CNA D said on 5/13/19 around 10:00 a.m., she knocked on Resident #1's door and opened it looking for CNA E. She said when she opened the door, she saw the privacy curtain was closed around Resident #1. She said she did not see Resident #1 and did not hear anything. She said she could see the foot of Resident #1's bed and saw CNA B adjusting Resident #1's covers. During an interview on 5/16/19 at 10:22 a.m., CNA [NAME] said she worked the hall with CNA B on 5/13/19. She said she and CNA D went outside to go smoke just before 10:00 a.m., and CNA D opened Resident #1's door. CNA D said CNA B came to her between 10:00 a.m. and 10:30 a.m. and asked her which resident was Resident #2, and CNA D told him Resident #2 was in the A bed. CNA D said CNA B said oh, I gave the wrong person a bath. CNA [NAME] said she was surprised to learn Resident #1 had blood in her brief and alleged that someone raped her. CNA [NAME] said she had not seen anyone in Resident #1's room, and the only person who was seen in Resident #1's room according to other staff was CNA B. During an interview on 5/17/19 at 9:05 a.m., RN A said when she went in to Resident #1's room between 8:15 a.m. to 8:30 a.m. on 5/13/19, Resident #1 was behaving normally and was in a cheerful mood. She said around 8:30 a.m., CNA B asked her who needed showers and she referred him to his pocket worksheet and she circled the names of the residents requiring showers on his pocket worksheet. She said she told him to give Resident #2 (Resident #1's roommate) a bed bath. RN A said between 9:15 a.m. and 9:30 a.m., she went back into Resident #1's room to administer medications to Resident #1 and did not notice anything out of the normal. RN A said Resident #1's sheets were dirty, her hair had not yet been brushed, and her linens had not been changed at that time. RN A said the linens were not soaked with urine and did not have blood on them, but just appeared unclean. RN A said after 10:00 a.m., CNA B came to her and reported he gave the wrong resident a bath. RN A said CNA B indicated he gave Resident #1 a bath instead of Resident #2. RN A said she asked CNA B why he did that, and CNA B did not give an explanation. RN A said she went back into Resident #1's room around 11:45 a.m. and Resident #1's eyes were closed, and her brief was saturated with blood. RN A said she immediately went to Resident #1 and touched her shoulder to wake her up and Resident #1 became very agitated and started swinging her arms. RN A said Resident #1 had never done that before. RN A said Resident #1 was screaming no, no, no, no and seemed scared. RN A said it took about 30 seconds to one minute to get the resident to calm down. She said she tried to get Resident #1 to spread her legs open, and the resident clenched her legs tightly together and kept screaming no. RN A said Resident #1 screaming no was unusual. RN A said she left and got CNA C to help her. She said she asked Resident #1 what happened, and Resident #1 asked If I tell you, will you make me leave? RN A said she assured Resident #1 they would not make her leave, but the resident did not tell them what happened. RN A said Resident #1's entire brief and sheets were saturated with blood. RN A said the resident was actively bleeding, but she could not see where the resident was bleeding from. RN A said she started playing back in her mind that CNA B said he had mistakenly given Resident #1 a bath. RN A said she left the room and went to the social worker and told him Resident #1 was bleeding and told him she suspected CNA B had something to do with it. She said her, and the social worker went to the DON's office and reported it to the DON and ADON. She said the ADON immediately pulled CNA B from the hall and the DON talked to him and asked him to leave. She said the ADON went to Resident #1's room to assess her. The ADON asked Resident #1 what happened to her and Resident #1 repeated I got raped, I got raped, I got raped. RN A said the words were clear and there was no doubt what she was saying. RN A said she had known Resident #1 since she was first admitted to the facility and Resident #1 never had any self-inflicted injuries and was never known to scratch or dig in her brief. She said Resident #1's hands were kept closed and were contracted, and she did not think Resident #1 was capable of scratching her vaginal area to the point of injuring herself. RN A said Resident #1 was observed with blood under her nails and blood on the top of her hand. RN A said she would have expected the blood to be on the bottom of her hand if the resident had caused any injury to herself. RN A said prior to the incident, she thought CNA B was weird, but he was always nice and did his work. RN A said she suspected CNA B sexually assaulted Resident #1 because he was the only person who had been in the room, and Resident #1 acted scared when she was normally smiling and making jokes. During a telephone interview on 5/17/19 at 11:04 a.m., CNA C said on 5/13/19 around 11:15 a.m., she was across the hall from Resident #1's room assisting another resident. CNA C said when she exited the other resident's room, she looked across the hall and Resident #1 appeared to be falling asleep. She said Resident #1 did not appear to be in any distress but Resident #1 did not respond when she spoke to her. CNA C said Resident #1 usually smiled and waved at her when she talked to her, and CNA C assumed the resident did not respond this time because she was falling asleep. CNA C said about 10 minutes later, RN A came to her and said she needed assistance cleaning Resident #1. CNA C said Resident #1 was bleeding and her brief was blood-soaked. CNA C said she used towels soaked with water to clean Resident #1, but as soon as she would wipe, more blood would quickly reappear. She said it appeared Resident #1 was bleeding from her clitoris area. She said she had never known the resident to have menstrual cycles and she told the nurse the bleeding did not appear to be from a cycle because she was bleeding near her clitoris area. CNA C said she stayed in the room when RN A left to get the social worker. She said RN A returned with the ADON and the ADON asked Resident #1 what happened and Resident #1 asked do you want me to tell you the truth? and promise you won't make me leave?. CNA C said Resident #1 was swinging her arms and said I was raped. I was raped. I was raped. CNA C said something had to have happened to Resident #1 for her to bleed that bad. CNA C said all three towels she used to clean Resident #1 up were saturated with the resident's blood. CNA C said she suspected CNA B did something to Resident #1. CNA C said CNA B was the CNA assigned to Resident #1 at the time and he reported to RN A that he had accidentally given Resident #1 a bed bath when she was not scheduled to receive one. During an interview on 5/16/19 at 9:20 a.m., the ADON said on 5/13/19 she went to Resident #1's room and asked Resident #1 what happened, and it sounded like Resident #1 said I was raped. The ADON said Resident #1 was excited and seemed upset. Resident #1 asked the ADON if she wanted her to tell her the truth. The ADON said Resident #1 asked If I tell you, will you take me outside? The ADON said Resident #1 indicated she wanted CNA C and RN A to leave the room, but would not answer any further questions after they left the room. A nursing note dated 5/13/19 written by the DON indicated the DON entered Resident #1's room in response to being notified of the resident bleeding in her peri area. The note indicated the resident was on a low bed and was laying back with the upper half of her body on the bed and her legs on the floor. The resident was wearing a hospital gown and had a towel over her peri area. The note indicated the resident was minimally verbal but was resistive to care. The note indicated the towel was removed and a there was a gross amount of bright red bleeding with a few small clots. The note indicated the DON was unable to determine if the bleeding was vaginally, but it appeared to be so. The note indicated the brief had a large amount of bright red blood and a tear was noted on the front left side of the brief. The note indicated blood was noted on and under the resident's right hand and nails, and the resident's nail on her middle finger was broken. The note indicated Resident #1 was not able to clearly state what happened but answered no when asked if someone hurt her. The note indicated 911 was called and the resident was transported to the emergency department. During an interview on 5/16/19 at 9:10 a.m., the DON said on 5/13/19 RN A reported she was in Resident #1's room and saw she had blood in her brief. She said RN A reported she approached Resident #1 and touched her the resident screamed no, no, no and was swinging her arms. The DON said Resident #1 had a history of [REDACTED]. The DON said Resident #1 said to RN A what sounded like I was raped. The DON said Resident #1 clenched her legs together when RN A tried to assess where Resident #1 was bleeding. She said after RN A took Resident #1's brief down, a significant amount of bleeding was observed but it could not be determined from where. She said RN A cleaned the resident up as well as she could, and RN A and the social worker reported the bleeding to the DON between 11:30 a.m. and 11:45 a.m. The DON said CNA B was assigned to Resident #1 during the shift and he indicated to RN A prior to the discovery of the bleeding that he had accidentally given Resident #1 a bed bath when he was supposed to have given Resident #1's roommate a bed bath. The DON said she pulled CNA B into the office to question him. The DON said CNA B said he gave Resident #1 a bed bath and provided Resident #1 with peri-care and there was nothing unusual. CNA B reported there was no bleeding noticed during the peri care. The DON said she informed CNA B he was suspended because he was the last person known to provide care for Resident #1 prior to her being found with unusual bleeding. The DON said CNA B said, that's just sick. She said CNA B wrote a statement and was immediately suspended and left the facility. The DON said she went to see Resident #1 and she had a significant amount of bright red bleeding from her vaginal area. The DON said she asked Resident #1 what happened, and the resident did not answer. She said she asked Resident #1 if she was hurt, and Resident #1 nodded yes. The DON said Resident #1 had jagged fingernails, her middle fingernail was missing, and she had blood on her hand and under her fingernails, and her brief was torn. The DON said she immediately suspected Resident #1 may have caused the injury to herself from itching due to a yeast infection or that the injury was possibly related to the removal of Resident #1's Foley catheter the day prior. The DON said Resident #1 was sent to the emergency room for further evaluation. The DON said there were no witnesses and the police came to the facility around 6:00 p.m. that night. She said it was at that time she learned the injury was likely a result of a sexual assault. The DON said they narrowed down a two-hour window when the injury likely occurred, and during that time CNA B was the only known staff member to provide care for Resident #1. During an interview on 5/16/19 at 10:51 a.m., the administrator said she received a call on 5/13/19 indicating Resident #1 was bleeding from her vaginal area. She said she immediately returned to the facility and CNA B had already been suspended. The administrator said she asked Resident #1 if anyone hurt her and the resident only said ouch. She said they interviewed all the staff who were at the facility and made a timeline and she was told the last person to have any contact with Resident #1 was CNA B. The administrator said if the hospital determined Resident #1 was raped, CNA B would have been the only one who could have done it. An ambulance patient care report dated 5/13/19 indicated EMS was dispatched to the facility a 12:40 p.m. and arrived at the scene at 12:54 p.m. The report indicated dried blood was noted on Resident #1's sheets and bed, and there was a clear trash bag full of blood-soaked towels and one blood-soaked adult diaper. The report said Resident #1 was unable to answer any questions, which was normal for the resident per nursing home staff. The emergency department nurse documentation indicated Resident #1 presented to the emergency department on 5/13/19 at 1:14 p.m. The note indicated EMS stated the resident had vaginal bleeding, and staff were concerned about a possible sexual assault. A sexual assault forensic examination report dated 5/13/19 indicated Resident #1 was brought in to the emergency department with genital bleeding. Resident #1 was assessed with [REDACTED]. The report indicated there was a laceration to Resident #1's right labia majora. The report indicated Resident #1 was not menstruating and it was unknown if there was penetration. The report indicated Resident #1 was minimally verbal and stated I don't know when asked the gender or race of the assailant. An operative report from the treating gynecologist/surgeon dated 5/13/19 indicated Resident #1 was examined under anesthesia on the operating table. The right labia were lacerated at the distance of approximately 7 cm with active bleeding noted at the inferior portion. The report indicated the surgeon was unable to identify the urethra, so another physician was consulted. The surgeon repaired the right labia laceration with mattress stitches. The report indicated it was estimated the resident lost 100 mls of blood. During an interview on 5/16/19 at 2:45 p.m., the gynecologist surgeon said she was called to the emergency room to evaluate Resident #1 because Resident #1 verbalized she was raped. The surgeon said she did not examine Resident #1 until she was in the operating room. The surgeon said she had to do a surgery to repair Resident #1's labia. She said Resident #1 was wearing a blood saturated brief, and there was so much blood and active bleeding, she could not find Resident #1's urethra without consulting a physician to assist her. The surgeon said specimens were collected as part of a rape kit to send to the state forensics department. The surgeon said Resident #1 was only able to answer yes and no questions and answered I don't know to every question to identify an assailant. The surgeon said she could not tell if Resident #1 was penetrated because there were no lacerations in her vagina and the injuries were only to her labia. The surgeon said Resident #1's injuries were consistent with a sexual assault, and said the resident also had scratch marks on her left breast. The surgeon said she did not feel the injury was self-inflicted because it was too deep, and the injury could not have been related to the removal of Resident #1's catheter the night before. The surgeon said, someone had to have done something to her. During an interview on 5/17/19 at 1:57 p.m., the police investigator said CNA B had been cooperative with the police investigation. The investigator said CNA B offered a DNA sample, his scrubs, and to take a polygraph test without hesitation. He said CNA B admitted to doing a[***]y job with Resident #1 and said he tripped and fell on to Resident #1 when he was preparing to give Resident #1 a bed bath between 8:00 a.m. and 8:30 a.m. He said CNA B referred to the bed bath as PTA, which CNA B informed the officer meant that he cleaned Resident #1's pits, tits, and ass. The investigator said CNA B said he did not go into Resident #1's room after that. The investigator said based on the information he currently had, there was not enough evidence to obtain a warrant for CNA B. The investigator said his main concern regarding how the facility handled the situation was they did not call the police when the allegation of rape was first made. The investigator said the hospital notified the police just before 5 p.m. on 5/13/19 and CNA B was not questioned by the police until 6:30 p.m. to 7:00 p.m. The investigator said it did not look as if CNA B cleaned himself up, but that amount of time gave CNA B the opportunity to possibly destroy evidence or wash his scrubs before they were collected by the police. During an interview on 5/17/19 at 3:18 p.m. with the vice president of clinical services, the administrator, the area director of operations, and the DON, the vice president of clinical services said the facility in-serviced after this incident to immediately notify the police of any incident reportable to the state agency. The administrator and DON said in hindsight, the police should have been contacted after it was suspected that Resident #1 alleged she was raped. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 5/13/19 through 5/14/19. The facility took the following actions: After Resident #1 was found with unusual bleeding to her vaginal area, the facility implemented the following interventions: *Resident #1 was assessed, the resident's physician was notified, and the resident was transferred to the hospital on [DATE]. *CNA B was suspended pending the outcome of the investigation and later terminated as he was the last CNA to care for Resident #1 prior to the discovery of the bleeding. *Head to toe assessments were completed on all residents on B hall, the hall where Resident #1 resided. *All staff were in-serviced on abuse and neglect starting 5/13/19. *All staff were in-serviced regarding signs of sexual abuse starting 5/14/19. *The DON and Administrator were in-serviced on 5/14/19 that the physician and police were to be notified of any potential sexual abuse immediately. *All interviewable residents were interviewed. *All staff were interviewed. *All current staff were checked to see if they were on the misconduct registry and their criminal history was checked on 5/14/19. *All residents were checked to determine if any resident was on the Texas sexual offender list on 5/14/19.

Based on observation, interviiew and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 1 of 6 residents reviewed for accidents. (Resident #s 2 and 1) The facility did not provide Resident #2 the required assistance of two staff members during incontinent care. Resident #2 did not have a low bed, bolsters or a fall mat per her care plan. Resident #2 fell off the bed and sustained a knee fracture. The facility did not provide Resident #1 with supervision while in the dining room. LVN E left the dining room and Resident #1 fell and sustained a head injury and lacerations to her forehead. Findings included: 1. A face sheet dated 10/16/18 indicated Resident #2 was an [AGE] year-old female, admitted [DATE] with [DIAGNOSES REDACTED]. A care plan dated 07/7/17 indicated Resident #2 was at risk for falls and potential injury related to balance issues and anti-depressant medications. The approach was low bed, bolsters and mat on the floor. The most recent MDS dated [DATE] indicated Resident #2 was severely impaired cognitively. She required 2-person assistance when performing all ADLs. Resident #2 required set up help with eating. She was incontinent of bowel and bladder. A radiology report dated 10/08/18 indicated Resident #2 had a distal femur left knee fracture. A care plan dated 10/12/2018 indicated Resident # 2 had an actual fall on 10/08/18. A Prescription Order signed 10/21/18 indicated Resident #2 was scheduled to receive Tylenol-[MEDICATION NAME] # 3 1 and 1/2 tablets 3 times a day. An as needed MAR indicated [REDACTED] A MAR indicated [REDACTED]. During an interview on 10/19/18 at 10:46 a.m., CNA B said she provided care for Resident #2 on 10/07/18. She said Resident #2 did not have a scoop mattress or bolsters at the time of her fall on 10/07/18. She said she was cleaning the backside of Resident #2 and she rolled out of the bed. CNA B said no one else was in the room assisting her. She said she was supposed to have another CNA with her during care but did not. During an interview on 10/16/18 at 11:56 a.m., physical therapist F said Resident #2 complained about her knee for the first time on 10/08/18. He said he was notified by the CNAs on 10/8/18 Resident #2 had a fall over the weekend when he entered the resident's room. Physical therapist F said when he assessed Resident #2 she said her left leg was sore. Physical therapist F said the nurse said Resident #2 fell on [DATE]. He said an x-ray was scheduled for (10/08/18). Physical therapist F said Resident #2 normally complained during stretches because of contractures but on 10/8/18 her complaints were worse and lead to her not participating in therapy on 10/08/18. During an interview on 10/19/18 at 3:26 p.m., the DON said Resident #2 required 2-person assistance when performing all ADLs. She was not aware Resident #2's care plan dated 07/07/17 indicated the use of a low bed, bolsters and fall mat. The DON said the use of a low bed, bolsters and fall mat should have already been implemented prior to the fall on 10/08/18. During an interview on 10/19/18 at 3:45 p.m., the administrator said the bolsters were taken off the residents' beds because the previous DON did not like using bolsters. A fall risk, managing policy with a revision date of (MONTH) 2007 indicated .based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and caused to try to prevent the resident from falling and try to minimize complications from falling . 2. A face sheet dated 10/16/18 indicated Resident #1 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was alert to person, time and had moderately impaired cognition. She required supervision with one person assistance with transfers and supervision when walking. She was independent with locomotion off the unit. Resident #1 required 1 person supervision with eating. She was frequently incontinent of bowel and bladder. A care plan dated 11/15/17indicated Resident #1 was at risk for increased falls and fractures as evidence by cognitive impairment/unsteady gait /potential for further falls related to disease process and medication. A therapy note dated 10/05/18 indicated Resident #1 could safely turn corners and change directions. She required a front wheeled walker and contact guard assistance (contact with patient due to unsteadiness) when walking. Under transfers, the therapy note indicated Resident #1 could safely, complete chair, toilet. transfers but required contact guard assistance. (contact with patient due to unsteadiness) An accident/incident dated 10/08/18 indicated Resident #1 was sitting on the floor in the dining room with facial injuries and laceration to her forehead. A hospital discharge summary. dated 10/08/18 indicated Resident # 1 sustained 2. 2 centimeter (cm) linear shaped lacerations to the right side of her forehead and a hematoma on the right forehead. The report indicated one wound was repaired with 5 simple sutures and the other wound with 3 interrupted sutures. A care plan dated 10/09/18 indicated Resident #1 had an actual fall. During an observation on 10/16/18 at 9:40 a.m.,Resident #1 was in the dining room. She had stitches in two areas above her right eye. During an interview on 10/16/18 at 12:51 p.m., CNA C said she worked on 10/08/18 when Resident #1 was found on the floor. CNA C said CNA D went into the dining room to get Resident # 1, but she refused to leave. She said CNA D left out of the dining room to give Resident #1 a minute to calm down because she was in an uproar and when CNA D returned to the dining room Resident #1 was on the floor. CNA C said someone was supposed to stay in the dining room until all residents had finished eating. CNA C said the nurse on duty was supposed to stay in the dining room to watch residents when the CNAs were taking other residents back to their rooms from lunch. CNA C said Resident #1 was left in the dining room alone. During an interview on 10/16/18 at 3:45 p.m., the administrator said LVN E was supposed to be monitoring the dining room on 10/08/18. The administrator said LVN E was out of the dining room when Resident #1 fell . She said LVN E should have stayed in the dining room until all the residents were gone. During a phone interview on 10/16/18 at 4:37 p.m., LVN, E said she was not in the dining room at the time of Resident #1's fall on 10/08/18. She said she was unable to remember details of the incident.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not know Resident #1 left the facility. A concerned citizen stopped to assist the resident after she reported she almost hit the resident with her car. The road where the resident was found had a speed limit of 50 miles per hour with no sidewalks. Resident #1 was found approximately .2 miles from the facility, (his walker on gravel and grass) and approximately .2 from a 4-lane intersection The facility did not implement interventions to prevent Resident #1 from leaving the facility again. An immediate Jeopardy was initiated on 5/17/18. The immediate Jeopardy was removed on 5/18/18; however, the facility remained out of compliance at isolated, no actual harm with potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 5 residents with dementia, who resided in the general population at risk for neglect, dehydration, injury, or death. Findings included: Physician orders [REDACTED].#1 admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had moderately impaired cognition. The resident had an unsteady balance with walking and turning and required a use of a walker. Resident #1 required supervision with all ADLs. A care plan updated 4/20/18 indicated Resident #1 had a problem of impaired decision making due to dementia. An approach was to .determine if decisions made by the resident endangered him . The resident had a problem of impaired visual functioning and was at risk for injuries. The resident was at .risk for falling due to balance issues and used a walker to walk . The elopement assessment dated [DATE] for Resident #1 indicated he was not an elopement risk. During an interview on 5/11/18 at 11:32 a.m., the maintenance director said on 5/10/18 he was going to the store and saw Resident #1 walking with his walker down the road. He said a car stopped on the road to pick up Resident #1. During an interview on 5/11/18 at 12:12 p.m., Resident #1 indicated he left the faciity on [DATE]. He said he left from the back of the facility through the smoking area and headed to the store to purchase cigarettes. Resident #1 indicated he did not sign out and didn't know he needed to sign out or had to tell someone he was leaving. A release of responsibility for leave and absence dated 5/10/18 indicated Resident #1 signed himself out at 3:10 p.m. The form indicated the resident returned on 5/10/18 at 3:35 p.m. During an interview on 5/11/18 at 2:22 p.m., Resident #1 said on 5/10/18, when he returned to the building, staff made him sign out and in. During an interview on 5/11/18 at 2:37 p.m., LVN A indicated she received a phone call on 5/10/18 at approximately 3:00 p.m., from a concerned citizen who reported they thought one of the residents was outside in the parking lot, pushing a walker. During an interview on 5/11/18 at 2:08 p.m., the social worker indicated he spoke to Resident #1 on 5/10/18, when he returned to the facility. He said Resident #1 said they would not let him smoke and he got angry and left the facility to go get cigarettes for himself. The social worker said this was a new behavior for Resident #1. During an interview on 5/11/18 at 4:00 p.m., the administrator indicated LVN A notified her at approximately 3 p.m. on 5/10/18, that Resident #1 was missing. The administrator indicated she did not feel the incident should be investigated or reported to the state agency because Resident #1 was not missing, he just did not tell anyone he had left after signing out. A video dated 5/10/18 at 1:23 p.m., provided by the concerned citizen who stopped for Resident #1 showed the resident was on the side of the road. The video showed a male and he said they did not know the resident was missing, if they did know the resident was missing, the resident would not have gotten this far. The male asked the concern citizen to take the resident back to the nursing facility. During an observation on 5/16/18 at 9:45 a.m., the road in front of the facility had a speed limit of 50 miles per hour. There were no sidewalks on the road. The road had approximately one foot of pavement on the side of the road before turning into grass. The road going south led to a 4-lane intersection approximately .4 miles from the facility; the speed limit changed to 45 miles per hour. The nearest place to purchase cigarettes required crossing the 4-lane intersection and was approximately .5 miles from the facility. There was no pedestrian assist at the traffic light. During an interview on 5/16/18 at 9:30, a concerned citizen said on 5/10/18 she almost hit Resident #1 with her car while driving south. She said the resident was trying to roll his walker in the grassy area next to the road and on the road. The citizen said she asked the resident where he lived, and he said he did not know. She said the resident said he was going to the store to get cigarettes. The citizen said she offered to take the resident to the store to get the cigarettes. She said the resident got in the back seat of her car. She said a man who worked at the facility driving by stopped and said the resident resided at the nearby nursing facility. The citizen said the man asked her to take the resident back to the facility. The citizen indicated the facility was appropriately .2 miles from where she found the resident. The citizen indicated she was concerned about the resident's safety because the road was often busy, and people drove fast. During a telephone interview on 5/17/18 at 10:36 a.m., LVN B said she was unaware Resident #1 was missing. LVN B said when Resident #1 returned to the facility he was brought to his room. She said she did not assess Resident #1 or notify the physician of his elopement. LVN B indicated there were no new interventions implemented for Resident #1. She indicated she did not believe it was safe for Resident #1 to walk to the store. LVN B said Resident #1 could get ran over, kidnaped, heat stroke or pass out. During a telephone interview on 5/17/18 at 10:44 a.m., CNA D said she was unaware Resident #1 was missing. CNA D said when Resident #1 returned to the facility he was brought to his room. CNA D indicated there were no new interventions implemented for Resident #1. She said Resident #1 did not have a steady enough gait to walk on the road or alongside the road. During an interview on 5/17/18 at 9:16 a.m., Resident #1's physician indicated he could not recall if the facility notified him the resident's elopement. The physician indicated he expected the facility to notify him. During an interview on 5/11/18 at 11:51 a.m., the ADON said she worked on 5/10/18. She indicated she was unaware Resident #1 was missing. During an interview on 5/11/18 at 12:20 p.m., the treatment nurse said she worked on 5/10/18 during the time the resident went missing. She indicated she was unaware Resident #1 was missing. During a telephone interview on 5/17/18 at 10:24 a.m., LVN A said it would not be safe for the resident to ambulate near the road because it poses a risk for potential harm to the resident. During an interview on 5/17/18 at 10:56 a.m., CNA E said Resident #1 would not be steady outside with walker, walking along side of the road due to the uneasiness of the terrain. During an interview on 5/17/18 at 10:58 a.m., CNA G said she worked on the 2-10 shift and provided care for Resident #1. She said Resident #1 would not be safe walking to the store because so much would be going on; cars racing, hot outside, that could be a distraction to him. During an interview on 5/17/18 at 11:00 a.m., CNA F said she provided care for Resident #1. CNA F said Resident #1 used a walker to ambulate. She said if Resident #1 was outside he could trip on rocks and crossing that intersection would be very dangerous. During an interview on 5/17/18 at 11:08 a.m., the treatment nurse indicated she did not believe the resident would be safe walking to the store. She said, the road is busy and she could not see the resident making it to the store without assistance. During an interview on 5/18/28 at 9:13 a.m., LVN H indicated the resident sign out book was usually placed on top of the counter of the nursing station. The clinical record for Resident #1 dated 4/20/18 through target date of 6/23/18 did not include a care plan to address the resident's elopement on 5/10/18. At https://weather.com/weather/monthly/l/USTX0793:1:US, accessed 5/21/18 indicated the temperature for Longview, Texas on 5/10/17 was 87 degrees Fahrenheit. A missing Patient Protocol dated (MONTH) (YEAR) indicated .upon the occurrence of a missing patient or a suspected elopement, the following steps must be immediately taken: 1. Determine if the patient is out on an authorized leave or pass . 4. notify the local police department 5. Notify the Department of Aging and Disability (DADS) [PHONE NUMBER] in accordance with the DADS Guidelines for reportable incidents . The administrator and DON were notified on 05/17/18 at 11:43 a.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 5/18/18 at 10:49 a.m , and included: .Resident was educated by Social Services Director on 5/10/2018 that when he signs out of the facility to also notify staff. Resident's care plan was updated to reflect current cognitive status. Residents sign out book was placed behind nurse's station so that resident will have to request to sign out to better ensure staff awareness. The facility will review care plans of residents that have a [DIAGNOSES REDACTED]. Residents with the [DIAGNOSES REDACTED]. Facility will review admission orders [REDACTED]. Residents that are assessed and deemed unsafe for independent outdoor excursions will be escorted by a facility staff member. Facility educated staff on missing resident protocol. Facility educated alert residents to notify charge nurse or administration staff when they sign out of the facility. Facility placed door alarms on all exit doors including facilities front door, back exit door, and smoking exit door. Facility will monitor alarms daily. Education initiated to facility staff regarding the alarms on exit doors and how to react appropriately. Nurse is to check to see who is going out of the building and if they are appropriate to go outside. Facility is to notify the Administrator/D.O.N. if the alarms are not in working condition . On 5/18/18, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews on 5/18/18 from 8:57 a.m. to 9:40 a.m., 5 residents said they were aware that they must notify staff when they wanted to leave the facility. During interviews on 5/18/18 from 8:56 a.m. to 10:29 a.m., 12 nursing staff said they received training to check with resident's responsible party when a resident wanted to check out from the facility and notify the administrator and the DON. The nurses indicated the sign out book would be kept behind the nursing station. During an observation on 5/18/18 at 10:17 a.m., door alarms were being installed on all exit doors. The care plans for 5 residents with dementia indicated interventions were in place to ensure the resident's safety. On 5/18/18 at 11:20 a.m., the administrator, DON, and corporate nurse were informed the IJ was removed; however, the facility remained out of compliance at isolated, no actual harm with potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 5/18/18 at 9:12 a.m., the MDS coordinator provided a list indicating there were 5 residents who resided in the general population that were independent with mobility and had a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for skin assessments. (Resident # 1) The facility did not assess Resident #1's feet for 19 days after returning from the hospital (10/30/16). Resident #1 had a history of [REDACTED]. This failure could place the census of 97 residents who received weekly skin assessments at risk of not receiving timely care. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood and usually understands others. Resident #1's cognition was moderately impaired. He required extensive two person assistance with transfers and toileting. The MDS indicated Resident #1 did not have pressure ulcers. A care plan last updated 9/30/16 indicated Resident #1 was to have a weekly skin assessment completed by a licensed nurse. A skin assessment dated [DATE] indicated Resident #1 returned to the facility from the hospital. He had multiple discoloration on both arms, there was no documentation regarding his right toe. There was no weekly skin assessment for Resident #1 for the week of 11/6/16. A skin assessment dated [DATE] indicated Resident #1 had a reddened area to his right lower neck that measured 4.5 centimeters (cm) X 5.5 cm with scattered red areas around it, there was no documentation regarding his right toe. There was no weekly skin assessment for Resident #1 the week of 11/20/16. A progress note dated 11/27/16 at 7:30 a.m., indicated Resident #1 had a fall and a head- to- toe skin assessment was completed, there was no documentation regarding his right toe. A progress note dated 11/28/16 at 10:45 a.m., indicated Resident #1 was sent to the hospital for a wound to his right great toe. A physician order [REDACTED].#1 was sent to the hospital for evaluation of an open wound to his right great toe. The emergency department nursing note dated 11/28/16 indicated Resident #1 presented to the emergency room for possible infection to right foot, and the wound was not new. The note documented Resident #1 had a .decubitus located on right great toe approximately 1.5 cm to 2.5 cm, is a stage 4, bed has eschar present, and wound is not draining . A wound culture report dated 11/28/16 indicated Resident #1 [MEDICAL CONDITION] to the wound on his right great toe. A consultation report dated 11/29/16 indicated Resident #1 had gangrene to the tip of his great right toe. .the gangrene is dry in nature, and no odor noted . During an observation on 11/29/16 at 1:30 p.m., Resident #1 was in the hospital. He had an area of eschar on the tip of his right great toe. During an interview on 11/30/16 at 9:17 a.m., RN A said on 11/28/16 therapy reported drainage on Resident #1's right sock. She said when she assessed Resident #1's toe it had puss and an odor. RN A said Resident #1 was sent to the hospital for evaluation. RN A said the nurses were to perform weekly skin assessments. She said the skin assessment should be documented under the observation section in the computer. RN A said she should have document Resident # 1's assessment prior to him going the hospital on [DATE], but did not. During an interview on 11/30/16 at 9:40 a.m., the DON said on 11/28/16 Resident #1's right great toe had serous drainage and moisture between his toes. She said the tip of Resident #1's great toe resembled eschar. The DON said Resident #1 was sent to the hospital. He said nurses were to perform weekly skin assessments on non-pressure sores and the treatment nurse performed skin assessments for residents with pressure ulcers. During an interview on 11/30/16 at 9:21 a.m., RN B said nurses were to perform weekly skin assessments and document under the observation section in the computer chart. RN B said when she last assessed Resident #1 on 11/27/16 at 7:30 a.m., she did not remove his socks or assess his feet. During an interview on 11/30/16 at 9:27 a.m., CNA F said on 11/27/16 she reported to the nurse Resident #1 had fallen. She said it was not the resident's shower day so she did not look at his feet. During an interview on 11/30/16 at 10:35 a.m., the ADON said on 11/18/16 she performed an assessment of Resident #1's neck and shoulder area only because his daughter called and reported seeing a bruise to the that area the previous night when she came up to visit. She said she did not look at Resident #1's feet. The ADON indicated the skin assessments were to be documented in the observation section. She said all residents should have a weekly skin assessment. The undated instructions for skin integrity conditions observation indicated .the assessment will be completed by the facility treatment nurse or designee weekly for each wound; this assessment will also be completed for residents who have wounds upon admission/readmission or upon the discovery of a new wound . During an interview on 11/30/16 at 9:40 a m, the DON said every resident in the facility should have a skin assessment done weekly. The CMS 672 dated 11/29/16 indicated the census was 97 residents.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit mistreatment, neglect, and abuse for 4 of 7 residents reviewed for abuse. (Residents #1, #2, #3, and #5) Resident #1 had a history of [REDACTED]. The facility did not put interventions in place to prevent Resident #1's behaviors. Resident #1 sexually assaulted Resident #2, made explicit sexual comments, touched staff inappropriately, was found in bed with Resident #3, and attempted to enter Resident #5's room. An Immediate Jeopardy situation was identified on 10/20/16. The Immediate Jeopardy was removed on 10/21/16. The facility remained out of compliance at a a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 22 residents who reside on the secured unit at risk for abuse. Findings included: A physician order [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 required extensive assistance of one person with transfers, dressing, and personal hygiene. He was able to move from seated to standing position without staff assistance. He required staff stabilization with walking. He had psychotic indicators of hallucinations and delusions. Resident #1 had behaviors that occurred daily of verbal threatening, screaming, and cursing. A care plan dated 9/3/16 indicated Resident #1 displayed verbally abusive behavioral symptoms to staff and other residents by screaming at others, cursing, and refusing care. Resident #1 displayed inappropriate disruptive behavioral symptoms, such as screaming, cursing, abusive acts, sexual behaviors, disrobing in public, hoarding, and rummaging through others belongings. Resident #1 displayed physically and sexually abusive behavioral symptoms, such as grabbing staff members inappropriately, hitting/attempting to touch staff and other residents, lying in other resident's beds, removing food from other residents, and encrouching in other resident's personal space/belongings. Some approaches were for Resident #1 to reside on the secured unit, keep distance between him and others residents, assess the behaviors to determine if they endangered residents or others. An approach dated 10/19/16 indicated to provide one to one care for Resident #1 when he was physically and sexually abusive. Nursing notes for Resident #1 indicated: On 9/5/16 at 4:46 p.m., Resident #1 displayed increased destructive behaviors, agitation, yelling out, cursing, and threatening other residents. Multiple attempts to redirect and distract were unsuccessful. On 9/6/16 at 6:42 a.m., Resident #1 was in another resident's room lying in the bed. Two staff attempted to assist the resident out of the bed. He became agitated. At 11:16 a.m., Resident #1 displayed increased anxiety and aggressive behaviors yelling out, I'm gonna F start knocking you son of a B out in a minute. He was calling staff names, cursing, and attempting to grab other resident's food at breakfast. He became combative when attempts were made to remove him from the dining room. He was striking out at staff and other residents, redirection was unsuccessful. On 9/17/16 at 4:27 p.m., Resident #1 was in the dining room and completely stripped off all of his clothes. He was physically aggressive and attempting to hit staff. On 9/18/16 at 11:01 a.m., Resident #1 was impulsive and running naked in the hall. On 9/19/16, Resident #1 required constant monitoring and redirection due to extreme aggression and verbal threats. His verbal abuse was aimed at staff, other residents, and family members. All attempts to correct, distract, and redirect him were unsuccessful. At 4:23 p.m., he took food from other residents and ate it. When redirected to his own table, he became agitated and verbally aggressive. On 9/20/16 at 4:43 p.m., Resident #1 required constant observation and redirection related to verbal and physical aggression aimed toward staff, residents, and visitors. On 9/27/16, Resident #1 was physically aggressive with inappropriate touching of a resident, redirection was unsuccessful. He was medicated twice for increased anxiety, but poor effect was noted. He continued verbal threats of violence toward others, he was extremely aggressive, and exhibited combative behaviors at times. Resident #1 was sent to a behavioral hospital. An Event Report dated 9/27/16 at 1:20 p.m. indicated Resident #1 was found in a female resident's room with his hand between her legs. The report indicated Resident #1 had physical behavior symptoms directed toward others daily such as hitting, kicking, pushing, scratching, grabbing, and abusing others sexually. He had verbal behaviors symptoms of threating others, screaming, and cursing others daily. Resident #1 had behavioral symptoms that put residents at risk for injuries and interfered with residents' care. He put others at significant risk for physical injury, issues with privacy, and was disruptive to the living environment. The report indicated on 9/27/16 at 12:39 p.m. Resident #1 had increased anxiety and agitation. He was combative and striking out at other residents, staff, and visitors. He was yelling, cursing, and threatening physical violence. The physician was called and ordered [MEDICATION NAME] 1mg. at 2:37 p.m. Resident #1 hit another female. The report indicated Resident #1 was very confused and not oriented to place and time. He had scattered thoughts and conversation. At 3:00 p.m. Resident #1 was inappropriately touching another female resident. Resident #1 also hit another female resident on the arm. The resident was sent to the hospital for an evaluation. An in-service dated 9/28/16 indicated staff was trained regarding residents on the secure unit requiring frequent monitoring, redirection, and cueing due to increased wandering and confusion. The in-service indicated Please keep a close eye and try to arrange staff to monitor residents in social areas as much as possible. An Elopement Risk assessment dated [DATE] indicated Resident #1 had behaviors and the ability to elope from the facility. Nursing notes indicated Resident #1: On 10/12/16 4:29 p.m., Resident #1 was readmitted to the facility. He was making demands on staff for various things. He was uncooperative, taking food away from other residents, agitated, aggressive, verbally threatening staff, visitors, and residents. All attempts to distract were unsuccessful. Resident #1 did remember the nicknames he gave to staff from admission. On 10/13/16 at 8:35 a.m., Resident #1 was extremely agitated and aggressive, uncooperative with all attempts to perform ADLs, yelling and screaming down the hall, and making verbal threats of violence directed towards staff, residents, and visitors. On 10/17/16 at 5:56 p.m., Resident #1 continued unacceptable behaviors such as foul language, shouted for no apparent reason, mood swings with aggressive threats, and increased irritability. He was given as needed medication for agitation and all attempts were unsuccessful. On 10/17/16 at 8:49 p.m., Resident #1 refused staff attempts at bedtime care. He said, I'm grown, I can go to bed when I want. On 10/18/16 at 3:31 a.m., Resident #1 was up and about the locked unit, very loud yelling at staff. At 11:51 a.m., Resident #1 was medicated this morning for increased anxiety with good effect noted. He was yelling out, cursing and using extremely foul and inappropriate language directed towards staff, residents and visitors. The resident required frequent monitoring for behaviors and became agitated and aggressive when inappropriate demands were rejected. He made verbal threats of violence and yelled down the hallway most of the day. At 3:12 p.m., Resident #1 had increased agitation and aggression. He was yelling obscenities, swearing, and verbalizing sexual comments. He was striking out, attempting to hit staff, residents, and visitors. He was threatening harm and acting violent towards all. He was yelling at other resident's family members and multiple attempts to enter other resident's rooms while families were visiting. Visitors expressed concern for the safety of residents when they are not there. Multiple attempts to re-direct were unsuccessful. At 4:21 p.m., Resident #1 was assisted to the dining room. He reached over a nurse while her back was turned and grabbed the vagina area from the back. The resident said I enjoyed touching her and she must not like it because she liked women. At 7:50 p.m., Resident #1 was extremely difficult to redirect. He was yelling profanities at staff and visitors. On 10/19/16 at 1:06 a.m., Resident #1 was found in another female resident's bed with only a brief on. He became very aggressive towards staff, cussing and stating,This is my wife and I'm fixing to make love to her. He was forcibly removed from the room. He was yelling profanities, threating staff, demanding food and cigarettes. He was observed afar due to violent nature. He had a bowel movement and pulled off his brief and smeared feces over himself and the dining room table. A physician progress notes [REDACTED].#1 had multiple behaviors including grabbing staff, inappropriate language, agitation, and delusions. The note recommended long term psychiatric hospital. Resident #2 A physician order [REDACTED]. An MDS dated [DATE] indicated Resident #2's cognitive status was severely impaired. A care plan dated 5/4/16 and last updated 7/13/16 indicated Resident #2 had cognitive loss (Loss of memory, time sense, and required assistance with decision making.) She was not always understood and not able to understand verbal and nonverbal expressions. Some of the of the approaches were to involve Resident #2 in low stress activities. Nursing notes dated 9/26/16 at 5:50 a.m. indicated Resident #2 had exit seeking and attempted to leave the facility two times. The resident said she wanted to go home, redirection was not effective. She was refusing care, and agitated. The family was contacted for possible day camp on the secure unit. A nursing note dated 9/27/16 at 3:38 p.m. indicated Resident #1 was in Resident #2's room while she was sleeping and touching her in the vaginal area with his hand on top of her brief and dress. Resident #2 was assessed with [REDACTED]. A nursing note dated 10/13/16 at 1:27 a.m. indicated Resident #2 was moved off the secured unit at another family's request. A Grievance/Complaint Report dated 10/13/16 indicated Resident #2's family felt Resident #2 was subjected to a lude environment with a resident that was abusive and inappropriate. The report indicated the resident in question returned from the Behavioral Hospital and had not exhibited any of those behaviors since readmission. Resident #2 was moved off the secured unit at another family's request. During an interview on 10/20/16 at 10:40 a.m., the social worker said he wrote a complaint report out today in regard to the family member of Resident #2 wanting her mother off the locked unit because Resident #1 had returned. He said he dated the form 10/14/16 because he was told by the administrator that was the day the family actually complained to him. He said the Resident #1 did not need to be in the facility. During an observation and interview on 9/20/16 at 9:01 a.m., Resident #2 was noted in a wheelchair propelling herself about with her feet. She said she did not remember anyone being rude or ugly to her. The resident was confused. Resident #3 A physician order [REDACTED].#3 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 was severely cognitively impaired. A care plan dated 3/16 and last updated 8/5/16 indicated Resident #3 was an elopement risk due to dementia, impaired cognition, daily decision making, independent locomotion, decreased safety awareness, and elopement episodes. Some of the approaches were placement on the secure unit and monitor every hour for resident safety. A nursing note dated 10/19/16 at 3:42 a.m. indicated Resident #1 was found to in bed with Resident #3. Resident #3 was clothed in bed and had bed linens covering her body. Resident #1 had on a brief only. There was no skin contact. Resident #3 was asleep during this occurrence. The male resident was removed from the room. At 10:08 a.m., a skin assessment was performed, no injuries were noted. During an interview on 10/20/16 at 10:10 a.m., Resident #3 said she slept well the night before and did not remember anything unusual happening. Resident #3 was confused and was repetitive in her answers; she said the same thing over and over. During an observation on 10/20/16 at 12:40 a.m. Resident #1 was in his bed asleep. There was no staff present. During an observation and interview on 10/20/16 at 12:36 a.m., CNA K was noted to be the only staff on the locked unit. She was sitting at the desk with ear buds in her ear and was watching television on a tablet. She said she worked last night when Resident #1 was discovered in bed with Resident #3. She said Resident #3 was under two blankets. Resident #1 climbed in the bed with her, and apparently climbed over Resident #3 and was against the wall. Resident #1 was under one of those blankets. He had on a brief and was spooning Resident #3 and rubbing on her bottom. CNA K said when she told him to stop he said that was his wife and he was going to make love to her. She said she had to hold his hands to keep him from touching the resident. CNA K said it took three people to get him out of the bed with Resident #3. She said as best she could remember the resident stayed asleep during the whole ordeal, even though Resident #1 was extremely loud and uncooperative. CNA K said she was only focused on Resident #1. She said she knew Resident #1 was supposed to be on one-to-one, but had not been since after dinner today 10/19/16. She said she was the only aide assigned to the hall at the current time. During a interview on 10/20/16 at 12:37 a.m., LVN F said last night she was notified by an aide that Resident #1 was found in bed with Resident #3. He was on top of the blanket, there was no skin contact. Resident #1 had on a brief and Resident #3 was under the blankets. She said Resident #1 said he was in bed with his wife and did not want to leave. It took her and two other staff members to get him out of the bed and out of the room. LVN F said the incident happened about 1 a.m. in the morning. She said at night there was one aide on the secure unit. She said on a normal day Resident #1 was very belligerent toward staff and residents. He was hard to redirect. There are times when he was very aggressive and they just leave him alone and observe him from a far. During an interview on 10/20/16 at 12:44 a.m., CNA L said she was told to come back to the unit and sit with Resident #1. She said she was informed he was supposed to be on one-one supervision. She said she had been on the unit and made rounds once during the night, but had not been assigned to Resident #1 until just now. She came to work at 10 p.m. She said last night Resident #1 was up all night. CNA L said Resident #1 was so upset after being caught in the bed with Resident #3, they took him out and sat him at the nursing station. He calmed down and she later saw him trying to go back into Resident #3's room about 4:30 a.m. He was cussing everyone out and saying he had a gun and was going to kill people. He stripped naked and sat in the dining room. During an interview on 10/20/16 at 12:59 a.m. LVN M said she was informed during report at 6 p.m. that Resident #1 was to be on one-to-one observation. She said she had come back to the unit frequently to check on him and make sure he was fine. She said he had not been on one-to-one observation until a few minutes ago. LVN M said she knew Resident #1 had behavioral issues. He grabbed a staff yesterday and would get aggressive. She had also seen him get naked, swing at aides, demand pain medications. She said he could make his needs known for certain things. During an interview on 10/20/16 at 9:23 a.m., LVN A said Resident #1 did not sleep all night the night before. She said she gave him some prn medications about 9:00 a.m. this morning. She said he was found in a female resident's bed last night. She said Resident #1 was put on one-to-one observation on 10/19/16 due to his behaviors. LVN A said Resident #1 was usually verbally aggressive, made sexually inappropriate statements, and talked about drugs and drug use. LVN A said Resident #1 was not appropriate to reside on the unit. LVN A said they try to redirect Resident #1 by taking him out to smoke. She said aides are all trained on dealing with residents with Alzheimer's/dementia, however; Resident #1 did not have Alzheimer's/ Dementia. During a telephone interview on 10/20/16 at 9:25 a.m., LVN I said she believed Resident #1 knew what he was doing. When he came back from the hospital on [DATE] he remembered all the staff's names. He went to the hospital, but was worse when he came back. LVN I said she was fearful of him; he had hit her in the face several times and touched her inappropriately. She said he would talk vulgar to the residents, staff and anyone that would listen. LVN I said she saw him take food out of another resident's mouth and eat it. The other residents were confused and the population on the unit was so vulnerable to his anger and behaviors. Resident #1 would say very explicit sexual things and made all the other residents on the unit afraid of him, especially the women. She said sometimes he acted out because he was not allowed to do what he wanted. He demanded things such as cigarettes, drugs, medications, and got very upset if he did not get those things. LVN I said most of the residents on the secure unit cannot express their fears and just stay away from him as best as they could. LVN I said Resident #1 was not appropriate for the unit. He was not a typical Alzheimer's resident. He knew what he was doing because sometimes he tried to get back at staff or residents. She did not trust him at night because he could slip into any of the resident's rooms without staff knowledge. During an interview on 10/20/16 at 9:39 a.m. CNA B said Resident #1 was very disrespectful to staff, residents, and visitors. She said he made rude sexually inappropriate comments all the time, he hit a nurse and an aide, would pull his brief off and walk down the hallway naked. CNA B said the residents and families were upset by his behaviors and several of the female residents mostly stayed in their rooms due to his behaviors. CNA B said there were occasions when Resident #1 was completely out of control. He would try to hit anyone within reach and would pick up chairs and try to hit people with them. CNA B said Resident # 5 stayed in the room all the time to avoid Resident #1. During an interview on 10/20/16 at 9:49 a.m., ADON/RN C said Resident #1 was found in bed with a female resident last night. He told staff she was his wife and he was going to sleep with her. ADON/RN C said Resident #3 was confused and did not remember the incident. ADON/RN C said Resident #1 was involved in another incident of sexually inappropriate behavior with Resident #2. He was observed sexually assaulting Resident #2 by groping her between her legs. ADON/RN C said Resident #1 would disrobe and walk down the hallway naked. During an interview on 10/20/16 at 9:58 a.m., CNA D said Resident #1 was very disrespectful, combative, aggressive, and sexually inappropriate. He would tell the staff and residents very explicit sexual acts he wanted them to perform on him, or he on them. She said she saw him with his hands between Resident #2's legs; the resident and her family were very upset. CNA D said sometimes Resident #1 talked with clarity about the things he would like to do, especially when he talked of drugs and sex. She said none of the residents or family members liked him. He talked bad to the residents, especially the females, calling them you old hag or you old B. During an interview on 10/20/16 at 10:04 a.m., CNA E said she was asked to come and sit with Resident #1 about 30 minutes ago when he was placed on on-to one. She said he was asleep which was unusual for him. He usually received medications and it did not effect him at all. He was usually loud, cursing, and scaring the other residents. He said things that were sexually inappropriate and nasty. CNA E said on some occasions Resident #1 was so aggressive they moved all the other residents away from him. They would back off and let him have his way or someone might get hurt. CNA E said she was not trained on dealing with Resident #1. They do the best they can and often times they have to get the nurse to deal with his aggressive behaviors. There were times when taking him out to smoke or giving him a snack would help and other times it did not. During an interview on 10/20/16 at 10:36 a.m., Resident #5 said there was a male resident that would come into her room, but she would throw him out in the hallway. During an interview on 10/20/16 at 10:40 a.m., the social worker said Resident #1 did not need to be in the facility. He was sexually inappropriate; he grabbed a female employee's vagina yesterday. He was sexually inappropriate with Resident #2 before being sent to the hospital on [DATE]. The social worker said Resident #1 returned from the hospital on [DATE] worse than when he left. Resident # 1 continued to be aggressive and sexually inappropriate. The social worker said they did not want to take Resident #1 back, but were told they had to because there was a court order by the judge saying so. However, he had not seen the order. He said he was in the process of trying to find an all-male unit for Resident #1 to be transferred to, but at the current time all refused to accept him. During an interview on 10/20/16 at 10:58 a.m., the DON said they were trying to find suitable placement for Resident #1. The DON said Resident #1 did touch Resident #2 inappropriately, but she slept through the whole incident on 9/27/16. They sent him to the hospital on [DATE] due to that incident and his continued aggression. During an interview on 10/20/16 at 2:15 p.m., Resident #1 said the facility lied on him about touching some staff inappropriately. He said he would not do anything like that. He said the staff were always on him about talking ugly. He admitted he used bad language. Resident #1 said he worked at an automotive shop in the past and that was the way all of the guys talked. Resident #1 talked with clarity for a few minutes and then he incorporated grandiose delusions saying he could care for a sick brother-in-law and he had money. He then was back on the conversation and expressed concerns for the health of his brother-in-law, and not being aware of his illness. During an interview on 10/20/16 at 2:33 p.m., CNA G said Resident #1 would get all the residents on the unit aggravated. He would not listen, and sometimes they left him alone until he calmed down. He would talk bad to residents and try to fight them. Resident #1 would call the other residents names. CNA G said they were in-serviced on Alzheimer's, however, Resident #1 did not seem to act like regular Alzheimer's residents. CNA G said Resident #1 would try to hit other residents; he did not fit in with the general population on the unit. CNA G said when Resident #1 was not there the other residents seemed fine, he tried to rile the other the residents up on purpose. She said after 6 p.m. there was no nurse on the hall. There are two aides until 10 p.m. and then only one aide. During an interview on 10/20/16 at 2:39 p.m., CNA H said Resident #1 had a nasty mouth, and was nasty to residents and staff. He tried to take advantage and intimidate other residents especially the women. He would call them old hags and old Bs. At meal times he would take other residents food and go in and out of other residents rooms. He ran his hands between a females staff legs. CNA H said she was pushing Resident #1 down the hall in his wheelchair. LVN I was leaning over the medication cart with her back to them. Resident #1 took his hand, reached between her legs, and grabbed LVN I. CNA H said she and the nurse were both surprised by the event for a few seconds. She told the resident that was inappropriate and he told her he enjoyed the touching. Resident #1 said LVN I did not enjoy it because she liked women. He began to laugh at LVN I's shocked reaction. CNA H said Resident #1 would pull off his clothes and walk down the hall naked. He would go into other resident's rooms and put on their clothes. During an interview on 10/20/16 at 3:03 p.m., LVN J said she assisted with the in-services and there was no special in-service for Resident #1 that she could find. During an interview on 10/20/16 at 3:15 p.m., the DON said they had not conducted a special in-service on Resident #1. He said his staff were aware of how to handle the resident and he did not feel any special in-service would assist in Resident #1's care. He also said they did not send Resident #1 to the hospital for sexually assaulting Resident #2; Resident #1 had some other issues on 9/27/16 such as hitting and being aggressive. During an interview on 10/20/16 at 3:40 p.m., the administrator said he was aware of Resident #1 inappropriately touching Resident #2. He did not call the incident in because a provider letter indicated the incident had to be willful, knowing and reckless before it was reported. He said Resident #1 was confused and Resident #2 did not know the incident occurred. He did say he was calling in the incident that occurred on last night, where Resident #1 climbed into bed with Resident #3. He could not explain the difference. Resident #3 was noted to be asleep and did not remember the incident and Resident #1 was confused according to the administrator. During an interview on 10/20/16 at 8:30 a.m., the DON said they were in the process of doing an investigation into the incident with Resident #1 and Resident #3. He said they had not obtained statements at this time. He said LVN F had written an incident report, but he did not know if she assessed Resident #3 after the incident. The abuse policy updated 10/17/14 indicated each resident has the right to be free from abuse. Residents will not be subject to abuse by anyone, including, but not limited to other residents. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and assessment of the interventions on a regular basis. Protection: In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. if the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged . During the time that the perpetrator is being discharged , the facility will monitor this resident on-on-one to protect all other residents. The administrator, DON, and corporate nurse consultant were notified on 12/20/16 at 8:50 a.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/21/16 at 11:55 a.m. and included: 1. RN Consultant in-serviced the Administrator and DON on Reporting Abuse, Neglect, Exploitation and other Incidents by Regional Nurse Consultant on 10/21/16. 2. DON/Designee in-serviced Staff on identifying reckless behaviors and Reporting behaviors to DON/Administrator on 10/21/16. 3. Social worker assessed residents for any issues related to behaviors of other residents on 10/21/16. 4. DON/Designee will ensure the safety and protections of the other residents, resident was placed on 1:1 observation on 10/21/16 until resident can be removed from unit and sent for admission to a Psychiatric Unit for evaluation. 5. DON/Social Worker will ensure resident will be sent to hospital for evaluation and placement into a Psychiatric Facility for evaluation. Resident will remain on 1:1 observation until EMS arrives for transport. 10/21/16. On 10/21/16 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 6 CNAs and 1 nurse were interviewed and said they had been in-serviced by the facility on identifying reckless behaviors and reporting behaviors. Resident #1 was no longer at the facility. The Social worker had assessed residents for any issues related to behaviors. The Administrator and DON were interviewed and said they had been in-serviced on Reporting Abuse, Neglect, Exploitation and other Incidents. On 10/21/16 at 11:55 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility census report dated 10/20/16 indicated the census on the locked unit was 22 residents.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit mistreatment, neglect, and abuse for 4 of 7 residents reviewed for abuse. (Residents #1, #2, #3, and #5) Resident #1 had a history of [REDACTED]. The facility did not put interventions in place to prevent Resident #1's behaviors. Resident #1 sexually assaulted Resident #2, made explicit sexual comments, touched staff inappropriately, was found in bed with Resident #3, and attempted to enter Resident #5's room. An Immediate Jeopardy situation was identified on 10/20/16. The Immediate Jeopardy was removed on 10/21/16. The facility remained out of compliance at a a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 22 residents who reside on the secured unit at risk for abuse. Findings included: The abuse policy updated 10/17/14 indicated each resident has the right to be free from abuse. Residents will not be subject to abuse by anyone, including, but not limited to other residents. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and assessment of the interventions on a regular basis. Protection: In the area of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. if the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician, then the resident will be immediately discharged . During the time that the perpetrator is being discharged , the facility will monitor this resident on-on-one to protect all other residents. A physician order [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 required extensive assistance of one person with transfers, dressing, and personal hygiene. He was able to move from seated to standing position without staff assistance. He required staff stabilization with walking. He had psychotic indicators of hallucinations and delusions. Resident #1 had behaviors that occurred daily of verbal threatening, screaming, and cursing. A care plan dated 9/3/16 indicated Resident #1 displayed verbally abusive behavioral symptoms to staff and other residents by screaming at others, cursing, and refusing care. Resident #1 displayed inappropriate disruptive behavioral symptoms, such as screaming, cursing, abusive acts, sexual behaviors, disrobing in public, hoarding, and rummaging through others belongings. Resident #1 displayed physically and sexually abusive behavioral symptoms, such as grabbing staff members inappropriately, hitting/attempting to touch staff and other residents, lying in other resident's beds, removing food from other residents, and encrouching in other resident's personal space/belongings. Some approaches were for Resident #1 to reside on the secured unit, keep distance between him and others residents, assess the behaviors to determine if they endangered residents or others. An approach dated 10/19/16 indicated to provide one to one care for Resident #1 when he was physically and sexually abusive. Nursing notes for Resident #1 indicated: On 9/5/16 at 4:46 p.m., Resident #1 displayed increased destructive behaviors, agitation, yelling out, cursing, and threatening other residents. Multiple attempts to redirect and distract were unsuccessful. On 9/6/16 at 6:42 a.m., Resident #1 was in another resident's room lying in the bed. Two staff attempted to assist the resident out of the bed. He became agitated. At 11:16 a.m., Resident #1 displayed increased anxiety and aggressive behaviors yelling out, I'm gonna F start knocking you son of a B out in a minute. He was calling staff names, cursing, and attempting to grab other resident's food at breakfast. He became combative when attempts were made to remove him from the dining room. He was striking out at staff and other residents, redirection was unsuccessful. On 9/17/16 at 4:27 p.m., Resident #1 was in the dining room and completely stripped off all of his clothes. He was physically aggressive and attempting to hit staff. On 9/18/16 at 11:01 a.m., Resident #1 was impulsive and running naked in the hall. On 9/19/16, Resident #1 required constant monitoring and redirection due to extreme aggression and verbal threats. His verbal abuse was aimed at staff, other residents, and family members. All attempts to correct, distract, and redirect him were unsuccessful. At 4:23 p.m., he took food from other residents and ate it. When redirected to his own table, he became agitated and verbally aggressive. On 9/20/16 at 4:43 p.m., Resident #1 required constant observation and redirection related to verbal and physical aggression aimed toward staff, residents, and visitors. On 9/27/16, Resident #1 was physically aggressive with inappropriate touching of a resident, redirection was unsuccessful. He was medicated twice for increased anxiety, but poor effect was noted. He continued verbal threats of violence toward others, he was extremely aggressive, and exhibited combative behaviors at times. Resident #1 was sent to a behavioral hospital. An Event Report dated 9/27/16 at 1:20 p.m. indicated Resident #1 was found in a female resident's room with his hand between her legs. The report indicated Resident #1 had physical behavior symptoms directed toward others daily such as hitting, kicking, pushing, scratching, grabbing, and abusing others sexually. He had verbal behaviors symptoms of threating others, screaming, and cursing others daily. Resident #1 had behavioral symptoms that put residents at risk for injuries and interfered with residents' care. He put others at significant risk for physical injury, issues with privacy, and was disruptive to the living environment. The report indicated on 9/27/16 at 12:39 p.m. Resident #1 had increased anxiety and agitation. He was combative and striking out at other residents, staff, and visitors. He was yelling, cursing, and threatening physical violence. The physician was called and ordered [MEDICATION NAME] 1mg. at 2:37 p.m. Resident #1 hit another female. The report indicated Resident #1 was very confused and not oriented to place and time. He had scattered thoughts and conversation. At 3:00 p.m. Resident #1 was inappropriately touching another female resident. Resident #1 also hit another female resident on the arm. The resident was sent to the hospital for an evaluation. An in-service dated 9/28/16 indicated staff was trained regarding residents on the secure unit requiring frequent monitoring, redirection, and cueing due to increased wandering and confusion. The in-service indicated Please keep a close eye and try to arrange staff to monitor residents in social areas as much as possible. An Elopement Risk assessment dated [DATE] indicated Resident #1 had behaviors and the ability to elope from the facility. Nursing notes indicated Resident #1: On 10/12/16 4:29 p.m., Resident #1 was readmitted to the facility. He was making demands on staff for various things. He was uncooperative, taking food away from other residents, agitated, aggressive, verbally threatening staff, visitors, and residents. All attempts to distract were unsuccessful. Resident #1 did remember the nicknames he gave to staff from admission. On 10/13/16 at 8:35 a.m., Resident #1 was extremely agitated and aggressive, uncooperative with all attempts to perform ADLs, yelling and screaming down the hall, and making verbal threats of violence directed towards staff, residents, and visitors. On 10/17/16 at 5:56 p.m., Resident #1 continued unacceptable behaviors such as foul language, shouted for no apparent reason, mood swings with aggressive threats, and increased irritability. He was given as needed medication for agitation and all attempts were unsuccessful. On 10/17/16 at 8:49 p.m., Resident #1 refused staff attempts at bedtime care. He said, I'm grown, I can go to bed when I want. On 10/18/16 at 3:31 a.m., Resident #1 was up and about the locked unit, very loud yelling at staff. At 11:51 a.m., Resident #1 was medicated this morning for increased anxiety with good effect noted. He was yelling out, cursing and using extremely foul and inappropriate language directed towards staff, residents and visitors. The resident required frequent monitoring for behaviors and became agitated and aggressive when inappropriate demands were rejected. He made verbal threats of violence and yelled down the hallway most of the day. At 3:12 p.m., Resident #1 had increased agitation and aggression. He was yelling obscenities, swearing, and verbalizing sexual comments. He was striking out, attempting to hit staff, residents, and visitors. He was threatening harm and acting violent towards all. He was yelling at other resident's family members and multiple attempts to enter other resident's rooms while families were visiting. Visitors expressed concern for the safety of residents when they are not there. Multiple attempts to re-direct were unsuccessful. At 4:21 p.m., Resident #1 was assisted to the dining room. He reached over a nurse while her back was turned and grabbed the vagina area from the back. The resident said I enjoyed touching her and she must not like it because she liked women. At 7:50 p.m., Resident #1 was extremely difficult to redirect. He was yelling profanities at staff and visitors. On 10/19/16 at 1:06 a.m., Resident #1 was found in another female resident's bed with only a brief on. He became very aggressive towards staff, cussing and stating,This is my wife and I'm fixing to make love to her. He was forcibly removed from the room. He was yelling profanities, threating staff, demanding food and cigarettes. He was observed afar due to violent nature. He had a bowel movement and pulled off his brief and smeared feces over himself and the dining room table. A physician progress notes [REDACTED].#1 had multiple behaviors including grabbing staff, inappropriate language, agitation, and delusions. The note recommended long term psychiatric hospital. Resident #2 A physician order [REDACTED]. An MDS dated [DATE] indicated Resident #2's cognitive status was severely impaired. A care plan dated 5/4/16 and last updated 7/13/16 indicated Resident #2 had cognitive loss (Loss of memory, time sense, and required assistance with decision making.) She was not always understood and not able to understand verbal and nonverbal expressions. Some of the of the approaches were to involve Resident #2 in low stress activities. Nursing notes dated 9/26/16 at 5:50 a.m. indicated Resident #2 had exit seeking and attempted to leave the facility two times. The resident said she wanted to go home, redirection was not effective. She was refusing care, and agitated. The family was contacted for possible day camp on the secure unit. A nursing note dated 9/27/16 at 3:38 p.m. indicated Resident #1 was in Resident #2's room while she was sleeping and touching her in the vaginal area with his hand on top of her brief and dress. Resident #2 was assessed with [REDACTED]. A nursing note dated 10/13/16 at 1:27 a.m. indicated Resident #2 was moved off the secured unit at another family's request. A Grievance/Complaint Report dated 10/13/16 indicated Resident #2's family felt Resident #2 was subjected to a lude environment with a resident that was abusive and inappropriate. The report indicated the resident in question returned from the Behavioral Hospital and had not exhibited any of those behaviors since readmission. Resident #2 was moved off the secured unit at another family's request. During an interview on 10/20/16 at 10:40 a.m., the social worker said he wrote a complaint report out today in regard to the family member of Resident #2 wanting her mother off the locked unit because Resident #1 had returned. He said he dated the form 10/14/16 because he was told by the administrator that was the day the family actually complained to him. He said the Resident #1 did not need to be in the facility. During an observation and interview on 9/20/16 at 9:01 a.m., Resident #2 was noted in a wheelchair propelling herself about with her feet. She said she did not remember anyone being rude or ugly to her. The resident was confused. Resident #3 A physician order [REDACTED].#3 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 was severely cognitively impaired. A care plan dated 3/16 and last updated 8/5/16 indicated Resident #3 was an elopement risk due to dementia, impaired cognition, daily decision making, independent locomotion, decreased safety awareness, and elopement episodes. Some of the approaches were placement on the secure unit and monitor every hour for resident safety. A nursing note dated 10/19/16 at 3:42 a.m. indicated Resident #1 was found to in bed with Resident #3. Resident #3 was clothed in bed and had bed linens covering her body. Resident #1 had on a brief only. There was no skin contact. Resident #3 was asleep during this occurrence. The male resident was removed from the room. At 10:08 a.m., a skin assessment was performed, no injuries were noted. During an interview on 10/20/16 at 10:10 a.m., Resident #3 said she slept well the night before and did not remember anything unusual happening. Resident #3 was confused and was repetitive in her answers; she said the same thing over and over. During an observation on 10/20/16 at 12:40 a.m. Resident #1 was in his bed asleep. There was no staff present. During an observation and interview on 10/20/16 at 12:36 a.m., CNA K was noted to be the only staff on the locked unit. She was sitting at the desk with ear buds in her ear and was watching television on a tablet. She said she worked last night when Resident #1 was discovered in bed with Resident #3. She said Resident #3 was under two blankets. Resident #1 climbed in the bed with her, and apparently climbed over Resident #3 and was against the wall. Resident #1 was under one of those blankets. He had on a brief and was spooning Resident #3 and rubbing on her bottom. CNA K said when she told him to stop he said that was his wife and he was going to make love to her. She said she had to hold his hands to keep him from touching the resident. CNA K said it took three people to get him out of the bed with Resident #3. She said as best she could remember the resident stayed asleep during the whole ordeal, even though Resident #1 was extremely loud and uncooperative. CNA K said she was only focused on Resident #1. She said she knew Resident #1 was supposed to be on one-to-one, but had not been since after dinner today 10/19/16. She said she was the only aide assigned to the hall at the current time. During an interview on 10/20/16 at 1:37 a.m., LVN F said last night she was notified by an aide that Resident #1 was found in bed with Resident #3. He was on top of the blanket, there was no skin contact. Resident #1 had on a brief and Resident #3 was under the blankets. She said Resident #1 said he was in bed with his wife and did not want to leave. It took her and two other staff members to get him out of the bed and out of the room. LVN F said the incident happened about 1 a.m. in the morning. She said at night there was one aide on the secure unit. She said on a normal day Resident #1 was very belligerent toward staff and residents. He was hard to redirect. There are times when he was very aggressive and they just leave him alone and observe him from a far. During an interview on 10/20/16 at 12:44 a.m., CNA L said she was told to come back to the unit and sit with Resident #1. She said she was informed he was supposed to be on one-one supervision. She said she had been on the unit and made rounds once during the night, but had not been assigned to Resident #1 until just now. She came to work at 10 p.m. She said last night Resident #1 was up all night. CNA L said Resident #1 was so upset after being caught in the bed with Resident #3, they took him out and sat him at the nursing station. He calmed down and she later saw him trying to go back into Resident #3's room about 4:30 a.m. He was cussing everyone out and saying he had a gun and was going to kill people. He stripped naked and sat in the dining room. During an interview on 10/20/16 at 12:59 a.m., LVN M said she was informed during report at 6 p.m. that Resident #1 was to be on one-to-one observation. She said she had come back to the unit frequently to check on him and make sure he was fine. She said he had not been on one-to-one observation until a few minutes ago. LVN M said she knew Resident #1 had behavioral issues. He grabbed a staff yesterday and would get aggressive. She had also seen him get naked, swing at aides, demand pain medications. She said he could make his needs known for certain things. During an interview on 10/20/16 at 9:23 a.m., LVN A said Resident #1 did not sleep all night the night before. She said she gave him some prn medications about 9:00 a.m. this morning. She said he was found in a female resident's bed last night. She said Resident #1 was put on one-to-one observation on 10/19/16 due to his behaviors. LVN A said Resident #1 was usually verbally aggressive, made sexually inappropriate statements, and talked about drugs and drug use. LVN A said Resident #1 was not appropriate to reside on the unit. LVN A said they try to redirect Resident #1 by taking him out to smoke. She said aides are all trained on dealing with residents with Alzheimer's/dementia, however; Resident #1 did not have Alzheimer's/ Dementia. During an interview on 10/20/16 at 9:25 a.m., LVN I said she believed Resident #1 knew what he was doing. When he came back from the hospital on [DATE] he remembered all the staff's names. He went to the hospital, but was worse when he came back. LVN I said she was fearful of him; he had hit her in the face several times and touched her inappropriately. She said he would talk vulgar to the residents, staff and anyone that would listen. LVN I said she saw him take food out of another resident's mouth and eat it. The other residents were confused and the population on the unit was so vulnerable to his anger and behaviors. Resident #1 would say very explicit sexual things and made all the other residents on the unit afraid of him, especially the women. She said sometimes he acted out because he was not allowed to do what he wanted. He demanded things such as cigarettes, drugs, medications, and got very upset if he did not get those things. LVN I said most of the residents on the secure unit cannot express their fears and just stay away from him as best as they could. LVN I said Resident #1 was not appropriate for the unit. He was not a typical Alzheimer's resident. He knew what he was doing because sometimes he tried to get back at staff or residents. She did not trust him at night because he could slip into any of the resident's rooms without staff knowledge. During an interview on 10/20/16 at 9:39 a.m. CNA B said Resident #1 was very disrespectful to staff, residents, and visitors. She said he made rude sexually inappropriate comments all the time, he hit a nurse and an aide, would pull his brief off and walk down the hallway naked. CNA B said the residents and families were upset by his behaviors and several of the female residents mostly stayed in their rooms due to his behaviors. CNA B said there were occasions when Resident #1 was completely out of control. He would try to hit anyone within reach and would pick up chairs and try to hit people with them. CNA B said Resident # 5 stayed in the room all the time to avoid Resident #1. During an interview on 10/20/16 at 9:49 a.m., ADON/RN C said Resident #1 was found in bed with a female resident last night. He told staff she was his wife and he was going to sleep with her. ADON/RN C said Resident #3 was confused and did not remember the incident. ADON/RN C said Resident #1 was involved in another incident of sexually inappropriate behavior with Resident #2. He was observed sexually assaulting Resident #2 by groping her between her legs. ADON/RN C said Resident #1 would disrobe and walk down the hallway naked. During an interview on 10/20/16 at 9:58 a.m., CNA D said Resident #1 was very disrespectful, combative, aggressive, and sexually inappropriate. He would tell the staff and residents very explicit sexual acts he wanted them to perform on him, or he on them. She said she saw him with his hands between Resident #2's legs; the resident and her family were very upset. CNA D said sometimes Resident #1 talked with clarity about the things he would like to do, especially when he talked of drugs and sex. She said none of the residents or family members liked him. He talked bad to the residents, especially the females, calling them you old hag or you old B. During an interview on 10/20/16 at 10:04 a.m., CNA E said she was asked to come and sit with Resident #1 about 30 minutes ago when he was placed on on-to one. She said he was asleep which was unusual for him. He usually received medications and it did not effect him at all. He was usually loud, cursing, and scaring the other residents. He said things that were sexually inappropriate and nasty. CNA E said on some occasions Resident #1 was so aggressive they moved all the other residents away from him. They would back off and let him have his way or someone might get hurt. CNA E said she was not trained on dealing with Resident #1. They do the best they can and often times they have to get the nurse to deal with his aggressive behaviors. There were times when taking him out to smoke or giving him a snack would help and other times it did not. During an interview on 10/20/16 at 10:36 a.m., Resident #5 said there was a male resident that would come into her room, but she would throw him out in the hallway. During an interview on 10/20/16 at 10:40 a.m., the social worker said Resident #1 did not need to be in the facility. He was sexually inappropriate; he grabbed a female employee's vagina yesterday. He was sexually inappropriate with Resident #2 before being sent to the hospital on [DATE]. The social worker said Resident #1 returned from the hospital on [DATE] worse than when he left. Resident # 1 continued to be aggressive and sexually inappropriate. The social worker said they did not want to take Resident #1 back, but were told they had to because there was a court order by the judge saying so. However, he had not seen the order. He said he was in the process of trying to find an all-male unit for Resident #1 to be transferred to, but at the current time all refused to accept him. During an interview on 10/20/16 at 10:58 a.m., the DON said they were trying to find suitable placement for Resident #1. The DON said Resident #1 did touch Resident #2 inappropriately, but she slept through the whole incident on 9/27/16. They sent him to the hospital on [DATE] due to that incident and his continued aggression. During an interview on 10/20/16 at 2:15 p.m., Resident #1 said the facility lied on him about touching some staff inappropriately. He said he would not do anything like that. He said the staff were always on him about talking ugly. He admitted he used bad language. Resident #1 said he worked at an automotive shop in the past and that was the way all of the guys talked. Resident #1 talked with clarity for a few minutes and then he incorporated grandiose delusions saying he could care for a sick brother-in-law and he had money. He then was back on the conversation and expressed concerns for the health of his brother-in-law, and not being aware of his illness. During an interview on 10/20/16 at 2:33 p.m., CNA G said Resident #1 would get all the residents on the unit aggravated. He would not listen, and sometimes they left him alone until he calmed down. He would talk bad to residents and try to fight them. Resident #1 would call the other residents names. CNA G said they were in-serviced on Alzheimer's, however, Resident #1 did not seem to act like regular Alzheimer's residents. CNA G said Resident #1 would try to hit other residents; he did not fit in with the general population on the unit. CNA G said when Resident #1 was not there the other residents seemed fine, he tried to rile the other the residents up on purpose. She said after 6 p.m. there was no nurse on the hall. There are two aides until 10 p.m. and then only one aide. During an interview on 10/20/16 at 2:39 p.m., CNA H said Resident #1 had a nasty mouth, and was nasty to residents and staff. He tried to take advantage and intimidate other residents especially the women. He would call them old hags and old Bs. At meal times he would take other residents food and go in and out of other residents rooms. He ran his hands between a females staff legs. CNA H said she was pushing Resident #1 down the hall in his wheelchair. LVN I was leaning over the medication cart with her back to them. Resident #1 took his hand, reached between her legs, and grabbed LVN I. CNA H said she and the nurse were both surprised by the event for a few seconds. She told the resident that was inappropriate and he told her he enjoyed the touching. Resident #1 said LVN I did not enjoy it because she liked women. He began to laugh at LVN I's shocked reaction. CNA H said Resident #1 would pull off his clothes and walk down the hall naked. He would go into other resident's rooms and put on their clothes. During an interview on 10/20/16 at 3:03 p.m., LVN J said she assisted with the in-services and there was no special in-service for Resident #1 that she could find. During an interview on 10/20/16 at 3:15 p.m., the DON said they had not conducted a special in-service on Resident #1. He said his staff were aware of how to handle the resident and he did not feel any special in-service would assist in Resident #1's care. He also said they did not send Resident #1 to the hospital for sexually assaulting Resident #2; Resident #1 had some other issues on 9/27/16 such as hitting and being aggressive. During an interview on 10/20/16 at 3:40 p.m., the administrator said he was aware of Resident #1 inappropriately touching Resident #2. He did not call the incident in because a provider letter indicated the incident had to be willful, knowing and reckless before it was reported. He said Resident #1 was confused and Resident #2 did not know the incident occurred. He did say he was calling in the incident that occurred on last night, where Resident #1 climbed into bed with Resident #3. He could not explain the difference. Resident #3 was noted to be asleep and did not remember the incident and Resident #1 was confused according to the administrator. During an interview on 10/20/16 at 8:30 a.m., the DON said they were in the process of doing an investigation into the incident with Resident #1 and Resident #3. He said they had not obtained statements at this time. He said LVN F had written an incident report, but he did not know if she assessed Resident #3 after the incident. The administrator, DON, and corporate nurse consultant were notified on 12/20/16 at 8:50 a.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/21/16 at 11:55 a.m. and included: 1. RN Consultant in-serviced the Administrator and DON on Reporting Abuse, Neglect, Exploitation and other Incidents by Regional Nurse Consultant on 10/21/16. 2. DON/Designee in-serviced Staff on identifying reckless behaviors and Reporting behaviors to DON/Administrator on 10/21/16. 3. Social worker assessed residents for any issues related to behaviors of other residents on 10/21/16. 4. DON/Designee will ensure the safety and protections of the other residents, resident was placed on 1:1 observation on 10/21/16 until resident can be removed from unit and sent for admission to a Psychiatric Unit for evaluation. 5. DON/Social Worker will ensure resident will be sent to hospital for evaluation and placement into a Psychiatric Facility for evaluation. Resident will remain on 1:1 observation until EMS arrives for transport. 10/21/16. On 10/21/16 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 6 CNAs and 1 nurse were interviewed and said they had been in-serviced by the facility on identifying reckless behaviors and reporting behaviors. Resident #1 was no longer at the facility. The Social worker had assessed residents for any issues related to behaviors. The Administrator and DON were interviewed and said they had been in-serviced on Reporting Abuse, Neglect, Exploitation and other Incidents. On 10/21/16 at 11:55 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility census report dated 10/19/16 indicated the census on the locked unit was 22 residents.

Based on observation, interview, and record review, the facility failed to provide services in accordance with the written plan of care for 1 of 13 residents reviewed for physician orders. (Resident #2) Resident #2 had orders to wear a shoulder immobilizer to the right arm for treatment of [REDACTED]. This failure could place 8 residents who received discharge orders from a hospital stay between 8/15/16 and 9/14/16 at risk for decline in health status and failure to heal. Findings included: Consolidated physician orders [REDACTED].#2 was [AGE] years old, re-admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had a recent change in condition, severe cognitive impairment, and required extensive assistance of two staff for bed mobility and transfer. The MDS indicated Resident #2 required extensive assist of 1 staff for dressing, eating, hygiene, and toileting. It indicated Resident #2 was only able to stabilize while moving from seated to standing position, walking, turning around, and surface to surface transfer with the assistance of staff. The MDS indicated Resident #2 did not have any problems with range of motion in his upper or lower extremities and was incontinent of bowel and bladder. The MDS indicated Resident #2 had two or more falls with no injury and 2 or more falls with injury such as skin tears, abrasions, or hematoma. A hospital discharge order dated 9/1/16 indicated Resident #2 had a right shoulder reduction and was to wear a shoulder immobilizer at all times and return to the emergency department promptly if the shoulder dislocated. A nurse note dated 9/1/16 at 11:25 a.m. completed by LVN J indicated Resident #2 returned from the hospital emergency room for dislocation of right shoulder with no new orders received. During an observation on 9/12/16 at 12:30 p.m., Resident #2's right arm had swelling from the shoulder to his hand. He did not have a shoulder immobilizer in place and he was unable to maintain his right arm in a position close to his body. The right shoulder had an obvious deformity. A hospice attendant was providing a bath and resident was not easily aroused, but grimaced with repositioning. During an interview on 9/13/16 at 7:15 a.m., LVN J said Resident #2 had swelling of his right arm from the hand to the shoulder that was scaled as 3 plus. LVN J said Resident #2 was unable to understand or follow instructions to keep his arm still and on a pillow. LVN J said when Resident #2 returned to the facility on [DATE] he did not see the order for the shoulder immobilizer and Resident #2 did not have the shoulder immobilizer on. LVN J said he would have initialed the order and put orders on the appropriate document. A nurse note dated 9/4/16 at 10:25 a.m., LVN D indicated Resident #2 was sent back to the emergency room after falling out of the wheelchair. LVN D indicated Resident #2 sustained a head injury and was cradling his right arm with his left hand complaining of pain. The note indicated Resident #2's primary care physician was present when Resident #2 fell from the wheelchair and gave orders to send to the emergency room for probable dislocated right shoulder and head injury. (There was no nurse note describing the condition of Resident #2's right arm of on return to the facility on [DATE]) During an interview on 9/13/16 at 5:00 p.m., GVN I said Resident #2 returned from the emergency roiagnom on [DATE] and did not have a shoulder immobilizer. Discharge instructions dated 9/4/16 indicated Resident #2 returned from the emergency room after treatment for [REDACTED]. The instructions indicated Resident #2 was to wear a shoulder immobilizer to prevent another dislocation to the right shoulder. During an interview on 9/13/16 at 12:10 p.m., LVN D said Resident #2 was not sent with the immobilizer when he was readmitted from the hospital on [DATE]; however, the resident did have an order for [REDACTED]. During an interview on 9/13/16 at 8:00 a.m., RN G said the hospital discharge order for Resident #2 for a shoulder immobilizer 9/1/16 and 9/4/16 should have been followed. RN G said the nurse who received Resident #2 back from the hospital on [DATE] and 9/4/16 should have followed up with the physician for clarification if there was a question and obtained the immobilizer if it was not available. During an interview on 9/13/16 at 8:32 a.m., LVN H said he could not recall Resident #2 ever having a shoulder immobilizer. He said he was not sure if Resident #2 ' s shoulder looked disjointed. During an observation on 9/13/16 8:57 a.m., Resident #2 did not have a shoulder immobilizer on and was grimacing when repositioned for wound care. During an interview on 9/13/16 at 2:35 p.m., after surveyor intervention, LVN H said would send Resident #2 for an evaluation of his right shoulder saying, it looked as if it could be out again. Discharge instructions from the hospital dated 9/13/16 indicated Resident #2 returned to the emergency department for a third time due to a shoulder dislocation. A care plan dated 9/13/16 after surveyor intervention indicated Resident #2 had a right shoulder dislocation on 9/1/16 and was at risk for increased pain and limited range of motion. There were no care plan interventions for the immediate after care of the initial right shoulder dislocation. During an interview on 9/13/16 at 2:25 p.m., OTA F said she did not know if a shoulder immobilizer was ordered for Resident #2. The OTA F said she recently treated Resident #2 for [MEDICAL CONDITION] control of his right arm. During an interview on 9/13/16 at 2:38 p.m., the DON said he did not believe they ever got a shoulder immobilizer for Resident #2 and expected nursing staff to notify the physician if there was a question or problem following the orders. During an interview on 9/13/16 at 4:20 pm., the ADON said the discharge order from the emergency room [DATE] and 9/4/16 was considered an order and should be implemented. The ADON said she did not know why the order for Resident #2 was not followed and the nurse receiving the resident back from the emergency roiagnom on [DATE] and 9/4/16 should have notified the physician for clarification and written a clarification order. The ADON said the nurse should have notified the DON if she did not know what to do or could not obtain ordered shoulder immobilizer. During an interview on 9/14/16 at 2:00 p.m. the administrator said he expected staff to follow the physician orders [REDACTED]. An undated Telephone Order Procedure indicated: .Purpose: 1. To assure those physicians orders are carried out. 2. To maintain optimum level of wellness for resident. 3. Record for future reference . A admit discharge report provided by the business office manager, dated 9/14/16 indicated 8 residents were readmitted to the facility from a hospital between 8/19/16 and 9/14/16.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to promote healing and prevent new sores from developing for 2 of 6 residents reviewed for pressure sores. (Resident #s 2 and 3) Resident #2 was at high risk for the development of pressure sores. The resident developed 2 avoidable facility-acquired pressure sores. A Stage 3 (re-opened) to her coccygeal area and a new Stage 2 to her left fifth toe. The facility did not provide assessments or treatments of the pressure sores until surveyor intervention, did not provide pressure relieving devices, and did not notify the physician of the pressure sores. Resident #3 was at high risk for the development of pressure sores and had a Stage 3 pressure sore on her left heel and a Stage 2 on her midline sacral area. The facility did not provide pressure relieving interventions. The resident developed 2 new avoidable facility-acquired pressure sores. The facility did not identify a new Stage 2 pressure sore on Resident #3's left buttock and a new Stage 1 on the resident's right inner ankle until surveyor intervention. The facility did not accurately assess the new pressure sores and did not notify the physician of the new areas. These failures contributed to the development of new pressure sores for Resident #s 2 and 3. This failure could place 4 other residents with pressure sores at risk for the development of new pressure sores and the worsening of existing pressure sores. Findings included: 1. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A Braden Scale dated 5/15/15 indicated Resident #2 was at high risk for development of pressure sores. The most recent MDS assessment dated [DATE] indicated Resident #2 had moderately impaired cognition, required extensive assistance with ADLs, including bed mobility. Resident #2 had an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated Resident #2 had one Stage 3 pressure sore. A care plan dated 7/23/15 indicated Resident #2 was at risk of developing pressure sores.Stage 3 pressure ulcers are indicated . Interventions included to: monitor for skin breakdown and report to physician, turn and reposition every two hours, and provide pressure relieving devices as needed. A skin condition report dated 7/1/15 indicated Resident #2 had shearing on the left top of second toe. A skin condition report dated 7/27/15 the shearing area on Resident #2's left 2nd toe was sized 0.4 X 0.5 with a black scabbed area. A skin report dated 7/21/15 indicated Resident #2's Stage 3 pressure ulcer (first identified on 4/30/15) on her coccygeal area was resolved. There was not a skin condition report addressing the Stage 2 on Resident #2's left fifth toe or a similar sheet addressing the reopened Stage 3 on her coccygeal area. During an observation and interview with LVN A on 7/31/15 at 7:15 p.m., Resident #2 was lying on her right side on a low air loss mattress. The low air loss mattress was covered with a fitted sheet. Resident #2's feet were covered with a sheet and blankets without a pressure relieving device to prevent friction and shearing on her toes. Her right foot was lying on top of her left foot without any pressure relieving padding in between her feet. LVN A said there should be padding in between Resident #2's feet. Resident #2's left second toe had a black scabbed area on the top of her toe. Resident #2's left fifth toe had a red opened Stage 2 on the outer side of her toe. LVN A removed Resident #2's brief and there was an opened hole at the top of Resident #2's coccygeal area (butt crack) that did not have a dressing covering. LVN A said the open area was a Stage 3, approximately 1/3 cm X 1/16 cm in depth. She said the area healed at one time, but reopened. LVN A said the treatment nurse was aware of the Stage 3. The Weekly Pressure Sore QI Log dated 7/29/15 did not include Resident #2. During an interview on 7/31/15 at 9:19 p.m., LVN A said on 7/27/15 during the 6 a.m. - 6 p.m. shift, she noticed the opened pressure sore on Resident #2's coccygeal area. She said she assumed the pressure sore was reported to the treatment nurse. She said was unaware of the any pressure sores on Resident #2's pinky toe. LVN A said she was instructed to report new skin areas to the treatment nurse. She said there were no new treatment orders for the pressure sores. She said she did not provide Resident #2 with wound care for the pressure sore on her coccygeal area. During an observation and interview on 7/31/15 at 8:50 p.m., Resident #2 was lying on her back on a low air loss mattress. The low air loss mattress was covered with a fitted sheet. Resident #2 said the treatment nurse was aware of the opened pressure sore on the resident's bottom. CNA B said Resident #2 required assistance with all ADLs. She said Resident #2 had one red mark below her tail bone, but no open areas. CNA B said she was unaware of any skin issues on Resident #2's toes. During an interview on 7/31/15 at 8:57 p.m., the treatment nurse said low air loss mattresses were not to be covered. He said if the mattress was covered it decreased the air flow which promoted pressure reduction. During an interview on 8/3/15 at 8:57 a.m., CNA D said Resident #2 had a low air loss mattress. She said the mattress was always covered with a sheet. CNA D said she assisted Resident #2 with a shower on 7/30/15 and she noticed redness at the top of the resident's coccygeal area. She said she documented the redness on Resident #2's CNA skin evaluation form. She denied seeing any other areas. CNA D said she gave the form to LVN E. A CNA skin evaluation form (not in the resident's record) dated 7/30/15 indicated Resident #2 had redness at the top of her coccygeal area. The form was signed as reviewed by LVN E. During an interview on 8/3/15 at 9:51 a.m., LVN E said she was unaware of any new areas to Resident #2's skin. LVN E said she reviewed Resident #2's CNA skin evaluation form dated 7/30/15, but must have overlooked the documentation of the redness on the resident's buttocks. During a telephone interview on 7/31/15 at 8:57 p.m., the treatment nurse said he was made aware of the reopened pressure sore on Resident #2's coccygeal area (butt crack) earlier in the day on 7/31/15. He said he told the CNA (could not remember who) to follow the facility's protocol for all new skin areas by informing the nurse who should then assess the resident, notify the physician, and initiate treatment. The treatment nurse said nurses notified him of new areas after initial treatment was made. He said he provided skin treatments Monday through Friday and nurses provided treatments on the weekends. He said he was not aware Resident #2 had a pressure sore on her left pinky toe. During a telephone interview on 7/31/15 at 9:30 p.m., RN C said she worked earlier that day on the 6 a.m. - 6 p.m. shift (7/31/15) and did not recall any reports of Resident #2 having new pressure sores. During an observation and interview on 8/1/15 at 10:05 a.m., Resident #2 was lying on a low air mattress. The mattress was covered with a sheet. Resident #2 said for the past couple days her buttocks hurt. After surveyor intervention, RN C measured the pressure sore on Resident #2's coccygeal area to be 0.3 cm x 0.5 cm x 0.2 cm in size. RN C said she thought the area was a Stage 3 pressure sore. RN C measured the area to Resident #2's left second toe to be 0.4 cm x 0.5 cm. RN C measured the Stage 2 pressure sore on Resident # 2's left fifth toe at 0.3 cm x 0.5 cm. The area was red with scabbing. RN C said this was a new area. A skin condition report dated 8/1/15 completed by RN C indicated Resident #2 had a Stage 2 pressure sore to her midline sacrum (coccygeal area) measuring .03 cm x .05 cm x .02 cm. The area was described as red and painful. A skin condition report dated 8/1/15 indicated Resident #2 had a Stage 1 pressure sore on her left fifth toe measuring 0.3 cm x 0.5 cm. The new area was described as red and painful. During observation and interview on 8/3/15 at 9:51 a.m., Resident #2's low air loss mattress was covered with a sheet. LVN E said Resident #2's low air loss mattress was always covered with a sheet. LVN E said a low air loss mattress should not be covered. During a telephone interview on 8/3/15 at 10:00 a.m., Resident #2's wound care physician said the resident's low air low air loss mattress should not be covered because it decreased the air flow which promoted pressure reduction. The physician said he was not aware of the reopened pressure sore on the resident's coccygeal area or of the new pressure sore on her left fifth toe. 2. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A Braden Scale dated 7/8/15 indicated Resident #3 was at high risk for the development of pressure sores. The most recent MDS assessment dated [DATE] indicated Resident #3 had severe impaired cognition, required extensive assistance with ADLs including bed mobility, and was incontinent of bowel and bladder. The assessment indicated Resident #2 had one Stage 2 pressure sore and one Stage 3 pressure sore. A care plan dated 3/25/15 indicated Resident #3 had a Stage 3 pressure sore on her left heel (problem start date 1/8/15) and a Stage 2 pressure sore on her coccyx area (problem start date 4/8/15). Interventions with approach start dates of 7/9/15 included: keep skin clean and dry, treat per physician orders [REDACTED]. A wound care specialist evaluation dated 7/7/15 indicated Resident #3 had a Stage 3 pressure sore on her left heel and a Stage 2 pressure sore on her midline sacral area. The wound care specialist recommendations included to float the resident's heels in bed to provide pressure relief for the pressure sore on her heel and to reposition the resident per facility protocol. The Weekly Pressure Sore QI Log dated 7/29/15 indicated Resident #3 had a Stage 3 pressure sore on her left heel and a Stage 2 pressure sore on her sacrum. A skin condition report dated 7/31/15 Resident #3's Stage 3 pressure sore on her left heel (identified on 1/8/15) was measured at 0.2 cm x 0.9 cm x 0.2 cm with drainage. A skin condition report dated 7/31/15 indicated Resident #3's Stage 2 pressure sore on her midline sacral area (identified on 4/8/15) measured 1.3 cm x 0.4 cm x 0.3 cm, serous (thin, watery) drainage with a pink wound bed. A wound care specialist evaluation dated 7/31/15 indicated Resident #3 had a Stage 3 pressure sore on her left heel and a Stage 2 pressure ulcer on her midline sacral area. The wound care specialist recommendations included float the resident's heels in bed to provide pressure relief for her pressure sore on her heel. During an observation and interview with RN C on 7/31/15 at 6:35 p.m., Resident #3 was sitting up in her Geri-chair without a pressure relieving cushion under her buttocks. RN C said Resident #3 required total assistance with all ADLs and was transferred with a mechanical lift. She said Resident #3 was incontinent of both bowel and bladder and dependent on staff for bed mobility. RN C said Resident #3 had pressure sores on her coccygeal area and left heel. During an observation on 7/31/15 at 7:39 p.m., Resident #3 was lying on her back in her bed and her heels were not elevated off of the mattress. During an interview on 8/1/15 at 9:32 a.m., the treatment nurse said Resident #3 had a Stage 3 pressure sore on her left heel and a Stage 2 pressure sore on her coccygeal area. He said the resident did not have any other pressure sores. The treatment nurse said Resident #3 had a gel cushion for her to sit on while she was up in her Geri-chair to help reduce pressure. He said the resident did not have a low air loss mattress because she did not have a Stage 4 pressure sore to qualify for a low air loss mattress. During an observation and interview on 8/1/15 at 9:49 a.m., Resident #3 had an open flesh-toned pressure sore on her coccygeal area. RN C said it was a Stage 2 pressure sore. RN C said there was a new area on Resident #3's bottom left buttock. The area was an open, superficial Stage 2. RN C measured the area to be 0.4 cm x 0.3 cm x 0.1 cm and said it was shearing. Resident #3 had a red Stage 1 on her right inner ankle. RN C said there was a new red area on Resident #3's right inner ankle, but she did not stage it and measured it at 0.5 cm x 0.7 cm. She said she was unaware of the new areas. A skin condition report sheet dated 8/1/15 completed by RN C indicated Resident #3 had an area on her right inner ankle sized at 0.5 cm x 0.7 cm and described as brown in color with an odor. The treatment order was skin prep. The area was not staged or described. During observation and interview with LVN E on 8/3/15 at 9:51 a.m., Resident #3 was sitting on a mechanical lift sling in a Geri-chair without a pressure relieving cushion under her buttocks. The resident's legs were hanging down with her left foot crossed over her right foot so that her left heel rested on her right foot. There was no padding or device in between the resident's feet to provide pressure relief. LVN E said Resident #3 was not sitting on a gel cushion. She said the resident had a cushion, but she had not seen it since last week. During an interview on 8/3/15 at 9:56 a.m., CNA F said Resident #3 required total assistance with all ADLs and was transferred with a mechanical lift. She said Resident #3 was incontinent of both bowel and bladder, and dependent on staff for bed mobility. CNA F said Resident #3 was not sitting on pressure reliving cushion. She said the resident had a cushion, but she had not seen it since last week. During a telephone interview on 8/3/15 at 10:00 a.m., Resident #3's wound care physician said he expected Resident #3 to have pressure relieving devices for her bed and Geri-chair. He said a low air loss mattress would be beneficial to Resident #3's wound care. During an interview on 8/3/15 at 10:05 a.m., the corporate RN said residents with Stage 3 or 4 pressure ulcers should have a low air loss mattress. The undated policy and procedure for Pressure Ulcer, Care and Prevention of indicated the following: .To prevent and treat further breakdown of pressure sores. Equipment: 2. Pressure reducing mattress. 3. Pressure reducing chair pad. 4.Foot cradle. 5.Pillows. General Guidelines for Assessment May Include, but are not Limited to: l. Skin at risk. 2. General condition of skin. 3. Any pain: report to physician . .8. Mobility status . .II. Incontinence of bowel and bladder. 12.Braden Scale for Prediction of Pressure Sore Risk. Procedures: .5. Use pressure-reducing devices to relieve pressure. 6. Tum the resident every two hours, or more frequently if indicated, and position with pads or pillows to protect bony prominence . .9. Off load heels if resident is unable to move lower extremities without assistance. l 0. Use bed cradle to relieve pressure of bed clothing, if needed . .13.Preventative measures as per MD orders . .17. Use lift sheet in bed to help reduce possible friction/shearing . The National Pressure Ulcer Advisory Panel at http://www.npuap.org/pr2.htm, accessed 8/6/15, noted the following pressure ulcer definitions: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons (a heralding sign of risk) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. NPUAP guidelines indicated: .Consider the potential impact of the following factors on an individual's risk of pressure ulcer development: a) Friction and shear (Subscale Braden Scale) Document all skin assessments, noting details of any pain possibly related to pressure damage. Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals. 3.2. Avoid subjecting the skin to pressure and shear forces. .The use of support surfaces to prevent heel pressure ulcers Ensure that the heels are free of the surface of the bed. 3.2. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. 3.3. Use a pillow under the calves so that heels are elevated (i.e., floating). Using a pillow under the calves elevates the heels from the mattress. 4. Use of support surfaces to prevent pressure ulcers while seated 4.1. Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. Different studies show that the use of a pressure-redistributing seat cushion prevents the development of pressure ulcers . The CMS 672 dated 7/31/15 indicated 6 residents had pressure ulcers.